Research Position Paper—David Hodges

How to Eradicate Polio

In 2003, we nearly saved the world. We had already saved it once, back in the 1970s, when the United Nations and the World Health Organization joined forces to rid the world of the scourge of smallpox. Dating back to perhaps 10,000 BC, smallpox routinely killed millions every year, was probably the disease that killed off one third of the Roman Empire, and had wiped out as many as 500 million people in the 20th century alone. By 1979, after a series of intensive vaccination campaigns, the UN declared smallpox eradicated; to date it is the only human infectious disease ever to have been wiped off the face of the earth.

That is, until 2003, when the UN and WHO again partnered, this time to end world polio. Like smallpox, polio is easy to defeat with a cheap, easily-administered vaccine that can be given to children as drops by mouth. Lightly trained volunteers can deliver the vaccine, which costs about 10 cents per dose. According to The Economist, June 23, 2004, vaccination efforts had reduced the number of worldwide polio cases from 350,000 in 1988 to a paltry 784 in 2003. Since 1999, the “countdown clock” at UN headquarters in New York had been ticking off the minutes to the hoped-for eradication by the end of 2005. The Americas were declared polio free in 1993. Europe had rid itself of polio by 2002. India’s and Africa’s eradications were nearly complete. And then a terrible setback.

In Kano, northern Nigeria, local leaders began theories that the vaccine contained HIV and anti-fertility agents. Very soon, the local media were reporting the popular conspiracy theory that the polio campaign was an effort to depopulate the north of the country. Within months, political leaders in Kano and adjoining states had suspended the polio campaigns; almost immediately, hundreds of children became been paralyzed as epidemic polio returned.

The virus rapidly spread from Kano to the megacity of Lagos and beyond, reinfecting polio-free countries, costing over US $100 million in emergency response activities. One of Africa’s most impressive achievements in health and international cooperation was undone by a rumor. For the first time in history, more countries suffered importations of polio than were actually endemic for the disease, putting the entire eradication initiative at risk.

Considering this terrible legacy of small setbacks undoing the work of generations, it’s hard to imagine that we’ll ever succeed in eradicating polio. But the lessons of smallpox eradication may help.

Like smallpox, polio spreads easily in congested industrialized countries, but also like smallpox, polio is easy to defeat with a simple vaccination. Until the 1960s, it paralyzed thousands of children every year, but the development of vaccines and the beginning of routine immunization in countries around the world halted its growth and made eventual eradication seem possible. The Global Polio Eradication Initiative website puts the matter this way:

In 1988, when the Global Polio Eradication Initiative began, polio paralysed [sic] more than 1000 children worldwide every day. Since then, 2.5 billion children have been immunized against polio thanks to the cooperation of more than 200 countries and 20 million volunteers, backed by an international investment of more than US$ 8 billion. Today, polio has been eliminated from most of the world and only four countries remain endemic. In 2009, fewer than 2000 cases were reported for the entire year.

Polio is a perfect candidate for eradication because the virus infects only humans, is carried in the body for a short period of time, and has an effective intervention. “We have great vaccines against polio,” says Harry Hull, chief of the World Health Organization’s (WHO’s) Polio Eradication Program. The WHO-led campaign uses the oral “Sabin” vaccine because it is cheap–8 cents a dose–can be easily administered by mouth by an untrained volunteer, and produces high levels of intestinal immunity.

Also encouraging is the fact that immunization is highly effective even when not every vaccination achieves immunity and not every child is vaccinated. Because the virus needs human hosts to survive and spread, a single case in a largely immune population is highly unlikely to create an epidemic.

Difficult as it may sound, vaccinating entire populations has not been  insurmountable. For example, one early morning in 2002, millions of health workers, many enlisted just for the day, headed out across India on  foot, or by camel, bike, car, or helicopter, to operate polio vaccination posts in 650,000 Indian villages . . . all on the same day. By the end of the day, 127 million children under the age of 5 had been immunized against polio. “Everybody said it just couldn’t happen. And, yet it does,” said Harry Hull. In February, 2012. India was declared polio-free.

Not isolated to India, in 1996, National Immunization Days vaccinated more than 420 million children–almost two-thirds of the world’s children under five–against polio. These dramatic campaigns captured the imagination of the world and have even persuaded hardened fighters in war-torn countries such as Afghanistan, Sudan, and Sri Lanka to stop fighting for a day so that their children can be immunized.

The primary impediment to eradication, then, is not the science, and not the will, and not the budget, but the suspicion of the intended recipients wary of the motives of the health workers who arrive unasked to give their young and healthy children “medicine to keep them from getting sick.”

In Kano, Nigeria, the seeds of the distrust are popularly attributed to religious leaders who, it is said, spread the rumor that the West was attempting to either kill or sterilize Muslim youth in an attempt to eradicate not polio but the Islamic population. While it is easy to dismiss their stories as mere West-bashing, or as a power grab, their suspicions were not entirely without reason.

