This post is part of the #ProtectingKids story roundup. Read all the stories here.
There is a popular saying that you cannot manage what you cannot measure. This is so true for the global effort to close the immunization gap. We need to localize and measure the gap before we can close it. Having good immunization data to evaluate how well we are reaching all children is a critical ingredient for success.
I was poignantly reminded of this fact a few weeks ago when I visited Damangaza community, an urban slum in Nigeria’s Federal Capital Territory, where one of our Women Advocates for Vaccine Access (WAVA) member works. A temporary settlement, Damangaza is made of mud huts, open sewers, zero infrastructure, friendly adults and playful children. This generous community hosts more residents than it can comfortably accommodate, even welcoming internally displaced families fleeing from Boko Haram. A mere 20 minutes drive from the heart of Abuja, the contrast in wealth and access between the community and the nearby Abuja city center couldn’t be any starker.
When WAVA member, Vaccine Network, began working in Damangaza a few years ago, majority of the children had never been vaccinated. The year before, an outbreak of measles swept through the community killing many children in its wake. Although by no means hard to reach, a community like this is one of many settings where children easily fall through the cracks and are missed by immunization services.
Little wonder current data shows that one in five African children is under-vaccinated. If we are to reach that fifth child, we need accurate and timely data to tell us who that child is, where they live and why they are missed. This is a big challenge in Nigeria where the two main sources of immunization data (survey and administrative) do not speak to each other.
Survey data is obtained by interviewing a representative sample of households in the communities about their child’s immunization status. The main ones are the National Demographic Health Survey (NDHS) or the National Immunization Coverage Survey (NICS) conducted every 4 to 5 years. Survey data is richer in details and considered the gold standard. Administrative data on the other hand is based on clinic and health facility records of children who are vaccinated in fixed or outreach posts; it is collated monthly. It is therefore more available to support program management.
Unfortunately, there is usually wide disagreement between the administrative and survey coverage estimates, with the administrative always higher than the survey for comparable years. For example, national coverage with the third dose of the pentavalent vaccine in the 2013 NDHS survey was 38% but 58% by administrative data. Put another way, survey says we reached nearly 4 in 10 kids while administrative says we reached nearly 6 in 10 kids. Which data is accurate?
Diving deeper in the NDHS 2013 raises concerns about retention in care and equity of coverage. For example, while 51% of Nigerian children get their first dose of pentavalent, only 38% end up receiving all three recommended doses, reflecting an absolute drop out rate of 25%. Furthermore, only a quarter of one-year olds received all required vaccines, while as many as 1 in 5 received no vaccines at all.
Looking the beyond the national average reveals staggering disparities by geography, residence, mother’s education and wealth quintiles. According to the NDHS, a child in the north western state of Sokoto is 32 times less likely to be vaccinated than his peer in the south eastern state of Imo. A child living in a rural area is 2.5 times less likely to be vaccinated than her mate in the city. If a child is born of a mother with no education, that child is 7 times less likely to be vaccinated than another child whose mother has secondary school education or more. Children from the poorest fifth of the wealth ladder are 11 times less likely to be vaccinated than their peers from the richest fifth.
Sobering statistics indeed. As I cradled adorable twins Hassan and Husiana in my arms during my visit to Damangaza, I knew the odds were stacked against them in terms of access to vaccination. Their mother had no education, she was in the lowest rung of the wealth ladder and they live in an urban slum. But then again, it struck me that their disadvantage can be overcome if we are intentional about finding and vaccinating children like them wherever they may be. But we will need good and timely data to do that. If administrative data over estimates coverage, we will have a false sense of accomplishment and still miss many children. If survey data is accurate but comes only twice in a decade, it is too infrequent to help us manage the program. We must find an alternative.
Dr. Chizoba Wonodi is the Nigeria Country Program Lead at IVAC.
As the global community works on ways to improve immunization data, I see a third way. This is to empower communities to generate and use their own data to track births and children’s immunization status. Through IVAC’s work on accountability for routine immunization in Nigeria, I have seen that it is possible use community structures like religious and traditional leaders or Ward and Village Development Committees to count how many children are born in the community every month. If health workers have an accurate number of births in their catchment area, the true target population, it is easy for them to measure how well they are doing with vaccinating kids.
