{Polio Eradication, Part 1}
By Alex Park & Robert Fortner
Authors’ note:
______In late 2017/early 2018, Alex Park and I co-authored a three-part series on polio for De Correspondent, originally appearing in Dutch:
Na 30 jaar en 15 miljard dollar is polio bijna helemaal uitgeroeid. Hoe?
Als je een ziekte bijna uitroeit. En daarmee een nieuwe variant de wereld in helpt
Waarom de miljarden van Bill en Melinda Gates malaria niet uit zullen roeien
De Correspondent initially planned to publish English versions of the articles but, during the course of our series, announced plans for an English-only web publication, The Correspondent. That publication has been struggling to get off the ground ever since.
Fortunately, we were able to find a home for the third piece in the series, at Undark under the title “The Enduring Appeal (and Folly) of Disease Eradication”. But parts one and two never found an English-language publisher.
Back in 2017 when we were writing, eradication of wild poliovirus was quite close but, to our astonishment, modeling showed a disconcerting 1 in 20 chance of huge outbreaks of 50,000 cases or more in the decades after eradication. These theoretical epidemics didn’t spell the return of wild polio-- the dreaded, crippling virus which has been the constant target of the largest medical campaign in history, but of vaccine-derived poliovirus (VDPV)-- another disease with virtually the same symptoms, and one whose sole cause is the oral vaccine meant to end polio in the first place.
Today, VDPV is expanding quickly in Africa, where it threatens to triggerbring potentially very large outbreaks of paralysis. One of us, Robert, is working on an article on the subject. But for now, there’s still too little discussion of this threat in popular media. So we are bringing the pieces forward in English for the first time. Part 1 is below, Part 2 is here.
After nearly 30 years and $22 billion, a massive, dedicated campaign has nearly eradicated wild polio. But as the campaign prepares to celebrate the end of one terrible disease, cases of an equally terrible one of its own creation-- vaccine-derived poliovirus, or VDPV, are rising. VDPV outbreaks could be massive and require restarting the eradication campaign after it ends. So why do we hear almost nothing about it?
In 1980, at a gathering of some of the world’s leading scientists, the person most responsible for the world’s first ever successful campaign to eradicate a disease was trying to prevent the idea of eradication from going mainstream.
DA Henderson, an American epidemiologist, had led the first campaign to successfully eradicate a disease. Smallpox killed an estimated 300,000 people in the twentieth century alone, and its official eradication in 1980 is still hailed as one of the great achievements in human health. As Henderson told the group, smallpox eradication had been a unique opportunity. The world had lept at a chance to wipe out the disease because unique circumstances meant it was possible. But, he added, “we have not demonstrated feasibility … with any other disease.”
There was another problem.
Henderson pointed out that the world’s health ministries widely agreed that the world should throw the weight of its healthcare resources into improving basic health infrastructure, to cope flexibly with multiple health problems. In a 1978 meeting in the Soviet Union, delegates from 134 nations had endorsed exactly this position under the slogan “Health for All,” with a goal of extending primary healthcare to all people by the year 2000. “A single-disease eradication program runs against this tide,” he said.
Henderson’s warnings were largely ignored. At the end of the meeting, the assembled scientists nominated three diseases for eradication-- measles, yaws, and polio. Yaws is a common but rarely fatal disease in some tropical countries. WHO nearly eradicated it in the 1950s and 1960s. More recently, WHO has described yaws as a “forgotten disease.” By contrast, measles remains a major child killer, causing almost 90,000 deaths last year. Yet back in 1988, WHO declared a goal of eradicating polio worldwide, formally launching a campaign which, nearly thirty years later, remains one of the most ambitious, most controversial, and best-funded health campaigns in history.
…
For the last two months, we’ve spoken with some of the people leading the polio eradication campaign about the campaign’s end stage.
Our interest in this story came from different starting points. For the last several years, Robert, a former employee of Microsoft, has been writing a book about Bill Gates. In 2010, Robert wrote a story for Scientific American on how super-human efforts in India, where polio was worst, had turned the corner. At the time, it seemed like one of precious few, transcendently positive developments in the world. But polio eradication was never India’s idea; they have had many, much bigger public health problems. And, as global eradication drew closer, WHO declared polio an emergency-- even though the threat of spread was lower than ever in human history.
