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| EDITORIAL |
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| Year : 2018 | Volume
: 11
| Issue : 2 | Page : 89-91 |
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Ratan Tata and a new car: Bill Gates and newer vaccines
Amitav Banerjee
Department of Community Medicine, Dr. DY Patil Medical College, Hospital and Research Centre, Dr. DY Patil Vidyapeeth, Pune, Maharashtra, India
| Date of Web Publication | 18-May-2018 |
Correspondence Address:
Amitav Banerjee
Department of Community Medicine, Dr. DY Patil Medical College, Hospital and Research Centre, Dr. DY Patil Vidyapeeth, Pune, Maharashtra
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/mjdrdypu.MJDRDYPU_1_18
How to cite this article:
Banerjee A. Ratan Tata and a new car: Bill Gates and newer vaccines. Med J DY Patil Vidyapeeth 2018;11:89-91 |
Ratan Tata, former Chairman of an Indian car manufacturing industry, was moved by seeing Indian families riding on two-wheelers, 4–5 members on a scooter, sometimes children sandwiched between parents.[1] His concern for the common man created a new car, the Tata Nano which became famous for being the cheapest car in the world.
Introduction of cheaper cars on Indian roads offer safety for middle-class families. It also meets the aspirations for the common man for mobility and a better quality of life. From this perspective, Rata Tata's vision of introducing a cheap car is laudable. What about the big picture?
Since 1951, the number of vehicles on Indian roads has increased by 11% annually, while the road network in the country has grown by a mere 4% yearly.[2] This has choked roads, increased air pollution and led to an increase in deaths and disability due to road traffic accidents. Government study findings reveal that 75% of air pollution in metros such as Delhi is due to increase of vehicles on the road.[3]
The crises of increasing traffic and air pollution have also driven the demand for creation of flyovers,[4] and more stringent norms regarding vehicle emissions.[5] However, traffic jams are a common feature in the metros irrespective of the number of ever-increasing flyovers.[4] While private vehicles account for almost 68% of the vehicles in India and occupy 67% of the road space, they carry only 37% of the commuters. Public transport like buses account for 24.4% of the vehicles occupying 38% of road space and carry 61% of the commuters.[4] Hence, increasing number of private cars on Indian roads, in the long run, does help neither the rich man nor the poor man. All suffer due to increasing air pollution, traffic jams, and road traffic accidents given the poor implementation of traffic regulations in our country. A permanent solution to traffic problems and air pollution lies in increasing the quality of public transport in the country which is in a pathetic state.
It has been aptly said that “A developed country is not a place where the poor have cars. Its where the rich use public transport.[6] Hence, Ratan Tata's new car may or may not be the appropriate technology for a country aspiring to become developed.
Bill Gates, founder and co-chair of the Bill and Melinda Gates Foundation, was moved by the fear in the eyes of parents of children in the Indian state of Bihar as they worried about their children falling victim to polio.[7] He was also motivated by reading reports about rotavirus deaths which killed over 600,000 children in the world. Consequently, vaccines become Gates Foundation's biggest investment. Gates Foundation pledged $ 750 million to set up the Global Alliance for Vaccines and Immunization (GAVI).[8] Over the years, the Gates Foundation's commitment to GAVI has exceeded $ 4 billion. Bill Gates philanthropic zeal is laudable. Again, what about the big picture?
Introduction of newer vaccines to the existing National Immunization Programme offers hope of preventing mortality and morbidity from a range of diseases depending on the local epidemiology. The Expanded Programme on Immunization (EPI), originated in 1974 after deliberations by the World Health Assembly to address morbidity and mortality from diphtheria, pertussis, tetanus, measles, poliomyelitis, tuberculosis, smallpox, and others depending on regional priorities.[9] Post EPI, and post smallpox eradication, the six vaccine regime for primary immunization sustained for almost 30 years in most countries. In recent years, a number of newer vaccines are been rolled out and getting incorporated in the National Immunization Programme of many countries including developing nations as a result of high-pressure promotion by GAVI aided by the Bill and Melinda Gates Foundation.
Vaccines in developing countries have had extraordinary successes as well as extraordinary shortcomings.[10] Vaccines are administered to millions of healthy controls and therefore adverse effects howsoever rare, raises issues of safety, ethics, and public confidence.[11] Neglecting these issues can erode public trust adversely impacting vaccination coverage. Robust monitoring and surveillance mechanisms are essential to identify adverse event following immunization (AEFI).
Introduction of newer vaccines has the potential to impact the existing immunization program and also the overall health system. Care should be taken to minimize any adverse impact on the existing immunization and health systems as a consequence of introducing a new vaccine.[12]
The core issues to be considered when introducing a new vaccine are public health priority of target diseases dictated by the incidence, mortality, morbidity, and whether other prevention and control measures are a better option than vaccination. It follows, therefore, that a proper health system with disease surveillance and monitoring should be in place to collect these inputs essential for decision-making before launching a new vaccine.
