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One drop at a time.

The Global Polio Eradication Initiative is the most ambitious public health programme ever undertaken. But with its historic goal in sight funding gaps, war and the killing of health workers threaten its success.

To the four-year-old Ethiopian girl standing barefoot in the doorway of a thatched mud hut, the burly white guy beckoning to her from his wheelchair must cut a curious figure. But with eyes wide and lips slightly parted, she steps towards him and opens her mouth as if to receive communion.

Steve Crane, 193 centimetres and 115 kilograms, holds out his hand and gives her a blessing in the form of a vial containing drops of oral polio vaccine.

Crane has come from Seattle to these villages in Yirgaalem, a province on Ethiopia's southern border with Kenya, to save children's lives, or at least to spare them from the disease that has so fundamentally altered the course of his own. I got it when I was 12 years old,' Crane recalls. 'It was 1955, just a few months before the Salk vaccine came out. Ethiopia isn't real wheelchair friendly. My friends had to pick me up to get over cracks in the dirt alleys, and haul me up and down stairs when we went to meetings in Addis Ababa. But I felt that I would do anything to prevent someone else from going through what I did.'


Crane is part of a group from Rotary International, whose members have been travelling at their own expense for almost two decades as part of the global network's main humanitarian cause: polio eradication. Together with the World Health Organization (WHO), the US Centers for Disease Control and Prevention (CDC), and UNICEF, it makes up the Global Polio Eradication Initiative (GPEI), which has been running immunisation campaigns for almost 30 years.

Last year's National Immunization Day in November had new urgency after Ethiopia, which hadn't had a new case of polio in five years, had an outbreak of six cases earlier in the year. Neighbouring Somalia recorded 183 cases,- Kenya had another 14 cases.

Nor was the Horn of Africa the only flashpoint. To the north, Syria, where civil war reduced the proportion of vaccinated children to 68 per cent from a pre-conflict 90 per cent, had an outbreak of 17 cases, raising fears of reinfection in Europe. The virus also surfaced in Israeli sewage in two locations.

All this in a year when polio workers were targeted for assassination in Pakistan, Afghanistan and Nigeria, the three remaining countries where the disease is still endemic. Although no-one claimed responsibility, suspicion fell on radical Islamists.

To be clear, support for eradication has been mostly robust throughout the Muslim world. Saudi Arabia requires proof of vaccination for children younger than 15 as a condition of making the Hajj. The Islamic Development Bank has made financing available to Pakistan, and Malaysia, Qatar and Kuwait have helped with financing and technical assistance, while last year, Abu Dhabi hosted a major global vaccine summit.

But as they do in other spheres, the extremists remain a source of consternation to the polio community. I don't think that there's any question that those groups have had an impact on polio eradication,' says Carol Pandak, manager of Rotary's PolioPlus vaccination programme. 'Al-Qaeda, the Taliban and the Hakani network tin Southeast Asia], Boko Haram [in Nigeria] and al-Shabab [in Somalia] have all made it difficult to gain access to children.'


Despite the headlines and setbacks, 2013 had its triumphs. Last month, India, once considered the disease's most intractable redoubt, marked 36 months without a new case--the WHO's mandatory period to certify it polio free. Of the endemic countries, Nigeria's cases fell by 60 per cent, and Afghanistan's 11 cases compared with 33 the year before. Afghanistan actually had no indigenous cases; all 11 infections were linked to cross-border transmission from Pakistan, whose situation worsened slightly. Of the three polio strains or serotypes, there were no new cases of Type III, which means that, with the elimination of Type II back in 1999, only Type I remains.

The scale of the GPEI is unprecedented, and the progress to date has been monumental. Since the initiative began in 1988, healthcare workers have given more than ten billion doses of vaccine to 2.5 billion children at a cost of US$8.5billion. When it started, there were 350,000 cases worldwide--about 1,000 new cases a day spread over 125 countries. Last year, there were 369 cases.

The programme has marshalled technology, lab resources, political leverage and meticulous strategic and tactical coordination to roll the huge engine of eradication forward. GPS, for example, is being used to find communities that don't exist on official records, yet can contain tens of thousands of people.

When polio does appear, teams are dispatched to interview families and collect samples that geneticists at the CDC can study to pinpoint the source of the infection. Genome sequencing allows them to trace the exact route that the virus has travelled all the way back to its origin. (This year's cases in the Middle East came from Pakistan: the Horn of Africa cases came from Nigeria. Both outbreaks underscore the importance of attacking polio where it's endemic in order to eliminate further outbreaks.)

The CDC then sends polio workers to the source, armed with doses of the vaccine and detailed charts that amount to a local census, on which they mark off every place in which a child lives and has been, or has yet to be, vaccinated. The WHO estimates that as a result of these interventions, more than ten million children--roughly the populations of London and Paris combined--have been spared from paralysis.

