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Archives for Global Health

Addressing Malnutrition – Turning Commitments into Action

As the Olympics came to a close last month, British Prime Minister David Cameron opened the doors of 10 Downing Street to a small gathering of world leaders.  They met to announce new initiatives addressing the global challenge of malnutrition, which affects two billion people worldwide.  Perhaps the most promising pledge to emerge from this Hunger Summit was the commitment to greater cooperation between governments, civil society and business.

Mother feeding a child in Kenya. Photo credit: Sight and Life

While we share the same goal—healthy, well-nourished families and communities—too often, agencies, ministries, donors and businesses operate in silos, hindering action and missing key opportunities for collaboration that could improve the health and lives of millions.

We have made tremendous progress in the last five years in terms of prioritizing the issue, and we now have a number of global commitments to address malnutrition.  It would, therefore, seem that we are no longer lacking political will.  In addition, we now know just how cost effective it is to invest in nutrition: there is literally no greater investment we can make in health and development. The Copenhagen Consensus named micronutrient solutions the single smartest way to allocate global aid dollars, with every $1 spent generating $30 in benefits. The fact is combating malnutrition is at the top of the list because its impact can be felt across sectors—from health to agriculture to the economy. Improving nutrition is the most effective way to secure a better future.

Although conversations like the UK Hunger Summit are important in tackling malnutrition, preventing stunting and improving the life chances of millions of children, ultimately, we won’t have the impact we seek to achieve through conversations alone. Yes, we need to convene and collaborate—but the reality is we need to come away with concrete actions clearly outlining how we will all work together across sectors, and be held accountable for our commitments. Cameron and fellow host Michel Temer, Vice President of Brazil, urged the world to take decisive action on malnutrition before the 2016 Olympic Games inRio. That’s just four years away. Between now and then, partnerships between governments, civil society and business have to move from talk to action—that is, effective nutrition programs in countries.

This week, as world leaders gather at the UN General Assembly (UNGA), we have the opportunity to again meet as a global community under the banner of the Scaling Up Nutrition (SUN) Movement, and to outline how we will strengthen current partnerships and explore new ones to accelerate implementation. Global convenings, like the Hunger Summit and UNGA, provide us with the space to create and sustain dialogue, and share knowledge. But then it’s up to each of us, as organizations and individuals, to carry the torch. Together, we can improve nutrition and give millions of children the opportunity to grow, thrive and reach their full potential.

Klaus Kraemer, Ph.D. is Director of Sight and Life, a not-for-profit nutrition think tank of DSM, which cares about the world’s most vulnerable populations and exists to help improve their nutritional status. Acting as their advocates, Sight and Life guides original nutrition research, disseminates its findings and facilitates dialogue to bring about positive change.

Have a Coke and Some Life-Saving Medicine

Lifesaving medicines are frustratingly unavailable to millions of women and children each year. Frank Naqvi, Photoshare

When was the last time you heard a woman say, “I went to the hospital to have my baby, but they sent me to the drug shop down the street to buy supplies?” Or a health worker say, “I knew what medicine my patient needed, but I haven’t had that medicine for months?”

If you live in the U.S. or any other developed country, you’ve probably never heard this, or would think this woman and health worker were joking. But for women, families, and providers in developing countries, these stories and others are all too common…and it’s definitely not a joke.  As my colleague, Mary Ellen Stanton, eloquently captures in her post earlier this week on Saving Mothers, Giving Life, lifesaving medicines are frustratingly unavailable to millions of women and children each year.  It is unimaginable that simple and affordable medicines could save millions of lives, yet are still so far out of reach for millions.

The medicine oxytocin is needed to prevent and treat severe bleeding after childbirth. Oral rehydration salts (ORS) and zinc are needed to prevent deaths from childhood diarrhea.  And family planning commodities are needed to ensure women and their families can decide when or whether to have children – all key factors in maternal and child survival.

Over the past few years, I’ve been working on access to maternal health medicines or commodities. During this time, I’ve learned that the issues related to lack of availability, access, and demand for maternal, newborn, and child health and family planning commodities have many causes, including lack of manufacturers; lack of quality control at many points in the supply chain; providers are unfamiliar with or untrained in newer medicines or equipment; supplies don’t reach the “last mile” to remote health centers; and people don’t know that treatments are available.

