By Dr. Kate O’Brien
This week scientists came together to declare that we will eradicate polio in 5 years. It’s an achievable goal, and admittedly an aspirational one. But, if we as a global community leverage proven strategies and follow through on commitments made, it will be met. It is amazing to think that this goal, which just two decades ago seemed impossible to many, is now firmly in our sights. It also gives me confidence that we can reach other goals, such as reducing preventable childhood deaths to a degree that any such death is seen as a shocking, rare event rather than predictable and intractable. This challenge, which the global health community laid out in last year’s Promise Renewed initiative may seem daunting, given that despite recent declines, 6.9 million children died in 2011. However, when you consider that worldwide polio cases have dropped by 99% since the Global Polio Eradication Initiative began in 1988, it is clear these problems are surmountable. Like polio eradication, we need a concrete approach to tackling the leading child killers, and we made a big step forward with today’s launch of the Integrated Global Action Plan for Prevention and Control of Pneumonia and Diarrhoea (GAPPD). Released by WHO and UNICEF, GAPPD clearly outlines the steps we must take to eliminate the two leading killers of young children in 20 years.
The Integrated Global Action Plan for Pneumonia and Diarrhoea (GAPPD)
Most of my professional life has been spent assessing and applying interventions to reduce pneumonia and diarrhea, both in the United States among American Indian communities and around the world in the communities where most child deaths still occur. I’ve seen the burden of these diseases in the numbers we calculate and on the faces of the patients I’ve treated. I’ve also seen that we have the tools we need to stop children from dying or suffering from severe pneumonia and diarrhea. When I worked in Haiti, the ward was full of children, over a third of whom would die in those beds. Nearly all of the illnesses these children had were fully preventable, mostly through the use of vaccines but also through other simple, sensible interventions. The interventions we have work, and the task we have is to figure out how to use them most effectively, to know if what we are doing is working, and to make adjustments in optimizing their impact. This feedback loop can only be put in place when we can measure the impact of what we’re doing. We may not be able to measure with absolute precision, but with enough precision to know if our time and treasure is being wisely spent.
We know what we need to do to tackle pneumonia and diarrhea, and establishing clear evidence on the burden of disease and on interventions that work creates the platform from which we can prioritize our efforts. A new series published in the Lancet today in conjunction with GAPPD provides updated evidence on this front. One of the papers, led by faculty in our Department of International Health at Johns Hopkins provides updated mortality estimates for pneumonia and diarrhea – together responsible for more than 2 million child deaths in 2011.
We also have a clear understanding of which interventions work, and we know that many of them overlap. As my colleague Bob Black pointed out in the Lancet series launch, while diarrhea and pneumonia have very different symptoms and causes, several risk factors for the two diseases are the same, including under-nutrition, suboptimal breastfeeding, and zinc deficiency, meaning that they can be effectively prevented and treated as part of a coordinated program. We also know that vaccination campaigns will play an important role. A second paper in the Lancet evaluated 15 key interventions using the Lives Saved Tool. It found that nearly one third of severe diarrhea episodes could be prevented by widespread vaccination against rotavirus and cholera, while up to two thirds of pneumonia deaths could be prevented by implementation of pneumococcal and Haemophilus influenzae type b vaccines. With ambitious scale-up – 80% coverage or more – the authors estimated all 15 interventions could effectively eliminate (95% prevented) diarrheal deaths and prevent around two-thirds of pneumonia deaths by 2025. All this at a total cost of just USD6.7 billion.
GAPPD and the Lancet series reflect years of work toward a consensus among all stakeholders that we must target our efforts on proven interventions, and we must work together in an integrated way. Many of the interventions for childhood diseases overlap, and can be delivered more efficiently if all parties work together. This integration will not only result in better care for each child, it is also crucial in resource-poor settings, where countries simply cannot afford to maintain siloed efforts and where partnering countries and organizations are increasingly demanding more impact for their investments.
We have the evidence, and our marching orders are clear. With polio eradication beckoning our efforts, it is the time to leverage this energy, know-how, and confidence by fulfilling our promises and advocating for all stakeholders – donors, governments, civil society, and other leaders – to fulfill theirs. We can all take inspiration and insight from polio eradication efforts and make the end of preventable pneumonia and diarrhea deaths a reality.