Still, the outbreaks in the Horn of Africa and Syria, the rising obstacle of extremists, and perhaps even more challenging to overcome, the funding gaps that threaten to restrict vaccination campaigns worldwide, are all lingering and real threats.


To understand how fragile the gains could be, it helps to understand the disease itself. Wild poliomyelitis is a highly contagious virus that usually spreads through faeces. After entering the victim via the mouth, it attacks the spinal cord and brain stem, in severe cases leading to paralysis in the limbs. It can eventually prove fatal if the paralysis spreads to the muscles that control breathing.

Based on Egyptian stelae that depict the telltale drop foot--a result of partial paralysis that causes the victim to step onto the forefoot rather than the heel while walking--we know that polio has been around for at least 35 centuries. Even so, polio only became a significant global problem in the late 18th century.

Paradoxically, polio epidemics were an unexpected consequence of the vast improvements that were made in hygiene and sanitation, especially in the provision of clean water and the removal of sewage in cities. Previously, people were regularly exposed to the virus and built up immunity to it.

Most people who contract polio never know it, experiencing mild flulike symptoms, drowsiness or a sore throat. Paralysis is actually quite rare, affecting one in 200 people who get the disease. But as the world became more populated and more sterile, reduced exposure meant that when the virus did show up, it had a larger population of unprotected people. In 1952, a global outbreak peaked with 600,000 cases. Photos from the period show wards of people, unable to breathe on their own, encased in contraptions known as iron lungs.

Health workers were encouraged to think that the disease was eradicable because, as with smallpox--which was vanquished in 1979 after a 12-year campaign--humans are the only reservoir in which it can survive. In other communicable diseases, a cycle of animal-human-animal infection can make pinning down the disease problematic.

Three years after the 1952 epidemic, Jonas Salk, a 40-year-old US researcher, developed an inactive injectable vaccine. In 1957 another American, Albert Sabin, developed an oral polio vaccine (OPV) that contained a live, but significantly weakened, form of the disease.

Although the OPV could cause polio--in about one in 250,000 cases--it had practical advantages: it was cheap and didn't require any expertise to administer. Children in rich nations began to be inoculated. The last case in the USA was in 1979: in Britain, which has an estimated 12,000 survivors, it was 1998.


The GPEI has had numerous bitter setbacks. The worst, still remembered as The Disaster', occurred in 2003 after rumours spread that vaccination was a Western plot to sterilise Muslim children. That shut down the Nigeria campaign for 13 months and led to reinfection in 20 countries. More recent rumours suggested that vaccinators were a front for Western intelligence agencies; reports that the US operation that eventually led to the death of Osama Bin Laden had involved a fake vaccination clinic didn't help.

The fear of failure for the current eradication effort is a vision of a catastrophic blowback as a consequence of people not having been exposed. 'Until it's completely eradicated, it can flare up again,' says John Sever, an infectious disease specialist and vice chairman of Rotary's PolioPlus Committee. 'If this spreads into populations that aren't well immunised, it could cross borders and reinfect areas that are currently polio free.'

In 2010, an economic analysis in the journal Vaccine determined that without total eradication, the disease could run up a bill as high as US$50billion by 2035 a figure that dwarfs the US$5.5billion the GPEI says it needs to complete the mission, including a post-eradication strategic plan that would run through 2018.

Indeed, for Rotary's Pandak, funding, even more than the extremists, is the key issue. 'We have US$4billion in commitments against the US$5.5billion we need,' she says. 'But only US$1billion has been operationalised. The challenge is to realise those commitments as soon as possible.'


The legacy of eradication, advocates say, is an infrastructure of people and systems that other health programmes will inherit, including a global laboratory and communications network and a team of health workers that number in the tens of thousands. The polio endeavour has also fostered a better understanding of how to move science from the lab to where the knowledge can be used. 'You have to have the entire civilian infrastructure behind you,' says Sona Bari, a spokesperson for the WHO. 'You need the ministry of transport. Roads and highways, for example, may have tollbooths, which are great places to immunise. You need education ministries to reach kids in school and day care centres. You need veterinary authorities for nomads who bring their herds in for care--while they're doing that, why not immunise?'

It also helps to enlist local celebrities and clerics to act as emissaries and ambassadors, and to build an international network of committed volunteers. Most people who've participated in the polio effort can recall a moment when they became wedded to the mission.

Like Steve Crane in Ethiopia, Ann Lee Hussey contracted polio in 1955 and also suffers Post-Polio Syndrome, the severe and lasting after effects that can strike decades later and be intensely painful and disabling. But despite these difficulties, Hussey has participated in 23 polio-eradication campaigns in places such as Mali, Bangladesh and Sri Lanka.

'It's very healing to give the drops,' she says. 'It's where I get my strength from. When I think of the faces and the people I met, I want to go again. It's what keeps me going.'
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Title Annotation:DISEASE: Eradicating polio
Comment:One drop at a time.(DISEASE: Eradicating polio)
Author:Pitock, Todd
Geographic Code:60AFR
Date:Feb 1, 2014
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