Community structures can also be used to track dropouts or left-outs, tracing them right down to the compound and household where the children live. Such real time information will not only help the health worker do their job better, it will also give community leaders a sense of ownership of the immunization program. I look forward to the day when a village chief can tell his community’s target population and vaccination coverage; that day will bring us many steps closer to bridging the immunization gap. Data is not just for experts and nerds; it is for all of us.
Dr. Chizoba Wonodi is the Nigeria Country Program Lead at IVAC.
By Ahmad Abdulwahab
Where do you go when you need medication? Treatment for a minor injury? Vaccination for your child? Education about preventing or managing disease? In Nigeria, the answer should be your primary health care (PHC) facility. PHCs are required to provide these services and more, including clean water and basic sanitation. But the truth is many can only manage to provide a subset. Due to a lack of skilled health workers and adequate supplies, these PHCs leave communities underserved and vulnerable to disease.
Indeed, while Nigeria’s PHC system has made great strides over the years—with a shift from narrow disease-specific vertical programs to a horizontal health system focus of the new “Primary Health Care Under One Roof” reform—there remain many challenges in the health sector, mostly concentrated at the primary health care level. Rather than enumerating these, it is perhaps better to focus on one root problem and a remedy - financing and basket funds, respectively. Initially implemented in Zamfara State to improve routine immunization, the successful basket fund model has since expanded to other states, with the goal of further enhancing overall PHC service delivery.
While working as the Director of Primary Health Care in Yobe State, and later as the National Programme Manager of the Partnership for Reviving Routine Immunization in Northern Nigeria- Maternal Newborn and Child Health (PRRINN-MNCH), I learned that financing lies at the core of Nigeria’s PHC delivery challenges. It is difficult to access the necessary funds to finance basic needs in the health sector. At the state level, federal and state allocations are occasionally misapplied, resulting in incomplete disbursement of local budgets. On the local level, budgets are not earmarked, leading to delays in the release (or at times non-release) of PHC funds—often hinging upon the political will and administrative priorities of those in power.
Dr. Ahmad Abdulwahab in a group photograph with LGA Chairmen of Zamfara State, the Honorable Commissioners of the State Ministry of Health and State Ministry for Local Governments and senior officials of the PRRINN-MNCH program after a meeting on the Basket fund.
A basket fund is a promising mechanism of addressing many of these financing problems. In 2009, Zamfara State with PRRINN-MNCH established the first basket fund in the country to improve routine immunization program and delivery. A basket fund pools resources from state, local, and federal governments as well as from donors and even the private sector. These resources are then directly disbursed to responsible officers for specific PHC activities such as immunization outreach and vaccine distribution to health facilities. Zamfara’s basket fund consists of government contributions (80%) and support from developmental partners (20%) for improving routine immunization.
Over the past five years, the Zamfara basket fund has been tremendously useful in addressing the issue of financial resources. By creating a strong set of checks and balances, the basket fund has increased accountability and transparency in how, when, and where the funds are disbursed. It has helped guarantee funding for basic PHC services and also ensure coordination so that duplication of resources does not exist. As a result of the basket fund, the number of political wards with regular disbursements to finance routine immunization rose from 14% to 100%. Similarly, the DPT3 immunization coverage significantly increased in these political wards over a period of six months.
Due to this success, Zamfara’s basket fund has now expanded to finance maternal health (in particular, the Midwives Service Scheme that mobilizes midwives to rural areas), polio supplemental immunization campaign, and nutrition programs and activities. In the near future, we hope to see the basket fund encompass all PHC services.
Many states with the support of partners are now replicating the Zamfara basket fund model in hopes of achieving similar success. For example, in 2013, Kano State established a basket fund, with an agreement to gradually reduce the significant contribution of international donors until 2016, when the basket should be completely funded by the government. Even the National Primary Health Care Development Agency (NPHCDA) has recognized the efficacy of basket funding and has incorporated it into the National Routine Immunization Strategic Plan as one of the interventions that the federal government recommends all states to implement.
However, basket funds are not without their own challenges. Namely, political will is critical. The Kano basket fund was established quickly with the strong endorsement of the Deputy Governor, but achieving such commitment has been slow in other states. Additionally, coordination and alignment of priorities among partners and the government is essential, and a liaison is often needed to spearhead this process.
Dr. Abdulwahab photographed along with the Zamfara State Public Health Officials and IVAC members.
