India triumphs over polio

A two-woman vaccination team in Firozabad, Uttar Pradesh, (Photo: UNICEF)

From my article on Ars Technica:

In the year since January 13, 2011, India has had zero cases of polio. Previously, India led the world, accumulating over 5,000 cases since 2000. Polio's last victim in India was 18 month-old Rukhsar, a girl in West Bengal who began showing signs of paralysis on this day in 2011. Now, epic immunization efforts have brought global eradication of the disease a giant step closer. Outside India, however, backsliding Pakistan and Nigeria and splotches of polio across Africa have blocked the final stamping out of the disease worldwide...




Globe-spanning effort tightens vise on polio; eyes on Angola

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.

NYT Mistaken on Polio Eradication Feasibility

Whether polio eradication should be pursued or whether it is central to global health are questions that should be and are asked by The New York Times in “Critics Say Gates’s Anti-Polio Push Is Misdirected.” However, the Times also contends that “Victory may have been closest in 2006…” when victory may be closer now than ever before. And the latest blast of polio funding and initiatives, described by the Times, comes not because the eradication effort is on its heels but because it’s going for the kill.

Eradication hinges less on the number of countries suffering polio cases than on knocking out the sources—or “reservoirs”—of the disease. The two largest such reservoirs are India and Nigeria. Today, both countries have historic, record low cases. The Times describes this as “doing much better.” Perhaps also underappreciated by the article, wiping out the reservoirs of polio will stop outbreaks. The Times mentions outbreaks in Nepal, Kazakhstan, Tajikistan, Turkmenistan and Russia. All originated from India.

Further, the case of India seems to demonstrate that there are no scientific or technological barriers to eliminating polio. In particular, the Indian states of Bihar and Uttar Pradesh once were the most impregnable redoubts for the poliovirus anywhere on the planet. Yet, because of the huge expense and exertions described by The New York Times, Bihar and Uttar Pradesh saw nearly zero cases even during the “high season” for polio. (See my Polio in Retreat: New Cases Nearly Eliminated Where Virus Once Flourished.)

In Africa, Nigeria has been the most intractable polio problem. No sooner is eradication on track in that nation, than new sources—Angola, Chad, Congo and Sudan—arose to continue infecting the continent. Indeed, Angola and Sudan have even reverted back into polio reservoirs, the disease spreading within and across borders. The Times properly draws attention to this indisputable, highly problematic regress. But the obstacles to eliminating polio in Angola do not compare with those of India where the degree of difficulty approached near impossibility. And Angola has gotten rid of polio before. How did it come back? Cases imported from India, a reservoir now drawn down to historic lows.

The New York Times represents a crucial exception to the influence of the Gates Foundation on global health coverage. It is important to question whether, in retrospect, polio eradication ought to have been undertaken, given all the costs. Also, whether today polio ought to be treated as the number one priority in global health is likewise a valid inquiry. And the Times is right that the Bill & Melinda Gates Foundation has doubled down on polio eradication several times before in the aftermath of setbacks to the program. However, the recent slew of polio announcements and initiatives is not in response to setbacks. It’s to unload a knock-out punch while the opponent is staggered. It might work.

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.



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 The map for 2009 is for illustrative purposes. It shows only half of 2009's cases with little fidelity to actual location.



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)