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Eradicating Polio: Challenges And Questions



February 16th, 2011

    Editor’s Note: The Bill and Melinda Gates Foundation and other global health leaders recently launched a new effort to eradicate polio. Below, Judith Kaufmann comments on the potential rewards and the risks of this new initiative, and in another post Scott Barrett offers his thoughts on the new initiative as well.

    On January 31, Bill Gates introduced his 2011 Annual Letter.  He chose an appropriate site, the home of Franklin Roosevelt in New York City, as much of the letter is devoted to ending polio. 

    The release followed the January 28 announcement by UK Prime Minister David Cameron at Davos, with Bill and Melinda Gates by his side, of a doubling of the UK commitment to the eradication of polio.  The commitment is structured as a matching grant:  for every $5 pledged by others from 1 January 2011 to 31 December 2012, the UK will increase its support by $1, up to a maximum additional amount of £40m (about $64,400,000).  In addition, on January 25 Bill Gates announced a $100 million collaboration with the Crown Prince of Abu Dhabi to purchase and deliver vaccines, including oral polio vaccine, to Pakistan and Afghanistan.  And, after a January 24 meeting with Bill Gates, Pakistan’s President Asif Ali Zardari announced the launch of Pakistan’s National Emergency Plan for Polio Eradication, supported by the Bill and Melinda Gates Foundation.

    All of this is welcome news.  We in the West tend to forget that too many around the world are still sickened and die of diseases we rarely, if ever, see.  Mr. Gates has not only put his money into the eradication effort, he has put his considerable influence and prestige.  His meetings with Northern leaders in Nigeria were an important step in rebuilding the polio eradication effort there after the disastrous boycott of 2003-2004.  He is a tireless advocate, using his extensive network of contacts to build political support. 

    What The Gates Letter Says

    The Gates letter:

    • Points out that since the goal of eradication was agreed to in 1988, cases have declined from 350,000 per year to fewer than 1,500 in 2010.
    • Notes that Nigeria, India, Pakistan and Afghanistan are the only countries where transmission of polio has never been interrupted and where the disease is considered endemic. 
    • Cautions that eradication is not guaranteed and that funding is critical to success.  The 2011-12 funding gap is $720 million.
    • Outlines the benefits of eradication, including that no child will die or be paralyzed from polio, that there will be long-term financial benefits, and that success will energize the field of global health.
    • Underscores that eradication “is a global project requiring every country to do its part,” including countries that have been polio-free and have grown lax about vaccinations.

    Mr. Gates’ letter rightly acknowledges the setbacks, including the interruption in the Nigeria campaign in 2003 and the fact that the majority of polio cases in 2010 were in countries that had previously been polio free.  Of the 946 confirmed cases in 2010, 568 were in non-endemic countries –458 of those from a single importation outbreak in Tajikistan.  (Another 540 suspected cases in previously-polio-free Congo have not yet been confirmed.)

    Challenges To Eradication Remain

    But the world has believed before that we were on the verge of eradicating polio, and each time the virus has shown the international community a new trick.  The endgame will not be easy.  As Donald McNeil wrote in the New York Times on January 31, eradicating the last one percent of cases has been “like trying to squeeze Jell-O to death.”  It is not likely to get any easier despite considerable success in the endemic countries last year. 

    In the July/August 2008 issue of Health Affairs, Scott Barrett wrote about the need to strengthen what he called the “weakest links”.  All ten of his weakest links are well known to the global Polio Eradication Initiative.  And the good news is that energetic efforts are underway to address them.

    • There is an active research agenda and an ongoing effort with vaccine manufacturers to develop guidelines on containment and alternative vaccines.
    • There is greater focus on sustaining population immunity in polio-free countries while improving immunization coverage in the remaining limited areas of polio virus circulation.
    • Even as the virus struggles to survive, the global polio eradication program is fine-tuning its ability to respond quickly to importations and putting management systems in place to improve the quality of every round of immunization. 
    • Similarly, efforts are being made with local leaders to gain access to children in conflict areas.

    Importantly, the Global Polio Eradication Initiative has established milestones in its 2010-2012 strategic plan to stop transmission in re-infected countries and in two of the four endemic countries by 2011, and in the two remaining endemic countries by 2012.  The international community is rallying behind these milestones, and an Independent Monitoring Board has been established to track progress and provide recommendations to stakeholders.

    Unanswered Questions

    The attention being given to these issues is vitally important and will yield important results.  But there are other issues that deserve attention and discussion.

    First, while current estimates are that less than five percent of the children missed in polio immunization campaigns are due to vaccine refusal, the Nigeria example shows that community sentiment can be volatile.   Canadian journalist Jonathan Kay pointed out in a recent meeting I attended that accepting immunization is “an act of faith.”  One has to believe that there is a need and that the vaccine is safe.  Vaccine acceptance implies trust in government (notably lacking in the Nigeria case in 2003, for example).  The growth of the Internet and social media allows positive messages to be shared about vaccines, but it can also spread conspiracy theories and fan distrust.  While much has been done to improve communication, awareness and demand for immunization generally, we have seen that a small but vocal minority can derail polio and other immunization efforts.  Work needs to continue with countries and community leaders to better understand the differing realities in each of the remaining polio endemic areas and devise new strategies to respond to changing circumstances on the ground. 

    Second is the question of what to do if despite our best efforts the goal of 100 percent eradication remains elusive.  This is a question that is implicit in the on-going discussion of whether control is a feasible strategy.  Reducing the number of cases by 99 percent is a public health success story of major proportions.   There continues to be incremental progress in reducing the number of cases, especially over the last year, and there is every reason to believe that more progress can and will be made.  But experience to date offers no guarantee that the remaining obstacles to success – technical, political and social – will be surmounted.  Is there a point beyond which the goal of total eradication is no longer worth the cost? How should that point be determined, and by whom?  To be replaced by what?  As the disease disappears, the pressure to shift attention to other important health issues increases.  Merely leaving it to the donors to decide with their dollars, through shifts to other health priorities, would be neither rational nor desirable, but that is what could happen.    

    The polio eradication campaign promises enormous benefits –   to the children who are not paralyzed, to their families who will not need to take care of paralyzed children, and to communities that will be spared the cost of treatment.   The work that has been done and is being done in polio eradication is helping in other ways.   Countries are increasingly using the mapping and surveillance data to support other immunization and disease control efforts.  Lessons are being drawn for other global health efforts about how to build coalitions and how to adapt strategies and operations in response to changing circumstances.  For these successes and many others, the world owes an enormous debt to the Bill and Melinda Gates Foundation, and to the legions of dedicated people around the world who devoted themselves to this life-saving campaign.

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