Columbia Journalism Review series on global health journalism: Part 1 of 2

The Columbia Journalism Review today republished my article, "How Ray Suarez really caught the global health bug." Part two goes up tomorrow.

As CJR's editor's note says:

This article was originally published on the author’s personal blog in July. With a few updates, we are running it as the first in a two part series exploring the implications of the Bill and Melinda Gates Foundation’s increasingly large and complex web of media partnerships. This part deals with a partnership between the PBS NewsHour and the Gates Foundation formed in 2008. Part two, running tomorrow, will examine a partnership with the Guardian, a British newspaper, announced in September, and one with ABC News announced on Wednesday.

Polio Turns Stealthy in India

Oral polio vaccine (Photo credit: quilty2010)  

Polio eradication may be entering a new phase in India where incidence of the disease has become so faint, it’s sometimes undetectable. Yet polio is still very much there and capable of spreading. Sewage in New Delhi tested positive for poliovirus six straight weeks recently. (Polio is usually spread by oral contact with water contaminated by the feces of people infected by the virus.) But no cases of polio have been reported in the entire state of Delhi for more than a year. How can there be circulating virus and no cases?

Only about one in 200 polio infections results in paralyzing disease. But these cases must be detected to be counted and to prevent further spread. Across India, more than 20,000 people comprise the detection network, in theory at least one to every block of every district in the country.

But in the states of Uttar Pradesh and Bihar, one of the world’s largest polio redoubts, the challenges of detecting polio cases are immense. The sheer reproductive force of the region astonishes: 500,000 children are born every month in Uttar Pradesh. Poverty, illness and death are likewise extreme in degree while infrastructure is scant. And many people are highly mobile, migrating far and wide, all of which makes detecting polio cases from this oceanic flux difficult. And it is getting harder.

Frequent, massive vaccination campaigns have beaten polio down. Uttar Pradesh hasn’t seen a case since April and only six in total this year. But the disease is cropping up elsewhere. New cases were reported in the state of Jharkhand, which borders Bihar, but also in Maharashtra on the other side of the country. And a spectacular outbreak ignited in Tajikistan a few months ago. 452 people became infected with a poliovirus traced back to Bihar. A smaller outbreak occurred in Nepal, again originating in neighboring Bihar.

But even giant outbreaks don’t threaten polio eradication. Make it rain oral polio vaccine and new outbreaks can be fairly reliably extinguished, albeit at significant cost. The problem facing eradication efforts is that the gauges read “zero” when clearly the actual number of polio cases sits above zero. As the World Health Organization put it, new cases in India last week and the sewage samples in New Delhi are “evidence of ongoing, low-level [poliovirus] transmission in the country.” (Wild Poliovirus Weekly Update, 11 August 2010).

The level of transmission has dropped to where it can’t always be seen but it remains high enough to sustain the cycle of infection.  The good news is that strenuous vaccination efforts have driven cases down. The bad news is that polio is not eradicated and now might fly too low to be picked up by the existing detection network, hindering efforts to stamp the virus out for all time.

Today the Bill and Melinda Gates Foundation invited proposals to address exactly this problem. According to the foundation, “as eradication nears the signal provided by paralytic disease will be eventually lost; new methods to monitor poliovirus circulation are increasingly necessary.” The foundation identified other obstacles to eradication that need to be addressed but the overarching theme was for what it described as the “poliovirus endgame.”

How close is this endgame? The steep fall in cases evokes guarded optimism from Steve Wassilak at the Center for Disease Control, which is part of the Global Polio Eradication Initiative. In email, he said:

We, the interested parties, do need to avoid over-weighing any decline in cases as a clear path to zero, given the ups and downs in the past, particularly in India. However, we are squarely now in the high season and the total number of cases is at an historical low…

The outlook for 2010 appears good, although according to Dr. Yash Paul, a pediatrician in Jaipur, India, “In India high incidence of polio starts June onwards, so we shall know the likely polio scenario in end August” because of reporting lags. Also, one good year doesn’t automatically beget another. While 2005 saw just 66 cases, 2006 brought over 600 cases while 2007 produced more than 800.