Chidi Achebe on the website Nigeria Village Report tells offers the explanation of a scandal involving Pfizer’s frought effort to combat bacterial meningitis in 1996, which had killed scores of Nigerians and was uncontrolled. Pfizer had received permission to test an experimental oral form of the antibiotic Trovan. Eleven of the 100 children in the test group died; others were paralyzed or became deaf. Family members sued Pfizer, claiming that its researchers

violated international law by failing to obtain informed consent from the families. They allege that Pfizer increased the risk of death and injury by failing to provide the proven treatment to patients who did not improve after swallowing Trovan and by giving control patients a weakened version of the standard therapy.

Medical ethicists have compounded the controversy by pointing out that the class of medications tested on these children is strictly prohibited for use in children in the United States and much of the developed world because their effects on bone maturation in the pediatric age group is well documented. Given that background, and other similar cases of distrust of Western medical efforts—particularly those that are offered freely to address a medical condition not obvious to the intended recipients—the warnings of the religious leaders sound more credible.

Less credible are the objections of parents in the developed world who resist vaccinations out of fear that they cause autism. Such links have been disproved to the degree anything can be scientifically disproved, but the fears persist and increasing numbers of parents are opting not to vaccinate their children. So far, this has not reintroduced polio into the West, for the reason given earlier—that near total immunization of a population—makes transmission so difficult, but there is no time to waste in eradicating polio from the rest of the world before the unprotectedness of children in the West permits new outbreaks in the developed world.

Any successful effort to eradicate polio once and for all will have to overcome the resistance of local populations, wherever they are encountered, whatever their cause. Combating this resistance will require a sensitivity to the needs and perceptions of the locals and a willingness to use whatever means necessary to achieve either their trust, their willing cooperation, or their coerced participation.

The latter will take some nerve, and here the example of the eventual, much-celebrated eradication of smallpox provides its most troubling but essential analogy. To eradicate smallpox, force was required. The May 08, 2010 issue of The Lancet puts the case this way:

Force was, of course, sometimes used to achieve immunisation targets . . . . Organised and violent resistance during epidemics could provoke ferocious responses from vaccination teams, especially as the successful eradication of smallpox began to seem a possibility in the mid-1970s. Opposition to vaccination was widely regarded as being dangerous to communities in regions that had been freed from the scourge, and this was seen as sufficient justification for the use of compulsion. It is, at the same time, important to remember that the use of force and that the clashes it stoked were mostly isolated incidents. Compulsory vaccination schemes were planned and implemented with the assistance of national and local administrative structures, including the police and paramilitary forces at their disposal, which had considerable societal support.

The question, then, is not whether we have the ability to save the world, but whether we have the nerve. We will have to consider the enormous benefits of a planet once and for all rid of the scourge that, if we permit it to return, could paralyze or kill millions of our precious youth. We’ll have to weigh those benefits against the chance that we’ll paralyze a few children by administering them the vaccine, and also the certainty that we will have to coerce those whom we cannot convince to willingly vaccinate their children.

Without that nerve, we will certainly never be rid of a dread disease. With sufficient nerve, though, we can and should once again save the world.

—END OF FIRST DRAFT—1600 WORDS

STUFF I COLLECTED BUT HAVEN’T YET USED

THE TOPIC BACKGROUND: POLIO
Polio (short for poliomyelitis) is an infectious disease that rarely kills but cripples about 1 in 200 of its victims. The virus invades the nervous system and can lead to irreversible paralysis in just hours. Adults fight off the infection more effectively than children, most often children younger than five. There is no cure, but there have been safe and effective vaccines for more than 50 years. By their nature, vaccines need only be administered once to be effective for a lifetime, so the strategy to eliminate polio once and for all from the planet is to vaccinate every child until transmission stops. If the world can be made polio-free for a moment, it will remain polio-free forever.

The virus enters the body through the mouth, multiplies in the intestine, and is passed to others through the feces; therefore, it ravages particularly countries with poor sanitation and hygiene. Children not well toilet-trained are a danger, but even flies can passively pass the virus from feces to food. A single case of polio, if it fails to migrate to other vulnerable children, can die out in that community forever. Complicating matters, most infected individuals show no symptoms and can silently pass the virus on unwittingly until it dies out in their bodies naturally. Therefore, a single reported case is usually taken as evidence of an epidemic.

EFFECTIVENESS OF VACCINATION
A simple, inexpensive, oral vaccination developed in 1961, administerable by non-physician volunteers, is the primary method of preventing polio among children. The vaccination produces antibodies in the blood to all three types of polio virus which prevent the virus from spreading to the nervous system. A single dose costs less than a dime. In a community where the polio virus would be spread through feces contact, so can the immunization be passively spread through the same mechanism. A single dose protects most recipients. Three doses protects 95% of recipients, probably for life. 100% immunity, while ideal, is not necessary to eradicate the virus, which will naturally die out if it cannot spread through a population.

COUNTERINTUITIVITY NOTE
In about 1 case per 3 million, the vaccine virus can itself cause paralysis. (A current theory is that paralysis results in recipients with existing immune deficiencies.) This risk, while devastating, is “accepted” by administering agencies as a necessary cost of saving “hundreds of thousands” of children each year from being crippled.