Then a real emergency broke: Ebola. In 2014, I was covering the West African Ebola epidemic from the Washington, DC office of the US news site Mother Jones. After I wrote a story about the funding problems at WHO, Robert shared some of his blog posts, and we started talking more, eventually publishing a story on WHO, the US government, and the Gates Foundation during the epidemic for HuffPost.
We found that while the Gates Foundation cared a great deal about polio eradication, in the early days of the outbreak, it had ignored and downplayed Ebola’s threat. But WHO had lacked the capacity to respond from the very beginning. In the middle of the crisis, WHO extended the polio emergency before finally declaring one for Ebola. The distorted priorities could be seen in the very make-up WHO. At the time, 38 percent of WHO staff in Africa were supported through polio funds. Polio eradication had become so big that WHO had been largely reorganized around it. How did that happen?
{What is polio, and how does it spread?}
One indisputable fact is that polio is a terrible disease, and one the world would be better off without. Polio attacks cells in the spinal cord that control the muscles. Affected people, usually children, lose the ability to move muscles, limbs, even their entire bodies. In the worst cases, when the virus affects the muscles which control breathing, polio can kill.
In wealthy countries, where polio has been eliminated except for lab specimens, the virus has historically spread through saliva. But polio can also spread through human waste. This is especially a problem in poor countries, such as Pakistan and Afghanistan, where the virus still exists, and where sanitation is often poor and sewage water can blend with sources of drinking water.
Polio has no cure. Though most people who contract it never show symptoms, for the minority who do, polio’s ravages can be mitigated but not reversed.
But if the health benefits are one motivation for polio eradication, another, perhaps even greater one is the right to say “we did it.” Reading the many reports on polio eradication and talking to its proponents, the desire to reach the end seemed at times to outweigh the desire to end a cause of paralysis in children.
Carol Pandak, director of the PolioPlus program at Rotary International-- historically one of the leading funders of polio eradication-- told us, “We made a promise to the world’s children, and Rotary keeps its promises.”
“It’s a superhuman achievement of the globe uniting against a common enemy,” said Walter Orenstein, an early advocate of the cause.
Had the original goal of the eradication campaign been lost after thirty years? Or had polio eradication always been about inspiring people, as much-- or more-- than it was about improving the health of the world? Before charting out the future of the eradication campaign (which we’ll discuss in Part II of this series), we needed to look at the origins of the campaign.
{What is the polio eradication campaign?}
In 1988, the year the global eradication campaign officially began, there were more than 350,000 cases of naturally occurring, or “wild” polio in 125 countries. So far this year, 15 cases of wild polio in two countries-- Pakistan and Afghanistan-- have been reported, a drop of 99.99 percent.
This massive reduction is the work of the eradication campaign. Today, what people typically call the eradication campaign is a formal entity called the Global Polio Eradication Initiative, or GPEI. Though its main office is housed at WHO headquarters in Geneva, WHO is, officially one partner among many. Others include the US government’s Centers for Disease Control and Prevention and nonprofit groups, such as the Bill and Melinda Gates Foundation and the volunteer group Rotary International. Though many governments support it, the Gates Foundation is currently the single largest contributor to the campaign.
In principle, the campaign’s job is simple: to inoculate the vast majority of the world’s children against polio, year after year, until the disease disappears. In most wealthy countries, like the Netherlands, health care workers use an injectable vaccine. In most poor countries, the available option is an oral vaccine. Dropped on a child’s tongue a few times over a period of months, the vaccine stimulates the immune system in the digestive tract, virtually guaranteeing the person will be immune to polio for life.
{What has eradication cost so far?}
But while vaccines are common component of public health regimens, the polio eradication campaign is not like any other public health effort in the world today.
“Eradication is a very unforgiving goal,” says Orenstein. “If I told you that I have a public health campaign that reduced disease incidence by 99.99 percent plus, you’d say ‘wow, what a program.’ But with eradication, one infection is one infection too many.”
Even polio’s double-digit figures are a nagging reminder that the campaign’s work is not yet done. Until the last case of polio is reported and isolated, the only way to prevent a resurgence is to vaccinate the vast majority of children everywhere, from Amsterdam to Tokyo to Zurich, from Armenia to Zambia, in cities, towns, and bedouin camps, war zones and refugee settlements. If vaccine rates drop before polio is gone forever, the risk remains that it could surge again.
