Too expensive, too slow, too discriminatory, and other myths about the polio eradication program
In 2017, there was a total of 22 polio cases in the world. To put that in perspective, in 1988, there were 350,000 cases of polio, with approximately 22 people (mostly children) becoming paralyzed every half hour. Today’s 99 percent reduction of cases should be cause for celebration.
At the same time some in the health community criticize the Global Polio Eradication Initiative for costing too much money, being poorly managed, and usurping resources from the overall global health effort.
The Optimist’s Ryan Bell sat down with Jay Wenger, director of the polio program at the Bill & Melinda Gates Foundation, to fact-check the most persistent myths about the effort to eradicate polio.
Myth #1: Other diseases deserved to be eradicated first
Smallpox was the first disease successfully eradicated. The virus killed about one-third of the people it infected. Once a good vaccine was developed for smallpox, it took 10 or 12 years to declare it eradicated. The last case was in 1977. This was proof that eradication could work for some diseases. While it would be great to eradicate all infectious disease, eradication is not possible for most. The tetanus bacteria, for example, lives in the soil for many years. The only guaranteed way to get rid of it would be to sterilize the Earth, and that's obviously impossible. And we are trying to eradicate other infections, such as malaria. In the ‘40s and ‘50s, the public health community killed mosquitoes with DDT and cured people with chloroquine. But the mosquitoes became resistant to DDT and the malaria parasite became resistant to chloroquine. The eradication program was later put on pause as funding dried up and the limited number of interventions lost their effectiveness. However, the malaria program learned a lot about eradication and now, with an acceleration of the development of additional tools needed to finish the job, we believe malaria can be eradicated in the future.
After smallpox, polio was a reasonable target for eradication because they had the disease burden information and a vaccine that worked.
Myth #2: In choosing to eradicate polio, the West thought only of itself
Polio has always been present in the developing world.
Ironically, it got worse with the arrival of modern-day sanitation systems. Previously, most people in developing nations were exposed to polio as infants, a small proportion developed paralysis every year, and survivors without paralysis did not get disease because they’d built up natural immunity. But when sanitation systems were put in place, it greatly reduced children’s everyday exposure to viruses and bacteria, resulting in no cases, but preventing people from developing those immunities. However, when polio actually did get into these communities, that’s when we started seeing polio outbreaks, with thousands of children becoming paralyzed when an outbreak finally did occur. At the same time, organizations like the March of Dimes put an international spotlight on polio. Studies done in the 1960s and ‘70s found there were as many cases of paralysis from polio in the developing and the developed world. So, the sentiment of the eradication program was to say: “We're not going to just get rid of this disease from the rich countries. We're going to get rid of it everywhere, because it is everywhere.”
Myth #3: Eradication is a myopic approach to managing global health challenges
There’s a debate in public health, going back 100 years, about taking a vertical or horizontal approach to health. Is it better to tackle individual problems, or do you improve the whole healthcare system?
The big critique of a systems approach is that it’s broad. It can mean everything from making sure the hospitals are built and equipped, doctors are trained, there's gas for the cars, political will to support the programs—all kinds of things, and that makes it hard to measure progress. A lot of money goes into fixing healthcare systems, often without rigor about how it's spent and what progress is made. The foundation’s Integrated Delivery team and partners are working to address this through an approach to primary health care systems measurement and improvement.
The major critique of vertical programs is that they focus on only one disease, ignore other health issues at best and at worst may divert existing health structures away from other health problems. On the other hand, by going after a single disease you can count the number of cases, know where you’ve made progress, and what measures are effective. Working specifically and aggressively on a single problem can yield technologies and strategies that can also be used for achieving broader public health goals. And by getting rid of a disease once and for all, it gives a boost to all health programs, giving people confidence that we can make progress.
There are arguments to be made on both sides, and at the Gates Foundation we believe the answer is to do both.
Myth #4: As a one-and-done program, polio eradication is a waste of effort
The polio program has created innovations and developed approaches that can then be used for other things. For example, recently we’ve create an Emergency Operations Center (EOC) in every country where there’s been an outbreak. This involves gathering all health partners together—ideally in the same room—to look at the relevant data and make strategy decisions. That may not sound brilliant, but when we started tackling polio in Nigeria, the WHO people were in one building, the Ministry of Health down the street, and UNICEF in another city. The EOC brought all the important actors together, under national government leadership. When the Ebola outbreak happened in Western Africa, the first case showed up in Nigeria. The Ministry of Health asked the polio program to set up an EOC and to loan our polio workers to fight the outbreak. They got rid of Ebola in six months, then went back to work on polio.
