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Statistics at left, tragedy at right Closer to victory than ever, polio eradication efforts have intensified, with 2011 bringing new initiatives and funding to most every front in the global war on the virus. The encirclement extends from presidential palaces to the streets of Luanda, Angola to tent villages on the Kosi River in India. “[T]he reach is incredible,” said Ellyn Ogden, USAID’s polio eradication coordinator, “to the doorstep of every child in the developing world, multiple times… It is an extraordinary human achievement that is hard for most people imaging in a peace-time program.”
In India, for example, an army of 2.5 million vaccinator visited 68 million homes and immunized 172 million children; the president of India kicked off the January campaign. Cumulative efforts have driven cases in India to historic lows, just 42 cases last year versus 741 in 2009.
In Africa, 15 African countries launched a synchronized immunization campaign late last year with 290,000 vaccinators targeting 72 million children. But a similar campaign took place the year before—and the year before that. Yet despite these huge efforts, polio keeps coming back. Some countries like Burkina Faso have gotten rid of polio three times.
Nigeria once exported the most polio in Africa, but record-setting progress has occurred there. However, polio has developed a new stronghold—in Angola, which has fed explosive cross-border outbreaks. This year Angola will likely be the source of one third of the world’s polios cases. Continued transmission there has caused the Global Polio Eradication Initiative (GPEI) initiative to miss a major end-2010 milestone. “Angola now is almost the most important front in the global war on polio, and the whole world is watching to see how we do here," said UNICEF Executive Director Anthony Lake. Lake visited Angola with Tachi Yamada, president of global health at the Bill & Melinda Gates Foundation, in January.
Angola freed itself of polio in 2002 only to suffer re-importation—from India. Since then, 33 vaccination campaigns over half a decade have failed to stamp out the disease. Lack of political commitment explains these failures, according to multiple sources within the eradication initiative. Angola’s vaccination rounds have been staffed to a large extent by children. Inadequate supervision has meant just a few hours of vaccinating a day, with efforts dropping off further over the course of three-day campaigns.
Political commitment now appears solidly locked in. Visiting Angola, Lake and Yamada met with President José Eduardo dos Santos. “ ‘I’ll lead the campaign,’ ” Yamada said the president told him. The following day, Angop, the state-run news agency, ran the headline “Head of State committed to eradication of polio.” Subsequent news releases showed a domino effect down the political chain of command from the vice-president, to governors, to administrators of individual districts. One release identified a district manager by name and as acknowledging “the availability of the necessary conditions for vaccinators to reach all areas of the district,” likely coded language for placing direct responsibility on the manager for ensuring vaccination of the 156,000 children under five in that district.
The World Health Organization (WHO) places equal emphasis on community involvement in its formula for effective immunization campaigns. In the past, vaccination plans have been centrally created and handed down for execution. WHO finds that the best “microplans,” which map out block-by-block strategies and awareness efforts, are developed by the communities involved. In this way, “communities hold themselves accountable,” as Tim Petersen, a program officer at the Bill & Melinda Gates Foundation, puts it. Angola conducted a three-day polio vaccination campaign, February 23-25, across five high-risk areas of the country. A WHO spokesperson said the new decentralized planning led to some “hiccups” in execution. A report from independent monitors, expected in about a week, will reveal the quality of the campaigns which aim to immunize 90% of children under five. [Note: I attempted to travel to Angola to cover the vaccination campaigns but was not granted a visa. The Angolan consulate in New York informed me four days before my flight that the signature page of my application was “missing,” that my letter from WHO did not meet requirements for documentation related to the purpose of travel and, still less plausibly, that the consulate had been trying unsuccessfully to reach me concerning these problems.] High risk areas will be covered twice more in upcoming nation-wide vaccination campaigns. However, “It is clear that Angola has a tough few months ahead,” says Sona Bari, communications officer for polio at WHO. But Angola has beaten polio before. Today cases are relatively few, at about 30 a year, certainly in comparison with 1999 which saw more than 1,000. Also, the intensity of transmission is much lower in Angola than that faced by, say, India.
While political commitment seems to be in place, stability might be an issue. Some political tremors from Tunisia and Egypt have reached Angola, such as a call for public protest on March 7. (Recently Angola was without internet access for about two days which state media attributed to a cut cable.) Prior to the 7th, US State Department spokesperson Hilary Renner said she was not aware of “significant demonstrations in Angola.” The Associate Press report on turn out and reaction on the 7th suggests revolutionary force so far is not strong.