Kate O’Brien, MD, MPH is Acting Executive Director of IVAC. A pediatric infectious disease physician, epidemiologist, and vaccinologist, she previously served as Deputy Director of IVAC. She also serves as Associate Director of the Center for American Indian Health.
By Dr. Juliet Otieno
This the second blog in a series from the Pneumonia Etiology Research for Child Health or PERCH study team. PERCH is a multi-country case-control study of the etiology of severe and very severe pneumonia in children aged 1-59 months. Led by IVAC and funded by the Bill & Melinda Gates Foundation, PERCH operates seven research sites throughout Africa and Asia.
As a Kenyan doctor, having completed my internship at a rural mission hospital and worked as a junior doctor in a paediatric hospital for just over a year, I found myself two years ago in a small rural town, Kilifi, in the heart of a study on the causes of childhood pneumonia, the Pneumonia Etiology Research for Child Health or PERCH. When I began working with the PERCH study, a study on the “causes” of pneumonia initially seemed to me as a rather counter-intuitive approach to the problem at hand. I had spent years cramming the national diagnostic and treatment guidelines for pneumonia and I was pretty confident in the management of children with acute and chronic respiratory illnesses. I did not need the much-cited research to know what pneumonia looks like or to understand its burden on our children.
Physicians from three different PERCH sites, Dr. Juliet Otieno, Dr. Bernard Ebruke, and Dr. David Moore, examine a chest x-ray of a patient with pneumonia during a cross-site visit in South Africa.
Childhood pneumonia is a topic I have always been able to easily relate to, starting from my days as a medical student in the busy paediatric wards where most of the very sick children had respiratory illnesses. While efforts have been instituted to ensure early recognition and treatment of children with pneumonia, unfortunately a child succumbing to death from a respiratory illness is still seen as an unfortunate but inevitable eventuality in most of our hospitals in Kenya.
Two years later, I have had many epiphanies along the way about the importance of investigating the causes of pneumonia, but a recent one has been particularly influential and has changed my mindset completely. I recently had the opportunity to attend a cross-site visit to Chris Hani Baragwanath Hospital in Johannesburg, South Africa – another PERCH study site – where I had a chance to look at a histopathology slide of lung tissue from a child who died of pneumonia. Post-mortem lung biopsy studies are carried out as part of the PERCH study in some of the participating sites because they can give researchers a much more direct, accurate diagnosis of etiology in fatal pneumonia cases. (Learn more in this 2011 article in Clinical Infectious Diseases.)
This particular post-mortem lung specimen we were examining was from a child who presented with clinical features consistent with pneumonia caused by pulmonary tuberculosis and was treated for this condition without success and died. The post-mortem analysis revealed that the child did not have TB, a bacterial infection, but instead the pneumonia had been caused by florid cytomegalovirus infection, a virus that spreads through bodily fluids and is especially dangerous for patients with compromised immune systems. If the doctors caring for him had known this, they would have treated him differently, and he might have lived. Unfortunately, we cannot get such an accurate picture of the pathogens present in the lung with current tests available for patients. It dawned on me just then how important post-mortem results are in defining the epidemiology of pneumonia in a particular setting, made possible through studies like PERCH, and which help doctors see the range of pathogens that are causing child deaths in their hospitals, so they might be more aware and ready to treat them.
I left wondering what definitive pathogens we would find if we carried out post-mortem studies on fatal pneumonia cases in Kilifi, and how this would influence our clinical management of pneumonia. Would we only find the “traditional” bacteria we expect? Or would we be opened to a whole new world of “atypical” bacteria that we occasionally treat as a last ditch resort? Would we see that the recently introduced vaccine against the streptococcal pneumonia bacteria caused a significant reduction in one of the most common “traditional” pneumonia-causing bacteria? Would our very definition of “atypical” pathogens be challenged? Would we be more confident in administering relevant antimicrobial treatment – albeit a non-conventional approach – in a more timely manner? I also wondered how post-mortem findings would compare to the induced sputum test results we gather through PERCH, which get us as close as we can to the lung while the child is living, but are still unproven, and leave us wondering if we’re really getting at the source of the infection. Most importantly, I wondered if all this knowledge could be the answer needed to save lives, reduce unnecessary use of antibiotics that can lead to resistance, and decrease the burden of pneumonia morbidity in our paediatric ward?