Wassilak pointed out that the passing of the high season for polio could snap the few remaining chains of transmission. Or not. “[A]n alternative,” Wassilak hypothesized, “is can mobile populations be sustaining/contributing to transmission but cases of paralysis among these populations be missed?” The sewage tests in New Delhi, at Swaran Cinema, might support this hypothesis if the moviegoers are from neighboring Uttar Pradesh.

Other known problems obstruct eradication. Notably, the oral polio vaccine quite often fails to elicit immunity. WHO began addressing this in April. (See Polio Eradication: Harder Than it Looks.) Similarly, the Gates Foundation, in its invitation for polio eradication proposals today, included investigating why “vaccines have shown reduced efficacy in children living in certain resource-poor environments.”

A newer potential problem is re-infection among persons who were earlier protected by prior immunizing exposure. Such re-infections might be helping sustain the poliovirus cycle in areas with long-running eradication efforts—a vicious circle.

Finally, India is not the only endemic source of polio. Nigeria, Pakistan and Afghanistan also have never interrupted transmission, although a decade ago, 20 countries fell in this category. Unfortunately, transmission has become re-established in several nations in Africa and is unlikely to be stopped in those places by the end of the year, a revised goal for the eradication effort which originally was supposed to conclude in 2000.

Still, the potential is there for this be the turning point.

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Related:

Gates Seeks to Close Out Polio in Nigeria (June 7, 2010)

Heavy Lifting: Raising Health Beyond Polio's Reach (May 13, 2010)

Wall Street Journal: Pulling the plug on polio eradication? (April 26, 2010)

Polio Eradication: Harder Than it Looks (April 14, 2010)

How Ray Suarez really caught the global health bug

The Gates Foundation, global health and the media

How did Ray Suarez catch the global health bug? Simple, he said in a recent talk answering  that exact question. Suarez explained: “The executive producer of the NewsHour, Linda Winslow, came into my office and asked me if I was interested in covering global health for the program and I said ‘yes.’ ”

But the actual reason is, following that conversation, Suarez wrote a proposal for the Bill & Melinda Gates Foundation resulting in $3.6 million of funding for NewsHour programming on global health. The Gates Foundation also sponsored the event at which Suarez was speaking. The moderator came from the foundation too, posing questions and selecting others from the audience, the funder interviewing a journalist whose global health education it had financed.

Suarez has heard gripes about Gates Foundation funding before. He defended the arrangement as giving an under-reported subject increased coverage while preserving “complete editorial independence.” Continued Suarez: “The foundation doesn’t hold the purse strings, encouraging some stories and discouraging others. And we don’t get approval before we embark on projects.”

But could Suarez’s own internal process for selecting stories and storylines be susceptible to influence? Certainly there are no stories thus far that seem contrary to foundation views. On the other hand, hardly every Gates-funded story examines an issue high on its agenda, obesity in China, for example. Malaria eradication does sit near the top of the foundation agenda. But NewsHour coverage of Tanzania mostly spoke of malaria elimination which targets specific regions rather than worldwide eradication which is more difficult and controversial.

Suarez went to considerable effort to avoid covering global health projects also funded by his funder. He described this as an accomplishment given “the remarkable number of pies around the world that the foundation has its fingers in…” However, the ubiquity of the Gates Foundation in global health is itself important. The malaria vaccine trial Suarez covered on his trip to Tanzania, for example, would never have taken place absent Gates Foundation support. The vaccine was shepherded forward by the Gates-funded PATH Malaria Vaccine Initiative. Both the event and its coverage are products of Gates money.

Every story has more facets than can be examined. But Gates Foundation funding discourages or even forecloses examination of certain storylines. Suarez can’t credit the foundation for making gigantic contributions to global health, for example. At the same time, the elephant in the room—the Gates Foundation—remains out of frame even as it pays for the camera.