But I’ve also learned that these are not insurmountable challenges. Commodities of various types do reach distant and hard-to-reach areas. One often cited example is Coca-Cola, a beverage enjoyed by millions every day, which is both affordable and available even in the most remote villages. You can actually get a Coke in remote Tshikaji, DRC!

And now, we are seeing renewed commitment among donors, country governments, and other stakeholders to make lifesaving health commodities accessible, affordable and available to millions of women, children and families around the world.

Today, the UN Commission on Life-Saving Commodities for Women and Children released 10 bold recommendations which, if achieved, will ensure women and children will have access to 13 life-saving commodities.

USAID’s long term, strategic vision looks to integrate these life-saving commodities as part of the next steps to other key efforts, like the Child Survival Call to Action and London Summit on Family Planning, in order to increase the speed at which we scale-up in host countries. It is important that we learn from our experiences and successes in getting vaccines and malaria, HIV/AIDS, and family planning commodities into the hands and homes of those most in need. Additionally, we need to integrate systems across commodities to better and more efficiently serve women and children everywhere, and scale up programs to have nation-wide impact.

Country leadership is also a vital component to successfully addressing many of the Commission’s recommendations.  Getting pallets of commodities in warehouses is just one step.  Medicines and drugs must reach people, and health care workers have to be present and skilled to administer them.

With our host country partners in the lead, we are working to strengthen supply chains for commodities, which include use of mHealth solutions; support local market shaping; improve the quality of medicines; and increase demand by mothers for necessary medicines.  This needs to happen if we are to ensure the poorest and most vulnerable women and children have the commodities they need.

These two themes, integration and country ownership, form the cornerstones of our work. My hope is that someday soon, I’ll walk past a market in a remote part of Africa with fully stocked shelves of Coke, and into a health clinic fully stocked with life-saving commodities and medicines.

Working Together to Save Moms & Kids in Afghanistan

A decade ago, Afghanistan’s health system collapsed, leaving crumbling and neglected infrastructure, widespread prevalence of malnutrition, infectious disease, and some of the highest maternal mortality rates the world had ever seen. Over the last decade, the Ministry of Public Health, in a strong partnership with the international community, has made major progress in improving the health of Afghan mothers and children. National programs to improve the quality of, and increase access to, basic health services and essential hospital services, along with programs to increase the number of trained female providers including midwives, and improved community-based healthcare, contributed to these significant achievements.

In Afghanistan, USAID is working with the Government to build capacity in its Ministry of Health, among midwives, and in local hospitals, and have helped to increase health coverage from eight percent to over 60 percent of the people over ten years.  This progress has helped the country realize an incredible drop in infant, child and maternal mortality rates, and the global community move the dial on Millennium Development Goals 4 and 5.

Watch Dr. Suraya Dalil, Minister of Public Health in Afghanistan, talk about this incredible milestone.

‘Reaching the Moon’ in Global Health

As the U.N. General Assembly opens, we are in the midst of a global health revolution.  Our collective work has delivered extraordinary results – a 70 percent decline in child mortality over the last 50 years, a 41 percent reduction since 1990 alone.  We have also made great strides in diminishing the desperation that has come with the threat of AIDS.  We can celebrate these great accomplishments, while acknowledging the remaining challenges and embracing a bold, action-oriented vision – to end preventable child deaths, create  an AIDS-free generation, invest in women and save mothers, and build the health system foundations for universal health coverage.  At UNGA, I and others will continue to focus on these themes and this vision, and I have confidence that the leaders gathered also now have global health and child survival included among their highest priorities.

These are not just aspirational or ambitious goals, but a collective moral and ethical test for humanity. Delivered more than 50 years ago, President Kennedy’s stirring “moon speech” rings true of the promise for global health today. “We choose…because that goal will serve to organize and measure the best of our energies and skills, because that challenge is one that we are willing to accept, one we are unwilling to postpone, and one which we intend to win.”  For health, “reaching the moon” will advance human progress—helping families escape devastating cycles of poverty and disease that drain vital health and economic resources, hold back communities and nations, and prevent young children from living up to their God-given potential.

In June, at the Child Survival Call to Action in Washington D.C., world leaders embraced the strategic shifts necessary to speed up progress in reducing preventable maternal, newborn and child deaths.  These shifts included increasing efforts in the countries where most deaths occur, focusing on vulnerable populations like the very poor, and investing in high impact solutions to address the biggest killers, such as neonatal complications.