Dr. Otieno demonstrates a nasopharyngeal swab during a training session.
At a clinical level, results from post-mortem studies are easily interpretable and could improve the outcome of pneumonia cases at our hospital. At the same time, they are often difficult because they require gaining consent from a grieving parent. But because I now understood the value of post-mortem studies in protecting all our children from fatal pneumonia, I went home with a stirring in my heart to test the waters of community acceptance. I was reminded of a common saying, “better the devil you know than the devil you do not know,” for despite the challenges associated with post-mortem studies, knowledge of the bugs causing pneumonia today would give us the best chance at saving lives in the future, rather than continuing to treat what we don’t know or what we only think we know.
I am grateful for the opportunity to visit another PERCH research site in South Africa and learn from my colleagues across the continent. I come away from the experience having realized that the value of postmortem analysis in pneumonia etiology studies cannot be understated. Working in this multi-site project has brought back the nostalgia of my internship year, including the steep learning curve, but also the accompanying fulfillment at the end of each day.
I also have a deeper appreciation that the PERCH study is indeed a landmark study. Working on this project has been an exciting experience and has given me the unique opportunity to be part of the global effort to protect millions of children around the world from pneumonia, and it has shaped my career trajectory towards pneumonia prevention strategies.
Juliet Otieno, MD, is a Clinical Research Training Fellow at Kenya Medical Research Institute (KEMRI) Wellcome Trust Research Programme and a member of the PERCH study team.
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.
By Nick Fancourt
This the first blog in a series from the Pneumonia Etiology Research for Child Health or PERCH study team. PERCH is a multi-country case-control study of the etiology of severe and very severe pneumonia in children aged 1-59 months. Led by IVAC and funded by the Bill & Melinda Gates Foundation, PERCH operates seven research sites throughout Africa and Asia.
You’ve probably heard that pneumonia kills more children than any other disease, but have you ever wondered how we ‘count’ pneumonia cases? As we look at disease burden figures from around the world, how do we distinguish pneumonia from other illnesses? There are several ways to count cases, but as it turns out, it’s harder than you might imagine.
Participants learned the subtleties of interpreting chest x-rays at PERCH workshop.
Why? Because we do not often get samples from the infected site (the lung) as this is very invasive. Instead, we can look at children who meet a clinical definition such as “rapid, shallow breathing,” but we know that kind of definition overestimates pneumonia cases – in other words, you get many false positives. We can also look to see if any bacteria grows in a blood sample from a child with likely pneumonia, but we miss many cases that way too, this time because of many false negatives, because bacteria aren’t always found in the blood and bacteria are not the only cause of pneumonia. The best approach has traditionally been looking at a chest X-ray or CXR, which is a frequently used tool for identifying pneumonia in clinical studies. But this leaves us with another not-so-simple question: what, exactly, does pneumonia look like on a CXR?
This is an important question for the Pneumonia Etiology Research for Child Health (PERCH) study team. With seven sites across Africa and Asia, PERCH is enrolling hospitalized children with severe and very severe respiratory symptoms according to WHO clinical definitions. The study aims to better understand which infectious pathogens are now causing childhood pneumonia in a variety of settings – rural, urban, HIV prevalent or not, differing vaccine coverage levels, and limited resource availability – so we can better plan for the interventions to prevent and treat pneumonia in the future. But to do this, we first need to know which children we think have pneumonia actually do, and which do not.
Defining pneumonia on a CXR can be more troublesome than it sounds. First, interpretation of a CXR involves subtleties of skill and experience than can make it a somewhat subjective process when comparing two doctors’ results. Doctors in different countries, or even just on different floors of the same hospital, may read CXRs differently. So, it is important that we have a standardized approach to radiologic diagnosis. In research (and for PERCH in particular) we are also very interested in those children who definitely do not have pneumonia, as understanding what pathogens are carried by sick children both with and without pneumonia helps us to know which pathogens are causing the greatest burden of disease. So we aim for specificity in our CXR interpretations, which is different from day-to-day clinical practice, where the focus is to identify definite cases of pneumonia in order to quickly treat the child.
Participants examined chest x-rays on laptops during the workshop.