On a scale of 1-10, I would rate Nigeria’s overall PHC system at three or four. This is an improvement from scores in the negative that it would have garnered several years ago when there was little effort in strengthening health systems. There is now greater awareness among policymakers and partners that primary health care is fundamental to improving the health of the nation.
I believe the basket fund is a high impact, easy, and replicable model that can help Nigeria achieve its goals of increased accountability, effective service delivery, and improved health outcomes. IVAC’s White Paper on Basket Funds provides a timely and useful resource for states wishing to establish and implement basket funds. If basket funds continue to grow beyond specific program priorities, they will cover all PHC services. This would be the ultimate realization of our vision of “primary health care under one roof.” Because of basket funds, the issue of lack of funding for basic PHC services may become an issue of the past.
Support from states and partners during this process will be essential for the success of basket funds. To reach its full potential and move the needle on PHC in the country, there must be strong political will and clear leadership. The time has come for Nigerian officials and partners to work together to usher in a new era in which the financing, resource allocation, and implementation of primary health care activities are designed in a way that is streamlined and accountable, and serves the true functions they were intended for. That is the vision many of us working in the PHC field have for this country.
Dr. Ahmad Abdulwahab, [MBBS, MPH], is a Nigerian medical doctor and public health/health systems specialist with over 18 years of experience in the Nigerian health sector. He has worked with both Government and International organizations at state and national levels. He was at a time the Director of PHC and Disease Control in the Yobe State Ministry of Health and served as the National Programme Manager for the 7-year 65 million pounds DFID/Norwegian Government funded Partnership for Reviving Routine Immunization in Northern Nigeria - Maternal Newborn and Child Health (PRRINN-MNCH) programme. He has also provided technical services to several International agencies such WHO, UNICEF, USAID, Netherland Leprosy Relief and Global Fund and has shared his extensive experience and knowledge of public health, policy development and health systems reform, through presentations at several national and international fora.
This post originally appeared on the Nigeria Health Watch and is cross-posted here with permission.
By Chizoba Wonodi
Nigeria launched the introduction of the pneumococcal conjugate vaccine (PCV)into its childhood immunization schedule in Lokoja, on December 22nd 2014. PCV prevents one of the deadliest bacterial causes of pneumonia, meningitis, blood infections and middle ear infections in children. Before now, only parents with the means could afford to vaccinate their children for thousands of naira in private clinics. But now, government is offering it for free to all kids. This is a big deal, so get excited!
Launch of PCV Vaccination in Lokoja
A journey that began 6 years ago has finally come to a successful end. But it was not an easy ride. As I think about the road to this introduction, I remember all the twists and turns along the way and marvel at the tenacity and perseverance of the chief actors in this story.
In 2008, I was working for a Johns Hopkins project called PneumoAdip, which was set up to accelerate the introduction of PCV into African and Asian countries. You may wonder why anyone needs a project to do that, right? Well, it turns out that having a vaccine that works is not enough to get countries to use it, unless the vaccine is for Ebola. I bet countries will scramble for an Ebola vaccine, if it comes. But then most diseases are not like Ebola. For more silent diseases like pneumonia, it takes concerted effort to make the decision makers recognize the burden of the disease, the value of the vaccine and the actions to take on it. For example, it took Nigeria 21 years to adopt the Haemophilus Influenza b (Hib) vaccine into our routine system. The first country to use Hib vaccine in their national program started in 1991, we started 2012.
I remember sitting in the Premier Hotel Ibadan during the 39th Annual General and Scientific Conference of the Paediatric Association of Nigeria (PANCONF) in January 2008. The halls were packed, the place was buzzing, the energy was infectious, pediatricians were milling around discussing how to save babies. I had come from Baltimore to field test a pneumonia diagnostic tool and discuss the prospect of Nigeria introducing PCV into the national immunization program.
At one of the session breaks, I cornered Dr. Abanida, then Director of Immunization at NPHCDA and asked him, “Doc, when are we going to introduce penta and PCV?” “Very soon” he replied, “We will apply for both vaccines this year”. This was an unexpected and pleasant surprise. I had predicted he would commit to only penta, but PCV as well? That was great. You see, it was no coincidence that we were coming late to the penta party when countries like Kenya had introduced the vaccine 8 year before. As a country, we had been preoccupied with battling polio, especially after the major polio vaccine rejection of 2004. In addition, our systems were weak. Indeed, before 2005, we would not have been able to apply for Gavi support for new vaccines even our immunization coverage was less than 50%, less than the required threshold. To get Gavi’s help, countries have to meet certain eligibility criteria and they have to formally apply and be approved for support.