ERADICATION EFFORTS

What bad news does that terse report hide? The four endemic countries are Afghanistan, India, Nigeria, and Pakistan. But four other countries no longer on the endemic list have re-established active and persistent transmissions following an importation: Angola, Chad, Democratic Republic of Congo, and Sudan. Add to that the countries currently experiencing outbreaks due to importation (Congo, Kazakhstan, Liberia, Mali, Mauritania, and 8 others including Russia) and the challenge of containing the virus long enough to eradicate it becomes obvious.

IMPEDIMENTS TO ERADICATION
An editorial in the journal Lancet, SEP 2006, indicates that polio vaccination campaigns have met with distrust in communities over the years. Incorrect but understandable fears that mass vaccination is a conspiracy by the developing world against poor countries complicate the efforts of volunteers to conduct one-day mass immunization efforts which have been the most effective part of the WHO plan for years. Just as important as funding, volunteers, and sufficient doses, is building trust among poor and often suspicious people through sustained efforts.

STARTLINGLY EFFECTIVE SINGLE-DAY EFFORTS
FROM THE JOURNAL SCIENCE

One early morning, millions of people across India, from the snow-peaked Himalayas to the deserts of Radjastan, set off by foot, camel, bike, car, or helicopter to run polio vaccination posts in 650,000 Indian villages. By the time this army of volunteers arrived home at the end of the day, 127 million children under the age of 5 had been immunized against this crippling disease. “Everybody said it just couldn’t happen. And, yet it does,” says Harry Hull, chief of the World Health Organization’s (WHO’s) Polio Eradication Program. Initiatives such as the Polio Eradication Program show that WHO’s foot soldiers can make a huge difference to the majority of the world’s population without adequate health care.

At first, the campaign to rid the world of a disease that has left some 10 million to 20 million people paralyzed did not seem to be making an impact. But in 1995, WHO and its partner, the United Nations Children’s Fund (UNICEF), adopted the new strategy of blitzing the entire child population of a country in a single day. In 1996, such National Immunization Days vaccinated more than 420 million children–almost two-thirds of the world’s children under five–against polio. These dramatic campaigns captured the imagination of the world and have even persuaded hardened fighters in war-torn countries such as Afghanistan, Sudan, and Sri Lanka to stop fighting for a day so that their children can be immunized.

Nigeria

series of misunderstandings about the safety and intentions of the vaccinators shut down the campaign, caused a nationwide epidemic, and led to reinfection of many polio-free countries. For the first time in history, more countries suffered importations of polio than were actually endemic for the disease, putting the entire eradication initiative at risk.

In Kano, northern Nigeria, local leaders began theories that the vaccine contained HIV and anti-fertility agents. Very soon, the local media were reporting the popular conspiracy theory that the polio campaign was an effort to depopulate the north of the country. Within months, political leaders in Kano and adjoining states had suspended the polio campaigns; almost immediately, hundreds of children had been paralyzed as epidemic polio returned. The virus rapidly spread from Kano to the megacity of Lagos and beyond, reinfecting polio-free countries, costing over US $100 million in emergency response activities. One of Africa’s most impressive achievements in health and international cooperation was undone by a rumor.

On January 15, 2004, the leaders of the World Health Organization and UNICEF met with the health ministers of the 6 remaining polio-infected countries and 3 of the recently reinfected countries to issue the “Geneva Declaration on the Eradication of Poliomyelitis,” stating that 2004 presented the best, and possibly last, chance to achieve this global public good. The declaration introduced an aggressive plan to immunize a total of 250 million children during door-to-door polio immunization campaigns in each country within the next 12 months. The Nigerian minister outlined an extensive program of joint work with Kano state authorities to resolve the remaining doubts about the safety of the polio vaccine and then allow the resumption of the polio immunization campaigns. In 2011, polio still exists in the world. Is the present moment, once again, our “best, perhaps last, chance” to eradicate the disease?

THE NAGGING AUTISM CASE
From JSPN (Journal for Specialists in Pediatric Nursing): A decade ago, a British researcher and 12 coauthors published a paper describing abnormal gastrointestinal features among 12 children who had been referred to their clinic. All children had some type of developmental disorder, and in 9 of the children, a diagnosis of autism had been made. In 6 of the 9 autistic children, either the parent or a physician had linked the onset of developmental regression with the receipt of the MMR vaccine for measles, mumps and rubella (Wakefield et al., 1998). In 2000, a second paper was published, in which measles virus RNA fragments were found in 3 of the 9 children. (Kawashima et al., 2000). This odd, tiny, substantially anecdotal evidentiary link is the basis for fears persisting until today that somehow measles vaccinations cause autism.

In 2004, 10 of the 11 coauthors of Wakefield’s original paper asked to “formally retract the interpretation placed upon these findings . . .” However, these initial reports of a possible relationship between the MMR vaccine and the onset of autism received significant attention, and in England, measles vaccinations dropped considerably.

MY WORKING THESIS: Eradication is possible and highly desirable even if to accomplish it we need to be slightly unscrupulous.

THE SMALLPOX EXAMPLE:
A brief query of Rowan’s MEDLINE database yields 232 results for a simple search “smallpox eradication.” I suspect I’ll be able to find adequate historical information to support the theory that if any infectious disease can be eradicated from the planet (as smallpox was), then polio can be.