Rest of the World: Key Fronts The eradication initiative must close out the major global sources of polio, India and Nigeria. India is closer to the goal and mostly needs to sustain its exertions. Nigeria trails but has made enormous progress; there are risks but today the country is essentially on track. If Angola too has turned in the right direction, Pakistan becomes the next focus.
Pakistan presents almost all possible obstacles to polio eradication. Like India, the oral polio vaccine in Pakistan fails to immunize among a significant number of children, usually under conditions of very low health and hygiene. Some parents in Pakistan refuse to allow their children to be immunized, a problem also once seen among Muslims in Nigeria who feared the vaccine had been purposefully tainted.
Much of Pakistan’s polio burden falls on border states with Afghanistan where security issues prevent vaccination teams from operating. The virus travels to more secure areas of the country where poorly run, corruption-riven vaccination campaigns fail to stamp it out. Even the house of a former minister of health was bypassed—twice—by polio vaccinators. “I had to call them to get my kids vaccinated,” reported the former minister.
Pakistan’s political stability is low. Natural disasters—huge flooding—have made a difficult situation worse. Last year saw a jump to 144 cases, up from 89. And so far in 2011, cases are accumulating more rapidly. Fortunately, the Pakistan/Afghanistan polio complex has not exported the virus to the rest of the world—so far.
Pakistan figured prominently in the careful eradication orchestrations of early 2011. Bill Gates met with President Asif Ali Zardari on January 15th. On January 25th, an emergency plan to immunize 32 million children was announced. The same day brought a joint announcement of $100 million in funding from the Gates Foundation and Mohammed bin Zayed Al Nahyan, crown prince of Abu Dhabi, to support vaccination efforts, with $34 million earmarked for polio immunization in Pakistan and Afghanistan.
Afghanistan offers ample challenges, including security problems. However the absolute number of cases, about 30 per year, is not extreme. Described as a “pretty strong program” by the Gates Foundation’s Tim Petersen, the Afghan polio eradication team appears to already enjoy the confidence of the members of the global eradication initiative. The least controlled polio rampage is taking place in the Democratic Republic of Congo (DRC). Cases last year exploded to 100 versus three in 2009. The DRC and its northeastern neighbor, Angola, comprise an epidemiological block like Afghanistan and Pakistan. There is “huge cross-border traffic” between Angola and the DRC, according to Apoorva Mallya, a program officer at the Bill & Melinda Gates Foundation. A lack of roads and transportation infrastructure greatly complicate operations. For example, biological samples from possible polio victims sometimes must be floated down the Congo River en route to a lab for analysis.
The eradication initiative is looking at “local, local solutions,” according to Mallya. At the same time it seeks high level political commitment, just as in Angola and indeed all countries. WHO Director-General Margaret Chan travelled to the DRC in February to meet with President Laurent Kabila. UNICEF’s Anthony Lake then visited in in the first week of March and called for “an absolute commitment” to vaccinate every child.
New Trends in Media Coverage
The front in the polio war has been discouragingly broad and variable. Countries have been won and lost—some more than once. Low numbers or even single cases perpetually spatter the map. Gabon just reported a case, its first in more than ten years. Seemingly safe areas like Tajikistan and Congo have recently seen blowout epidemics. Transmission has become fully re-established in four African countries, not only Angola but also, for instance, Chad. Total cases globally have rarely dipped under a thousand a year over the last decade, giving rise to the view that this “last one percent,” like Jell-O, will squish somewhere else no matter how hard it is squeezed.
But the polio eradication initiative has focused on choking off the sources, following the strategy of von Clausewitz, who in, On War, recommended subduing the enemy “center of gravity.” In polio, that’s India and Nigeria. No other countries come close in polio burden. It’s not over, but India is astonishingly near to eliminating polio. The states of Bihar and Uttar Pradesh, where polio has been worst in India, haven’t seen a single case in six months. Among much else, this required tracking and immunizing enormous mobile populations. As many as six million people are on the move each day, according to a WHO estimate, with accessibility complicated by flooding of the Kosi River in Bihar. In addition, India’s eradication effort has overcome vaccine failure by achieving very high levels of population immunity: the virus basically can’t penetrate the thicket of immune people to access the vulnerable, those children in which the vaccine didn’t take.
The Associated Press recently recognized these developments in "India brings hope to stalled fight against polio." ABC News posted a story in which progress in India provides hope for polio becoming “just the second disease to be wiped off the planet since smallpox.” (ABC News received $1.5 million from the Gates Foundation to support a television series on global health, making the representativeness of their current coverage more difficult to ascertain.)
Most recently, The Globe and Mail ran a polio package driving off successes in India, saying “Polio is all but gone from India…” (I have written to similar effect in Scientific American.) One article is entitled: “Anti-polio battle on verge of victory.”