Just as Dr. Abanida had declared, in April 2008, Nigeria tendered their first Gavi application for penta and PCV introduction support. In June 2008, the reviewers granted the application a conditional approval.
Disappointed but not deterred, in September 2008, the new vaccine application team led by Dr. Oteri, then Gavi desk officer at NPHCDA, responded to the conditions and queries from Gavi. But the second submission was rejected and the country was asked to re-apply.
Three things then happened that delayed the process for the next two and half years. First, Gavi suspended all new vaccine applications due to internal processes and funding constraints. No country could apply for new vaccine support in 2009. Second, Gavi revised their new vaccine application policy, now requiring an immunization coverage rate of at least 70% instead of 50%. Third, Nigeria’s vaccine coverage dropped below 50% to 42% according to WHO-UNICEF estimate released in June 2010. This new drop caused Dr. Dorothy Esangbedo, then the President of the Pediatric Association of Nigeria, to lament bitterly and call for stronger action to shore up routine immunization.
Under the new policy and with the lower coverage, Nigeria could not re-apply in 2010. In fact, a workshop in August 2010 convened by NPHCDA to develop the third submission was truncated by the twin news that our coverage rate had dropped and Gavi coverage requirement had increased.
When Gavi began revising their policy, there had been talk and expectation in some quarters that countries such as Nigeria, who were already in the application process before the policy change, would be “grandfathered in”. That did not pan out. To help matters, Gavi delayed the implementation of the new coverage requirement by one year, which left Nigeria with one window of opportunity to apply in May 2011.
But there was one more hurdle to scale. Coverage estimates for 2010 had to be 50% or better. The National Immunization Coverage Survey (NICS), showed coverage to be 71% for 2010, but Gavi only recognizes the WHO/UNICEF estimates, which was still 42% and would only be updated in July. Nigeria needed the updated estimates to apply in May. The update would be two months late. What to do?
The emails and phone calls started going back and forth advocating for a solution. At IVAC we pushed for different options: allow Nigeria use the NICS to apply, allow a phased introduction, so that states that meet the coverage criteria can be supported to introduce the vaccine, while effort be made to raise coverage in the other states. Dr. Mohammad Ali Pate, then Minister of State for Health, was very vocal in his advocacy to find a solution. Eventually and exceptionally, Gavi allowed Nigeria to apply for penta and PCV in May 2011. Then in July 2011, penta was approved and PCV was conditionally approved. All decisions were subject to the 2010 WHO/UNICEF DTP3 coverage estimates being >50%.
After the July 2011 conditional approval for PCV, Nigeria worked on responding to the conditions attached to the approval by strengthening the cold chain system. Then, 15 months later, in October 2012, Gavi gave the final approval for a phased roll out of PCV to begin in 2013. However, due to global supply constraints and other operational issues such as strikes in the Nigerian health sector, the first child could not be vaccinated till December 2014.
I didn’t go for the launch, but my colleagues went, and it was gratifying to see the culmination of everyone’s effort. Big thanks should go to the NPHCDA, Gavi, UNICEF, WHO, Pediatric Association of Nigeria, CHAI and all other groups who have pushed hard to see this happen.
First Nigerian Child to receive the Free Pneumococcal Conjugate Vaccine
As I look at the grainy picture of baby Collins, who is the first child to be vaccinated, cry out in pain from the shots of the first PCV vaccination, I wish I could tell him,
“Baby, don’t cry, laugh instead, even though that injection is painful. You are getting a shot a life. Something that babies before you did not get, but thankfully those after you will receive. If we are able to immunize 87% of your fellow babies every year with this vaccine, we can save about 200,000 lives by 2020. Isn’t that something to laugh or even rejoice about? Yes indeed, it is cause for celebration. I only wish it didn’t take six long years for this to happen. Think of all the babies we could have saved in that time. Anyway, you are too young to understand all this. After all, what do you know? You are just a baby. You probably just want to suck you mother’s breast right now, forget all this noise and go to sleep. So I’ll let you be.”
Dr. Chizoba Wonodi (MBBS, MPH, DrPH),
Nigeria Country Programs Lead, Johns Hopkins International Vaccine Access Centre,
Advisor, Saving One Million Lives Initiative,
Advisor, Gavi’s Strategic Demand Forecast for vaccines.
