The public health gospel teaches us that most health is gained or lost outside the NHS. So public health programmes such as tackling inequalities and Saving Lives: our healthier nation need at least 10 years to deliver real benefits. A cynic might say such a time-frame lets government and local agencies off the hook while we focus, as ever, on short-term objectives.
But sandwiched unobtrusively within the objectives of waiting- list targets in the latest national priorities guidance sit the key short term public health objectives for immunisation.
1 Immunisation was selected as one of the top 10 public health achievements in the US.
2 Not so in the UK. Trends in the uptake of childhood immunisation have been depressing - especially for measles, mumps and rubella.
3 The old reasons are still to blame: difficulty reaching and recording mobile, inner-city populations, parents unfounded concerns fuelled by unbalanced media reporting, practitioners uninformed views and target payments that don't provide enough incentive for practices with the lowest uptakes.
But now the shortage of childhood vaccines - including the new meningitis C vaccines, BCG and PPD - has set us back further. This shortage has been quietly accumulating over many months.
Some claim the difficulty lies with drug companies monopoly over vaccine production. The real reason has more to do with the lack of political priority given to immunisation.
If the supply of Tamoxifen were suddenly at risk of drying up, wouldn't there be an immediate professional, public and political outcry resulting in a quick resolution of the problem? It is arguably a life prolonging drug for many women.
But isn't the health of children equally important?
What has been done to combat this shortage? The Department of Health has issued a flurry of messages reassuring us of the continuity of vaccine supply. We have been promised that the supply of diphtheria and tetanus has been secured through an alternative producer, and that increased supplies of the new meningitis vaccine will be available for the campaigns next phase.
4 Those delivering the programme know it will not be enough, and colleagues are intimating not to be in too much of a hurry to get it into top gear in case the supply runs out again. Who will count the cost to the children and young people who we have tried so hard to reach, and who may not come back when recalled?
Rates of 74 per cent uptake based only on a random sample of universities are not high enough, and will need to be set against the actual rates achieved in every district.
As for BCG, there is no prospect of continuity of vaccine supply. The schools BCG programmes have been shut down, and neonatal and essential contact-tracing programmes may be at risk.
Little noise has been made about this. It clearly isn't a key issue outside London and deprived inner city areas. What would the mayor of London have to say?
Clearly, schools BCG programmes are not the only plank of TB control in the inner city, reflected in the latest TB policy framework from London regional office, which rightly emphasises treatment completion.
5 Cities such as New York have effectively controlled their own TB epidemic without a BCG programme. But if this is the case, why is it still national policy to retain a BCG schools programme if we need to shift the much-needed resources into other aspects of TB prevention?
The DoH has attempted to call the drug manufacturers to account, bringing some - but not enough - improvement in the supply of the meningitis vaccine. Yet despite months of shortage, and speculation in the GP press, no formal guidance has been issued on how health authorities GP target payments should recognise any reductions in uptake targets because of the shortage.
The only sensible solution - suggested by local medical committees - would be for HAs to continue to pay GPs on the basis of the uptake in the same quarter in the previous year. Money for old rope, some may say, but preventing public health effort from being wasted and minimising further risk for children are all part of this argument.
So what needs to be done? First, the DoH should resolve the GP payment issue to avoid penalising communities and their GPs for something beyond their control.
Second, the meningitis vaccine makers should have further bombs put under them until the supply route is adequate, and specially protected supplies of BCG should be provided to those parts of the country where the risk is highest.
How should this be done? If we have a monopoly supplier we should use our good World Health Organisation connections to airlift supplies. Third World problems need Third World solutions.
Finally, we must reform our dinosaur communications system for notifying which vaccines are available. We are all in electronic contact - we should use it properly .
The longer-term challenge is for the DoH to hold the drug manufacturers more effectively to account for their contribution to health.