Does that matter if the main effect of Gates funding is to increase awareness of global health? As Suarez pointed out:

A few months ago in Washington, I watched Bill & Melinda themselves give a presentation on global health research to an auditorium packed with a who’s who of Congress, the executive branch, think tanks and the media, not demanding one policy approach or another or recommending one drug protocol or another as much as hammering home the idea that public knowledge creates support for [global health] efforts…

By funding the NewsHour as well as Public Radio International, the foundation heightens general awareness of and support for global health. However, while the Gateses might not have advocated for specific programs, they and their foundation do have distinct policy preferences and require strict compliance.  Furthermore, the foundation’s policy-agnostic advocacy efforts link together with its policy-shaping efforts, again by influencing the media.

In October 2008, the same time it awarded the NewsHour funding, the Gates Foundation granted the Kaiser Family Foundation (KFF) $2 million with a remit to “inform policy making and program development and implementation” for U.S. global health policy. The Kaiser Family Foundation doesn’t specify precisely how it uses these funds and publishes no annual reports on its website. Concerning its spending and governance, the KFF website only alludes to the possibility of such funding:

With an endowment of over half a billion dollars, Kaiser has an operating budget of over $40 million per year.  The Foundation operates almost exclusively with its own resources, though we do occasionally receive funds from grant-making foundations, primarily to expand our global programs.

Prominent among these programs is KFF’s US Global Health Policy portal. The portal selects and summarizes global health news from more than 200 worldwide sources spanning mainstream media outlets to blogs. KFF sends a daily email news digest to policy makers, opinion leaders and journalists. Also, KFF offers its own original research and analysis, from cheat sheets for journalists to extensive reports on subjects such as the US global health architecture.

Gates Foundation financing of the enterprise is, arguably, hidden. KFF’s daily emails carry no boilerplate mention of Gates funding. The only disclosure on the KFF US Global Health Policy site resides under the “About” link at the bottom right of page, which says only that KFF’s work on global health and the global health gateway receives “substantial support” from the Gates Foundation.  

In other respects, however, the influence of the Gates Foundation is more apparent. Not only does KFF have the power to choose what constitutes global health news but, in summarizing the stories it selects, it can give them a construction of its choosing. In key instances, the Kaiser Family Foundation’s global health news coverage suggests bias both in story selection and preferential treatment of the Gates Foundation.

In May 2009, the Lancet ran two papers and an accompanying editorial offering multiple, sharp criticisms of the Gates Foundation. The KFF summary muted the few criticisms it repeated and dismissed the one paper it discussed as “marred by ideological assumptions.” The summary quoted the Gates Foundation as saying “We welcome the article and its findings…” although, as the Lancet editorial noted, the foundation had actually “declined our invitation to respond…” Unusually and perhaps uniquely, KFF did acknowledge in its daily email that it “receives substantial support from the Bill & Melinda Gates Foundation for the Kaiser Daily Global Health Policy Report.”

In June, USA Today ran a largely positive story on the Gates Foundation. But the article also said:

…the Gates Foundation has been painted by critics and even admirers as sometimes too heavy-handed in saying how its money is used and too prone to listening to the recommendations of experts vs. grass-roots groups when setting its strategies to battle global poverty.

In Kaiser’s rendering, this became: “The article reports on different perspectives about the Gates Foundation's influence and approach to global health and other work.” While not strictly false, such gentle treatment does appear to be reserved for the Gates Foundation.

A June 19 Lancet story entitled, “WHO heads back to the drug development drawing board” became in KFF’s version “WHO Scraps Old Drug Development Group, Creates New One” and featured quotations about “unclear methods, a lack of transparency and signs of industry interference” as well as “suspicions of impropriety.” Although the Lancet story quoted one source as saying “We think this is a landmark decision,” that more positive perspective was not included in the KFF summary.

 BMJ recently alleged improper ties between WHO H1N1 advisors and the pharmaceutical industry. KFF quoted the editor-in-chief of BMJ saying “The WHO's credibility ‘has been badly damaged.’ ” However, four days later, Nature News/Scientific American wrote:

To judge from media coverage last week, a major scandal had been exposed in the handling of the H1N1 flu pandemic by the World Health Organization (WHO). But nothing could be further from the truth.