TOPICS FOR SMALLER PAPERS:
If there’s a class difference between polio and smallpox that interferes with this conclusion, I may be able to devote one of my smaller papers to detailing that difference, either to minimize it or to recommend a different approach for eradicating polio than was successful for smallpox.

WILL COMPULSORY VACCINATION BE REQUIRED?
Regarding the successful eradication of smallpox from the planet, an article in the May 8, 2010 Lancet offers insight I may need to use. <blockquote>Force was, of course, sometimes used to achieve immunisation [sic] targets…. Organised [sic] and violent resistance during epidemics could provoke ferocious responses from vaccination teams…. Opposition to vaccination was widely regarded as being dangerous to communities in regions that had been freed from the scourge, and this was seen as sufficient justification for the use of compulsion. Compulsory vaccination schemes were implemented with the assistance of police and paramilitary forces which had considerable societal support.</blockquote>

CURRENT STATE OF THE RESEARCH PAPER
The thrust of my research continues to convince me that the effort to once and for all eradicate polio from the planet is a worthwhile and achievable global good. I will propose continued and even stepped-up efforts to eliminate this virus from the planet once and for all, despite excellent arguments to the contrary, for example:

  1. that the money could be used to alleviate more suffering more immediately by attacking less recalcitrant diseases;
  2. that human beings will never universally accept the necessity and efficacy of the effort and will therefore sabotage the effort;
  3. that eradication is a myth since new strains will always replace the old before the old dies out.

I feel strongly that the tiny risk of transmitted paralysis to one child in 3 million is “acceptable,” God forgive me for saying so.

I also insist that it might be necessary to compel the reluctant last however-many-thousands to submit to vaccination against their wishes. I recognize the moral dilemma, but think it might be forgivable to lie about that tiny risk if to do so put a rumor to rest that threatened the entire program.

There is much reading yet to do. Topics I’ll be investigating include the success rates of various vaccines (there are four); more opinions on the origins of the Nigerian rumor (there are many); details of the life-cycle of the poliomyelitis virus (when will we know it’s really, really gone for good?); ancillary techniques for immunization (can we use bad sanitation to our advantage?). I love the counterintuitive result that immunization can be spread accidentally the same way the virus is spread!

Text from The Lancet
The Lancet, Volume 375, Issue 9726, Pages 1602 – 1603, 8 May 2010

It would be simplistic to reduce the worldwide smallpox eradication programme to the ideas and actions of a handful of individuals or, indeed, the institutions to which they were associated. There can be little doubt that agencies such as Fiocruz (Brazil) had an important role in Latin America, that the US Centers for Disease Control and Prevention made pioneering contributions within western Africa, and that WHO headquarters in Geneva helped mobilise people and resources across the then politically unstable south Asian subcontinent. It is also beyond doubt that all these institutions went on to play key roles in advising colleagues, funding initiatives, and contributing personnel and vaccines on an international scale. However, this should not lead us to assume that their employees were unquestioning instruments in the implementation of a finite set of ideas developed by a select leadership. To the contrary, the enormity of the success of global smallpox eradication can only be appreciated when one acknowledges the continued presence of variations in training, attitude, ability, and commitment in groups involved in vaccination, smallpox searches, and disease isolation regimes.
Some determinants of this success were deeply personal in nature and were connected to beliefs about religious, political, social, and institutional obligations; other stimuli were external, in the sense that they took the form of myriad political, social, economic, and cultural challenges presented from within the localities where work was undertaken. The attitudes and work of personnel for smallpox eradication programmes were not divorced from such wide-ranging stimuli; they were influenced by an ever-changing combination of factors. This, in turn, fostered ways of designing, applying, and evaluating policy, which contributed to the creation of an intricate mosaic of operational diversities.
As the 30th anniversary of the certification of global smallpox eradication nears, it is no surprise to witness organised efforts on the part of government and non-government agencies to highlight their contributions to this memorable triumph. The danger, of course, is that these exercises will chronicle relatively few voices and then present them as being representative of the “reality” of the eradication programme as a whole; such an approach is to be avoided, although these individual voices are, of course, valuable. The global project to limit the spread of variola, as it evolved in the 1960s and 1970s, involved countless participants. It was simultaneously an international and local entity, and each avatar had several constituents. The first included donor nations and multilateral health agencies such as WHO. But the global smallpox eradication programme also involved federal and provincial governments, as well as members of elected local authorities who remained answerable to a variety of urban and rural electorates. Ground realities were complicated further by the fact that the day-to-day running of the national chapters of the global programme remained largely dependent on the efforts of workers drawn from within the countries themselves. Local personnel were involved in house-to-house searches, and also served as team leaders, translators, vaccinators, supervisors, and guards of lodgings where smallpox cases were being isolated. Such local participation was not just enforced by shortages of international staff; it was actively encouraged in the 1970s by senior programme managers situated within WHO offices in Geneva and New Delhi.