This is the second in a series of profiles to help IVAC partners and friends get to know our team. This one features Chizoba Wonodi, an epidemiologist who leads IVAC’s Nigeria work. We caught up with Chizoba just before she made a big move back to Nigeria with her family. After living in Baltimore for 10 years, Chizoba will now represent IVAC in country, and she will dig deeper into efforts to work with the Nigerian government and other stakeholders to improve routine immunization and increase accountability.
Tell me a bit about your background and when you joined IVAC.
Before coming to Baltimore, I worked as a physician in Nigeria, concentrating mostly on adolescent sexual and reproductive health and HIV/AIDs prevention. I came to Johns Hopkins for my masters in public health and, after that, I went on to the DrPH (Doctor of Public Health) program, completing both programs as a Gates Institute Scholar. In 2006, in my third year of the doctorate program, a colleague introduced me to the PneumoADIP project that would later morph into IVAC. I thought the whole concept of accelerating access to vaccines was novel and cool and I wanted to be part of it. So I sought and got work as student research assistant with PneumoADIP.
When I graduated from my doctoral program in 2009, I joined the Hopkins faculty knowing I wanted to focus my work on Nigeria. My desire has always been to take what I learned at Hopkins and apply it to my home country. At IVAC, I have been able to do just that. My work is to support the Nigerian government in developing effective policies and programs to deliver life-saving vaccines to children. We work alongside many organizations, including the WHO and UNICEF, in helping the government build stronger immunization systems. We do this through policy and operations research, translating evidence to policy, and brokering or advocating for relevant interventions. Instituting accountability within the health system is also a big part of my work in Nigeria.
Chizoba Wonodi with her niece. (Photo credit: Tyrone Shoots)
What inspires you to work in global health?
I think the potential to make a difference on a large scale drew me to global health. I came to this realization after medical school, when it was time to choose a clinical specialty. I considered pediatrics because I love children, but I didn’t have the affinity for one-on-one interventions when thousands were dying of preventable causes. I wanted to change things at a broader level. With public health, you can see how the policies and programs you implement affect large populations.
What does it mean for you to be doing work to help Nigeria?
It is a privilege because not everybody has the opportunity to come to Johns Hopkins, a world-class institution, and receive training from the best in the field and work beside them. It is wonderful to be able to take what I learned here back to Nigeria and try to make a difference there. However, it isn’t just about taking knowledge back, but also learning from the dynamic changes that have occurred in Nigeria.
Can you explain the kind of dynamic changes Nigeria has gone through?
There is more human capacity than before. In the last decade, a crop of globally educated public health revolutionaries – if I may call them that – have returned home with cutting-edge knowledge, skills, and attitudes. They’ve melded the global perspective with their local knowledge and sensibilities and have become a force for change. They resist doing business as usual and push for decisions to be evidence-based. They are forging partnerships in unusual places, demanding accountability, and focusing on results not just inputs.
Chizoba Wonodi at the National Vaccine Summit in Abuja, Nigeria, April 2012. (Photo courtesy of Tyrone Gibson)
In the vaccine world to be exact, there has been a growing awareness of and greater access to new vaccines. For instance, Haemophilus influenzae type B (Hib) vaccine was introduced last year, hopefully next year, pneumococcal conjugate vaccine (PCV) will follow. Although it took more than 15 years for these new vaccines to become available in the country, the momentum is shifting rapidly as more stakeholders acknowledge the importance of immunization. In April 2012, we saw a massive outpouring of support and promises at the National Vaccine Summit. Many hands are now on deck to help prop up the routine immunization system, and we are seeing positive results. Top among the donors is GAVI, who provides the single largest investment in routine immunization in Nigeria. As more partners come on board, the program space gets crowded and the pace quickens. It is all very exciting. However, one has to be nimble and responsive, to be relevant.
What has been your most rewarding or memorable experience at IVAC?
Seeing the impact of the policies we’ve helped influence result in access to new vaccines for children has been most rewarding. I remember when I came to the PneumoADIP and we were working on the introduction of PCV into developing countries. At that time PCV was considered too expensive for poor countries, but by getting countries to recognize the burden of pneumococcal disease, by convincing vaccine manufactures that there was a market beyond Europe and America, and by mobilizing the right financing, we (and others) helped accelerate PCV introduction into Africa and Asia.