The effort to get rid of polio has also driven the program to reach children in the farthest corners of a lot of countries. Now, more kids are vaccinated for polio in the world than for any other disease. In doing so, the polio program has created disease surveillance systems that weren’t in place before. I saw that first-hand in India, where I ran the National Polio Surveillance Project from 2002 to 2007. We had 300 medical officers all across India, with eyes on almost every village. When there was an outbreak of something like meningitis, as happened in the state of Uttar Pradesh, I would get a call from the government asking if our medical officers could go see what was going on—the polio surveillance system could be used to report on these kind of problems. And now that polio is gone from India (the last wild polio virus case was in 2011), that system is being used to monitor for cases of measles, diphtheria, pertussis, and more.
Myth #5: The developed world keeps the best vaccines for themselves
There are more factors than just cost that go into the choice of vaccine used for stopping polio in a given country. And “expensive” doesn’t always mean “better.” The “inactivated polio vaccine” (IPV) was the first one developed. The injection contains dead virus and can stop an exposed child from becoming paralyzed. The problem with IPV, though, is it doesn’t stop polio from spreading in countries where sanitation is not good. Vaccinated children can still host polio in their gut if they are infected with the virus, which they defecate out, keeping polio alive in their communities. The other problem is that IPV is expensive to manufacture. The foundation is supporting research to create a cheaper IPV, which I hope we'll have relatively soon. But I think of it as an insurance policy to protect children, not a tool for eradicating polio.
The only option for eradication is the “oral polio vaccine,” or OPV. It’s given by mouth, making it cheaper to make and easier to distribute. OPV has live virus (in a weakened state) and creates immunity in the stomach. After vaccination, if a person is exposed to a polio outbreak, the wild virus can’t reproduce in their gut. That’s the only way to eradicate polio in a community. But there is a problem with OPV. If not every child in a population is vaccinated, the vaccine’s own polio virus can move from kid to kid and mutate a bit each time. We call this “vaccine-derived polio virus,” or VDPV, and in rare cases it can cause paralysis. Those outbreaks tend to occur in places where vaccination efforts aren’t thorough, such as in parts of Africa and the Middle East. Luckily, those outbreaks are easy to stop with the OPV vaccine. It’s our workhorse.
The idea of the eradication program is to get rid of the virus totally so we don't have to worry about polio anymore. That takes a while, so in the meantime, we recommend that kids get a dose of IPV to at least protect them from paralysis if the virus is floating around. It’s like our insurance vaccine. But IPV won’t get us to eradication because it doesn’t work at the gut level.
Myth #6: Polio will never be eradicated due to war and conflict
Every global health program is eventually going to have to operate in a conflict zone. The polio program first encountered civil wars in Latin America, where both sides agreed to have “days of tranquility” when vaccinators could cross the fighting lines to vaccinate children. We successfully and peacefully eliminated polio in Latin America before some of those conflicts were over. In Africa, countries like the Democratic Republic of Congo and Somalia held cease fires for polio workers. And, recently, during the Syrian civil war, the polio program was able to work with the many different sides to negotiate access for health workers to stop outbreaks in that region. It remains a challenge in Afghanistan and Pakistan where the governments only control part of their geographic areas, but there are many examples of the polio program being successful despite civil wars and insurgencies.
Myth #7: The polio eradication program is way over budget
It’s not uncommon to hear something like, “Why spend a billion dollars on a disease that, last year, caused just 22 cases?”
There are two answers to this question. First, the whole point of eradication is that you see it through to the end—zero cases. The biggest benefits of the program become obvious after the virus is eradicated, so looking at the cost-per-case ratio for the program at the very end is misleading. The fact that we’ve only got 22 cases is a big success, not a reason to complain about spending a lot of money. Without spending the money, we’d be having hundreds of thousands of cases each year. We’ve got to get to 0 by getting to very small numbers first, and when we do get to zero, we reap benefits forever.
A better way to look at what we’re getting from the program right now is by the number of cases it has prevented. The Global Polio Eradication Initiative has prevented 18 million people from being paralyzed by polio, with hundreds of thousands more prevented every year, even before we get to zero!