WHEN PAULINE OTIENO’S second child caught malaria, a decade ago, it meant an anxious, feverish week in hospital. When her third-born fell sick recently, he recovered after being given some pills and a few days’ rest. The difference might have been luck, or it might have something to do with the world’s first malaria vaccine. It has been available at Ms Otieno’s local clinic in Migori county, in south-western Kenya, since 2019. Her third child had received it; the second had not.
Vaccines are a vital new tool to stop children in poor countries falling sick and dying of malaria. Though not perfect, they are a useful supplement to bed nets and anti-mosquito sprays. A swift rollout in the countries worst affected by the disease, all of which are in Africa, could save as many as 1m lives in the next five years. Yet that probably will not happen. The main reason, as rich countries slash their aid budgets, is that nobody wants to pay for it.
Two vaccines are currently in use. Three doses of the one (known as RTS,S) that has been piloted in Migori since 2019 halve a child’s chance of falling ill over the following year, and soften the severity of symptoms. A study in Kenya, Ghana and Malawi shows a drop of 13% in deaths among children who were eligible for the shots. A newer, cheaper vaccine known as R21 has proved to be at least as effective. A fourth, booster dose of either vaccine helps sustain protection.
Manufacturers say they can make enough shots to vaccinate all eligible children in the worst-affected countries. GSK, a British pharmaceutical company, will be able to produce 15m doses a year of RTS,S from 2026. India’s Serum Institute, which makes R21, says it can churn out 100m doses a year, rising to 200m if needed.
But most of the current capacity is unused, though African governments have begun rollouts. Gavi, an international alliance that funds vaccines in poor countries, plans to spend $1.1bn on malaria over the next five years, jabbing 50m children. That could avert 170,000 deaths, save families money on hospital bills and free up resources to fight other illnesses.
Yet at the rate envisaged by Gavi it will take another decade to vaccinate all children under three in the countries at greatest risk from malaria (see chart). The Centre for Global Development (CGD), an American think-tank, reckons that goal could be achieved by 2027 at an extra cost of $3.5bn over five years, which is less than Americans spend every year on costumes at Halloween.
Gavi’s ambition is bound by the generosity of the governments and philanthropists that fund it. Donors were supposed to meet in Brussels in March to pledge contributions for the next five years, with a target of $9bn for all diseases. But the summit has been postponed until June.
The postponement reflects a funding crisis in global health care. Historically nearly a quarter of Gavi’s routine funding has come from Britain, which is slashing foreign aid to pay for more defence spending, and one-seventh from America, which said this week that it would stop funding Gavi. Seth Berkley, who led Gavi until 2023, says that an American retreat would be “very hard” and a British one “devastating”. He hopes that Gavi’s reputation might protect it. Last time it asked for money, in 2020, it raised more than expected. Canada recently pledged C$675m ($470m) for the current funding round.
Aid cuts have made the rationale for Gavi no less compelling. Vaccines are a cheap way to save lives yet too expensive for many countries to afford. Just $4,000 spent on a programme involving R21 is enough to avert one death. By procuring vaccines in bulk, Gavi ensures lower prices and a stable supply. It also shields governments from some of the currency risks they would face if they bought vaccines directly. Even so, the recommended four doses cost $15.60, which is more than many African governments spend per person on health care in a whole year.
That means that when budgets are tight, resources could be diverted from other anti-malaria interventions. Bed nets are just as cost-effective as R21. The best results come when the two are used together. The Global Fund, which helps pay for nets and other tools, is also trying to raise money this year. It is even more dependent than Gavi on American support.
One way for Gavi to save money, according to CGD, would be to prioritise R21, which is a third of the price of RTS,S. However, Sania Nishtar, Gavi’s chief executive, says diversity of manufacturers helps encourage competition and ensure the security of supply. In the long run, that is probably true. Yet in the short run it will mean buying fewer doses of the vaccine.
Without Gavi’s support, more children will die. Nearly a third of all malaria deaths occur in Nigeria, which is slightly too rich to qualify for much outside help, even though it spends only $15 a year per person on health care. A vaccine rollout began last year in two of its 36 states. Muyi Aina, the official in charge, says it will reach “a couple more” by next year and the rest “eventually”. How long until every Nigerian child is vaccinated? “The sooner the better, but you’ve got to be able to pay for it,” he says, citing the high price.
Where vaccines are available, people embrace them. Nurses in Kenya’s Migori county say they have met less suspicion than they did during covid-19 vaccination campaigns, perhaps because the burden of malaria is so familiar. The biggest challenge is reaching children for the fourth, booster, dose. Families are unused to having older children vaccinated and also often move around, for instance to work for months at a time in small-scale gold mines. In some countries, such as Cameroon, conspiracy theories have spread. But civil-society groups and religious leaders have helped to counter misinformation, says Olivia Ngou, a health-care activist there.
In Migori a more pressing problem is the hit to other anti-malaria programmes because of the cuts in American aid. The supply of bed nets is uncertain. Insecticide sits unused in a warehouse, because there is no money to pay for spraying it. With the arrival of vaccines, the world has more tools than ever to fight a cruel disease—if it chooses to wield them. ■
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