The week of December 17 was a grim one for the polio eradication effort in Pakistan. Seven Pakistani women health workers and two Pakistani men, all working to ensure the success of the polio campaign, were killed, presumably by members of the Pakistani Taliban. This is a tragedy, for the families of those killed, for the children who will go unvaccinated after the government’s suspension of the vaccine campaign, and for the effort to eradicate polio worldwide. Pakistan is one of only three countries remaining with endemic wild polio virus (the others are Afghanistan and Nigeria). It also had turned a corner in its efforts, with only 56 confirmed cases of polio caused by the wild virus this year, down from the 175 confirmed cases at this time last year.
One observer said, “In the same way that the northern-Nigeria boycott was a game changer, I think this is.” She was referring to the 2003-2004 boycott of polio immunization in parts of Northern Nigeria that led to the spread of polio to previously polio-free countries. Clearly, the suspension of the polio vaccination campaign in Pakistan following the killings is a setback. The real question is: Where does the global eradication program go from here?
In its November 2012 report, the Independent Monitoring Board (IMB) of the Global Polio Eradication Initiative (GPEI) suggests that, in addition to planning for the final push (the so-called endgame), the GPEI also must engage in contingency planning. They suggest two scenarios that require such thinking:
- What happens if only two of the three endemic countries succeed in interrupting polio transmission (interruption means no new cases for a year; eradication is certified after three years without a confirmed case of polio caused by the wild virus)? While they may have been thinking of Nigeria as the possible unsuccessful country, Pakistan must now be considered, as well.
- What should the priorities and contingencies be if funding for the next six years falls short of the $5.5 billion dollar estimate of needs? If eradication efforts fail again, this scenario becomes even more likely.
Engaging in contingency planning is not to give in to pessimism about the chance of success in eradicating polio; rather, it is a sign of realism, and of a firm determination that everything will be done that can be done to achieve eradication. To take on a task as big as polio eradication requires a healthy dose of optimism. Fund-raising also requires a sense that the goals can be achieved. However, it is possible to be optimistic and realistic at the same time, as the IMB shows.
The importance of new voices. It is time for the GPEI to take seriously other IMB recommendations, not only at country level, but at the global level. Accountability and transparency must begin at the top. It is no longer sufficient or prudent to leave both decision-making and oversight in the hands of the same small group of founding partners. This is not to take away from the commitment of the spearheading partners, nor their ability to adapt to new circumstances. The IMB, the Strategic Advisory Group of Experts on Immunization (SAGE) and the Global Partners Group offer independent opinions on what changes are needed. But, to ensure that we achieve the final goal of polio eradication, new voices must be heard.
One suggestion would be to enlarge the circle of those with a voice and a say in planning, to include social scientists. The challenges that remain are not only medical and technical. In Northern Nigeria, and now in Pakistan, they are political, social, cultural, and economic and require a new lens on how they can be overcome. Central governments are often viewed with mistrust in the remaining endemic areas and among the marginalized groups that are often the hardest to reach. This also suggests that the current international partnership, with its Western predominance, should be expanded to include those who can better gain the trust of the parents and communities where polio remains. As the IMB said in October of 2011, “The Programme (sic) cannot afford to limit the scope of inputs from which it learns.”
Emphasizing the quality of immunization campaigns, not their frequency. The IMB has made other suggestions that should be seriously considered. They point out that frequent campaigns lead to fatigue, with parents and communities questioning why these interventions are necessary, and reducing the time between campaigns that could be used to improve quality. Yet, the draft “endgame” strategy calls for a continuation of frequent immunization campaigns. What has worked so well in the past may be counter-productive to achieving the final goal. Quality over quantity should be the watch-word.
The IMB also proposes that whenever possible polio immunization activities be paired with other health interventions. This may mean subordinating polio to other health activities in order to reach more children, which would also contribute to the goal of interrupting transmission. There has long been a debate about whether polio eradication efforts have helped or hurt routine immunization. It is time to realize that both are necessary and that each can and should facilitate the other, helping children generally.
We are so close to eradicating polio. All but 0.1% of polio has been eradicated globally. Thus far in 2012, there have been 214 wild polio cases confirmed, compared to 585 at this time last year. Of the three endemic countries, only Nigeria saw an increase in cases this year. India, a country some felt might never interrupt transmission, has been polio-free for almost two years. But, as the IMB says, polio resurges more easily than it is contained. There is a real possibility of more cases in 2013 than in 2012. The killings in Pakistan should not lead to pessimism about achieving the end goal of eradicating polio for all time. But the victims should be honored with a thorough re-think of how that goal can best be achieved.