Can We Really Eliminate a Virus? The Polio Puzzle

On Wednesday a milestone was established in the fight for the eradication of polio. It has been one year since the last reported case of the childhood disease in Myanmar (data usually takes a month or two to collect so this may change). That makes two countries this year, the other being Somalia, who have surpassed a year without an outbreak in 2008. Currently polio is endemic in four countries: Pakistan, India, Afghanistan, and Nigeria. The organizations who fight the disease encounter a two-fold challenge in each of these countries; immunize all children under 5 with enough doses to be effective, and contain the disease within the country until it can be eliminated. These challenges are further complicated by war, political insecurity, famine and distrust of medicine. To overcome these roadblocks and eliminate the disease will require supreme diligence and innovative ideas from those on the ground in these last few strongholds which continue to spawn cases of polio.

The press to eradicate polio across the globe started in 1988. The World Health Organization (WHO), Rotary International, UNICEF, and most developed countries (with the US far and ahead with greater than $1,000 million US donated so far) set out to conquer the disease that was endemic to over 125 countries. 20 years later only 4 countries suffer through a constant battle to interrupt transmission. 10 other countries reported infections in 2007 and all but 2 have had cases this year (the total cases to-date in 2008 is 453 globally).

One major factor standing in the way of success in many of these countries is political instability and war. Afghanistan and Somalia, as well as parts of Pakistan and Ethiopia, suffer from armed conflicts that make "vaccination logistically difficult and unpredictable at best." But the will of the people on the ground, doctors and volunteers who want to make a difference in their home countries, finds ways to operate around such dangerous situations. Negotiations for 'days of tranquility' (the suspension of hostilities in order to allow for vaccination) have been successful in Sudan and previously in Somalia and Ethiopia. These individuals show great courage and determination in the face of a major roadblock. Many times simply receiving and delivering vaccinations with the workers is a strain on the patience with multiple searches and questions. Soldiers don't take to kindly to strangers, especially those who create large crowds of citizens. But there are success stories from countries with far worse conditions than any face today. Bangladesh, Vietnam, Rwanda, and Zimbabwe all offered serious problems. Polio was eradicated from Angola in the midst of a civil war. In 2002 an outbreak in Kandahar was stopped by a WHO-led mop up crew despite the Afghan war. Currently Afghanistan faces challenges with a power struggle happening in the country. Basic supplies are in short order, many parts are barren or hard to reach by vehicle, and regional conflict has made most villages wary of any outsiders. This final roadblock presents a whole new challenge for the eradication efforts.

Once the organizations have been allowed to organize a vaccination effort the ground campaign must begin to recruit trained medical personnel and volunteers to monitor and administer the vaccine. A huge part of this effort is to inform citizens of the intentions and purpose of the operation. Dr. Atul Gawande, a surgeon from the United States, traveled to his family's native India after his residency to volunteer in the fight against polio. In his book, Better: A Surgeon's Notes on Performance, Gawande writes,

One difficulty came up repeatedly--from local doctors, from villagers, from workers trudging house to house. The question was: Why? Why this huge polio campaign when what we need is--fill in the blank here--clean water (diarrheal illness kills 500,000 Indian children per year), better nutrition (half of children under three have stunted growth), working septic systems (which would help prevent polio as well as other diseases), irrigation (so a single rainless season would not impoverish farming families)? We saw neighborhoods that had had outbreaks of malaria, tuberculosis, cholera. But no one important had come to visit in years. Now one case of polio occurs and the infantry marches in?

There are no simple answers to this question because truly the access to clean water, or good nutrition would save a larger number of children than polio eradication ever will. I know I would have trouble answering questions like that, I know I would explain I was there to do what I could, and polio eradication has been decided as what I can do. An old saying explains a better reason maybe; if you're starving, becoming paralyzed certainly isn't going to help. While it is harsh it is true, the doctors on the ground are just following what they can do to help. These guys are truly what makes the eradication goal a feasible one, the ability to organize and convince the population of the importance in the face of true struggle is a skill that a large organization cannot achieve, only in small step swill individuals gain the trust of an entire population.

Perhaps the goal of global eradication of polio is an absurd ambition, India alone creates a new pool of potential polio victims the size of Venezuela's entire population. Staying caught up means organizing a mammoth campaign to immunize every child under 5, and the cost has been overwhelming. So far about $3 billion has been spent worldwide, more than six hundred dollars a case. To put that in perspective the total health care budget for India's government in 2003 amounted to four dollars per person. The truth is, no cost-benefit analysis calculus can assure us just now that the money is well spent. But this remains a task that as a civilization we can do that would benefit mankind forever. The eradication of smallpox was a gift from the previous generation to all who are to come, and now, perhaps, the eradication of polio can, too. But it will be achieved on the backs of those on the ground who represent a monument to the perfection of performance, showing what can be achieved through diligent detail coupled with great ambition.

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