In response to:

Syria’s Polio Epidemic: The Suppressed Truth from the February 20, 2014 issue

To the Editors:

Dr. Annie Sparrow’s article “Syria’s Polio Epidemic: The Suppressed Truth” [NYR, February 20] is a stark reminder of the devastating impact that conflict can have on public health, and the difficulties of obtaining accurate information and responding to outbreaks during complex emergencies.

Accuracy of data is paramount to an appropriate response to polio and protecting children. By confusing the definitions of suspected and confirmed polio cases, Dr. Sparrow inadvertently overstates by more than 100 percent the number of cases that have actually been confirmed in the country, irrespective of source. Such inaccuracies confuse public understanding of the magnitude of the outbreak, the risk it poses in relation to other major health challenges in the country, and the prospects for its rapid control.

It is also untrue to state that the UN is “ignoring the epicenter of the epidemic.” Already, three major campaigns have been launched inside Syria, in both government- and opposition-held areas, reaching nearly three million children in the most recent round; four more campaigns are planned over the next four months. Unfortunately, the article contains a number of similar errors of fact or omission.

More concerning is the suggestion that the World Health Organization is anything but impartial in aiding communities on all sides of this conflict. In Syria, as in any humanitarian crisis, WHO operates under and remains completely committed to the fundamental principles of humanitarian action and spares no effort in reaching everyone in need.

Dr. Bruce Aylward
Assistant Director-General for Polio and Emergencies
World Health Organization
Geneva, Switzerland

Dr. Annie Sparrow replies:

It is regrettable that the World Health Organization, the leading UN organization in the Global Polio Eradication Campaign, feels compelled not to publicly contradict the Syrian government’s downplaying of the polio epidemic in Syria.

Aylward begins by misrepresenting how paralytic poliomyelitis is identified by relying only on laboratory reports rather than clinical diagnoses of patients. According to the US Centers for Disease Control, the identification of polio is done foremost by clinical means. Laboratory testing is done to determine whether the paralysis is due to wild or vaccine-derived virus. Application of this clinical definition is considered appropriate by the CDC to current conditions in Syria, a country previously free of polio with more than three million un- or undervaccinated children, ongoing exposure to contaminated water, terrible living conditions, and limited ability for laboratory testing. In the middle of an outbreak under these circumstances, it is naive to argue, as Aylward maintains, that clinical cases of “acute flaccid paralysis” are not polio until they are laboratory-confirmed. Rather, these clinically determined cases of polio should be counted and addressed immediately.

Yet for months, the Syrian government, and hence WHO, reported only the seventeen cases in which polio had been laboratory-documented. In late January, they revised that number to twenty-three. They arrive at these small numbers by treating more than 140 cases of “acute flaccid paralysis” reported by the government as “non-polio,” while even the Damascus Expert Committee classified four of these cases as polio in November. Aylward’s bland reassurances about his understated numbers are thus misplaced.

Moreover, the numbers are even worse than this if cases identified by the opposition-organized Assistance Coordination Unit (ACU) are considered, which for political reasons WHO refuses to do. The ACU has now identified seventy-two cases that meet the clinical criteria for polio, thirteen of which have been laboratory-documented. Even the government now admits that there were seven new polio cases in November and December, including in two new governorates, showing that the virus continues to spread even in the cold of winter (polio transmission peaks in summer). As recently as January 30, while on the Syrian border, I documented a fourteen-month-old girl with polio from a small town in Hassake, a few miles from the Iraqi border, previously unknown to either WHO or the ACU. Despite Aylward’s minimization of the situation, this is not a small outbreak, polio is not controlled, and polio’s return to Syria remains a regional threat.

Aylward soothingly writes that the WHO vaccination campaigns have already reached “nearly three million children” but the UN itself acknowledges that the campaign was “unable to reach” some “800,000 children who possibly reside in inaccessible areas.” Moreover, Aylward’s “nearly three million” includes the campaign to protect the 1.4 million children in opposition areas that is being conducted not by WHO but by the ACU, which WHO does not officially support because it involves cross-border aid from Turkey that the Syrian government forbids. Meanwhile, the Syrian military continues to shell those areas where the ACU is vaccinating children. A vaccinator was killed in Aleppo on January 30 by the government’s barrel-bombing of the city, as were several children he had just vaccinated.

Aylward claims that WHO operates under humanitarian principles in Syria. This is incorrect because WHO is constrained by its current mandate with the Syrian government—a situation that would change only with a UN Security Council resolution mandating that cross-border aid be provided impartially to all those in need. But rather than at least allowing those unencumbered by WHO’s institutional constraint to speak the truth about what is happening in Syria, Aylward mounts an attack, apparently placing the defense of WHO’s reputation above its mission to promote public health and polio eradication.

To its credit, WHO helped the government to set up a surveillance system and launch a vaccination campaign in October. But knowing that vaccination rates had dropped precipitously in Syria since the onset of the conflict and that polio was circulating in the region, WHO should have insisted on mass vaccination across the country long before the first case occurred. It did not, and the inevitable result was the emergence of clinical polio in a country that had been free of it for almost two decades. And vaccination in the opposition-held areas where polio cases appeared—areas that could properly be reached only by cross-border assistance from Turkey—began only in mid-December. Due to the delay in obtaining vaccinations, it was not until early January that the ACU was able to begin effective mass vaccination in these areas, long after the outbreak began.

Moreover, vaccination alone is insufficient. It must be accompanied by comprehensive food aid (the pervasive malnutrition in opposition-held parts of Syria renders the vaccine less effective) in addition to decontamination of water, rebuilding of sanitation systems, and access to a health system that the Syrian military has been attacking. Aylward ignores these broader problems.

It is well and good for Aylward to mouth platitudes about WHO’s commitment to humanitarian action. But for polio, the key principle is transparency about the problem and the steps needed to address it. There is no prospect for controlling Syria’s polio outbreak absent a comprehensive response that can be implemented only by giving priority to Syria’s children over the government’s narrow preoccupations. This outbreak exposes obstacles in the existing official administration of global health that need to be overcome to control polio in Syria and beyond its borders.

Dr. Annie Sparrow