At one level, this inclusiveness was a formal recognition of the fact that the task at hand was far too large for a small group of international workers. In other ways, field experience taught managers that local political and infrastructural conditions deserved careful study to help avoid problems, assist in effective negotiations with the target population, and allow for the meaningful adaptation of policy as and when it was necessary. Such strategies, although time-consuming, enabled the mobilisation of support from among civilian communities. Based on the willingness of workers to spend long stints of time on the road, this policy revolved around winning trust locally; mobile teams were often required to spend time in villages and towns, making an effort to get to know members of local administrative bodies and community representatives. Social engagements, in the form of participation in grand village feasts or discussions over more private meals, frequently formed important points of interaction and negotiation. These communication strategies contributed to a scenario where the use of forcible vaccination remained a fairly rare phenomenon in most national contexts.

Force was, of course, sometimes used to achieve immunisation targets, as some important commentaries have noted. Organised and violent resistance during epidemics could provoke ferocious responses from vaccination teams, especially as the successful eradication of smallpox began to seem a possibility in the mid-1970s. Opposition to vaccination was widely regarded as being dangerous to communities in regions that had been freed from the scourge, and this was seen as sufficient justification for the use of compulsion. It is, at the same time, important to remember that the use of force and that the clashes it stoked were mostly isolated incidents. Compulsory vaccination schemes were planned and implemented with the assistance of national and local administrative structures, including the police and paramilitary forces at their disposal, which had considerable societal support. All countries in the world are characterised by the presence of complex social formations, and it is thus imperative that chroniclers of smallpox eradication avoid describing national and local societies as monolithic entities that responded in uniform ways. National contributions to the global smallpox eradication programme had many facets. The planned use of compulsion in vaccination programmes, and the resultant social and political backlash, which varied in intensity across nations and their locales, was one of them. Considered reflection about these trends, and the many factors that influenced them, such as deep-rooted concerns about vaccine safety, can allow for the presentation of a more rounded picture of global smallpox eradication. This exercise is pertinent precisely because descriptions of episodes involving official force and social resistance are frequently downplayed in tomes seeking to celebrate the contributions of individuals, public health institutions, and national governments.
Broad-ranging assessments of the intricacies of the global smallpox eradication programme can also offer other insights. They can, for instance, allow us to query simplistic understandings of vaccination strategies used in the 1970s, including explication relating to the holy grail of search and containment policies. The importance of the decision to direct field work on the identification and isolation of smallpox cases and the vaccination of contacts is undeniable; this was a revolutionary concept borne out of the necessity of working with finite vaccine stocks. It is also true that the approach was trialled by groups of young American workers in western Africa in the late 1960s and then adopted elsewhere by wider constituencies. However, it would be incorrect to assume that the transfer of such practical information was unidirectional, universal, and uncontested. Search, containment, and vaccination work was actually also tested in 1967—68 in Madras, India, with the active encouragement of WHO officials. Reports about the success of these field trials were widely distributed and encouraged some, but not all, Indian administrators to embrace the new strategy. This is, perhaps, not surprising. In an age marked by cold war hostilities, hypernationalism, and widespread conflict, the origin of a policy or a set of practices was important to questions about implementation and reception. This also helps explain why the older practice of mass vaccination was continued across large tracts of south Asia well into the late 1970s. This approach was often preferred by groups of local and international workers, and was sometimes a response to demands emanating from within the target community. Indeed, mobile teams were often faced with requests to vaccinate everyone in the village and it was generally considered expedient to accept such requests. It is important to keep all these trends in mind, lest the ideas, actions, and contributions of large numbers of people—and the sheer complexity of field practice—is forgotten as the celebrations connected to the continued absence of smallpox start in earnest.
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20 Responses to Research Position Paper—David Hodges

  1. tbrody92 says:

    I’m not exactly sure why you left out the information about how inexpensive the vaccine is. It’s a good point that could convince uneducated readers who believe that vaccines must cost a lot of money.

    • tbrody92 says:

      Strike the first comment.

      “The question, then, is not whether we have the ability to save the world, but whether we have the nerve. We will have to consider the enormous benefits of a planet once and for all rid of the scourge that, if we permit it to return, could paralyze or kill millions of our precious youth. We’ll have to weigh those benefits against the chance that we’ll paralyze a few children by administering them the vaccine, and also the certainty that we will have to coerce those whom we cannot convince to willingly vaccinate their children.”

      You refer to “we” a lot in this essay. Who is “we?” Mankind? Us in the classroom? Those who wish to eradicate polio and no one else? I wouldn’t use “we” as much in this paragraph in particular, and you should be more clear on exactly who “we” are.

      • davidbdale says:

        Thanks for that, Taylor. You’re right to remind me that “we” is not obvious. I thought that since the essay begins with a very broad “we saved the world once” comment, it would be clear I was crediting all of humanity with averting its own extinction, but I see that’s not true.

  2. primav01 says:

    Dan Primavera:
    The statement, “For the first time in history, more countries suffered importations of polio than were actually endemic for the disease, putting the entire eradication initiative at risk,” is sort of confusing and is in need of more explaining/clarification. Other than the fact that many may not understand the “suffered importations” part, the whole sentence is sort of an unclear statement.
    The paragraph on the day-vaccination of basically all of India is a great part to help in your argument and if there is more to it maybe expand on that because it is a great example for trying to end polio spread.
    So after reading the whole essay, I would have to say that other than these two points (above) being addressed, after adding in the info you have given below the essay, it will turn out very nicely.

