Vaccines have long occupied a unique space in the history of public health — on the one hand, the scientific community has maintained that vaccines and immunization have saved countless lives, essentially reshaping human development and evolution. On the other hand, the fact that many vaccines are patented and sold — often at a significant markup — by large pharmaceutical companies means that, in the pursuit of saving lives, doctors and public health experts must juggle commercial concerns.
How can the public health community re-shape this conversation? Looking back on the deadly epidemic of polio, the New York Times points out the vaccine was developed via government and foundation funds rather than a pharmaceutical company. The polio vaccine, invented by Dr. Jonas Salk in 1954, was never patented so as to reach the largest number of patients possible.
This kind of “public health first” approach may be needed to combat future diseases. Economically, however, much has changed since the days of polio. Global governments and not-for-profit institutions have a vested interest in a populace that is vaccinated, fighting mass infection and the high costs associated with treatment. At the same time, government regulations could also be employed, capping vaccine prices so as to fight rampant inflation and price-gouging.
Public health officials and experts, in particular, have a role to play in greater vaccine availability. Both as advocates for price regulation and as community-level authority figures educating the public on the dangers of infection and the importance of vaccines, public health officials can serve as crucial go-betweens — working to see research subsidized, prices lowered and availability increased.
Tension between public health and pharmaceutical interests
The differences in opinion between professionals in the epidemiological fields and drug companies regarding the availability of vaccines have led to an underlying tension between these two groups. From the perspective of many within public health, the fact that vaccines are treated as commercial products is counterintuitive to positive public health outcomes. The fundamental questions are: What obligations do the drug companies have to the public, given research that shows vaccines can save lives? At what point does a vaccine stop being a commercial product and move into the control of the patent holder? And what is in the future for vaccines and vaccine sales, navigating the complicated financial and public health interests?
Research into how vaccines impact human health and development reveals that, unequivocally, vaccines have reduced mortality rates of many of the world’s deadliest diseases. Limiting the scope to measels, a 2014 report from the U.S. Centers for Disease Control and Prevention showed that a 20-year U.S. immunization program called Vaccines for Children (VFC) prevented or will prevent more than 21 million hospitalizations and 732,000 deaths. Started in 1994, the VFC program focused primarily on federally subsidizing the distribution of the measles vaccine — a vaccine that became commercially available in 1963.
“Thanks to the VFC program, children in our country are no longer at significant risk from diseases that once killed thousands each year,” CDC Director Tom Frieden, M.D., M.P.H., said on the program’s 20th anniversary. “Current outbreaks of measles in the U.S. serve as a reminder that these diseases are only a plane ride away. Borders can’t stop measles, but vaccination can.”
Data from the World Health Organization (WHO) concur with this conclusion: In 2015, the WHO released a report from the Measles & Rubella Initiative, estimating that vaccination has been responsible for saving 17.1 million lives since 2000. Yet, in a press release highlighting these results, the WHO also pointed out that progress toward global immunization against the disease has been slow to nonexistent. While mass vaccination campaigns have brought global first dose vaccination up from 72 percent to 85 percent from 2000 to 2010, this number hasn’t increased significantly in the years since. Additionally, only 50 percent of children worldwide receive the clinically recommended second dose of the vaccine.
Why people aren’t vaccinated
The gap between the vaccine being made commercially available and global vaccination rates shows the challenges facing public health officials pushing for increased access to vaccines. In the case of both polio and smallpox, the advent and global administration of a successful vaccine effectively eradicated the disease. According to the WHO, smallpox — estimated to have caused nearly 300 million deaths in the 20th century — was declared eradicated in 1980 with the last known natural case occurring in Somalia in 1977. Polio — a disease where 1 in 200 infections leads to irreversible paralysis — followed a similar track, with an over 99 percent decrease in reported cases since 1988. Currently, wild poliovirus transmission is isolated to rural areas of Afghanistan and Pakistan, with fewer than 100 cases reported in 2016.
By foregoing significant profit on drug sales, the disease was effectively rooted out throughout the world. Yet cases of measles continue to proliferate, both in the U.S. and abroad, with those infected either unsure of their vaccination status or unvaccinated. While some may choose to opt out of vaccines, either due to distrust or a cultural/religious objection, affordability and availability is the most important driver of vaccination rates. In a 2016 study of Polish and Hungarian mothers and their willingness to vaccinate their child against diarrheal illnesses, vaccine cost was proven to be the most significant consideration for those surveyed — followed by severity of illness prevented, effectiveness of the vaccine, mode of administration and other factors.
This is where programs like the VFC and subsidized healthcare via the Affordable Care Act have made a substantial impact on vaccination rates. By being able to mitigate the costs of vaccination, more people opt to get vaccinated. Yet the root of the issue — the commercialization of the vaccines set by manufacturers — remains at play.
Why vaccines are more expensive
With evidence suggesting that a low cost would drive up vaccination rates, public health officials have decried efforts by manufacturers to drive up the price of certain vaccinations. The New York Times reports that what would have cost $100 in 1986 to fully vaccinate a child with private insurance now costs $2,192.
“It’s a risky business developing vaccines, so you can explain — if not necessarily justify — the higher costs of vaccination,” Dr. Alan Hinman, a former head of the immunization division of the C.D.C. and now a senior scientist at the Task Force for Global Health in Georgia, told the Times.
Even with the federal government buying nearly half of all vaccines to administer to children at a deeply discounted — or even free — rate, the companies producing the vaccines have continued to increase prices while boasting ever-rising profits. With this information in mind, many epidemiological and public health experts have criticized the pharmaceutical companies for putting profits over people.
“You have to make back your investment and pay your shareholders, but at what point do you say, ‘Look, you’ve had your steak, gravy and potatoes and this is enough?’” Dr. Steven Black, a vaccine expert at Cincinnati Children’s Hospital, told the New York Times.
A public health perspective on vaccine cost mitigation
For public health experts looking at vaccinations, the cost-benefit analysis of greater availability is clear: The CDC reports that, in the years between 1994 and 2014, the VFC program alone saved nearly $295 billion in direct treatment costs and $1.38 trillion in total societal costs.
Fundamentally, the way we approach vaccine development and distribution has to change. As epidemiologist Seth Berkley discussed in his TED Talk regarding vaccines, often companies go into vaccine development from a financial perspective, rather than a public health and health outcome perspective.
“The sad reality is, we develop vaccines not based upon the risk the pathogen poses to people, but on how economically risky it is to develop these vaccines,” Berkley said in his talk. “Every year, we spend billions of dollars, keeping a fleet of nuclear submarines permanently patrolling the oceans to protect us from a threat that almost certainly will never happen. And yet, we spend virtually nothing to prevent something as tangible and evolutionarily certain as epidemic infectious diseases.”
Berkley’s point about the evolutionary certainty is an apt one: Infectious diseases — such as Zika, West Nile and others — have been making headway through the world, spurring conversations about the way that vaccines are developed and made available. Indeed, the limitations of the current commercial vaccination model are already apparent in areas like Nigeria, where doctors attempting to contain a deadly meningitis outbreak are inhibited by the cost of the vaccines.