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Can We, Should We Really End Polio?
This post was originally produced for Forbes.
For the past week, I have been a guest of Rotary International here in Ethiopia to participate in and observe an expedition of U.S. and Canadian Rotarians and friends of Rotary (I am a member of the Salt Lake City Club) to support the National Immunization Day for polio. The lessons from this effort for social entrepreneurs and other change agents are important.
The opinions and conclusions of this article are, of course, entirely my own.
The group of 35 North Americans who came to Ethiopia have been received almost as heroes. President Mulatu Teshome, elected Ethiopia’s president in 2013, took time to meet with a subset of the group that included me; our visit with the President and our efforts to eradicate polio were the subject of a four-page story in the local paper. While we as a group immunized only a few hundred children, we brought attention to and helped to reinvigorate the effort to vaccinate every child in Ethiopia last week.
Rotary team meets with Ethiopian President Mulatu Teshome
Ethiopia was declared polio free in 2001, but recent outbreaks in Somalia have led to 10 cases of polio in Ethiopia over the last 24 months, the last of which was in January of 2014. The country is still on high alert, hoping to quickly eliminate the virus not only from the country, but from the continent and then the world.
According to the Global Polio Eradication Initiative or GPEI, there have not been any documented cases of wild polio virus in Africa in the last 90 days on the entire continent. That said, James McQueen Patterson, with UNICEF, told us during our visit that real or potential gaps in surveillance mean that no one should start celebrating until at least six month after the last reported case.
Even as Africa seems to finally be getting a tight grip on polio, things are going badly in Pakistan, with 235 cases so far this year, more than any year since 1998. Many of the Pakistan-originating cases end up in Afghanistan, so it too is reporting cases.
Ever since the U.S. identified and killed Osama Bin Laden in Pakistan, the Taliban there has forbidden children in regions it controls to be immunized and a reported 60 health workers and their security have been murdered in the effort to immunize children there.
Rotary’s Polio Plus Chair in Pakistan, Aziz Memon, explains, “The Taliban in Pakistan oppose polio vaccination after the CIA’s undercover agent Dr. Shakeel Afridi was responsible for locating Bin Laden’s hideout using a fake campaign. It jeopardized the work of many International NGOs and humanitarian workers. The ban imposed on North and South Waziristan in June 2012 by the tribal leader Hafiz Gul Bahadur caused some 350,000 children to be deprived of vaccination for a period of almost 2 years. However, there are other tribal leaders in the Pushtun belt where polio vaccine is riddled with misconceptions and myths some of them range from reason for refusals as stated: cause of infertility, not halal (kosher), contains pig fat, against religion, [and] vaccines cause harm.”
This begs the question, can we ever expect to get polio eradicated from the planet? Won’t there always be someplace on the globe where we simply can’t make people accept the vaccine?
Let’s take a look at that these questions together.
There is no question that eradicating polio will be difficult, so it is fair to ask whether or not the dread disease can actually be eliminated.
The premise for eradicating polio is actually rather simple. The virus lives only in humans and in no other species. You can’t get polio from a pig, a monkey or any other critter. While it can and does live outside of a host for some time, no animals except humans are at risk of getting polio. So eradicating polio is theoretically not that difficult. If every child is immunized no one can get the disease and the virus will be extinct.
That’s why Rotary tackled the problem in the first place; it looked distinctly possible even then. Looking back, Rotary was perhaps naïve, thinking in 1988 that polio could be eradicated by 2005, the organization’s 100th anniversary. Naïve maybe. Optimistic, no doubt. But that naiveté combined with help from the U.S. Centers for Disease Control, WHO, UNICEF and more recently the Bill and Melinda Gates Foundation and participating governments around the world, have brought us to the brink of the disease’s extinction.
The virus, which causes paralysis in children, once caused about 400,000 cases per year. In 2013, there were only 416 cases of wild polio on the planet, meaning that we have reduced the number of cases by 99.9 percent.
The last cases will be the hardest to eliminate for political reasons more than biological. Ebola is stealing lots of attention—for good reason—from the polio fight, but that puts the polio work in West Africa at risk if just one outbreak occurs there in the coming months.
We’ve already talked about Pakistan where the number of cases of polio are actually increasing rather than decreasing.
Even give those concerns, being here on the ground in Ethiopia and having participated in and observed the effort on the ground in India in February, it begins to make sense.