More than 141 governments, 119 civil society organizations, 90 faith-based organizations, and 20 new private sector partnerships made pledges and commitments to keep our promise and work to end preventable child death in a generation. And those numbers continue to grow.  First, these partners agreed to accelerate actions to achieve MDG 4 and 5 targets.  They went further to embrace an aspiration of getting below 20 child deaths per 1000 births by 2035, and to reduce disparities within countries already at or below that level.  And they agreed to hold themselves mutually accountable for achieving this accelerated progress. This is not a far-fetched dream, and countries themselves are the key partners in making this vision a reality.  For example, domestic health spending may double in many of USAID’s partner countries within the current decade, marking a significant economic transition for health and an opportunity to maximize the impact of that increased spending.

Nearly 30 years ago, USAID and the United Nations Children’s Fund (UNICEF), with the support of the U.S. Congress, launched a “child survival revolution” aimed at reducing the number of deaths among young children in developing countries.  At the time, an estimated 15 million children under age 5 in the developing world died from common, preventable diseases each year.  Without reduced rates of mortality, the number of deaths today would be about 17 million each year. Instead, it is 6.9 million. Of course, 19,000 children dying of largely preventable causes is far too many, but our progress in the past gives us great hope for success in the future.

The last generation went to the moon, and this generation has an equally incredible opportunity to meet the moral challenge I’ve discussed here.  We need to end preventable child and maternal deaths.  This is not just a vision for health, but a fundamental pillar of sustainable development.   This is a shared vision and opportunity we can all work toward, and neither the moon nor the end to preventable child death are too far away.

A Gamechanger: Using Vaginal Rings to Deliver HIV Prevention

You’ve all seen the commercials, and may have friends that are using it – the contraceptive vaginal ring.  It’s quickly gaining popularity in the U.S. and elsewhere, because it’s so effective AND convenient to use – just pop it in once a month and forget about it.  The contraceptive vaginal ring has certainly sparked the interests of scientists working on HIV prevention, since use of a vaginal ring to deliver anti-HIV drugs would be a huge benefit in the fight against HIV, particularly for women.

Well, we’re one step closer to making that a reality: with funding from PEPFAR through USAID, researchers from the New York-based Population Council have found that a vaginal ring releasing an anti-HIV drug can prevent the transmission of SHIV in monkeys.  Their findings were recently published in Science Translational Medicine.  This study provides the first efficacy data on the delivery of an anti-HIV drug from a vaginal ring, and indicates strong potential for the success of such rings in women.

In their study, Council scientists examined whether vaginal rings containing a proprietary anti-HIV compound called MIV-150 could prevent the transmission of SHIV — a virus combining genes from HIV and SIV (the monkey version of HIV). Macaques received MIV-150 vaginal rings either two weeks or 24 hours before exposure to SHIV; a second group of macaques received placebo rings in the same manner.  In both groups the rings were removed either immediately before or two weeks after exposure to SHIV.

It turns out that it didn’t matter whether the MIV-150 rings were inserted two weeks or 24 hours before virus exposure – only two of 17 macaques with the MIV-150 rings got infected (compared to the placebo group, in which 11 out of 16 became infected). What was interesting, though, was that the protection was lost if the MIV-150 rings were removed just prior to virus exposure: in that scenario, four of seven monkeys were infected.

This important study in monkeys provides additional scientific support for clinical trials that are already starting in southern Africa with another anti-HIV vaginal ring.  This ring (releasing a drug called dapivirine) was developed by the International Partnership for Microbicides with support from USAID and a number of other donors. Further testing will take several years to complete.

What’s really exciting is that research organizations are working on vaginal rings that could deliver compounds that prevent HIV, other sexually-transmitted diseases such as HSV and HPV, and unintended pregnancy.  This kind of combination prevention option especially for women, also known as “multipurpose prevention technologies,” is a new area of research spear-headed by USAID, in collaboration with other donors such as the National Institutes of Health (NIH), the U.K.’s Department for International Development (DFID), and the Bill & Melinda Gates Foundation that support research in family planning and reproductive health.  Learn more about new contraceptive and multipurpose prevention technologies in our slideshow.