Six years later, it is gratifying to see PCV introduction has outpaced earlier projections. This means many more children (in the millions) are being vaccinated and protected than we ever thought possible. There aren’t many opportunities where you get to contribute to change as big as that.
At the National Vaccine Summit in Nigeria (left to right): Dr. Ado Mohammad, Executive Director of the National Primary Health Care Development Agency; Dr. David Okello, former WHO Representative for Nigeria; and Dr. Chizoba Wonodi, Epidemiologist and Nigeria Projects Lead at IVAC. (Photo courtesy of Tyrone Gibson)
Wow, that sounds wonderful but also very demanding. What do you do in your free time to relax?
I like to cook. I watch the Food Network to learn new recipes. I love Asian food so I started learning to cook Chinese and now Korean food.
Speaking of cooking and eating, if you could have dinner with anyone – alive or dead – who would you pick and why?
I would choose Nelson Mandela. I don’t think there is anyone in the world as loved and as esteemed. I would like to feel the essence of the man and understand what makes him stand out so much. It would be a wonderful opportunity to learn from someone who has so much compassion, knowledge, and wisdom.
So through our conversation so far, it is obvious you are very proud to be Nigerian. What about Nigeria do you like best?
I love the people. We are proud and very happy people. In fact, there was a study that found Nigerians are the happiest people on earth. You wouldn’t think that given all our challenges and issues; but that is just who we are. We are very welcoming and very hospitable. And I love that when you meet a Nigerian, they proudly proclaim they are Nigerian.
What is your wish for Nigeria?
My immediate wish is that the 2015 elections will come and go flawlessly without any major upheavals. I also hope that the bloodshed in the north will stop so people can get back to living their lives. And I wish that Nigerian leaders would recognize and build our biggest resource – our human resources. Part of that includes making sure girls are educated. Once girls are educated, half the job is done in terms of alleviating poverty, adopting healthy behaviors, and nurturing the next generation.
Lastly, if you could visit anywhere in the world, where would that be and why?
Bhutan. I had a colleague that worked at the Hib Initiative who visited Bhutan. It is very difficult to go there, and you need to have a special reason to visit. My colleague went as a part of a vaccine delegation and she said the country is just pristine, the air is clean and clear, and you can hear birds chirping everywhere. I would love to see that country which has been unspoiled by modern life.
This is the first in a series of profiles to help IVAC partners and friends get to know our team. We thought we’d start with Lois Privor-Dumm, a long-time IVAC team member and Director of our Alliances and Information team. We caught up with Lois in between her busy travel schedule to chat about her background, her work at IVAC and what she likes to do in her spare time.
Tell us a bit about your background, what inspired you to work in global health, and how you ended up at IVAC.
I didn’t set out to work in global health, but I’ve always wanted to work internationally. I spent most of my career in the private sector and was fortunate enough to have the opportunity to launch Prevnar®, the first pneumococcal conjugate vaccine (PCV), in the U.S. and then help other countries around the world introduce the vaccine. I had worked with other vaccines and pharmaceuticals, but this experience, coming in direct contact with families impacted by pneumococcal disease, particularly meningitis, made a major impression. I saw the value that the vaccine had for countries that had introduced, but also recognized the severe disparities that existed in vaccine access around the world. I decided I could play a role in helping reduce those disparities. Although I was able to influence some change while working in pharma, I thought I could make a bigger impact by bringing my understanding of the industry and my marketing and operations experience to public health. I was fortunate to be working with experts on PCV, including Orin Levine, Mathu Santosham and Kate O’Brien, who recognized how my perspective – despite my non-traditional background for a public health career – could be beneficial. We shared the vision that new vaccine introductions did not need to see delays of 20 years or more between licensure and introduction in low-income countries, and helping devise and implement a plan to achieve this goal was very intriguing to me.
So, I first joined Hopkins in 2005 as Director of Communications and Strategy on the Hib Initiative and soon after took on the role of Director of Access and Implementation, and later Communications, for the PneumoADIP. Our approach of addressing the needs of all stakeholders – countries, donors and suppliers – proved to be an effective way to achieve our vision, and we’ve been fortunate that we’ve been able to continue our mission through what is now IVAC. I consider myself very lucky to work with such a diverse, creative and talented team. I think it is the team and the way we work that has enabled us to work on some really tough challenges that have a big impact and achieve success.