However, after this debunking, KFF only reported that “the authors of the BMJ piece agreed the timeline they presented in the article was off.”

KFF lets hard knocks for some organizations through, but cushions blows for the Gates Foundation and sometimes ducks them entirely. The Los Angeles Times ran a series of stories in January 2007, beginning with “Dark cloud over good works of Gates Foundation.” The Times contended that the foundation’s endowment investments worked against its global health objectives:

The Gates Foundation has poured $218 million into polio and measles immunization and research worldwide, including in the Niger Delta. At the same time that the foundation is funding inoculations to protect health, The Times found, it has invested $423 million in Eni, Royal Dutch Shell, Exxon Mobil Corp., Chevron Corp. and Total of France — the companies responsible for most of the flares blanketing the delta with pollution, beyond anything permitted in the United States or Europe.

The Kaiser Daily Global Health Policy Report never mentioned the series.

KFF frequently mentions coverage of the Gates Foundation appearing in the Seattle Times. But the Times' recent, June 15 story, “Gates Foundation gets low marks in relations with non-profits” went ignored. The foundation actually surveyed not just non-profits but all 1,544 of its grantees from a recent one-year period. There was good news, according to the foundation: “strong ratings for our work in grantees’ fields,” and “a positive impact on knowledge, policy, and practice in our strategy areas.” However, the Gates Foundation received “lower than typical ratings on many other aspects of the grantee experience,” such as communication and clarity with respect to goals and strategy.

The foundation paid out roughly $3 billion to its grantees over the timeframe examined yet the obvious potential story about the effectiveness of foundation spending received neither mention nor exploration, an omission true of all media organizations, not just the Kaiser Family Foundation. Concerns about transparency, raised by KFF in different circumstances, here go dormant.

The lens of KFF’s portal gives particular shape to reader perception of the world’s coverage of global health. KFF is also studying global health journalism in a project led by former Boston Globe global health writer and Pulitzer Prize winner John Donnelly. Donnelly left the Globe in 2008 to join Burness Communications, a media consultancy, where he is vice president and senior editor. At the same time, Donnelly became a media fellow at Kaiser Family Foundation. (I was interviewed in June by a member of Donnelly’s project.)

“Newspapers,” Donnelly said in a telephone interview, “have very strict ethical standards that assure you’re unbiased.” He characterized his past work for the Globe as “independent,” his stories involving consultation only with editors. As budget cuts swept the newspaper industry, the Globe closed its foreign bureaus, about a year before Donnelly departed. “In global health,” said Donnelly, “there are really very few of those jobs left.”

Asked about the possible influence of Gates Foundation funding on journalism, Donnelly explained in email:

I'm rarely doing much pure journalism now, so I don't know if I can answer the question of whether Gates' underwriting of journalism creates a conflict for journalists. I would think that journalists working on global health issues at NewsHour and NPR would be in the best position.

Donnelly seemed to defend non-disclosure of Gates Foundation funding to certain media organizations. “Indirect funding is not really seen as independent journalism,” he said by phone. “It’s seen as advocacy-based journalism.”

Donnelly currently writes for Global Health, a magazine published by the Global Health Council. The council has a three-year, $10 million grant from the Gates Foundation to “to foster policies that accelerate scale-up of cost-effective, proven health approaches and diffusion of best practices and innovation that have policy significance.” The grant was awarded in October 2008, like those won by the NewsHour and KFF. Global Health, which began publication in the winter of 2009, does not disclose Gates funding, as of this writing.

Donnelly said he didn’t know if Gates funding supported Global Health. He recently blogged the Pacific Health Summit for that publication. The invitation-only summit paid most of his airfare with the balance coming from another non-profit receiving Gates Foundation support.  “I don’t know who funds the summit,” said Donnelly, other than numerous different organizations. On the summit website, the National Bureau of Asian Research (NBAR) sits atop the marquis of the four organizations behind the event, including the Gates Foundation. However, the Gates Foundation paid part or all of NBAR’s share of the Summit, $700,000. Again, the event and its coverage originate from the foundation whose role is larger than it appears.

