Although Jenner first used his smallpox vaccine more than 200 years ago, not until the latter half of this century did the "age of immunizations" begin. No other technological innovation has come close to yielding the public health benefits that are provided by vaccines, nearly all of which have become available within the past 50 years. Frighteningly palpable during the first half of the century, scourges like poliomyelitis, diphtheria, measles, pertussis, and mumps, with their unavoidable epidemics and frequently disabling sequelae, are now almost unknown in countries able to muster and sustain effective immunization-delivery programs. The most recent and dramatic demonstration of the power of vaccines to yield triumphs in public health is the near elimination of disease due to Haemophilus influenzae type b in the United States and other countries. Within a decade of the introduction of effective vaccines against H. influenzae, disease rates dropped by more than 98 percent. Meningitis due to this pathogen provided a fertile training ground for pediatricians before these vaccines were introduced; now, just a few years later, most pediatricians in training will never see a case.
Impressive results notwithstanding, this is just the beginning. The development of new vaccines is accelerating. For example, new hepatitis B vaccines are already changing the epidemiology of chronic liver disease and cancer; a vaccine against rotavirus has recently been licensed; and vaccines to prevent childhood pneumococcal disease are on the way. These diseases have the dubious distinction of causing substantial suffering worldwide. In fact, their greatest impact is in developing countries, where their effect on mortality is staggering. During the next few years, we may well have vaccines against pathogens such as respiratory syncytial virus, parainfluenza virus, group A and B streptococcus, and human papillomavirus and improved vaccines against influenza. Biotechnology will provide tools that can prevent cancers either directly or by prevention of infection due to agents with oncogenic potential.
With so much success, what is the problem? As innovation provides new vaccines, it has not been possible to introduce them in settings where they are needed most, in poorer nations where rates of disease and death are often highest. Also, progress has been slow in addressing the considerable scientific challenges in the development of vaccines that would have their primary use in poorer nations (such as malaria and improved tuberculosis vaccines).
If the latter half of this century saw industrialized nations become free of many diseases through the use of vaccines, the next few decades will be a time when the promise of vaccination is more fully realized in poorer nations, or so the founders of the Children's Vaccine Initiative hoped. In this book, Muraskin skillfully and engagingly reveals how a moral imperative incubated, taking form in fits and starts in the hands of some of the greatest public health leaders of our time. Ultimately, the idea evolved into a means by which the development and use of safe and effective vaccines globally could be accelerated, especially in poorer nations where solutions to diseases affecting children are desperately needed.
The goals of the Children's Vaccine Initiative were initially focused on the development and introduction of new, high-quality vaccines that would substantially reduce mortality from infectious diseases, as well as on the development of vaccines and techniques that would simplify immunization by mucosal delivery or by a reduction in the number of injections. Few could reasonably argue with these goals or with the fact that considerable focusing, catalyzing, and filling in of gaps would be needed to achieve them. However, there are often barriers to instituting good public policy, and it seems that this effort did not lack them. Muraskin illustrates how personality conflicts, protection of turf, nationalism, and economic considerations stood in the way at every turn and how determined champions can be highly effective in achieving a cause -- or highly damaging to one. Although historical accounts are heavily dependent on the person who does the accounting, Muraskin highlights each challenging issue and synthesizes the viewpoints of key founders of the Children's Vaccine Initiative, creating a clear picture of events, including the failures that always seem avoidable in hindsight and the successes that were not anticipated when the initiative was formed.
During the World Summit for Children in 1990, an international group of experts noted that "scientific progress, matched with improved capacities of all countries to immunize their children, provides an unparalleled opportunity to save additional lives and prevent additional millions of disabilities through a global Children's Vaccine Initiative." They urged world leaders, concerned agencies, and the pharmaceutical industry to commit themselves to the initiative, which aimed "to produce and deliver ideal children's vaccines." Despite the many gains that have been made over the past decade, this book provides a splendid reminder that the need for an alliance like the Children's Vaccine Initiative has not diminished.
Students of public policy, global health, and vaccinology will find this book wonderfully informative. So will those who are in a position to form anew an effective global coalition to optimize the use of vaccines for all the world's children, listening to the lessons of the past and not repeating mistakes.
Reviewed by Robert F. Breiman, M.D.
Copyright © 1999 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
--This text refers to the
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