Teacher notes - Sir Gustav Nossal

Realistic funding for health

There's a great seriousness about the difficulties of managing immunisation in arenas where the budget is falling. How are you going to overcome the economic problems?

Well, through the great generosity of UNICEF and of Rotary International, we have the Expanded Program of Immunisation (EPI), a solid program which has got rid of poliomyelitis from the Americas and should have got rid of poliomyelitis from the world by 2000 or within a couple more years – a wonderful triumph. This same program has materially upgraded the use of the six vaccines that are common in childhood and it has also made big progress in measles.

Now comes the big 'but'. We got stuck at a coverage rate at or just below 80 per cent. Going the extra mile to put it into the 90s or even the high 90s has proven very difficult. And, of course, countries are heterogeneous. In the 28 poorest countries of the world, mostly in sub-Saharan Africa, the progress has been less than remarkable.

So, constraints. In financing, the hundred million bucks or so that UNICEF brings to the party are not enough. That is why recently I've been working very hard with the World Bank. It's my real belief that it should be lending more in health for development, and what better area to begin to lend in than in this field of vaccines. You see, if you use soft-money loans with very low or in some cases even negligible interest rates, repayment 20 years down the track by a country that has upgraded its development because it has upgraded education and health is not so very difficult. And the cash flows of a World Bank exceed by at least one order of magnitude, if not two, the cash flows of organisations such as UNICEF.

Is it realistic to assume that the World Bank and the economic community are going to bail out the Third World? Surely it's been going the other way in the last 10 years.

Let me tell you what I think is realistic. I think it's realistic to see the World Bank as a big agent in the poorest countries of the world. Its President for the last 2½ years is Jim Wolfensohn. He happens to be an Australian and our friendship goes back 40 years plus, to university. Under Wolfensohn the Bank has a very special focus now on Africa, and we had an excellent meeting with him just a few weeks ago. I think for the countries that are a bit further along the pathway of development we can get the Bank to do a lot of advocacy. At the level of international movements the World Health Organization comes in and talks to ministers of health, who unfortunately are usually rather lowly individuals in the decision-making processes of the Third World, but the Bank comes in and talks to heads of state or at least finance ministers, who are much more influential.

If we get that advocacy, with a trickle down of, 'Yes, vaccines are good. Vaccines buy you a lot of health for a small amount of money,' I think we can have industry coming in and we can let the free market work. Industry actually wants to be in India, in Indonesia, and above all in China. We need a push that says, 'Now look, amongst the things that you do we want you to go in there and we want you to sell your vaccines – but of course at a price that the market can bear.' Industry is good at that. It's actually quite good at setting differential prices for different markets, and in some countries we may not require the Bank to do much more than advocacy. That is realistic.

To galvanise the world

I think you're looking forward to the new millennium, when you're going to be able to announce the absence of polio from the world. It'll be a classical moment.

Yes. I actually think that if we can do this task – it's now only a matter of time – it will have a galvanic effect on the world. We had the smallpox triumph, but in our lifetimes smallpox really affected only people in very poor countries, whereas polio crippled a President of the United States. Practically everybody has a friend who's got a gammy leg or arm from polio. The chief executive of my wonderful Victorian Health Promotion Foundation is very seriously handicapped in the legs from polio, and she's only in her 40s. So people can identify with that. If that's gone from the world, if you do not have to vaccinate any more, just think of the savings. Not having to vaccinate would probably pay for all of the previous research on vaccines since the dawn of history in a single year. It'll have a galvanic effect, and I want to be able to do that again and again. I want to do it with measles, which is a very serious disease in a Third World setting. Looking further ahead, neither hepatitis A nor hepatitis B has an animal reservoir and they should, in principle, be eradicable – but over a very long time.

Are river blindness and schistosomiasis and all these other things on the agenda too?

It's good to get back to parasitism. The river blindness (onchocerciasis) story has been a great triumph. It started off in an inefficient way by dumping a lot of insecticides into rapidly running waters where the vector of the disease breeds, so getting the larvae of the flies that carry it. But the real breakthrough has been drugs. Ivermectin, which is given to dogs for heartworm, was actually given free to these African countries. It was backed up by a second drug, and the remarkable fact of the matter is that that disease has now virtually gone, even from some of the poorest countries in the world. I certainly don't think immunology is the only important science. Chemotherapy is hugely important, as is vector control, vector biology, and – though I'll only confess it to friends – even environmental sanitation, seen as the big rival of the technological fix with vaccines and antibiotics, is enormously important.

I mentioned these things because I knew they were also important in your horizons at WHO. Perhaps now we could take the measles story.

The cessation of measles transmission in certain Latin American countries, including Cuba, is totally fascinating because the immunisation rates of infants are not that flash: 80 per cent or anyway the high 70s. But if you combine that with catch-up immunisation, on so-called national immunisation days, where there is a great involvement of the media, where there's a great involvement of political personalities and where you line up all kids under five, in the case of Latin America, you will catch the hard to catch. It may have to be all kids under 14 in a country like the United Kingdom, where you've had a brilliant measles eradication campaign coordinated by David Salisbury, a great man. But you don't have to achieve 100 per cent. If you can achieve, say, 90 per cent, the virus doesn't have enough soil in which to grow and it dies out – the herd immunity effect. So I think that measles eradication is possible. Some of the Latin American countries have shown it, as have some of the Scandinavian countries and the United Kingdom (all cases of measles in the United Kingdom now are imported). In Australia we've had tremendous help from Michael Wooldridge, our relatively new Minister for Health, who is very keen on public health, and we're going to give it a shot here.

An edited transcript of the full interview can be found at http://www.science.org.au/scientists/interviews/gn.htm.

Focus questions

• Nossal says 'Vaccines buy you a lot of health for a small amount of money'. Explain what he means by this.

• What do you think the 'herd immunity effect' is?