USAID Book Club: A Farewell to Alms

Fall semester @USAID banner image

As part of USAID’s Fall Semester, we will host an online book club for our readers this fall. The Impact Blog will post suggestions from our senior experts at USAID to suggest a book on important issues in international development.  We’ll provide you and your book club with the reading suggestions and discussion questions, and you tell us what you think! Our fall reading list will  explore solutions to the most pressing global challenges in international development—mobile solutions, poverty, hunger, health, economic growth, and agriculture.

This week’s choice comes from: USAID Administrator Rajiv Shah

Dr. Rajiv Shah serves as the 16th Administrator of USAID and leads the efforts of more than 8,000 professionals in 80 missions around the world.

Dr. Rajiv Shah serves as the 16th Administrator of USAID and leads the efforts of more than 8,000 professionals in 80 missions around the world.

Book: A Farewell to Alms: A Brief Economic History of the World, by Gregory Clark

Synopsis: The source of human progress has long been a subject of debate. What makes rich countries rich, and poor countries poor? In the this book,  University of California, Davis, Economist Gregory Clark offers a provocative take on the age-old question, arguing that it was culture—rather than geography, natural resources or centuries of exploitation—that left some parts of the globe behind.

According to Clark, relative stability and effective workforces enabled certain societies to take better advantage of the Industrial Revolution’s new technologies and opportunities. Those countries with lax systems or undisciplined workers lost ground, and stayed there.

Clark’s book is skeptical of whether the poorest parts of the world will ever achieve real progress. For development professionals, it offers up a challenge to the belief that outside intervention can help bridge the vast economic divide between rich and poor.

Review:  This book impacted me because it shows how for hundreds, or even thousands, of years basic economic progress was largely stagnant. You didn’t have rapid compound increases in living standards until the Industrial Revolution when some countries and some societies got on a pathway towards growth – towards better health, longer life expectancy, higher income per person and more investment in education. Others remained on a slower-moving pathway.

That great divergence, and the study of it, is at the core of development. It is that divergence that we try to learn from and correct for. We define success in development as helping communities and countries get on that pathway towards improved health and education, and greater wealth creation.

I didn’t choose this book because I think it is the definitive story on development, but rather because I share its focus on core economic growth as the driver of divergence.

I disagree where Clark concludes that some societies failed to take advantage of the availability of modern technology because their cultures were antagonistic to development. With the right conditions in place, you can unlock a formidable work ethic from a range of different cultures and communities. The last 50 years have shown us that. By investing in local capacity and local institutions, we can leave a legacy of economic infrastructure, strong and capable leadership, and transparent, effective public and private sector institutions.

USAID’s partnerships in Latin America helped country after country develop strong institutions. The same can be said for South Korea. Unfortunately, there have been examples where aid and assistance have been provided in a manner that was not as sensitive to building lasting local capacity and institutions. This is true for all partners, not just our Agency. That’s why we’ve launched a program called USAID Forward, to refocus on working in a way that will create durable and sustained progress.

Administrator Shah is on Twitter at @rajshah. You  can also “Ask the Administrator” your questions on Crowdhall

Discussion Questions

1. Do you agree with Clark that some societies failed to take advantage of the availability of modern technology because their cultures were antagonistic to development?

2. The Nobel prize-winning economist Robert Solow has said Clark does not take into account how institutional factors, such as cronyism, inequitable taxation and ineffectual government cripple development. What role do you think these institutional factors play?

3. Clark challenges how effective outside intervention can be in helping poor nations progress. Do you agree?

4. Regardless of why some nations have fallen behind, how do you think they can bridge that gap today?

5. Has your world view changed after reading this book and how?

Get Involved: Use the comments section of this blog post to share your answers, or tweet them to us at #fallsemester

Water, Sanitation, and Hygiene Help Fight Disease

Guest Author Lisa Schechtman is the Head of Policy and Advocacy for WaterAid in America.

Earlier this year, I attended a meeting of the Alliance for Global Elimination of Trachoma. I was there to represent safe drinking water, sanitation and hygiene (WASH), which are critical to the global strategy to eliminate blinding trachoma, the leading cause of preventable blindness. Partnerships such as these, which bring those from the water, sanitation and hygiene sector together with other health professionals, are vital in developing a holistic approach to tackling the root causes of trachoma, and other diseases known collectively as Neglected Tropical Diseases (NTDs).

