Roving thoughts and provocations

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The Wrong Way to Fight Polio

Behrouz Mehri/AFP/Getty Images
A child suffering from Polio outside his house near Islamabad, Pakistan, July 6, 2011

This week, nine members of a polio vaccination team in Pakistan were murdered by gunmen thought to be linked to the Taliban, which has long regarded vaccinators as potential spies or part of a secret plot to sterilize Muslims. The team was working for a global UN-led campaign supported by billions of dollars from the Bill and Melinda Gates Foundation and the Rotary Club to wipe out polio from the face of earth. This might seem like a good idea. Polio is horrible, and cases of death and paralysis from the disease have fallen from hundreds of thousands a year to a few hundred since 1988, when the campaign started.

But the polio eradication campaign is ill-conceived. It’s a holdover from a heroic Cold War age when the UN was viewed as a neutral player uniquely positioned to advance public health anywhere in the world. During the 1970s and 80s, UNICEF and the World Health Organization carried out highly effective vaccination campaigns in countries allied to both the Soviet Union and the United States. In Sudan, El Salvador, Lebanon, and elsewhere they even persuaded warring parties to suspend hostilities long enough for health teams to administer the vaccines and then get out. The agencies rightly received Nobel Prizes for this work, and their vaccination campaigns became the model for today’s polio crusade.

The killings in Pakistan—which played out in a series of attacks in several different cities on December 18 and December 19—were heinous. But they also point to some serious problems with the heroic approach. For one thing, in conflict areas where the US is trying to route out insurgents with drone strikes, the UN is often not seen as neutral. But more fundamentally, the lavishly funded, multiple immunizations the polio program requires don’t always make sense—to local political leaders and warlords, or to ordinary poor people who are struggling just to keep their children alive. In order to avoid further tragedies, donors should work more closely with local people to improve the health of children in general, rather than strive for some romantic victory over a single virus alone.

In fact, the goal of eradication may be an elusive one. As a mass vaccination program, the polio campaign resembles the techniques used by the World Health Organization to eradicate smallpox in the 1970s. But getting rid of polio is much harder, because the virus can live for ten years in soil that an infected person has defecated on. If a child plays in that soil and consumes some of it accidentally, the epidemic will bounce back with a vengeance, unless everyone the child comes into contact with is immunized. Smallpox, which was transmitted directly from person to person, had no such hiding place, so vaccination teams could close in on communities where there had been a recent outbreak, immunize everyone to keep the disease from spreading further, and then cease vaccination in that area and concentrate efforts on the remaining “hotspots.” It was difficult, but far less so than polio eradication, which requires regular, expensive vaccinations across an entire population for a very long time, even if there are no outbreaks in an area.

While the UN concentrates on this one cunning virus, the rate of child mortality in the tribal areas of Pakistan is greater than 10 percent; polio, even before the special campaigns, has always accounted for a tiny fraction of this. Most child deaths are caused by diarrhea and pneumonia, often exacerbated by malnutrition. These diseases are easy to cure if basic health care is available, but often the only thing people see the government doing is intensive polio vaccination. The vaccinators turn up every few months, but have virtually no observable effect on the health of children, and in some cases might even make things worse. Since the campaigns are usually run by local health workers, this means that during the campaigns, there may be no one at the local clinic to treat sick children in urgent need of care. In some countries, including Pakistan, campaigns to promote one type of vaccine through a special campaign have resulted in decreased vaccinations for other, equally deadly, diseases.

Faced with such invasive visits by foreigners, people living in a region of political turmoil may think the worst. This is why the polio campaigns have raised so much suspicion, even before a vaccination team in Pakistan was found to be spying on Osama bin Laden at the behest of the CIA. In Nigeria in 2003, local political leaders assumed the polio program was really a clandestine mass sterilization program, and shut it down long enough to substantially set back the global eradication goal. In Pakistan, some think the vaccinators are spies, while others can’t believe they have the interests of Pakistani children at heart because the campaigns are supported by the same white Westerners who are launching drone strikes that inadvertently kill those same children.

The Gates Foundation, Rotary Club, and the UN should be working closely with local leaders in Pakistan to improve the entire health system so that fewer children suffer from all diseases, including polio. For example, they could support a program to ensure clinics are adequately staffed and stocked with medicine and that parents are taught how to recognize and act on dangerous symptoms quickly—like fever, relentless coughing and diarrhea. Left untreated, these medical problems can kill a child in a day or so, and if parents delay seeking healthcare because they don’t have the money, or they think their child’s illness is caused by evil spirits, or because there’s no health worker or medicine at the clinic, it’ll be too late. Addressing these problems would help give local people and health workers alike more control over their own well-being, as well as a sense that they are engaged in defining and solving their own problems, rather than relying on the largesse of institutions and states they are (sometimes with good reason) suspicious of. Such an approach could also do much to improve relations between the people of Pakistan and the West.

A program in Northern Ghana run by the Ghana Health Service with technical assistance from Columbia University and funding from The Doris Duke Charitable Foundation does exactly this. Obviously, the political circumstances are much simpler, but it could nonetheless become a model for programs anywhere. Nurses based in clinics built by local volunteers regularly visit every family with a pregnant woman or small child and offer whatever medical help is needed. Child mortality in this area is now 4 percent—the lowest in the country —even though this is Ghana’s poorest, most remote area. Because polio vaccination is part of Ghana’s general health program, there is no polio. The nurses cost an additional $1.92 per person per year, on top of what the government already spends on health. By contrast, the polio eradication campaign costs about $2 billion per year, slightly more on a per child basis, though it addresses only this one disease.

Even in Ghana, problems do arise, such as petty corruption, power struggles and simmering political rivalries, but local people tend to work them out themselves, for the benefit of their own children. There will be no Nobel Prizes for this type of work because the heroism is widely shared, but every so often, the entire community—chiefs, politicians, civil servants, villagers—gathers to sing and dance in celebration of the nurses, who are seen as champions, not adversaries.

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