PHA-Exch> Polio’s Last Stand

[Claudio Schuftan]

From: Vern Weitzel <vern.weitzel at gmail.com>
crossposted from: "[health-vn discussion group]" health-vn at cairo.anu.edu.au


http://www.newsweek.com/id/180968

Polio's Last Stand

Bill Gates is bent on eradicating the disease, but the war isn't going well.

By Fred Guterl | Newsweek Web Exclusive
Jan 22, 2009


In the universe of global diseases, polio would seem to be a minor problem.
Fewer than 2,000 people in the world were stricken last year. AIDS and
malaria, by contrast, killed more than three million people. In a list of
the world's most threatening infectious diseases, polio would rank pretty
far down—past measles, meningitis, influenza and drug-resistant
tuberculosis, to name a few. Which raises the question: why did Bill Gates
release $255 million of his foundation's money on Wednesday to fight polio?

The answer many health officials give is that polio is on the brink of being
eliminated once and for all. A campaign of mass inoculations around the
world, led by the World Health Organization, has reduced cases by 99
percent, cornering the disease in a few pockets of resistance. What's
needed, health officials argue, is an infusion of funds to get them over the
hump.

Trouble is, it's not clear that more money is going to do the trick. It's
not easy to wipe a disease off the face of the planet—especially one like
polio, which spreads easily and quickly through contact and occasionally
through contaminated food and water. Only one in 200 children who contract
the virus shows symptoms (usually paralysis), which makes the other 199
silent carriers. Indeed, more than two decades of fighting the disease
around the globe has taught health workers that it is far more stubborn than
originally thought. The failure to deliver the knockout blow has cast doubt
on whether eradication is a viable strategy in the war on polio—even with a
donor as bold and wealthy as Gates.


The polio eradication campaign began in earnest in 1988. It came on the
heels of the smallpox campaign, which became the first (and only) disease
ever to be eradicated; the WHO had declared it dead eight years before. Even
though polio cases numbered 350,000 that year, it was by no means the most
urgent threat, but health officials decided that a campaign to deliver the
vaccine would serve also to improve access to vaccines for measles and other
diseases. That turned out to be true for the most of the world. Polio
dropped to a little more than 1,600 cases last year, but it hasn't
disappeared. It stubbornly persists in several poor, densely populated
areas—for reasons that money may not fix.

The most difficult challenge is Nigeria, where the culprit is poor
governance. Despite the cooperation of the health ministry in Abuja, polio
vaccines aren't being delivered reliably to children in Kano, a northern
state where 20 to 30 percent of children remain unvaccinated. One problem is
that the oral vaccine, which is cheaper than the injectable one, requires
refrigeration, which is hard to come by in Africa. Also in Nigeria's north,
illiteracy and a lack of trust in the government, which is notorious for
corruption, may be the bigger problem. In 2003, inoculations in Kano came to
a halt when rumors spread among tribespeople that the vaccine caused
sterility. By the time health officials were able to convince local leaders
that the rumors were unfounded, the virus had "exploded" out of Nigeria,
says Dr. Steve Cochi, a senior advisor at the Centers for Disease Control in
Atlanta. It quickly spread to 20 or so neighboring sub-African countries
where it had previously been eliminated as well as to Yemen and distant
Indonesia. Putting out that fire set the eradication effort back several
years and added nearly $1 billion to its cost. More resources would help
health workers respond to such a setback in the future, but getting more
children to take the vaccines is going to take some doing.

The problems in northern India are completely different, but no less
intractable. Although local government in Uttar Pradesh and Bihar have been
efficient and cooperative in carrying out inoculation, the vaccines
themselves are not wholly effective. Scientists don't understand exactly
why, but they suspect that the typical child harbors so many intestinal bugs
that the immune system is overwhelmed and fails to pick up on the vaccine.
In relatively sanitary Europe or the United States, a child typically
requires three doses of an oral vaccine to gain immunity; kids in northern
India need as many as 12 doses. Getting this medicine to children and
keeping track of who's gotten what is a staggering logistical challenge.

New funding would help, of course. All told, contributions from Gates, the
Rotary Foundation and the German and British governments amount to an
infusion of $630 million toward the effort. That could help bring injectable
vaccines, which are more effective and expensive than the oral versions, to
India. It could also help increase the support for inoculations in Nigeria,
reaching more children, and increasing the presence of health workers to
advocate for the program. On the other hand, it won't guarantee that health
workers will reach every last child. Nor will it do much to help efforts in
war-torn areas of Pakistan and Afghanistan, where the disease also persists.
"New funding is necessary but not sufficient," says Cochi. "The job will be
won or lost based on what happens in the countries and at local levels."

Smallpox took about a decade to wipe out. The polio effort, now 21, is
burning through more than $600 million a year, with no end in sight. D.A.
Henderson, the former WHO official who headed up the smallpox program in the
1970s, believes that control, rather than eradication, might be the best
option for polio—dialing back inoculations, and concentrating on responding
quickly to outbreaks. Cochi agrees that the current program is unsustainable
but fears that a cutback in inoculations would lead to an unacceptable rise
in new cases. Eradication is an all-or-nothing gamble: the disease is wiped
out, or it comes back. Gates and the other donors are upping the ante.
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