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.
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.
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.
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:
- that the money could be used to alleviate more suffering more immediately by attacking less recalcitrant diseases;
- that human beings will never universally accept the necessity and efficacy of the effort and will therefore sabotage the effort;
- 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