Worldwide, one billion people are affected by one or more NTD, many of which are linked to lack of access to high-quality water, sanitation and hygiene. For example, poor hygiene allows flies, attracted by dirty faces, to spread trachoma, or skin-to-skin contact to spread yaws. Sanitation and waste management could help control spread of these diseases in the first place.  Schistosomiasis (also known as bilharzia), and guinea worm, also NTDs, are spread by infected snails or fleas that live in water contaminated due to a lack of sanitation.

While crucial to preventing NTDs, hygiene promotion takes targeted work with individuals and communities; it is not often prioritized and even less often measured and evaluated. Sanitation is one of the farthest off-track of all Millennium Development Goal targets, with 2.5 billion people still needing access to even a basic pit latrine. We still have a long way to go to reach universal access to WASH; yet, if we don’t address these neglected issues, we won’t succeed in addressing the consequences.

Neglected Topical Diseases have that name for a reason. They affect the most marginalized and forgotten members of our global community—those who live in extreme poverty, in rural areas “off the grid,” already affected by disabilities, chronic illness and other challenges.  Though unknown to most Americans, these diseases can cause blindness, physical disabilities, impaired cognitive development, heart failure, and a host of other consequences, including death. Yet with holistic development and global health programs targeting the poorest people, NTDs can be prevented and ultimately eradicated as they have been here in the United States.

Eradication of NTDs requires focused responses in affected localities, to promote hygiene or control disease vectors such as flies and mosquitoes, but also broader attention to infrastructure basics, such as latrines. This requires political will, coordination, and innovative partnerships to challenge business as usual

From the U.S. President’s Global Health Initiative driving integration across sectors at the highest political levels, to partnerships between WaterAid and other national and international NGOs that ensure the right expertise is available for household-based sanitation drives, coordination of WASH and NTD control efforts is part of what makes progress possible.

An added value of focusing on Neglected Tropical Diseases is that it requires us to consider equity, dignity, and the most basic needs of the people most often left behind. In order to really eradicate many of these diseases, equitable WASH access must be a shared goal. Together, we must maintain—and accelerate—momentum, keep our promises, and forge new relationships to be sure we’re reaching those most at risk of preventable illness and death. After all, the primary value of doing this work is simple indeed: we do it to save lives.

The END7 Campaign Unites!

Guest author Dr. Neeraj Mistry is the Managing Director of the Global Network for Neglected Tropical Diseases.

The work to control and eliminate neglected tropical diseases (NTDs) is one of the greatest examples of the power of innovative public-private partnerships.  Endemic country governments, development partner governments such as the United States, non-profit organizations, pharmaceutical companies, the World Health Organization, the World Bank, and many others have come together in an unprecedented way to demonstrate support for populations affected by these terrible diseases.

In spite of this progress, though, we noticed that a crucial population was missing: the general public.

That’s why in January 2012, the Global Network for Neglected Tropical Diseases launched END7, the only public awareness campaign focused exclusively on NTDs.  END7 is a compelling digital campaign that relies on a variety of social media channels and visual communications to get the word out about NTDs and rally mass appeal around our goal of eliminating the seven most common NTDs by 2020.

So far, we’re thrilled with the response.  Since January of this year, we’ve grown to a community of more than 20,000 supporters and we’ve enlisted the help of big names in the music and entertainment industry in spreading the word far and wide.

But even more than the reach, we’re excited about the two-way engagement that we see taking place on Facebook, Twitter and YouTube.   We recognize that disease names like onchocerciasis and schistosomiasis don’t exactly lend themselves to casual conversation, so the active level of participation evident on these channels is a certain sign that our supporters both understand the problem and want to be part of the solution.

As we continue into year two of the campaign, we will continue to create buzz around NTDs. We know that by doing so, we’re helping to promote our partners’ terrific work in the field and enticing new supporters and partners to join us.

For those not yet acquainted with the END7 campaign, we encourage you, your colleagues, and your friends to visit our website and join us on Facebook and Twitter!

Together we can see the end!

The Next Chapter in the Fighting Neglected Tropical Diseases

Guest Author Rachel M. Cohen is the Regional Executive Director of DNDi North America.

