Room for expansion / by Donald Allan

Room for expansion In 1987, some $500 million is being spent on EPI, or about what the world spends on armaments every six hours! But double this amount will be needed to finish off the job Routine immuniz- ations have long been part of nat- ional health strat- egies around the world. By 1974, however, it was estimated that no developing country had exceeded even five per cent coverage for all six EPI target diseases. For lack of adequate reporting, many countries did not recognise the seriousness of the problem. Clearly a major new campaign was needed. At the World Health Assembly in that year, Dr H.-G. Kupferschmidt, of the German Democratic Repub- lic, urged that "the experience by Donald Allan gained in the smallpox eradication programme and the personnel em- ployed in it should be used in the control of other communicable diseases, such as measles, polio, tetanus and tuberculosis, from which millions of children die in developing countries." Professor J . Kostrzewski of Poland proposed the launching of "an expanded pro- gramme of immunization in every country." The Assembly responded by call- ing on WHO to develop immuniz- ation programmes and to increase the availability of inexpensive, good-quality vaccines to develop- ing countries. EPI was on its way. It became a full-fledged programme in 1977, when the 1990 target date for immunizing all the world's chil- dren was chosen. In that year too the first WHO courses to train national managers were given. An important lesson of the smallpox campaign was that health personnel needed to be taught new management skills in Another small child goes to an early grave. This pathetic scene is being re- peated daily around the world. EPI is striving to save many of these lives. Photo WHO/P. Almasy order to take the big step in scale from routine to expanded im- munization-to integrate the con- tributions of many branches of gov- ernment and to involve all levels of the community in campaigns. " Expanded" in the WHO defini- tion meant adding more disease- controlling antigens to vaccination schedules, extending coverage to all corners of a country and spreading services to reach the less privileged sectors of society. It meant concen- trating on immunizing babies dur- ing the first year of life and reaching mothers with convincing messages to assure their cooperation. National immunization days have proved effective in galvanis- ing all levels of society, from top politicians to celebrities, journalists, teachers and clergy, to attain a goal and raise public understanding. Such campaigns in Brazil lowered polio rates from 3,596 cases in 1975 to under 100 since 1979, and in Colombia from 576 in 1981 to 24 in 1984. The challenge is to assure that such days are designed to rein- force, not replace, the primary health care services that must pro- vide immunization on a regular basis to young children. The "cold chain" plays a vital role, keeping vaccines at tem- peratures below 8 Centigrade ( 46 Fahrenheit) and shielded from light, so that they don't lose their poten- cy. If a breakdown in the cold chain goes undetected and children become infected with a disease because their vaccination was worthless, the entire health service loses credibility among the local population. In 1987, only about US $500 mil- lion is being spent on EPI-about what the world spends on arma- ments in six hours. This needs to double by 1990. And the flow of donations is indeed rising. Rotary International has pledged $120 mil- lion for polio vaccines. The Arab Gulf Fund, the Sasakawa Health Foundation and the bilateral aid agencies of more than a dozen industrialised nations, the World Bank, UNDP, and UNICEF have all increased contributions to immu- nization programmes. "No country with a realistic EPI plan of operations needs to be con- strained by a lack of vaccine, cold chain equipment or supplies," WHO's Director-General, Dr Halfdan Mahler, reported last year. The WoRLD HEALTH, Jan ./Feb. 1987 Test-firing of a military missile with the potential to carry out a nuclear war- head. Arms spending surpasses the annual cost of EPI every six hours. Photo L. Sirman © most serious bottleneck today, he said, is "management capacity within national programmes" . Even though WHO courses have trained more than 20,000 EPI man- agers and workers, and national adaptations of WHO materials have helped to train at least another 350,000, acceleration of EPI re- quires more skilled manpower. Some countries in Africa and the Middle East are facing severe dif- ficulties and may not make the 1990 target, says Dr Ralph Bender- son, EPI's Director at WHO head- quarters in Geneva. These are the ones burdened by war, famine or extreme poverty of resources. Still others will probably need expatri- ate staff to supplement national human resources for quite a few more years. And in some develop- ing countries the health establish- ment needs to unbend and recog- nise the importance of involving non-medical community personnel to increase popular participation. But already officials of the Pan American Health Organization are predicting that poliomyelitis will be banished from South America by 1990. Chances are good that polio will be virtually eradicated world- wide by the end of the century. Improved vaccines, equipment and methodologies give promise that the five other diseases can be brought under control on schedule. "If everybody decides 'We're going to do it,' it will be done," says Dr Henderson. The aim of EPI is to provide immunization for every child. But even if only 80 per cent get full protection, the six diseases will for all practical purposes be on their way to oblivion. • 9