I’m also a strong believer that there are always solutions and, at Hopkins, I value the opportunity to help facilitate those solutions, bringing both a manufacturer perspective and that of someone working with global health colleagues and country leaders. There’s been significant progress in vaccine access in the past decade or so, and I hope our work will continue to accelerate greater access and equity for vaccines and other interventions that make such a difference in peoples’ lives and contribute to healthier and more productive societies.
What projects do you work on at IVAC?
Lois Privor-Dumm and a group of children at the 1st National Vaccine Summit in Abuja, Nigeria in April 2012.
I lead the Alliances and Information team at IVAC, which includes projects covering advocacy and communications – both globally and in-country – as well as policy research and supply and access issues. I spend a great deal of time on our country-focused work, namely India, where we have been working to synthesize the evidence base and advocate for interventions for pneumonia and diarrhea at both the national and state level, and Nigeria, where we have helped analyze barriers and solutions to improve routine immunization and continue to provide technical support and encourage government accountability. I’m also excited that we’ve recently added country work with Pakistan.
Our work is varied, and there is never a dull moment. Our efforts have helped others become advocates and add their voice to important issues in child health. For instance, we’ve run advocacy workshops and collaborated with a network of trained experts to address child pneumonia and diarrhea in their countries. We support the efforts of experts including the ROTA Council, a dedicated council of scientific experts working to accelerate the introduction of rotavirus vaccines, and the Global Coalition Against Child Pneumonia. With the help of key partners, we established World Pneumonia Day to call for action on protection, prevention and treatment of the leading global killer of children. Our team also coordinates closely with IVAC’s Epidemiology and Economics & Finance teams to help communicate the results of their work and highlight the work of other researchers that relates to vaccines and child health.
Last but not least, I spend much of my time on our supply and access work, which is also very important. One of our more recent projects centers around primary container decision making and building awareness of how these seemingly straightforward decisions have significant impact on not only cold-chain space and procurement cost, but also wastage and other costs, vaccine coverage, and safety. We’ve developed a framework and have been working with various experts to help advocate for a more robust approach to considering all the implications of these decisions.
I’d be remiss not to mention, that none of this, of course, could be done without the great team of hard working and very capable individuals and students on the A&I team.
What have been some of your most rewarding or memorable experiences at IVAC?
One of my most memorable experiences was my first week at Johns Hopkins. I was working with the Hib Initiative and went to the Gambia and Bangladesh to film the BBC World Kill or Cure: Hib documentary, which highlighted the impact of the disease and efforts needed to bring a vaccine to developing countries. I remember meeting people at the labs and families that had been affected by meningitis and seeing how dedicated they were to finding the solution. I have great memories from that trip, for example touring the lab at MRC and then having tea with a family in the Gambia with little kids around very curious about all of our cameras. Bangladesh was no different, although it was tough seeing a child and her mother who did not know whether her daughter would survive the night or succumb to a severe case of pneumonia.
Another big moment was the first World Pneumonia Day in 2009 and seeing that kick off not only in the U.S. but probably more importantly around the world. That sense of pride continues when I see how many other people have taken up the cause. As we move into World Pneumonia Day’s fifth year, I am increasingly impressed by the level and volume of activities that take place – creating a global community of sorts. The fact that people are talking about antibiotic access, bringing new vaccines into countries, improving breastfeeding rates – it is very gratifying.
What is the most interesting place you’ve traveled to? Anyone who has seen your passport will know this will be a tough question to answer.
Yes, it is. Everywhere I’ve gone has been interesting. Large countries hold a lot of interest for me simply because of the level of contrast you see within the same country. I’m always struck by the disparities within the countries, but at the same time, the level of hope and generosity of those that don’t have much. I am fascinated by the diverse modes of transportation like the trucks that are brightly painted with “honk please” signs in India and Bangladesh, navigating the same roads as people walking with bundles of firewood on their heads or families piled three or four onto a small motorbike seat. In Nigeria I’ve been captivated by the people and the diversity of just about every aspect from dress to food, language and density of the population. And in some countries you’ve got such a long history that can’t help but impact you – Angkor Watt in Cambodia, Petra in Jordan, and slave quarters in Africa – it reminds me of how far the countries have come, yet how much more is still to be achieved.
Since you spend a lot of time in India and Nigeria, what similarities and differences do you see between the two?