This means every year until polio is officially eradicated, the campaign must buy and ship hundreds of millions of doses of vaccine, particularly to poor countries which cannot afford it on their own. Since vaccine is perishable, the campaign pays for refrigerators, coolers, and generators to carry it from factories to the field, often in rural areas in remote villages. Since polio cannot be diagnosed in these hard to reach places, the campaign also maintains a network of labs in cities around the world which can test for it. And all over the world, in cities, towns, and villages, the campaign marshals an army of workers to carry vaccine to anywhere and everywhere there are children.
After thirty years, sustaining this level of commitment has proven enormously complex and expensive. To date, the campaign has cost an estimated $15 billion. The campaign has also set-- and missed-- three deadlines-- in 2000, 2005, and 2012-- and is fast approaching a fourth, in 2018. At a current cost of around $1.25 billion per year, it ranks with HIV/AIDS and malaria as one of the most costly disease-specific campaigns in history.
But was polio also one of the most destructive diseases? Not really. In 1990, two years after the campaign began but before it had substantially cut down infection rates in most of the poor countries where polio remained, the World Bank estimated polio constituted 0.24 percent of the burden of all diseases on the world economy. This is an imperfect measure, but it points to a fact that was widely understood at the time: polio was not one of the greatest disease threats in the world. By comparison, measles, often called the greatest killer of children in history, caused four million deaths in 1990, representing a more than ten-fold greater burden. Yet WHO had chosen to dedicate massive resources to its eradication anyway. Why?
{How was polio chosen?}
When we spoke with campaign leaders about its history, one name that came up repeatedly was Albert Sabin, the Polish-American inventor of the oral polio vaccine.
The historical record reveals some interesting details about how he promoted polio eradication as a goal. Remember that, after the 1980 meeting in the United States, attending scientists largely agreed that eradication of some disease was a worthwhile goal, but they ended the conference with a list of three candidates, of which, polio was just one.
Sabin had a preference, however, and it was polio. A few months after attending that meeting, he traveled the country to address thousands of members of Rotary International, a volunteer organization known for a well-connected membership dedicated to public service. Rotary members volunteered their time in their communities to help alleviate poverty. But in his address, Sabin said that, before it could eliminate poverty, the world first had to address the health problems of poor children, like polio. And as he explained it, Rotary members could lead this effort.
Together, Rotary and Sabin came up with a number for global polio eradication: a mere $120 million.
In 1985, Rotary adopted global eradication as a goal. Soon after, the organization sponsored campaigns that used oral vaccine to either dramatically reduced or eliminated polio in the Philippines, Bolivia, and the Gambia. With these successes, healthcare leaders came to a realization: Polio was useful for attracting outside funders-- an attractive cause with a clear objective that could bring in money for the less easily defined mission of building healthcare.
“You can go to donors and say, ‘help us do this thing which will take a really long time,’ or you can go to them and say ‘help us eradicate this disease,’ and they like that other option more” says Svea Closser, an anthropologist at Middlebury College in the United States, who has studied polio eradication.
Latin America was the next target. There, Rotary and local healthcare leaders appealed to governments and private donors, using the donations to eliminate polio and increase vaccinations for a number of diseases, including tetanus, pertussis and measles. Infection rates for widespread diseases plummeted while polio disappeared.
Though early critics of polio eradication had worried that focusing on a single disease would take away support from everything else, the Latin American case suggested the opposite was true. Polio eradication was the rising tide that would lift the health of the entire region.
{How did the campaign become global?}
By the late 1980s, WHO could no longer avoid joining the campaign. In 1987, several eradication leaders published a paper in WHO’s in-house journal calling for a global campaign. Polio eradication would be “a banner” which other health projects could rally behind, the group wrote. But these benefits would be ancillary. The priority would be eradicating polio once and for all.
“Global poliomyelitis eradication eradication… is inevitable,” they wrote. “The only question is whether we will accomplish it or pass on the needed action to our successors.” One year later, in 1988, the World Health Assembly declared a goal of eradicating polio worldwide by the year 2000. As healthcare workers had done in the Americas, the new campaign would use the oral vaccine.
In the Americas, polio eradication had been a common cause for an array of people wanting to lift the health of millions of people. But in becoming a global cause, eradication separated itself from any cause but its own.
