In Defense of Health, Beyond Humanitarianism
Marketing Vaccines as National Security Products
Arguing that vaccine-preventable diseases erode both human and economic development and should be viewed as enemies, Dr. Najwa Khuri-Bulos challenges the global health community to market vaccines as inexpensive weapons for national security.
While many consider vaccines to be the most cost-effective public health intervention, 24 out of 125 million infants born yearly around the world do not receive the most basic childhood vaccines.  Lack of funding for these basic vaccines is primarily to blame, along with the failure to deliver newer and underutilized vaccines to children in high-burden, low-income countries. Alarmingly, the difference in the vaccine access of those living in developed versus developing countries is increasing, with people in developed countries receiving twice the number of vaccines as their counterparts in other areas of the world. Unhappily, this inequity is growing, despite massive efforts by international organizations such as GAVI  and international financing mechanisms like the Advanced Market Commitments  aimed at addressing this issue. Unless the international community makes a concerted effort to brand and market childhood vaccination as an urgent need for which an updated, sustainable funding mechanism must be found, these life-saving interventions will not reach many of the world’s at-risk children and other population groups.
The global community, in my opinion, is currently operating under the paradigm that poor countries are not able to, and even should not be asked to, provide funding for vaccines for their own populations—an underlying assumption that must be challenged. In many developing countries, vaccines are not even included in national health budgets.  Even countries that do include budget lines for their vaccines have little room to expand those numbers to introduce new vaccines, and the vaccines that are included also compete for funding with many other health priorities. For example, while 85 percent of African countries had a budget line for vaccines in 2006, only 53 percent actually obtained government funding for vaccines, and only 43 percent had government funding for overall immunization, with the rest relying on external, primarily donor financing. 
Indeed, the perception that vaccines should be donations, as held by many policymakers in the developing world, conveys little appreciation for the value of these tools by the very people whose communities need them most. The value of vaccines continues to be a contentious issue in many communities and populations. If the global health community were to make a paradigm shift in how they market vaccines, and policymakers and populations better appreciated the value of vaccines, perhaps more funding could be raised from within these countries to help pay for these life saving products.
One industry that has been most successful at raising funds from within countries is the defense industry. Even in the poorest countries, governments and the public regard military spending as an acceptable expense—a public good. The general population rarely questions the benefit of procuring weapons even though those weapons may never be used. In the poorest countries in Africa, defense budgets are often in excess of fourteen billion dollars annually.  Consider this against the backdrop of the public outcry against the perceived wastefulness of government spending when some countries such as France were left with excess supply of H1N1 vaccine in 2010. 
During that year, the former president of the French Red Cross, Dr. Gentilini, criticized mass purchasing of H1N1 vaccine as “extravagant” and “costly”.  Such an outcry was also noted in Jordan when, as a member of the H1N1 influenza advisory committee, I was one of the scientists who advised the Jordanian government to prepare for the possible pandemic by purchasing flu vaccines for the population. When this stockpile was not used, the committee, myself included, was queried by the media about this “wasteful” behavior. In reply through a personal interview with one of the leading newspapers, I pointed out the analogy of buying weapons in preparation for war and that these weapons frequently go unused.
The challenge for the health community is to closely examine the ways in which the defense community “markets” military products and apply these tactics to urgent health issues. Using a framework whereby vaccines are measured in security and stability terms, rather than simply health terms, I offer that it would be effective to market vaccines as defense weapons, necessary for public protection just like any other weapon.
Recent resurgences of vaccine-preventable diseases due to lapses in vaccination coverage, (whether a result of distrust of vaccines or weak health systems) illustrate the sobering consequences of allowing immunization coverage to fall, thereby leaving populations unprotected. One such example is the refusal of numerous Nigerians to be vaccinated against polio in 2003, which led not only to a resurgence of polio in the country, but also to the spread of polio to many neighboring and even distant countries, with devastating human and economic consequences.  An increase in polio not only means higher costs and family tragedy, but the security consequences also include panic and potential cross-border conflict, which could augment other already existing tensions, even if those tensions are not health-related. Less dramatic, but also informative, is the 2010 reemergence of measles in South Africa, a sobering reminder of what can happen when delivery of the most basic vaccines is allowed to lapse. 