Is this ubiquity simply a property of global health, a consequence of a generosity both welcome and immense? Should air have to disclose that it is 21% oxygen?

I used to write about the Gates Foundation for the Seattle-based Crosscut. I stopped in November of 2009 after Crosscut, following financial struggles and a switch to non-profit status, announced it had received a $100,000 grant from the Gates Foundation. Some weeks after learning about the Gates grant in Crosscut, I inquired of the editor, David Brewster: “Any thoughts about editorial policy with respect to coverage of the Gates Foundation under Crosscut's new funding paradigm?” Brewster responded:

No change at all. You should get it out of your head that Gates is funding us, and they insist they would be embarrassed if their funding in any way altered our independent reporting on them.

The episode is suggestive of the ubiquity of Gates funding in the media, from unknown Crosscut to the PBS NewsHour. The subject of Gates funding is uniformly uncomfortable to those receiving it—which should perhaps suggest that something is wrong. Finally, the effects of foundation funding are quite universal:  journalists who need the money seem to believe they can remain objective about their coverage.

John Donnelly says his study of global health journalism examines “what’s going on, how things have changed,” and what the future might look like. Perhaps it will conclude that the objectives of global health might not be harmed by increased transparency of funding sources. Journalism and the processes of an open society, quite obviously, are harmed when money influences coverage invisibly.

Certainly, Ray Suarez should be asking questions of the Gates Foundation, not the other way around.

Gates Seeks to Close Out Polio in Nigeria

Bill Gates returned to Nigeria yesterday, outwardly to laud progress on polio but also to thrust vaccination and eradication efforts through to decisive conclusion. 

Polio is way down in Nigeria, in part because of Gates' first visit there early in 2009. A year and a half on, polio cases are nearly zero, just three so far in 2010 compared with 288 in the first half of 2009. Gates' arrival coincides with the first of two large-scale vaccination sweeps in Nigeria this month. Also, rather than directly fund polio vaccination efforts and hope for good results, the Gates Foundation agreed in 2009 to indirectly buy down existing World Bank loans to Nigeria when the country achieves specific vaccination targets. (See the picture Gates posted on Twitter which he entitled: "Reviewing statistics with leaders...")

Nigeria has 42 million children under 5; reaching 80% vaccination coverage takes an army of about 200,000 vaccinators. If polio can be dispatched in Nigeria, that would leave only India as a major polio epicenter, which Gates visited just three weeks ago. India also has seen its case rate fall precipitously but, unlike Nigeria, the oral polio vaccine doesn't always work even after repeated doses in the most polio-intensive regions of India. After Nigeria and India, the remaining polio redoubts are Aghanistan and Pakistan where vaccination campaigns are often impossible because of war-time conditions. Those are likely the only polio frontlines Gates won't visit.

Note on graphic: The location of the three cases reported so far in 2010 comes from AllAfrica.com. The map for 2009 is for illustrative purposes. It shows only half of 2009's cases with little fidelity to actual location.

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Related:

Polio Turns Stealthy in India (August 19, 2010)

Heavy Lifting: Raising Health Beyond Polio's Reach (May 13, 2010)

Wall Street Journal: Pulling the plug on polio eradication? (April 26, 2010)

Polio Eradication: Harder Than it Looks (April 14, 2010)

Goodbye Mars, Hello Malaria: Bill Gates’ Imprimatur on Science and the 21st Century

The cover story in the May 14 Science featured not space probes or cancer stem cells but malaria and tuberculosis. This first culminates trends away from classic 20th century research ambitions like a cure for cancer, becoming a spacefaring race and genetically engineering a new post-human species. Instead, as the pages of Science make clear, it’s goodbye Mars, hello malaria. Bill Gates printed out this new agenda, putting his stamp both on it and the new century.