Lois Privor-Dumm and fellow participants at a national course on pneumonia and diarrhea prevention in Delhi in December 2012.
That’s a great question. I’d love to hear the perspective from those who live in one of the two countries. From my perspective though, they are similar in that they both have some wonderful, high caliber people. Both have large bureaucracies and complex environments, and I’m always impressed by
individuals who’ve been great champions of children who’ve successfully been able to navigate the environment and overcome some real barriers to getting things done. The real heroes are the ones who’ve been able to not just talk about change, but have been able to see things through, and there have been examples in both places. Another similarity is that health is very much a state subject, and implementation and sustainable change is highly dependent on the individual states. As different as priorities and ways of life are between these countries, the same can be said of individual states, and it is important to understand the priorities and players in each.
Both countries obviously have had to tackle an ongoing challenge of polio, and the related challenges and opportunities of an enormous vaccine effort. India has now gotten ahead of the curve with no cases of wild-type polio for the past two years. Nigeria still faces many challenges with polio, but has moved ahead to strengthen routine immunization and add new vaccines.
One major difference may be in the way vaccines are portrayed in the press in each country. Although the dialogue is changing and more and more positive stories emerge surrounding vaccines, media in both countries still often like to report on sensationalist stories that do not hold scientific muster, and controversy reigns. Politicians and bureaucrats often do not recognize how political capital can be built by improving routine immunization. In Nigeria, although there are anti-vaccine sentiments, particularly surrounding polio in certain areas, health is an important issue, and leaders will take advantage of reporting on the steps they’ve taken to combat disease.
On a related note, what progress have you seen in vaccine access in India and Nigeria recently, and what do you expect to see in the next few years?
I think there is much more recognition in both countries that the systems must be strengthened, infrastructure for delivering polio immunization can be leveraged, and that a focus on bringing up routine immunization coverage will benefit new vaccines and vice versa. There has been a greater level of engagement at the state level, and I expect that this will become increasingly important moving forward. As states are implementers and must ultimately ensure that there is both adequate demand and supply, their engagement in the planning and decision-making process is key. Another area that should see improvement over the next few years is surveillance, not only to be able to measure the impact of the vaccines but also to be able to monitor any adverse events that may happen and to quickly determine if they are related to the vaccine. This has especially been a challenge in India, where activists and media have questioned whether adverse events are due to vaccine and have treated government assurances with suspicion. Good surveillance with baseline measures of child health statistics prior to introduction will make it easier to assess claims and address concerns that may be unfounded, as well as provide a basis for measuring the trends and impact that are so important to communicate to sustain public and policy maker support for vaccines.
On a personal note, when not traveling internationally, you split your time between Baltimore and West Chester. What do you like about each?
Yes, both places are great. West Chester is where I’ve lived for a long time, and where I spend a part of the week with my husband and dog. It is a historic city with brick sidewalks, and a small town where I’ve gotten to know a lot of people over the years. I consider it home, although I am originally from upstate NY. Baltimore is a great city. I love where I live in Fells Point, right by the water. I’ve got great colleagues and friends in the city, and the ability to walk to work is a huge bonus!
Do you have any interesting hobbies?
I like doing things outside, including spending time gardening, hiking and exploring different places old and new. But, there is no place I’d rather be than under the water diving (although on safari is a close second). I’ve been diving since 1992 and try to go every year. One of my favorite places is the South Pacific where you have just an amazing range of color and variety of marine life – sharks and eels and all sorts of different things. I think I like it because I’m an explorer at heart, and you never know what you’re going to find down there, and it’s a way to really relax.
What is the most recent book you’ve read?
I just read Cutting for Stone about a doctor from Ethiopia and am now reading Behind the Beautiful Forevers – Life, Death and Hope in a Mumbai Undercity. I like reading about places I’ve been or would like to go. I also have been reading some of the excerpts from an international thriller novel a friend of mine is working on publishing – can’t wait to see that in print.
Ok, just one last question. If you could have dinner with anyone, alive or dead, who would you pick and why?
That is a really tough question. Can I just throw a party?! I’d love to meet famous women who have made a difference – like Aung San Suu Kyi or, closer to home, Hillary Clinton. They are role models for how you can help change the world. And then there are people who I’m just starting to hear about who are doing some cool things with social innovation – not as well known of course, but just as inspirational. Coming from a business background, I’m interested in hearing about new ways to solve the world’s problems.