Adding on newer vaccines to the National Immunization Programme without first improving the public health system and disease surveillance mechanisms can be hazardous as this is a double-edged phenomenon. On the one hand, it can nudge the public health system to get its act together. On the downside, it can overwhelm the poorly functioning public health system in most developing countries.[13] As a consequence both the benefits and adverse events of a newly introduced vaccine can be difficult to discern. Intensive disease surveillance is needed to monitor the impact of existing and newly introduced vaccines.
For this, we need a robust public health infrastructure throughout the country. Regrettably, our public health system is in a bad state and keeps deteriorating due to poor government expenditure on health, market forces, and corporatization of healthcare. Public health experts familiar with Indian realities are often overlooked in favor of biotechnological solutions nudged by foreign agencies.[14] Health solutions unlike Information Technology (which Bill Gates is familiar with and perhaps using its methods to promote newer vaccines), is rooted in social and cultural contexts. Using local evidence and framing policies in harmony with regional context rather than taking off the shelf solutions from other countries without a critical evaluation of feasibility in our setting cannot offer long-term solutions. Prioritizing immunization over comprehensive child care or tackling the causal determinants of infectious disease is a piecemeal solution.
In a vast and epidemiologically diverse country like India, policymaking is in the hands of a small group of individuals and few institutions. These narrow involvement limits search for alternatives. Many public health experts believe that technological solutions such as vaccines cannot substitute public health action and investments to beef up the flailing public health infrastructure.[14]
At times important decisions are taken hastily and arbitrarily. In India, a secretary is empowered to select his own experts to introduce a new vaccine on the advice of “experts.”[14] On the other hand, in a country like the US such a decision would take over 3 years after complying with the procedure. This comprises a technical committee selected from among applicants after vacancies are advertised, and consultations with wide range of people in government; health professional organizations; consumer bodies; and specialists in infectious diseases, pediatrics, internal medicine, family medicine, virology, immunology, public health, preventive medicine, vaccine research and policy, economics and cost-effectiveness, geography, race and ethnicity, sex, disability, etc. In all such committees, membership is only for the US nationals, a no-conflict-of-interest policy is strictly observed and minutes of all meetings are in the public domain.[14] On the other hand, in our country, we have yet to form a credible surveillance system for tracking child morbidity. In the absence of our own data, we depend on data provided by donors or donor funded research.
In resource-poor settings with poor surveillance systems, it becomes even more difficult to gather evidence for confirming any adverse event following immunization (AEFI). The absence of evidence becomes evidence of absence as far as AEFI is concerned.
Due to such concerns, Bill Gates missionary zeal to promote an ever-increasing list of childhood vaccines without first tackling basic public health issues, may or may not be the appropriate technology for the developing world.
There are hundreds of infectious diseases. So will we have hundreds of vaccines in the future? We may sum up, “A developed country is not a place where all get only vaccines. It is a place where all have access to good public health facilities, safe water, nutrition, housing, and environment together with judicious use of vaccines.”
Even a developed country can fail at times in ensuring good public health as illustrated by the Flint water crisis in recent times.[15] The public water supplies of Flint, Michigan was contaminated with lead, microorganisms and toxins exposing over 100,000 American citizens including pregnant, nursing women, and children to these harmful substances.[16]
Only focusing on vaccines for disease prevention at the cost of larger public health issues can act as a red herring for both developed and developing countries.
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| 7. | Gates B. Foreword. In: Plotkin SA, Orenstein WA, Offit PA, editors. Vaccines. 6 th ed. Philadelphia: Elsevier Saunders; 2013.  |
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| 9. | World Health Organization. Twenty-Seventh World Health Assembly 1974. Resolution WHA 27.57. WHO Expanded Programme on Immunization. WHA27/1974/REC/1. Geneva: World Health Organization; 1974. |
| 10. | Snape MD. Immunization. In: Davidson R, Brent A, Seale A, editors. Oxford Handbook of Tropical Medicine. 4 th ed. Oxford: Oxford University Press; 2014. p. 893-912. |
| 11. | Ward H, Toledano MB, Shaddick G, Davies B, Elliott P. Vaccination. In: Oxford Handbook of Epidemiology for Clinicians. Oxford: Oxford University Press; 2012. p. 108-10. |
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| 13. | Wang SA, Hyde TB, Mounier-Jack S, Brenzel L, Favin M, Gordon WS, et al. New vaccine introductions: Assessing the impact and the opportunities for immunization and health systems strengthening. Vaccine 2013;31 Suppl 2:B122-8. [ PUBMED] |
| 14. | Rao KS. Governance: Impacting the health system. In: Do We Care? India's Health System. New Delhi: Oxford University Press; 2017. p. 111-95. |
| 15. | Carravallah LA, Reynolds LA, Woolford SJ. Lessons for physicians from flint's water crisis. AMA J Ethics 2017;19:1001-10. [ PUBMED] |
| 16. | Craft-Blacksheare MG. Lessons learned from the crisis in flint, Michigan regarding the effects of contaminated water on maternal and child health. J Obstet Gynecol Neonatal Nurs 2017;46:258-66. [ PUBMED] |
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