    • davidbdale says:

      I see what you’re saying about the syntax of that sentence, Dan. It does indeed help to understand the difference between endemic polio and cases of imported polio, and I haven’t made that distinction clear in advance of this sentence.

      There is quite a bit more material available on the “one day” mass inoculation programs and you’re right, they are impressive and very effective. They might be the best way to force an entire population to subject to a last eradication effort, if force is necessary.

  3. justinbaker2007 says:

    You could say how much money the whole operation would cost, not just the vaccine. Cost for how the vaccine would get to various places, cost for people to administer the vaccines, and other costs. Money is something people always want to know about.

    • davidbdale says:

      You are absolutely right about this, Baker. I deliberately left out the discussion of the overall cost to see who would discover it was missing. I couldn’t agree with you more. 🙂

      It’s also important to discuss the cost in any consideration of whether polio should really be the high priority target so many have made it. The same hundreds of millions of dollars could prevent or cure so many cases of diarrhea or dehydration that kill far more kids than polio ever did.

  4. cdisarcina says:

    P2 : India’s and Africa’s eradications were nearly complete. And then a terrible setback. – Fragment Sentence. You can change it to: India’s and Africa’s eradications were nearly complete until a terrible setback occurred.

    P12: Would it be easier for recipients to be given their vaccinations by local members of the area? It seems that since the suspicion of the West is so great, it would be easier to give the vaccinations to people living in areas needing immunizations, and then they would accept the vaccines and not be wary of the intentions.

    P13: Chidi Achebe on the website Nigeria Village Report tells offers the explanation of a scandal involving Pfizer’s frought effort to combat bacterial meningitis in 1996, which had killed scores of Nigerians and was uncontrolled.
    — fraught? This sentence’s structure is so random. Does Achebe know the sole reason for the scandal? // You can change it to: Chidi Achebe, of the Nigeria Village Report, offers an explanation to the uncontrolled deaths behind the Pfizer’s 1996 effort to combat bacterial meningitis.

    P14: Is there any explanation on how Pfizer received permission to perform tests on children, even though there was documented research on how the “medicine” affected bone maturation these children. – Would it be beneficial to charge small fees for the vaccinations? Then, it would seem that they’re actually working towards something and the recipients could not be distrustful of free vaccines. Also, is there an educational program set up in these areas to discuss what polio does to the body and how the vaccine is designed to help them?

    P15: “ but there is no time to waste in eradicating polio from the rest of the world before the unprotectedness of children in the West permits new outbreaks in the developed world.” – doesn’t this just fuel the West-bashing in undeveloped areas.

    P17: Opposition to vaccination was widely regarded as being dangerous to communities in regions that had been freed from the scourge. This seems like a good route to go down. Make the majority of people in an area pro-vaccine and scare the minorities into getting vaccinations. The benefits of total vaccination do seem to outweigh the consequences. The children that die/get paralyzed from the vaccine will have died/gotten paralyzed for the whole of mankind. Shouldn’t parents encourage their children to be heroes? These children are, in a way, saving our entire planet from polio.

    P18: Without that nerve, we will certainly never be rid of a dread disease. With sufficient nerve, though, we can and should once again save the world. // Do you mean a dreaded disease that will last and infect mankind till its end? Or do you mean that it’s a dreadful disease for those who suffer from polio. Where did the nerve go from when we absolved the world from smallpox? Why is the world different now?

    • davidbdale says:

      P2. I like my fragment, but yes, you’re right. That’s what it is, and your correction is effective.
      P12. That’s a brilliant suggestion that health agencies in fact employ whenever they can. I can’t speak to the details of the Nigerian catastrophe, but you’re so right it’s important to know whether the Nigerians mistrusted outsider inoculators or their own.
      P13. Yeah, my sentence is sloppy, but the fix won’t work, I’m afraid. The point is not that there’s a better explanation for the deaths; the point is that the deaths that resulted during a drug trial (for whatever reason) have made the locals suspicious of Western drug programs.
      P14. These are very fine questions, Chris, some of which seem to require answers. It wouldn’t help to make excuses for Pfizer if the local population isn’t mollified by them. Your idea to charge a fee for the vaccination is fascinating, but frought (fraught?) with a small difficulty. 100% participation on a one-day campaign is the goal. Even a small fee would endanger that plan. There are definitely efforts to overcome with distrust, but they sometimes become forums for the suspicious to spread rumors that the inoculations kill, maim, cause infertility, or contain pork.
      P15. I’m not sure how you mean this but, yes, there’s nothing more maddening that our own local idiots refusing to be vaccinated.
      P17. You are wicked.
      http://davidbdale.wordpress.com/2012/03/04/the-cost/
      P18. I mean a dreaded disease that doesn’t have to last forever if we have the nerve to compel inoculation, as we did to eradicate smallpox. The world is different now because we have more of a conscience about respecting the rights of local populations and are less willing to bully them like our own colonial subjects, at least overtly.

      Thanks, Chris. That was fun. You’re very impressive.

  5. clarkn92 says:

    P2: I think that this paragraph should describe the costs of the vaccine and how much money it would cost someone who is suffering or is affected by someone suffering from polio. I feel that people are always willing to know more about the cost of certain things and I think that it is important to add it in.