Research and Development to Address Urgent Patient Need for New Tools 

The United States government and its country partners should be commended for the tremendous achievements in the fight against neglected tropical diseases (NTDs) as part of the U.S. Agency for International Development (USAID) NTD Program. When it comes to research, the US government also plays a major role in NTDs: the National Institutes of Health is by far the largest funder of basic research for NTDs. The commitment to NTD implementation programs and research has spanned several presidential administrations, receiving widespread bipartisan support from both sides of the Congressional aisle.

However, not all NTD research is created equal. Beyond basic research, much more research and development (R&D), including late-stage product development, for new drugs, vaccines, and diagnostics is urgently needed for those NTDs where adequate tools do not exist. Without such new tools, disease control and elimination will not be possible for certain NTDs – greater investments in research are urgently needed.

For example, when it comes to the filarial parasitic-worm diseases of river blindness (onchocerciasis) and elephantiasis (lymphatic filariasis), which together infect over 150 million people, the standard treatment of ivermectin, alone or in combination with albendazole, can lead to brain damage or death in people co-infected with loiasis (Loa loa, also called African eye worm). Also, current drugs kill only juvenile and not adult worms, which continue to infect, requiring repeated mass drug administrations. The Drugs for Neglected Diseases initiative (DNDi) – a not-for-profit R&D organization – is looking to develop a new macrofilaricide (a drug targeting adult worms) to address this gap in NTD treatment.

Of the 17 NTDs defined by the World Health Organization, DNDi focuses most of its attention on the three with the highest case fatality rates – African sleeping sickness, Chagas disease, and kala azar (visceral leishmaniasis, or black fever). These diseases are not yet included in the USAID NTD Program.

Although cases of African sleeping sickness (human African trypanosomiasis) have dropped over recent years, this fatal disease continues to infect people in remote, conflict-ridden pockets of the Democratic Republic of Congo, among other hotspots. Diagnostic tools are inadequate – painful lumbar punctures must be performed – and the current treatment requires hospitalization and intravenous infusions, which are difficult in unstable, resource-poor settings. DNDi is therefore aiming to develop an easy-to-take oral pill for sleeping sickness, which can treat both stages of the disease and do away with the need for painful lumbar punctures. This would go a long way in helping eliminate the disease once and for all.

While continuing to provide existing medicines for NTDs, greater commitment to developing new NTD treatments and other tools is sorely needed if disease control or elimination is to be achieved. Patients infected now with these neglected afflictions are anxiously waiting.

Child Survival: Did You Know?

America’s legacy in child survival is a proud one: With strong bipartisan support, U.S. support of global health has saved many millions of lives. 

Nearly 30 years ago, the United States Agency for International Development (USAID), and the United Nations Children’s Fund (UNICEF), with the support of the U.S. Congress, launched a “child survival revolution” aimed at reducing the number of deaths among young children in developing countries.  At the time, an estimated 15 million children under age 5 in the developing world died from common preventable diseases each year.  Without reduced rates of mortality, the number of deaths today would be about 17 million each year. Instead, the latest estimates indicate that there are fewer than 7 million child deaths globally, still far too high but clearly indicating great progress.

Thirty years ago 46,000 children died every single day. Today that number is less than 19,000.

But a child dying anywhere in the world is a tragic loss and undermines peace and stability.  This year, the United States co-hosted a Child Survival Call to Action that challenged the world to reduce child mortality to below 20 child deaths per 1,000 live births in every country by 2035. Assuming countries already on track continue to make progress at their current rates, achieving this target will save an additional 5.6 million children’s lives every year. That means 50 million more children will survive and thrive.

Past USAID investments led to innovations that now reach millions, saving lives throughout the developing world.

For decades, USAID has played a vital role in the development and delivery of low cost, high impact health interventions that can reach children in poor countries to prevent or treat the most important causes of child death – pneumonia, neonatal conditions, diarrhea, and malaria.  Innovations include safe injection technologies like auto-disable syringes and vaccine vial monitors, a diagnostic test for anemia and for vitamin A deficiency, safe birth kits and other products that are now used in countries throughout the developing world.

Helping children reach their fifth birthdays and beyond has brought about happier parents, smaller, more prosperous households, and children with much brighter futures.

Improving child survival brings a demographic dividend through fertility declines, reduced mortality, and increased economic productivity Reduction in child mortality can result in billions of dollars in direct economic savings –life-saving vaccines alone could save 6.4 million lives and $231billion in lost productivity by 2020.

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