To help achieve the goal of a uniform diagnosis, the WHO developed a methodology for the standardized interpretation of pediatric CXRs. The methodology encourages simple definitions for pneumonia and aims for a high level of agreement between CXR readers. This approach was developed for vaccine impact studies, however, which are importantly different from PERCH’s questions relating to the causes of disease. Beyond PERCH there is continued demand for radiological standardization in environmental studies, antibiotic treatment studies, and epidemiologic studies of pneumonia.
Although a complete review of the WHO methodology is not a primary objective of the PERCH project, the PERCH team knew it was important to organize a comprehensive training program before we began interpreting CXRs in the study. In late August 2012, 14 physicians and radiologists (each associated with one of the seven study sites) met in London, along with collaborating colleagues from the CDC’s International Emerging Infections Program, the Drakenstein Child Health Lung Study in South Africa, and the PCV (Pneumococcal Conjugate Vaccine) Impact Study in Kenya. They were joined by members of the PERCH core team and four technical experts from Australia, Kenya, and the United Kingdom, who served as trainers for the meeting. The purpose of this meeting was to realign the WHO methodology to current study goals, identify ways in which it can be optimized, and ensure PERCH CXR readers have a harmonized approach to diagnosing radiological pneumonia.
X-rays may be one of medicine’s oldest technologies, but our challenge was to improve their interpretation to help a very contemporary study. This gathering allowed the team to think critically about how CXR diagnosis can best serve PERCH’s needs, and the outcomes will help not only the PERCH project, but broader pneumonia diagnosis and research efforts as well. We were able to refine the outcomes we are gathering from CXRs, to be clear on which children have normal CXRs and which definitely have pneumonia, while at the same time calibrate CXRs from PERCH against the WHO methodology to extend these definitions beyond the vaccine impact setting. We now have a group of highly trained CXR readers who will be providing assessments on all of the CXRs from cases within the PERCH study, and we have established a feedback mechanism so that the quality and safety of CXRs at each site is maximized both within the study and beyond.
With this important step now complete, we are armed to interpret the subtle CXR findings that a study like PERCH may identify. So now, for PERCH, the ‘counting’ begins.
Nick Fancourt is a PhD candidate at the Johns Hopkins Bloomberg School of Public Health and member of the PERCH study team. He is also an International Fulbright Science and Technology Fellow.
The views and information expressed within this blog are the author’s alone and do not represent the Fulbright Program or the U.S. Department of State.
In October, Dr. Kate O’Brien took over as Acting Director of IVAC. One of IVAC’s founders, she reflects here on how far the organization has come and her vision for the future, while also sharing a bit about her diverse career in global health.
You have been at Johns Hopkins University for more than 20 years. Can you tell us a bit about your background and how you ended up at IVAC?
When asked about my background, I find myself saying first and foremost that I am a Canadian, which helps explain who I am and why I do what I do. As a pediatric infectious disease physician, as well as an epidemiologist and vaccinologist, I’ve had the great fortune to work on meaningful problems and with remarkable people. Much of my training and career has been spent at Johns Hopkins where I first came to work as a pediatric intern in 1988. I also did my infectious disease training, and my Masters of Public Health at Hopkins. Following those formal training programs I joined the Centers for Disease Control in Atlanta as an Epidemic Intelligence Service Officer where my career direction was really set in motion, working on pneumococcus, Hib, and other bacterial diseases of childhood. Although over the years I’ve worked on many different pathogens and vaccines, all of that work has been held together by the concept of preventing disease in children, and specifically preventing disease through vaccines. For me an important notion is that throughout the developed world we have the incredible good fortune to live in communities with abundant resources. When it comes to children, vaccines are a social justice issue. Every parent, everywhere in the world wants their child to have a life of opportunity – it doesn’t seem fair, or just, that some kids have the benefit of receiving vaccines and others don’t, by the quirk of where they happen to be born. My work is about assuring not only that we have the best vaccines possible for preventing as much disease as possible, but also that the benefit of those life-saving vaccines should be available to all kids around the world regardless of where they were born, or whether their families can pay.
