Is Polio Eradication Slipping Out of Reach?

Over the weekend, I sat in an airport in the midwestern United States for a 12-hour stretch, trying to get a standby seat. Time after time, the goal was in sight — the customer service agents and the video screen hanging from the ceiling all told me I was No. 1 on the waitlist — but every time a flight opened up to boarding, a few higher-priority customers popped up at the last minute and slid onto the list in front of me. The possibility of my getting a seat dangled just out of reach: never impossible, but despite the exhausting wait, never quite achieved.

I suspect this is what polio eradication feels like.

The long effort to wipe the paralyzing disease from the planet, begun in 1988 by a coalition of the World Health Organization, the Centers for Disease Control, UNICEF and the service organization Rotary International (recently joined by the Bill and Melinda Gates Foundation), has several times missed its goal of interrupting all transmission of wild virus — first in 2000, then in 2002 and then again in 2005. The hoped-for date has been moved again, to the end of 2012 this time.

But last week, an independent assessment bluntly warned that the international effort “is not on track to interrupt polio transmission as it planned to do by the end of 2012” and likely will miss that goal as well.

Because the eradication effort has been going for so long, and operates so far out of the awareness of most of the  industrialized world, it’s important to say why the campaign ever got started. Polio spreads easily: The virus enters the body via the mouth, replicates in the gut, and passes out of the body in feces — and thus poses a risk of transmission in any situation where the organism is present and sanitation is poor. It causes at least partial paralysis in roughly 1 of every 200 victims, usually young children.

Because most of the victims are poor to begin with and live in countries with little or no accommodation for disability, those children may never find work or live independent lives — and thus their society loses not only their earning potential, but also the earnings of whatever family member stops work to care for them. And among those who are paralyzed, 1 in 10 will be so severely affected that they cannot breathe, speak or swallow. They die.

When the eradication campaign began 23 years ago, there were more than 350,000 new cases of polio a year. There are now a few thousand. So it has been successful, but at enormous cost, about $8 billion; the next year, to the 2012 target date, will cost $1 billion more. On the other hand, if the campaign were to fail, the WHO estimates that the cost of containing resurgent polio would be another half-billion, every year.

The current situation is that there are four countries where polio transmission has never been interrupted (Nigeria, Afghanistan, Pakistan and India) and four more where the chain of transmission had been broken, but the disease has been solidly re-established (Chad, Angola, Sudan and the Democratic Republic of Congo). Since the beginning of 2010, polio has also been re-imported to 14 countries where it has caused sporadic outbreaks. In fact, re-imported polio has become more of a problem than ongoing transmission in the places where the disease has always been, as this graphic from the report shows.

The report by the Independent Monitoring Board of the Global Polio Eradication Initiative — which was created last year by the World Health Assembly, the yearly voting gathering of the 193 member countries of the WHO — is acute and candid about the risks facing the seemingly Sisyphean effort. It says the campaign is doing poorly at:

  • ending transmission, again, in the four “re-established” countries,
  • predicting where polio will be imported next,
  • recruiting political support and guaranteeing technical training in some of the problematic countries,
  • and especially at controlling ongoing transmission in Pakistan and Nigeria.

It cautions that the northern states in Nigeria keep reseeding polio into surrounding countries where polio was thought vanquished and routine immunization stopped. And it warns that Pakistan, where the number of cases is rising, “risks becoming the last global outpost of this vicious disease” — and that was written before the news broke that the CIA used a false vaccination campaign as a cover for attempting to locate Osama bin Laden.

Deep in its analysis, the monitoring board reports poor performance at the most local levels of the campaign. Polio eradication is completely dependent on the granular: drawing maps of every neighborhood, accurately recording every vaccination, making sure that every over-the-shoulder cooler can keep  its load of vaccine cold for as long as needed. Yet the report says:

What does it say if a team is standing at its post, not actively engaging with the crowd? It suggests that they are not effectively engaging with the task with which they are charged, of vaccinating as many children as they possibly can… If data tally sheets are being falsified, what does that say about commitment to the programme? It is not likely to be an isolated event, but to reflect deep and damaging dysfunction.

The most discouraging assessment, though, comes toward the end. The board says, essentially, that the eradication effort has failed to tell its story in a manner that convinces anyone not already involved in the campaign:

In the minds of those supporting and working towards polio eradication, it is a great international endeavour of historical importance. In the minds of the public, we see a different story. Some vaguely believe that polio has already been eradicated. Most do not understand its relevance… [T]he issue remains more prominent in the health and political spheres than it does in the public psyche. The programme suffers as a result.

I ended my airport entrapment last weekend by figuring out a new multi-city path to my destination and laying down a credit card to pay for it. The eradication campaign certainly needs the equivalent of my AmEx — the report calls the current funding shortfall “deadly serious” — but what it needs even more is a new path to its goal. The monitoring board’s report makes it soberingly clear that the campaign will face great difficulty reaching it from where they are.

Cite: Independent Monitoring Board of the Global Polio Eradication Initiative. Report, July 2011.

Update: In a toughly worded editorial this morning, the Financial Times tells leaders of the effort to “radically step up their commitment or have the courage to abandon the goal”:

$1 million is spent for each infection currently not prevented. For that amount of money, many more lives could have been saved through providing drugs and vaccines for other diseases, let alone better health systems and improved sanitation. Without such structural change, tackling polio alone looks difficult.

Meanwhile, single-minded polio campaigns – often several each year in countries like Pakistan – are placing enormous burdens on thinly stretched healthcare staff in some of the world’s poorest countries. That costs lives by distracting them from providing treatment and prevention of other diseases.

Abandoning polio campaigns overnight would lead to a damaging resurgence in infection, wasting the money invested so far. But if eradication is to be given a last chance, it needs a more strategic approach.

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