No country has been as difficult as India. The obstacles in the countries of the rest of the world are largely different combinations of known problems which have been surmounted somewhere already. Polio has been expunged from anarchic, conflict-ridden states like Somalia. Rejection of vaccine by parents on cultural or religious grounds has been overcome in Nigeria. The quality and coverage of vaccination campaigns has been lifted even amidst rife corruption. Clearly, however, past performance doesn’t guarantee future results. Completely novel problems could arise. Failure on one or more of the numerous fronts in eradication is likely; compound failures could wreck the broader enterprise.
However, while feasibility remains an issue, coverage appears to be shifting—to whether the polio “endgame” can be won. The wild poliovirus is not the only threat to eradication. Very rarely, the oral polio vaccine, which uses a live attenuated virus, mutates into virulent form. Thus, in a sense, the eradication effort is fighting fire with fire, as a recent op-ed piece in the Los Angeles Times points out in “The Polio Virus Fights Back.” Not long after, Myanmar reported just such a case of vaccine-derived poliovirus. These mutants can—and have—spread. So far no related cases have been reported because the vaccine protects against it. And in Myanmar, “Immunization demand is high and the country conducts good quality campaigns,” according to WHO’s Sona Bari. In India, where oral polio vaccine dosing has been most intense, 2010 saw only one case of vaccine-derived virus. Rightly, however, the subject will likely gain in prominence in media coverage.
Not only has the nature of feasibility questioning changed, shifting to whether the next phase can be won, the position of arch critic of eradication now appears to be open. Donald Henderson played a key role in smallpox eradication but has long been skeptical of polio eradication. According to a January Seattle Times article, however, Henderson changed his mind six months ago and now believes polio could be eliminated. But not long after, The New York Times cited Henderson as a vehement critic of eradication. In mid-February, however, they ran a different story, Can Polio Be Eradicated? A Skeptic Now Thinks So, which (re-)disclosed that Henderson had changed his mind. The title of the earlier article in which Henderson was a critic also appears to have been changed online from “Critics Say Gates’s Anti-Polio Push Is Misdirected” to “Gates Calls for a Final Push to Eradicate Polio.”
At present, this leaves only the desirability of polio eradication in question. While no one argues for polio, there are other diseases which are more widespread, taking more lives and causing greater suffering. According to The New York Times, Richard Horton, editor-in-chief of The Lancet tweeted that: “Bill Gates’s obsession with polio is distorting priorities in other critical [Bill &Melinda Gates Foundation} areas. Global health does not depend on polio eradication.”
The Gates Foundation, however, embraces the accusation. “We are overemphasizing polio,” says the foundation’s Tachi Yamada. Polio became the foundation’s number one priority late last year. And it’s not just Bill Gates or his foundation. In 2008, WHO Director-General Margaret Chan said “I am putting the full operational power of the World Health Organization into the job of finishing polio eradication… I am making polio eradication the Organization’s top operational priority on a most urgent, if not an emergency basis.”
But the emphasis on polio is indeed disproportionate. Both the Gates Foundation and WHO recognize that eradication would not just rid the world of a horrific disease: it would be a giant symbolic victory for global health. Chan, in her 2008 speech, also said “We have to prove the power of public health,” a goal which eradication would achieve. Similarly, Gates Foundation’s Yamada doesn’t want to give “fuel to cynics” by having eradication fail but instead to demonstrate that “this is what development assistance can do.” Returning to the matter of eradication critics, The New York Times also quoted bioethicist Arthur L. Caplan, a professor at the University of Pennsylvania as saying “We ought to admit that the best we can achieve is control.” In June, 2009, Caplan wrote an opinion piece in The Lancet entitled, “Is Disease Eradication Ethical?” Caplan wondered if eradication was possible since it hadn’t worked after more than two decades of effort. The financial cost was high and diverted resources from better, more life-saving uses. Caplan declined to comment for this article. However, questioning eradication as a strategy in global health, as polio demonstrates, is a worthwhile endeavor. And if polio resurges, so will skepticism of eradication. Space Race to Human Race The upcoming retirement of the Space Shuttle likely will attract enormous coverage. The Shuttle is not being replaced, however. And there are currently no plans for even a single human to permanently leave the planet. Still, the expectation of a spacefaring humanity persists although the 1960s might remain the golden age of manned space exploration. In other words, the world has missed that the next giant step for humankind will take place on planet earth. The polio eradication effort might actually be larger than the Apollo program. Already in India, the number of cases can be counted down to zero; other countries might follow. It’s a good story.
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