Dr. Kate O'Brien, Acting Director, IVAC
This is the foundation of IVAC and before that the PneumoADIP project, whose provenance is an interesting story. I had returned to Hopkins from CDC to work for the Center for American Indian Health on vaccine trials [Editor’s note: Dr. O’Brien continues to serve as Associate Director of the CAIH]. Soon after I returned, Orin also came back to Hopkins to join our group after he had spent time at the CDC and NIH. Soon thereafter, the RFP for the PneumoADIP was issued by GAVI; I remember sitting in my office with Orin discussing if I wanted to go in on this, to which I naively committed but warned him that I didn’t know what an “ADIP” was! We submitted a proposal setting out our ideas of how a set of activities could accelerate pneumococcal vaccine decision-making and were awarded the PneumoADIP grant. That was a really stimulating period of time and one that was transformative within the School by bringing together domains of science, finance and communication in a way that was not typical for the kinds of projects Johns Hopkins was doing at the time. Through that project we envisioned a place within the School that worked on vaccines from a multi-dimensional perspective and brought together skills and domains that go beyond the traditional science or academic ways of working. When the PneumoADIP project came to an end we embedded those principles into the founding of IVAC – to use the skills that we have within academia, of unbiased, rigorous, data driven decisions, always being clear as scientists that we allow the data to speak for themselves, and to bring those into the world of policy development and advocacy for vaccines.
You have had quite a varied career within public health. What inspired you to work in global health specifically?
Working in global health for me is really a social justice issue. Growing up in Canada, where the values of contributing to society are very strong, I hold as a guiding principle that all people are precious regardless of their station in life; children especially should not only have the opportunity, but they should also have the right to good health and the right to protection from preventable diseases. So for me the global health sphere is one that really speaks to my values, one that informs what I want to spend my working days doing, and how I want to contribute to society. From a personal perspective, it is a remarkable opportunity to constantly learn from others. It is also a career that demands humility – there are very few concrete “right” ways of solving problems, because there are just so many different ways people make decisions and contribute to health, and so many ways that communities and societies interact to make decisions for the collective good. In all those ways there is always a learning curve, always a way to feel enriched and a great sense of contribution.
The global health landscape has really expanded in the past several years, and some would say that the space is now crowded. What makes IVAC stand out?
That’s a great question. There are some really clear things that make IVAC special in the global health arena. One is that IVAC is fundamentally seated within a university. Being in an academic setting means the fundamental characteristic of our work and approach is being balanced, agnostic and neutral – the pursuit of new knowledge, the revelations of new learnings, will always lead us in the direction of benefit and good decision making. This philosophy, that the data will speak for themselves, draws people to IVAC as faculty and staff who are committed to letting the evidence drive our efforts. The second thing that makes IVAC unique is that within the university, IVAC is really an unusual center; sitting within a single center are people working in diverse domains of vaccines where interaction with each other on a daily basis doesn’t usually happen. I think this was the incredible lesson of PneumoADIP – when you take people who are experts in financing, strategic vaccine supply, advocacy and communications, and you put them in the same space, thinking about the same problems as the epidemiologists, the vaccine clinical trialists, and the people who are scientifically driven, you end up with a learning space and leveraging of those skills well beyond the sum of the parts. You end up being able to look at problems in the vaccine space with solutions that were otherwise not imagined by any one group of people working on the problem. It is this multi-dimensional characteristic that is unique, and the emphasis and demand for excellence in all we do, which I think is what comes out of the academic atmosphere.
Dr. Kate O'Brien with a child in Bangladesh.
Along those lines, what have been some of the proudest moments at IVAC over the years?
There are many, but what come to mind are several tangible things. Going back to PneumoADIP days, a really proud moment was the launch by GAVI of the Advance Market Commitment for pneumococcal conjugate vaccines. PneumoADIP’s mission for five years was to figure out – in collaboration with the many global partners and country partners who all had views on and interests in this – whether or not pneumococcal vaccine should and could become a reality for the poorest kids around the world. So, the launch of the Advance Market Commitment was really one way when it all came together and became tangible; we knew we had reached a goal. There were many steps, some of them small steps and some of them really big steps, that culminated in an expression that global health decision makers, viewed the evidence as sufficient, credible and conclusive that pneumococcal conjugate vaccine was a product worthwhile to deliver to kids in the developing world and that there was a way of making that happen. So that was an incredibly proud moment and really felt like a culmination.
Since then, each time a country launches pneumococcal vaccine it is a proud moment because it is an on-going living expression of the value of the work that we have been doing. It becomes something real for me that there are infants and children whose lives have been saved by those vaccines; of course we don’t know which kids they are but we know they are there.