In the developed world, there isn’t much of a dedicated polio infrastructure. Virtually all children are immunized routinely shortly after they are born and there haven’t been cases of polio in most of the developed world for decades. It is hard to imagine or even understand the scale of the global polio infrastructure.
In the developing world, there are places where the only contact poor villagers have with the outside world is a polio health worker or volunteer coming in to immunize a child. There are on the order of 20 million volunteers working on polio eradication around the globe. The Global Polio Eradication Initiative partners mentioned in this article have spent billions of dollars and anticipate spending another $5.5 billion in what they call the “end game strategy.”
Here on the ground, I can tell you first hand that they aren’t merely throwing money and volunteers at the problem in a brute force effort, rather they are working with increasing sophistication to reach every last child and to monitor every case.
Using genetic testing, every case of polio can be traced to a strain to know exactly where it came from, allowing everyone to trace people and provide immunizations around people and communities at risk. By combining focused immunization campaigns in at risk communities with nationwide efforts to immunize every child in a country multiple times per year, the disease can be defeated.
In Pakistan, where much of the polio world’s attention is now focusing, every possible tactic is being used. Permanent immunization clinics along with national immunization days and new applications of technology that allow health workers with simple cell phones to text data to central repositories to accelerate surveillance responses to neighborhoods and villages with outbreaks.
Furthermore, in the North Waziristan region of Pakistan controlled by the Taliban, people have been allowed to leave the region. Hundreds of thousands of people have done so. Their children are being immunized at check points there as they leave the region, so thousands of previously unvaccinated children are now being vaccinated.
Aziz Memom, Polio Plus Chair, Pakistan
Memon explains further, “Our social mobilizers at the Resource Centres, the UNICEF mobilizers and the Provincial Government are constantly holding community meetings, workshops, seminars, Ulema conventions, encouraging renowned scholars and religious leaders to hold International Conferences and issue ‘Fatwas’ (decrees) on the safety of polio vaccine. These leaders from around the world gather at International forums to spread the word to mobilize other religious clerics to pass these Fatwas to Ulemas at grass roots through mosques and madrassa’s. The incidence of refusals have reduced considerably, but a constant reminder is necessary for recall.”
Additionally, just this week, the AP reported that the government of Pakistan is stepping up its efforts. One new initiative is a law that makes it illegal for a religious or community leader to prohibit members of their communities from receiving vaccinations.
Having witnessed the challenges and the success in both India and Ethiopia, I conclude that we certainly can eradicate polio. While there may be a few dozen recent cases in the world, there are huge investments of time and resources being deployed to those communities to extinguish the outbreaks. Just as the disease was improbably eradicated in India, it can be done in Pakistan, Afghanistan and Nigeria—and in the other countries where it has resurfaced in recent years.
Not only can it be done, it can be done soon. In India in 2009, there were 741 cases. The following year, there were just 42 and the last case in India was in January of 2011. When the political will exists, the resources will be found to end polio and there is no reason to believe that can’t happen in 2015. If it does, the WHO will certify the world polio free in 2018 and we can stop immunizing children against polio and put those resources to work on ending another disease.
Given the difficulty and the cost of polio eradication, some have asked if we shouldn’t just be happy with the 99.9 percent progress we’ve made. Should we make the final push to eradicate polio?
The Gates Foundation looked at the financial aspects of this question to determine if the rather expensive end game strategy has a positive return on investment or ROI. The Foundation concluded that certainly it does.
In a world where polio continues to impact hundreds of children each year, not only do we need to continue to immunize every child in the world against the disease, but we need to provide expensive, lifelong care to those who are crippled by the disease. This virtually ignores the fact that some children will die from the disease and the world loses their potential contributions permanently.
Don’t forget that the rate of immunizations in the U.S. has fallen in recent years. As the world shrinks effectively, drawn closer by technology and increasing global affluence allowing more and more people to travel around the world, American children are at serious risk of getting polio.
The Ebola epidemic today is a reminder that allowing a terrible disease to persist in impacting a few people each year simply because it doesn’t impact a lot of people is a not a strategy at all.
We owe it to the world to eliminate the risk of disease that we can eradicate. How would we explain to the hundreds of children impacted by polio each year in the future that we simply don’t care enough about them to do the hard things required to protect them.
The fact of the matter is that the resources are largely there. A funding shortfall of $600 million in the total $5.5 billion end game strategy is all that stands between us and polio eradication. That, and a bit more political will.
We can do this. We should do this. In fact, we must.