    P8: I find the first sentence in the paragraph to be confusing. I understand what you are trying to say but I think that the sentence should be reworded or split up into two completely different sentences.

    P12: I feel that this paragraph needs more information regarding the rumor about the West attempting to kill Muslims to eradicate the entire Muslim population. I think that this claim needs more information regarding the rumor. I think that proof is needed to support this claim.

    P15: I feel that this paragraph makes sense when opposing the thought that polio vaccinations cause autism but I feel that this needs a source to prove this. This is the only paragraph that relates to autism and I feel that it should use a source and extra information to prove the claim about how vaccinations could cause autism.

  6. oconne92 says:

    In the first paragraph you us “we” without explaining who “we” is. The third sentence, first off, rambles on about smallpoxs’ history, but incoherently jumps between talking about the disease and the people it affected. The second paragraph gives a statistic on the number of vaccinations but doesn’t clearly explain that this means the disease is dying. The last four sentences are also very short and dry “thoughts” that should be in fuller and more developed sentences. Paragraph 3 could be worded better, using a phrase like “very soon” doesn’t give a good measurement of time. This paragraph is also quite short and could easily be combined with the next paragraph. That paragraph uses the phrase “the megacity of Lagos and beyond”, this seems to stylized or artistic of a phrase to use in a scientific paper. The next little section I’d consider more of a transition put between paragraphs. It has personal inference, “it’s hard to imagine”, and ideas that aren’t fit for a whole paragraph. Overall, the facts are there, but the way they are presented leaves the reader wanting more out of what they read.

  7. kmbuttari says:

    I’m quite surprised that you didn’t explain what polio was in the argument. I know it’s in your list of things that have yet to be used, but I think it would be somewhat important to have its definition in your argument. Someone reading this without knowing what polio is will more than likely not care all that much about the paper because they have no idea what it’s about.

  8. kaileewhiting says:

    “Is probably the disease that killed off one third of the Roman Empire,”
    You need to make concrete definitive statements about diseases, telling us it “probably” what killed everyone isn’t going to cut it. We aren’t as scared of the disease when you’re unsure of it.

    The smallpox facts are great, but they make us only scared of smallpox. They do not do anything to prove how scary polio is.

    “Like smallpox, polio is easy to defeat with a cheap, easily-administered vaccine that can be given to children as drops by mouth. Lightly trained volunteers can deliver the vaccine, which costs about 10 cents per dose. “ I think you’re wasting space and time with these sentences which say just about the same thing. “Just like smallpox, polio is an easily defeated disease that is can be cured by volunteers that administer mouth drops that only cost 10 cents,”

    You keep mentioning smallpox, and I’m not entirely sure why. It’s something that can completely be taken out or even expanded on. But it has to be one of the two, you can’t leave it the way it is in your paper. It’s flimsy and has little to no support.

    The structure of this is really odd. In the third and fourth paragraph you talk about how rumors killed the polio eradication program in Africa. But then again in paragraph 12, 13, 14, 15, and 16 you pick back up on the rumor mills in Africa and why they came to be. If it was altogether it wouldn’t be so confusing to your readers.

    “For the reason given earlier,” give us this reason again. At this point, towards the end of your paper, many of us have already forgotten many of your points since this paper is full of information.

    The analogy of that since smallpox used forced immunizations means that polio will be have to forced upon people is flawed. In the excerpt you give us it says that the times that it had to be forced upon people were isolated and didn’t happen often. Polio has resistance by many. You can’t just forced a whole nation of people down and give them mouth drops. It doesn’t work that way.

  9. billykluge says:

    In the first paragraph the essay refers to “we” but never declares who “we” is. In just the third sentence the use of the word perhaps and probably makes it sound unsure of the information and as if it was made up. The sentence also goes back and forth with referring to the subject of the disease and people affected.
    The second paragraph starts with a sentence that seems as though it should have been paired with the last sentence of the first paragraph. The entire paper has problems with making random references without fully clarifying as to what is being discussed. There are also numerous sentence fragments and overuse of commas. The author could also look into and add why some officials are against the eradication more. He does say that they believe the vaccination contains other diseases but it isn’t said why the vaccinations are believed to be bad. Also at one point in the essay the vaccination is said to be 10 cent a dose, but a few paragraphs later says it is eight cents a dose.

  10. kovnat77 says:

    In your 14th paragraph you begin with the sentence “Chidi Achebe on the website Nigeria Village Report tells offers the explanation of a scandal involving Pfizer’s frought effort to combat bacterial meningitis in 1996, which had killed scores of Nigerians and was uncontrolled.” Breaking this sentence down, and working from the most simple of mistakes on, you use two words back to back that are trying to both serve the same purpose in your sentence; “tells offers”. You should choose just one, so that the sentence has a bit more of a flow to it, since it acts a bit like a stone under a carpet, halts you in your tracks.
    Next, in a way you neglect to define who Chidi Achebe is, and whether or not they are a valid speaker regardless of where you found their comment. You can go on the New York Times website and find comments by people that consist of ill informed conjecture, and quote them without having defined that person as a valid source. One could quote a person, stating that on the New York Times website Bill Bigsby offers an explanation as to how 76% of people in South Beach Florida have, since 2006, become addicted to opium thanks to local food chains incorporating it into their food. Any person not from South Beach, or even Florida for that matter may not know that the information is total garble, and that this Bill Bigsby is severely misinformed. When using a person as such a backer in terms of support for one of your arguments, you have to make your reader understand the validity behind their information, so as to enhance your argument, not hinder it.