Other proud moments come from the spirit and enjoyment of the people at IVAC and those we work with in partner organizations; there is real motivation by the mission and by the creativity and innovative way that we work. Events like World Pneumonia Day that bring pneumonia fighters to the streets of Washington or events like Pneumonia’s Last Syrah in New York where we sold wine to promote the prevention of pneumonia are really amazing – those are just not activities that the average pediatric infectious disease physician gets to spend time working on!
So looking to the future, what are your top three priorities for IVAC as we move into 2013?
My top priority for 2013 is to continue delivering the highest quality work for every project we’re are engaged in. This is the guiding core value of IVAC and we will continue to deliver the quality of work that we have always delivered.
The second priority is for IVAC to contribute meaningfully to new areas of work---that could be new projects within areas that we’re already engaged in, or completely new areas. Whether it is pneumonia etiology studies, impact evaluations of vaccines, economic and advocacy projects that help decision makers understand the best use of vaccines, or work on prioritization and implementation of those vaccines – there are many areas where IVAC can contribute its expertise to really important decisions.
The final and foundational priority is to assure that the people within IVAC continue to have a supportive atmosphere where their effort is valued and where they know that the work they are doing is making a difference.
Building on that and taking it forward, what does success look like for IVAC in the next five years?
That’s an easy one; success for IVAC is when, five years from now, there is a healthy IVAC. And what I mean by that is IVAC continues its contributions in the global health sphere with people who are working on topics that they feel are important and that the global health community is deriving value from that work. It’s really important that we not be rigid in what that looks like, instead we need to be flexible to address the needs of the community. A successful IVAC in the next five years is responsive to the needs that emerge to actually get vaccines where they need to be and demonstrate the value of those vaccines so they can continue to be supported.
Tell us a little bit about your family.
My husband is an adult infectious disease physician who also works in the global health sphere, but mostly in the domain of HIV/AIDs. We met while working in Haiti. We have two kids, Emma who is 15 and Jack who is 13. My extended family still lives in Canada so we spend a good deal of time there.
As some readers may know, you moved from the Washington, DC-area to Geneva last year. What do you and your family like best about living in Geneva?
Beyond the work we do here what we appreciate most is the incredible access we have to the outdoors and the stunning beauty of this land. Everyone in our family really loves being in the mountains, being on a bicycle, taking a walk in the woods or through farmland, or skiing or ice-skating. Switzerland is such a small country, it means all of these things are close by. We love having the ability to enjoy this remarkable part of world for however long we are here.
We also really appreciate the opportunity to live in more than one language. Just having that lovely experience of coming into other cultures and into other peoples’ ways of living means we all can learn a lot about better ways of living.
What is the most interesting place that you have traveled to?
I knew you were going to ask me that!
We thought it might be Haiti, since that is where you met your husband.
I should say that, shouldn’t I? In fact Haiti is probably the most interesting place I’ve ever lived. It has an incredible mixture of cultures and histories, the European influence, the African influence – it is really a remarkable and unique culture. The art and the music that comes out of Haiti is phenomenal. It has a deeply troubling and in many ways tragic political history, but in spite of that there is a resilience and love that people have for their culture, for their country and for each other. Another place that is a favorite of mine is Jerusalem. It’s hard not be overwhelmed by the presence of history there.
One last question. You’ve had an amazing career – what are some of the highlights you’d like to share?
The greatest highlight has been the privilege to care for my patients…there are many kids and their families who have touched me in ways that they will never realize. I know this is a common experience for every physician, for every nurse, but it is true. There is far more that our patients give back to us than we can ever give to them, much as we try. The communities I’ve been able to serve are undoubtedly a highlight, in particular the Navajo and White Mountain Apache tribes who I’ve worked with for over 14 years, trying to address health disparities from vaccine preventable diseases. Those communities have a beauty and a history that is deeply humbling, showing us how little we really understand about life and spirit in this contemporary, modern, western society we live in. The other highlight is one that underlies everything, and that is the people I’ve worked with over the years. Those who know me know that beyond all else is my belief that in the end our work, our success, our joy, is always all about the people. Over the years I’ve had the most amazing mentors, colleagues, collaborators and students at Hopkins, at CDC, and at many other organizations around the world. In the end, it is always, all about the people.