Eradicating a disease is a bit like landing a man on the moon, or, as the Austrian daredevil Felix Baumgartner recently did, parachuting down to the earth from the edge of space and living to tell the tale: it’s a risky venture requiring single minded determination to succeed, technical expertise, generous funding and a huge helping of luck.
The global campaign to eradicate polio will require all of this if it is to succeed. The polio virus remains stubbornly entrenched in pockets of Nigeria, Pakistan and Afghanistan and the campaign is set to miss an end 2012 deadline of deadline to end transmission of the wild, or natural polio virus globally.
Eradication campaigns are the most ambitious and technically complex of global health programmes. Consider what polio eradication involves. It aims to wipe off the face of the earth the virus that causes polio . This virus is one of the most basic forms of existence on earth: a sliver of RNA encased in a protein coat, visible only through powerful electron microscopes. This speck of genetic material has to be hunted down and driven to extinction. Because it can only reproduce in human beings, if enough humans are immune to it, the virus will eventually find no place to reproduce and die out. The polio campaign’s strategy is to build enough population immunity through large scale immunization campaigns to drive the virus to extinction. But with hundreds of thousands of non-immune children born every minute in countries where the polio virus still exists, this is not an easy task.
Eradication campaigns also have to be time bound: they are expensive, high intensity public health programmes that only make sense if they meet their goals within a defined time. If they drag on too long, they pull resources away from other public health priorities.
The campaign missed its original target of 2000 and it would take a miracle for it to meet its current end 2012 deadline. What will happen after that? Will funding keep coming if there are no tangible signs of progress in these countries? Or will the polio campaign go the way of the vast majority of disease eradication campaigns that the world has seen. Ambitious programmes to eradicate malaria and yellow fever which had to be shelved when it was found that the technical knowledge of the disease that the campaign had been based on, proved to be faulty. Smallpox has been the only successful eradication campaign so far. Will polio eradication go the way of malaria and yellow fever, or will it prove to be successful like smallpox?
The polio eradication campaign argues that all that is required is a greater effort by the governments of Nigeria, Pakistan and Afghanistan to implement their polio immunization campaigns more effectively so that large numbers of children are not missed.
But it is more than a question of greater effort. Disease control and eradication programmes are not merely about health: they are also about politics and governance. Health and politics are intertwined, and global disease eradication campaigns are where the global and the local meet and often clash.
One reason Afghanistan, Pakistan and Nigeria are struggling is because the polio campaign has become enmeshed in the geopolitical fault lines of the post 9/11 world. In all three countries, the polio campaign is seen by Islamic militants and clerics as a proxy for western interests. In Pakistan, tribal leaders in North Waziristan have banned polio immunization teams from entering the province in protest against US drone attacks against suspected Taliban targets. The use by the CIA of a Pakistani doctor to get intelligence on Osama Bin Laden through the guise of a hepatitis B vaccination campaign threw a cloud of suspicion over all international immunization campaigns.
In Afghanistan many parts of the 13 districts in the southern part of the country where polio persists are no go areas for polio vaccination teams. The polio campaign hopes that importance of eradicating disease will triumph over politics and vaccination teams will be allowed to work in the midst of conflict.
This could happen, but it does not mean that local communities will embrace the idea of polio vaccination. Polio is not a major public health issue in the countries it exists in . Malaria, measles, diarrheal diseases, lower respiratory tract infections and malnutrition are the major causes of illness and death in children. Yet when their children suffer from these common illnesses, people often need to travel long distances and pay money to get medical care. In contrast, vaccination against polio is delivered to their doors free. This raises suspicion and anger: why has polio been give such priority, and if it is possible to deliver polio vaccine like this, why can’t other more urgent health care also be brought to people’s door steps?
Issues like this tend to be dismissed by the polio campaign as stemming from ignorance, and elaborate communication campaigns have devised to get people to accept polio immunization. But those who refuse polio vaccination for their children are not ignorant; they are pointing to the gap between their health priorities and health priorities set at the global level by international organisations. Polio has been difficult to eradicate partly because of this gap between local and global priorities. A key lesson for the future global health programmes is to find ways to reduce this democratic deficit between what people in developing countries feel their health greatest health needs are, and the kind of programmes that are developed at the global level by the WHO and international donor agencies.
( An earlier version of this article appeared in The Hindu http://www.thehindu.com/opinion/op-ed/polio-endgame-not-immune-to-politics/article4028364.ece)