Science both sets and reflects the agenda for American science. In the United States, cancer is the second biggest killer; malaria caused only four deaths in the most recent annual count, all from infections occurring abroad. Although coverage of cancer in Science still overwhelms that of malaria, in 2000 the count of cancer mentions in Science turned down for the first time in the history of the publication. At the same time, malaria coverage tilted up, reflecting a shift from developed to developing world health concerns. (As if in emphasis, last week Nature also ran a malaria cover story.)

Symbolic New Year’s Day 2000 saw the establishment of the Bill and Melinda Gates Foundation. Gates said then of his foundation’s mission: “I think that we could have the goal that every person in the world would have the same type of healthy life that people in the United States have.” His words now seem to have instantly reshaped the trajectory of science.

Source: Science

2000 marked an inflection point for NASA—and a turn in Science toward the terrestrial. Previously, the magazine's affections for space exploration had grown and grown even as the golden age of the 1960s receded. Ironically, coverage reached an apogee at the dawn of the 21st century and began falling back to earth in 2000. President Obama's subsequent cancellation of the Ares program earlier this year scaled back human space exploration to the vanishing point.

Neither are we on a trajectory to create a new, post-human species. In 2001, mentions of malaria in Science exceeded those of genetic engineering for the first time, a predominance that continues.

Can these shifts really be traced to the influence of Gates Foundation? Concerning the new emphasis on malaria, Gates is indisputably causal. The disease began gaining column inches in Science before Gates, from 1980 forward. However, the last decade’s spike to all-time highs not only coincides with Gates’ rhetoric but an enormous funding surge largely orchestrated by the Gates Foundation.

Research agendas are a zero-sum game. Consequently, the rise of malaria and global health automatically de-emphasizes all else. But difficulties specific to cancer, space, and genetic engineering also contributed to their demotion. The war on cancer and the space age are each roughly half a century old and not much nearer to victory or realization. By contrast, exponential advances in DNA sequencing technology seemed to be leading inexorably to a post-human species. However, genetic explanations of both complex diseases and complex traits have been—and might remain—elusive. As the number of genes involved in the relatively straightforward trait of height has grown, the prospects for and coverage of genetic engineering have dropped.

Gates still could have jumped on the spacewagon with fellow software billionaires Paul Allen, a major funder of SETI, or Jeff Bezos (with Blue Origin) and Elon Musk (SpaceX) who continue undeterred towards the spacefaring vision. Even software millionaires like John Carmack (Armadillo Aerospace) can’t help themselves. But Gates isn’t susceptible. In 1997, he praised the (unmanned) Mars Pathfinder mission as “a fine example of small science ... undertaken on a strict budget [with] limited, achievable goals.” He believed space would not be transformative: “Though humanity will do some great things in space in the next 100 years, and there will be enormous benefits, I don't think what goes on in space will fundamentally change the way we live.”

Concerning genetic engineering, Gates contended “It’s all a question of how, not if,” in 1995. He may still believe that, but his energies are going into saving rather than surpassing humans.

The opportunities (and imperatives) presented by global health might be greater than for any alternative research program. But nature yields to science only grudgingly no matter the frontier. Gates’ goal to eradicate malaria will be a multi-decade grind offering frequent parallels with the bogged down, four-decade war on cancer. Already polio eradication is a decade overdue. 

It’s a volitional, pivotal moment. Gates, his full weight on Archimedes’ lever, is moving the world in a new direction altogether different from 20th century imagination and expectation.

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Related:

How Ray Suarez really caught the global health bug

Heavy Lifting: Raising Health Beyond Polio's Reach

Two of the world's kids, Bihar, India. (Photo: kuann)

Bill Gates expanded the campaign to eradicate polio during a frontline visit to India yesterday. The new strategy: lift health beyond polio's reach.

The largest remaining pockets of the disease are the Indian states of Bihar, site of Gates' visit, and neighboring Uttar Pradesh. Over 240 million people live in the region.  Fertility rates are high with more than 500,000 children born monthly in Uttar Pradesh. The new births are accompanied--and perhaps driven by--the highest child mortality rate in India.