Could a shift in many policymakers’ and populations’ perceptions of vaccines have helped to avoid these kinds of resurgences? By branding vaccines as “health defense products” it might be possible for the immunization community to win more appreciation and financial support from the public and governments, rather than by continuing to follow the current humanitarian strategies under which they currently operate.
While it is highly unlikely that health spending will ever rival defense spending, or that defense budgets would transfer funding toward health, learning from the marketing techniques of the defense community and linking vaccines to security issues, however, could help fill the chronic funding gap for immunization by appealing to a new range of potential contributors. It could also help challenge the assumption that low-income countries cannot generate their own funds for vaccines.
The challenge for the global health community is to counter existing assumptions about, and perceptions of, vaccines as an optional item and reframe them as necessities just as important to the public as any other weapon for national security.
The devastating potential of infectious agents and their ability to destabilize communities may be far easier for many to appreciate than the “enemy from within,” such as pneumonia and diarrhea, which are largely preventable by vaccination and yet continue to kill more children than wars.  However, these and many other vaccine-preventable diseases continue to erode both human and economic development and should be viewed as enemies—equally threatening biological agents for which there are very inexpensive weapons: vaccines.
 GAVI Alliance Facts and Figures, http://www.gavialliance.org/media_centre/facts/index.php.
 The GAVI Alliance is a global health partnership representing stakeholders in immunization from both private and public sectors to assist with the achievement of the Millennium Development Goal for child health—a two-thirds reduction in the number of deaths in the under-fives by 2015. See the Gavi Alliance website, http://www.gavialliance.org/.
 Advance Market Commitments (AMCs) are incentive programs designed to provide vaccines to developing countries. Donors agree to prices and commit funds in advance, guaranteeing a market for new vaccines. This allows manufacturers take on less risk for research and development. See the Advance Market Commitments website, http://vaccineamc.org/about.html.
 Immunization financing indicators, World Health Organization, http://www.who.int/immunization_financing/analyses/jrf_analysis/en/index.html.
 Patrick Lydon, Pa Lamin Beyai, Irtaza Chaudhri Niyazi Cakmakd, et al. “Government financing for health and specific national budget lines: The case of vaccines and immunization,” Vaccine 26, no. 51 (December 2008): 6730, http://www.sciencedirect.com/science/article/B6TD4-4T07XH3-2/2/c8a059c0550f8b1bcf7c71517c560dbe.
 SIPRI Military Expenditure Database 2010, http://milexdata.sipri.org.
 “France on the defensive over flu vaccine surplus,” Agence France-Presse, January 4, 2010, http://www.france24.com/en/20100104-france-defensive-over-flu-vaccine-surplus.
 Anne Chaon, “France joins Europe flu vaccine sell-off,” Agence France-Presse, January 3, 2010, http://www.google.com/hostednews/afp/article/ALeqM5jWpBtiyt08M7Za5M8dABAcjf6Qww.
 “Rumors cause resistance to vaccines in Nigeria: Some families fear the polio shot is part of a plot to sterilize girls,” Associated Press, September 25, 2006, http://www.msnbc.msn.com/id/15005238/ns/health-infectious_diseases/.
 Nandi Siegfried, Charles S Wiysonge, David Pienaar. “Too little, too late: measles epidemic in South Africa,” The Lancet 376, no. 9736, (17 July 2010): 160.
 Igor Rudan, Shams El Arifeen, Robert E Black, Harry Campbell. “Childhood pneumonia and diarrhoea: setting our priorities right,” The Lancet Infectious Diseases 7, no. 1, (January 2007): 56–61.
Najwa Khuri-Bulos is Dean of Research and Professor of Pediatrics and Infectious Disease at Jordan University and Head of the Division of Infectious Disease at Jordan University Hospital