  11. jpassalacqua says:

    You could add more information about the days of peace that Afghanistan, Sudan, and Sri Lanka put in place to get the vaccine to children. Considering the countries currently are some of the most war torn in the world, you could probably find more information about how these days of peace are established. How could the governments convince every opponent of war to cease fire? Is there a way that even groups such as Al Qaeda agree to stop fighting? I do recall reading somewhere that countries in Africa with a lot of gun violence also agree to these days of peace. Each one of these countries could have different intentions and methods of how they reach these peaceful agreements.

    Other things to talk about could be with the countries arguing that the vaccines cause Autism and are actually spreading the HIV virus. Those arguing that the vaccine is giving children HIV are also living in countries that have a strong HIV problem. The people saying the vaccine is a way to give children HIV may only be saying this to point the blame to someone else, in turn, trying to get aid from the US for causing something that they have nothing to do with. Development of autism, although rare, is in fact possible. But the causes are mostly linked to lead, mercury and aluminum poisoning. As far as I know, the vaccines do not include any of these toxic metals. You could make a strong argument about what makes up the vaccines and how the people arguing that they cause diseases are wrong.

    I’m not entirely sure my last paragraph makes perfect sense, but I hope this comment provided a plentiful amount of feedback.

  12. mmiddleton1 says:

    P2: I am not very sure why you list the date of America’s polio eradication and Europe’s polio eradication if you never mention anything else on it. Why these two countries?
    Alternatively I see that America was declared polio free in 1993, then Europe, and then closing in on India and Africa. All of these are listed in ascending order of population so could there be a correlation between that or are there just more efforts in America and Europe opposed to India and Africa.

    P4: It seems like you’re saying the costs in emergency response activities far outweigh the cheaper cost of producing the antidote.
    What are the most impressive achievements in health and international cooperation that you are talking about? This sentence in general seems out of place. The previous sentence talks about the costs of reinfection polio-free countries while the following sentence re-enters the topic of polio’s reinfection with this sentence stuffed in-between.

    P8: I think that this paragraph goes slightly against the topic of a way to “Eradicate Polio.” If you say that to eradicate polio you must wipe it completely off the face of the earth then saying it is “encouraging” to leave some hosts affected contradicts itself. If the argument is solely to say that you need courage to eradicate a disease, then maybe provide facts that show encouraged people are more likely to aid in efforts.

    P12: What would be useful is information if the people who distributed the medicine attempted to gain trust. This could have been done through a simple example proving on another individual that the vaccine did not harm the recipient.

    P17: The previous paragraph goes on to explain that the need of sensitivity to perceptions of locals is required to combat the resistance. This paragraph; however, talks about the need of nerve to “force[fully]” achieve the eradication of a disease. The previous paragraph seems useless unless forcefully immunizing people can be done with “sensitivity.”

    Excluded Material

    If smallpox was eradicated in a very similar manner then surely there were similar problems of vaccinating the under-developed countries. Information and ways that this was done would definitely help the argument become much stronger. Smallpox was mentioned, but the primary way it was distributed was not.
    The inclusion of whether or not vaccinations should be compulsory is necessary. Often while reading the argument the question “Why not just make it required to take the vaccine for the benefits of the entire world?” This information would clear that up.

  13. adkins70 says:

    Include statistics of the percentage of the world that is currently vaccinated and where the disease still exists. Including the argument of the vaccine not helping where the Africans need it would probably just be detractive and lead the paper astray because the argument is not about how to help Africa, it is about how to help the world, which is something you need to stress. This is an accomplishment worthy of celebrating and marking as a major one for all of mankind, a step towards world peace perhaps?

  14. lebano55 says:

    After looking over the draft and reviewing some of the additional information that wasn’t included (yet), the info that I’d really like to see in the final draft is the discussion of the effectiveness of the vaccine, as well as a little more background info on the polio virus too. As the draft already states, “polio is easy to defeat with a cheap, easily-administered vaccine that can be given to children as drops by mouth. Lightly trained volunteers can deliver the vaccine, which costs about 10 cents per dose.” I’d just like to know more about why we’re stuck with this difficult controversy and why this risky vaccine’s benefit to society is greater than its flaws.

    Also, the last sentence of the second paragraph doesn’t really work for me. Maybe I’m not reading it the right way, but it’s giving me some sentence-fragment vibes.

  15. adamtwths says:

    To really get the point across you could include statistics on polio from its early history until now. Also a background on the history of polio to start off the article would be help prove that the vaccine is really essential in the world. Another great point would be to explain in greater detail about when the volunteers vaccinated millions of kids in a couple days. That is really heart warming and it shows how important the vaccine is. The point about the middle east stopping war efforts to get their children vaccinated was a great point, it should be brought to light more though.

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