{What happened?}
Speaking with some of the people involved in polio eradication today, it was clear that many of them were tired of fighting polio. It’s hardly surprising: Many of them have been waiting for the end for decades.
But fatigue is not a new condition for the people working in and paying for polio eradication. Closser, the anthropologist, who attended meetings with leaders of WHO and other campaign partners in Pakistan a few years later, said the desire to finish the job narrowed the focus to polio alone. “I went to a lot of meetings where people said, ‘routine immunization is good, but we have to eradicate polio now or it won’t get done,’” she told us. “To get polio eradicated [they believed], they had had to push forward with this single-minded focus, and if they got too involved in routine immunization, it would slow them down and they would never eradicate polio.”
The campaign might have died around this time if not for the intervention of the richest man in the world.
{How did Bill Gates get involved in polio eradication?}
In fall 2007, Steve Landry, the vaccine program manager at the Bill and Melinda Gates Foundation, asked Linda Venczel, a foundation program officer, to give a presentation on polio eradication to Bill Gates. Gates, whose aunt had been a polio victim and whose father was a Rotary member, was in the process of leaving Microsoft, the company he had founded, to become more involved in his namesake foundation.
Venczel had made similar presentations before, having spent three years as the deputy director of the polio eradication branch of the US CDC. What was different this time was the amount of money she had to budget for.
“I wasn’t used to the kinds of budgets that we could throw at a problem as we could at the foundation,” Venczel said with a laugh. “When I asked, ‘how much money,’ I was told ‘you can start at $400 million.’ That was an incredible amount that could really be game changing.”
Over two hours, Venczel stood before the organization’s executive leadership, describing in detail the various options for eradicating polio within the allotted budget. Throughout the meeting, Gates, whose aunt had been crippled by polio when he was a child, peppered Venczel with technical questions. “One thing about Bill Gates is he’s very astute,” Venczel said. “He’s very quick to understand the science of everything, so he truly is a technical partner in thinking through things.”
Then Gates, once a math major at Harvard, asked a big question. If he funded it, what percent chance did polio eradication have of succeeding? It was impossible to know for sure, so Venczel offered two other numbers. About 30 percent of the factors that would determine success-- like war, natural disaster, or political turmoil in the remaining countries-- were outside anyone’s control, she said. The other 70 percent depended on the campaign itself, and the money available to support it. Up to a point, with more money, the chances of success would increase.
If he wasn’t already, Gates was persuaded. Before the meeting adjourned, he committed $700 million to polio eradication, nearly a third of a billion dollars over the original baseline.
We don’t know why, exactly, Gates chose to focus so much on polio. When we asked the Foundation, they directed us to several speeches Gates had made, where he made broad statements about uplifting humanity. But like some of the early proponents of polio eradication, Gates has promoted the idea of eradication itself as an idea. Even before he committed resources to polio, Gates had declared a desire to eradicate malaria. Since then, he has connected polio eradication to malaria more specifically. “Polio, we hope to get done by 2018,” he said in a 2014 interview. “The credibility, the energy from that will allow us to take the new tools we’ll have then and go after a malaria plan.”
Just as polio eradication was launched through the dedication of a very small group of people invested in the idea of eradication itself, under Gates’ leadership, that tradition continues.
{What’s next?}
With Bill Gates now serving as its de facto leader, polio eradication is closer to success than ever. But while the campaign’s leaders prepare to celebrate the end of wild polio, another problem is slowly threatening to undermine its progress.
The reason is that the oral vaccine, unlike the injectable vaccine used in wealthy countries, uses a weakened but still-living form of the poliovirus which retains a penchant for mutating back toward paralyzing virulence. The resulting infection is called vaccine-derived poliovirus, or VDPV.
Since 2000, scientists have known that VDPV can spread through saliva and drinking water, and cause paralysis in children, just like wild polio. Technically, these cases are called Circulating VDPV, or cVPDV And while wild polio appears to be in terminal decline, VDPV cases are rising: In 2016, there were three cases of VDPV in the world. So far this year, there have been eighty. Scientists largely agree that VDPV will continue to exist after wild polio is gone.
VDPV would not be a serious threat if vaccination rates remained high throughout the world. But with the eradication campaign ready to declare victory, many fear that VDPV infections could surge. By one estimate, cases of VDPV-associated paralysis could number in the thousands after wild polio is officially eradicated.
So why don’t we hear anything about this disease of the campaign’s own creation?