World Polio Day: Why the disease persists, 18 years after the WHO deadline to eradicate it
In 1988, the World Health Organisation (WHO) announced an ambitious campaign to rid the world of polio by 2000. It’s 2018, and polio still persists in pockets, including cases of vaccine-derived polio in India.
In 1988, the World Health Organisation (WHO) announced an ambitious campaign to rid the world of polio by 2000. It’s 2018, and the disease still persists in pockets, including cases of vaccine-derived polio in India. Though it is no longer a major health hazard, the campaign continues to cost about a billion USD annually. So why did the campaign fail to achieve its target? In his new book Polio: The Odyssey of Eradication, journalist and academic Thomas Abraham looks at what went wrong; from the assassination of vaccinators, to resistance from parents, to how it became a casualty of geo-politics in the post-9/11 world. Abraham, who was previously editor of the South China Morning Post and worked at the United Nations, spoke about the campaign, the disease and the vaccine, on the sidelines of the Global Investigative Journalism Network’s third Asian Investigative Journalism Conference in Seoul.
Following are the edited excerpts from the conversation:
How did this idea to look at this campaign start? And what in essence led to the campaign’s failure?
The polio programme started in 1988 and it was to end in 2000. Now it is 2018 and it still hasn’t finished. The obvious first question is why has it taken so long? That was one interesting question that in turn led to a whole bunch of other issues. The three remaining countries in 2011 (which still had polio) were India, Pakistan and Nigeria. War and conflict was one issue, lack of confidence was another.
Eradication, if you look at it from a scientific point of view, is like a moon shot; putting a man on the moon. What eradication means is ending a disease permanently by removing the cause of the disease. And in polio, the cause is a virus. You are trying to drive that to extinction, globally. That itself is an amazing thing. Even for human beings, it is hard to drive other life forms to extinction. And you are trying to drive it to extinct through a vaccine. Lots of questions jump up when you start travelling. First of all, why was polio chosen for this? Polio is a global programme, the vaccine was coming straight to people’s doorsteps. You didn’t have other health services, instead, you are having these repeated doses of polio vaccines. So parents started shouting and saying 'when our kids are dying of other things and we can’t get any medicine for that, and we have to pay for this stuff... all you are giving us is for polio'. And polio, to be honest, was a really, really small cause of childhood death. So there was a natural pushback. From India, it started in the 2000s.
The old polio vaccine was amazing but it was not as effective in tropical conditions where you have a high population density. It can persist for a long time along with poor sanitation. This was what was happening in India and Pakistan. The vaccine didn’t work that well so it needed repeated vaccination campaigns. That led to certain suspicions.
In Nigerian Muslim communities, there was also a rumour that the polio vaccine is the West’s revenge for 9/11. They don’t care about your kids, they want to make sure all kids are sterile. This brings us to Pakistan and Afghanistan where the polio campaign fell into this crevasse in the global divide that opened up after 9/11 between the West and parts of the Muslim world.
How did that happen?
In parts of Pakistan, you had American drone attacks, and the Taliban figured this campaign is important to the government and the Americans, and said unless you stop the drones we won’t allow vaccination here. This was around 2007. Another thing was the Talibanisation of the north-west frontier meant that women polio workers were being targeted. And unless you have women vaccinators it’s difficult to get access to homes. Prominent mullahs were doing propaganda against the vaccine. That was part of it. Why did it go so wrong, why it has taken so long? These are all the things: bad vaccines, lack of demand, geopolitics.
Though the campaign wasn’t fully successful, it succeeded to a very large degree, isn’t that correct?
Oh yes. But the aim wasn’t to succeed to a large extent. So the question was, should we have tried to eradicate the disease or bring it to a manageable level? But here you decided the aim is to bring it to zero and make sure there is not a single exemplar of poliovirus in nature. And you can’t step away.
Why was 2000 chosen as the cut-off date?
They thought it would be an easy thing. And eradication programmes need to be time-bound, because they are very intensive. In eradication, as opposed to a vaccination programme, you put a lot of effort for a short period of time and wipe it out permanently. But if it persists and you put this huge effort year after year then the system breaks down, nobody can afford it any more.
How did you approach the writing? Did anything surprise you or were there any assumptions that were overturned in the process?
It took about five years to report and write. The story kept changing. As you dig deeper, the story becomes more complex and more interesting. The whole thing is a learning process. Why were vaccinators being assassinated? Why are rational parents refusing vaccination? Once you start with these questions the answers get a lot more interesting. If you don’t ask the questions you don’t get the answers.
You also mentioned the ethical dilemma in a campaign such as this – when parents are resistant, for instance.
There is a huge ethical dilemma. For examples, parents were threatened with jail in Pakistan. That would be completely unacceptable in other parts of the world. Why do you have two standards? Then this idea of informed consent ingrained into medical practice. Here there was no consent, informed or otherwise. Do parents know the risk? In the United States there was a compensation programme because there is a known risk [of vaccine-derived infection]. Another ethical point, if vaccinators are getting killed is it worth an adult human life to save a child from paralysis? Where does the balance lie?
Is eradication the only way to approach a public health issue?
Only certain diseases are capable of being eradicated. It means the virus must be removed from society. And those are diseases where the bug exists only in human beings. Even if you ensure every human is flu-free, it can be reintroduced. And most diseases are like that. The exceptions are smallpox, measles, Guinea worm disease. Technically very few diseases can be eradicated. The feeling in the 1970s and 80s was a great belief in the ability of science to achieve a lot of things. If we can, let’s go for it.
What about the argument that it is better to focus on simple things like water and sanitation rather than attack single diseases?
That’s valid. Public health has many religions and sects within it. Some would say focus on single diseases, others say it’s a waste of time, strengthen primary health care, fix water, sanitation and save more lives this way for the same amount of money. There is this continuous argument in public health. Here a certain way was chosen. At that point in time, they thought we can finish in it 12 years. Rotary International was willing to provide money. And everyone thought it would be pretty easy. The whole idea in 1988 was that it would be a gift from the 20th to the 21st century.
What were the lessons learnt then from this for public health in general?
The big issue is, as a government, do you focus your resources on one disease or on building up infrastructure; sanitation, primary health care centres etc? And the answer to me is [the latter]. If you look at the child as a whole, you are preventing the child from getting polio but the same child may die of measles or malaria or diarrhea or all these childhood killers. You are saving the child from paralysis and polio but what happens after that? There are arguments on both sides but this is the question that needs to be addressed.
So what do you think is a realistic date for the world to become polio-free?
The earliest according to the WHO is 2022. Will they meet it? I don’t think so. I think it will take a lot longer. If you look at the rate at which vaccine-derived polio cases are springing up, it’s hard to put a date on this. And neither can you stop; you’ve reduced it to about 30 cases globally. If you take your foot off the gas, the danger is it could explode. It’s at a point of no return at the moment.
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