Should GAVI support disease eradication efforts, such as the ongoing polio campaign and a proposed campaign targeting measles? Or is it better to finance broader disease control efforts that emphasize rebuilding failing public health and immunization systems?

"The polio campaign is the sixth disease eradication campaign ever tried, and only one (smallpox) has worked so far," said Dr. Bruce Aylward, head of WHO's global polio eradication program. (The others were malaria, measles, yellow fever and yaws.) Critics say this history shows that eradication programs suck up too many resources at the expense of broader public health efforts. Nonetheless, Aylward contends that GAVI should support the polio campaign because it could kick-start broader immunization efforts in areas where polio is still endemic.

Reported vaccination rates in developing nations are often unreliable, dictated more by what donor agencies want to hear -- and what qualifies for more money -- than by reality. "We need to keep in mind that it's actual reductions in disease and mortality that we're after, not coverage rates," said Dr. Gustav Nossal, a world-renowned Australian immunologist and longtime vaccine adviser to WHO.

GAVI and its financial arm, the Global Fund for Children's Vaccines, certainly have industry's attention now that there is money to be made on products tailored specifically to meet the needs of developing countries. "But their jaws drop when we talk about price," said Melinda Moree, who works for the Malaria Vaccine Initiative. Pharmaceutical companies want to get paid in the range of $10 per dose of vaccine, Moree said, but UNICEF and WHO want prices counted in pennies so poor countries can eventually afford these vaccines.

That tension recently intensified as governments in Africa, Asia and South America announced their intention to flout international patent law to produce generic, and much cheaper, AIDS drugs to treat people who could not afford the prices charged by European and U.S. pharmaceutical companies.

While this flap does not directly involve vaccines, it could affect the relationship between GAVI and industry. One of the goals of GAVI is to develop sustainable, self-reliant public health systems. But the pharmaceutical companies that sit on GAVI's board may bolt if the alliance supports the creation of competitors in the Third World.

The initial focus of the alliance was on the world's 74 poorest countries, where the average resident earned no more than $1,000 per year. To qualify for aid, those nations had to demonstrate that their basic vaccination rates were between 50 and 80 percent.

But should GAVI provide assistance in countries where per capita incomes are above $1,000, if they are failing to immunize many of their children?

Last fall, President Clinton signed legislation authorizing $435 million to help ease the debts of 33 of the world's poorest countries, many of them in Africa. The legislation included a $50 million grant to the Global Fund for GAVI, with an additional $200 million promised over the next five years. In a sense, this was legislative recognition of the link between disease and poverty.

Joyce Millen, co-director of the Institute for Health and Social Justice in Cambridge, Mass., said GAVI's success or failure depends largely upon how firmly it holds to this link between economics and health. "In the past, most of these health campaigns imposed upon the developing world from outside accomplished very little lasting change," she said. One of the reasons is few resources were devoted to building up infrastructure such as reliable public health and medical systems.

"The Gates Foundation has a long-term goal that sounds good, if they can accomplish it," she said. "But as grand as it sounds, it could still turn out to be just another Band-Aid."

Dr. Gordon Perkin, director of Gates' Global Health Program, said that's why the foundation's overall strategy includes an emphasis on poverty reduction and family planning as well as vaccines.

"But it starts with vaccines, because these are the single most cost-effective health interventions we can make," Perkin said.

The first delivery of GAVI vaccines will be made next month in Mozambique and Kyrgyzstan.

Of the 74 poorest countries identified by GAVI, 47 have now been approved for aid from the Global Fund.

And after a decade of stagnation and deterioration in immunization rates, Bill Gates' money has put vaccines back on the world's agenda. Nations like the Netherlands and Norway have already jumped on the bandwagon, contributing $100 million and $125 million respectively to the Global Fund.

Britain has given $5 million and promised $20 million. The United States has pledged $50 million this year and promised $200 million in years to come.

GAVI clearly is moving. Meanwhile, some of the decisions that will help chart its future course -- and answer some of the lingering questions about its mission -- are being debated here in Seattle.

Last week, the steering committee for Gates' Children's Vaccine Program, the catalyst for GAVI, gathered at the Marriott Residence Inn on Lake Union. The meeting featured representatives of WHO, UNICEF, the U.S. Agency for International Development, the National Institutes of Health, vaccine makers and others.

The Children's Vaccine Program is at the front edge of the GAVI agenda -- figuring out how to keep the momentum going by looking further ahead. At the Seattle meeting, its leaders debated methods for striking the right balance in partnerships with industry, how best to leverage the money donated by Gates, and the need for better information on disease in the developing world.

It's clear that respiratory illness is the leading killer globally, said Dr. Kim Mulholland, an Australian pediatrician and former WHO official. "But a large proportion of pneumococcal disease is hidden to our conventional means of diagnosis."

Without better disease surveillance and tracking, it's hard to persuade government officials to spend money against a disease they can't identify, added Dr. James Maynard of the Program for Appropriate Technology in Health (PATH), which operates the Children's Vaccine Program.

Dr. Michael Free of PATH said another "holy grail" technology being pursued by his organization is creation of heat-stable vaccines that don't require refrigeration. He said industry has shown little interest in large-scale manufacturing even though it appears technically feasible.

"There's no doubt we could do it. It's just being held up by economics.... The question for GAVI is how do we break this logjam."

Bill Gates broke the logjam that has prevented millions of children from receiving life-saving vaccinations.

"Our world has changed significantly in one year," said Dr. Mark Kane, director of the Children's Vaccine Program. "I think we've assembled the most enthusiastic, energetic and effective immunization team on the planet."