Waves of vaccination campaigns have failed to eliminate the disease from the two states. Disconcertingly, even multiple doses of the oral vaccine don't guarantee immunity here, a failure usually explained by widespread unhygienic conditions, undernutrition and illness. By improving broader health conditions, the chain of circumstances favorable to polio could be broken.

The World Health Organization recently began investigating the biology underlying the vaccine failure. Meanwhile, however, Bill Gates signed an agreement with the state of Bihar to "to improve and increase the availability, quality and utilisation of health-care facilities and services," according to the Economic Times.

For all its assets, however, the Gates Foundation cannot fund better health care at Bihar and Uttar Pradesh scale. The memorandum between Bihar and the Foundation might represent a quid pro quo. Polio affects very few, even in India which experienced just 741 cases in 2009. The benefits of eradication accrue to the entire world but India must do the actual work at least to the partial exclusion of more pressing priorities such as child mortality.

A few weeks ago, the Wall Street Journal speculated that Gates might shift away from eradication toward strengthening health systems. Instead Gates added improving health infrastructure to his still-relentless campaign for eradication.

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Related:

Gates Seeks to Close Out Polio in Nigeria (June 7, 2010)

Wall Street Journal: Pulling the plug on polio eradication? (April 26, 2010)

Polio Eradication: Harder Than it Looks (April 14, 2010)

Wall Street Journal: Pulling the plug on polio eradication?

In counterpoint to the New York Timespositive coverage of the war on polio earlier this month, the Wall Street Journal on Friday put forward a case for abandoning the goal of eradication—and not just for polio. The Journal depicts a potentially seismic policy shift as emanating from the de facto leader of global health, Bill Gates.  Such a reversal is unlikely.

Gates got behind polio eradication in 1999 with a $50 million grant he believed would close out the disease. He predicted in 2000 that “If necessary resources and political will are devoted to polio eradication, the world can claim victory over this killer by the end of this year and certify the planet as polio free by the year 2005.” A decade and nearly a billion dollars later, the result is not eradication but oscillation, case numbers rising and falling.

Debate about the wisdom of the eradication policy has ensued. Millions of children die from malaria, for example, compared to which polio’s afflictions, although still horrible, are minute. More suffering could be averted, the argument goes, with a different allocation of global health dollars. The Wall Street Journal urges a move away from disease-specific campaigns and towards strengthening of overall health systems.

Polio might be expensive, but dropping eradication might be more so.  A Lancet study in 2007 concluded that control would be more expensive than eradication. But whatever the optimal policy, it requires funding. Eradication provides a sense of urgency and heroism; a control strategy does not.

Credibility is also at stake for global health advocates and Bill Gates in particular. Gates has backed not only getting rid of polio. In 2007, he and wife Melinda strong-armed a skeptical global health community to embrace malaria eradication. As hoped, tremendous energy and funding were released. A giant vogue for malaria eradication ensued, like Ashton Kutcher’s Twitter-driven campaign for bed nets. At the governmental level, the largest surge in funding commitments to battle malaria came one year after setting eradication as the goal. Arguably to protect these gains, the Gates Foundation doubled-down on polio eradication in 2008. And as the Wall Street Journal points out, Gates personally led the assault, descending in 2009 on the hottest polio spot, Nigeria, where vaccination lagged.

A resurgence of polio that came from consciously letting up on the disease, even if the best policy, would be a public relations disaster. The current trajectory also presents serious problems but far less severe: Eradication is expensive and doesn’t appear to be working. The solution has been continued mass dosing of the polio-vulnerable in the developing world and, for donor nations, a steady drip of good news that, yes, we are at the absolute cusp of eradication. Right now, the news is good in Nigeria and indeterminate in India, the familiar cusp yet again.

Ultimately, polio can be snuffed out by the downward pressure of eradication, the strengthening of health systems and much broader, slower and more costly development—improvements in food, water and sanitation.  In the near term, eradication will remain the strategy, but elusive.

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Related:

Polio Turns Stealthy in India (August 19, 2010)

Heavy Lifting: Raising Health Beyond Polio's Reach (May 13, 2010)

Polio Eradication: Harder Than it Looks (April 14, 2010)

Polio Eradication: Harder Than it Looks

Why it might require a new vaccine

The global campaign to eradicate polio crushed 90% of the disease in the space of a dozen years, by 2000. In the decade since, complete elimination has swung tantalizingly close—and then away again when case counts spiked and outbreaks reappeared in countries recently cleared of the virus. Once again, cases are ebbing and hopes rising. The New York Times recently reported that for four straight months, India has seen no new cases in its two most polio-burdened states. But the real news is the unnoticed opening of a new scientific front in vaccine research, portent of a longer battle.

The polio-free streak in the state of Uttar Pradesh, while encouraging, is actually only two months old and in the state of Bihar just over three. India as a whole did have zero cases in March. But in four of the last ten years, the country has started off with even fewer total polio cases only to see the tide turn. Nationwide, the total cases so far this year, 19, equals the number at this time in 2009. Polio incidence usually rises in May; given reporting delays, by July, the direction of the trend should be clearer.

The Times article cites extraordinary vaccination efforts to explain the new swing toward eradication. Polio vaccination campaigns in India are monumental undertakings, war-sized in scale involving an army of over two million vaccinators going house-to-house and overseen by a supervisor corps numbering greater than 100,000. However, the most enduring reason polio continues in India has not been a failure to vaccinate, but a failure of the vaccine.

If the population covered by campaigns is increasing, so too is the frequency of the campaigns. Vaccinations became monthly in Uttar Pradesh, for example, in 2007 in order to cover more quickly the 500,000 children born there each month.

Although the remarkable vaccination efforts have greatly pushed down polio cases, eradication has remained elusive because eight vaccine doses or even more don’t necessarily confer immunity. In India, the number of polio cases where the individual hasn’t been vaccinated has plummeted toward zero. Instead, increasingly the victims have been vaccinated over and over—to no effect.

In most places in the world—and many places in India—the Sabin oral polio vaccine works after two doses. No one knows what makes it go awry in Uttar Pradesh and Bihar. Those states are highly populous but low in income. Overcrowding and hygiene conditions help infection spread. But the vaccine's inability to elicit immunity is thought to be a product of malnutrition, immune suppression caused by other diseases and possibly genetic factors.

The World Health Organization just closed a call for research proposals to find out why, part of an ongoing large investment in improved vaccines. Critics of the eradication program have vociferated about the oral vaccine for some years. But developing new vaccines or drugs is time consuming, costly and not guaranteed to work, perhaps explaining the reluctance to open a scientific front in the war on polio. Previously, global eradication, while hugely daunting and complicated, came down to logistical execution, will power and funding.

Bruce Aylward, who heads the eradication effort at the World Health Organization, has ample willpower, but worries constantly about finances. He has steadily forecasted the imminent demise of polio for years. To fund the pursuit of eradication, he has learned that when there’s good news, like a favorable turn in case numbers, you cash it in. Aylward told the New York Times: “We’ve never had so many things looking so positive across so many areas.” Concerning a funding shortfall, he hastened to add: “I spend as much time in donor capitals as I do in infected countries.”

Hopefully his efforts will pay off. But if eradication remains unachieved, we will almost certainly be on the verge of it—still.

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Photo credit: Jean-Marc Giboux via quilty2010, Sub-National Immunization Day. Lucknow, Uttar Pradesh

Source, 2nd graphic: AFP Surveillance Bulletin—India Report for the week ending February 6, 2010

Source, 3rd graphic: Paul, Y., Polio eradication in India: Have we reached the dead end?, Vaccine.  2010 Feb 17;28(7):1661-2.

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Related:

Polio Turns Stealthy in India (August 19, 2010)

Heavy Lifting: Raising Health Beyond Polio's Reach (May 13, 2010)

Wall Street Journal: Pulling the plug on polio eradication? (April 26, 2010)