Last week was a turbulent one for polio eradication. On the one hand, we’re about halfway through “the fastest vaccine rollout ever”, which involves all countries switching from one vaccine to another kind in the space of a single fortnight (see progress here). On the other, violence against those on the front lines continues: seven policemen protecting polio vaccinators were shot and killed in broad daylight in Karachi, Pakistan on Wednesday. The Taliban swiftly claimed responsibility.
At first, it seems both unfortunate and puzzling that these two states of violence and progress could exist side by side. How did it get this way?
In 1988, the World Health Assembly resolved to eradicate polio by 2000. Sixteen years on from the initial deadline, the politicians, populations and health systems of the world are still working on this mission, long after the original terror of the disease has faded. Yet, the nature of eradication means that resources, time and international pressure has to be kept up until every last case is gone from the remotest, poorest and least accessible corners of the world. When a goal is so all-encompassing, and decided so long ago, we can begin to understand why communities nowadays might be a little confused by its prioritisation.
— Helen Branswell (@HelenBranswell) April 18, 2016
Today, the polio’s final frontiers are the crowded slums of urban Pakistan, and the mountainous regions lying between Pakistan and Afghanistan, which are also known for hosting terrorist groups and being the focus of the illegal drone war. In these places, any kind of healthcare is often inaccessible, and conditions such as diarrhoea and pneumonia far exceed polio in terms of the little lives they sadly claim.
For all these reasons and more, the final steps towards eradication may well be some of the most difficult, and they require intense determination from all involved.
But as time has passed, this necessary single-mindedness itself has put the campaign under threat; from the religious resistance to the vaccine in Nigeria in the 2000s to the tragic violence in Pakistan last week, polio eradication has come to represent something suspicious in certain communities.
It doesn’t help that the issues around vaccination are pretty complicated. The basics are this: there are three types of polio, which can be “wild” or, very rarely, vaccine derived. There are also two main types of vaccination, one consists of a few drops given orally (it comes in a few different varieties); the other is a standard injection. None of this presents a huge problem in theory, but explanations are naturally challenging to explain these differences and the changes that are needed for eradication in practice. For example, for many years the oral polio vaccine has been used in developing countries, and delivered in campaign form (i.e. not in a clinic or alongside other health services), whereas children in wealthier countries have benefited from the injectable version as part of their routine paediatric services. Now, many developing countries are introducing the injectable version as well, meaning that for some time both vaccines will be used at the same time. There are good scientific and practical reasons behind all this, but explaining them is not easy to get right in a country with low levels of literacy.
The current vaccine switchover is no less complicated – it involves swapping an oral vaccine containing three types of polio to one containing just two, since one kind has not been seen since 1999 and the risks of including it in the vaccine now outweigh the benefits.
An inability to explain these differences and complexities, added to constantly changing polio campaign strategies, have historically contributed to confusion and resistance to eradication. Understandably so – communities with low education levels will have to trust that this chopping and changing is for the benefit of their children, which in places where governments are corrupt and public services barely exist can sometimes be a stretch.
None of this negates the fact that we’re closer than ever to eradicating this terrible disease, and I am firmly among the ranks of those who would love to see the back of poliomyelitis. But I also hope that after a process that is likely to span 30 years or more, real lessons can be learned around the most effective ways to eradicate disease: through a health system. This approach ensures that the program is placed in its proper context and can be administered with whatever local sensitivities are already in place for other health services.
The tools to eradicate polio have been around for a very long time. The technical ability has been known about for many years. It’s the people, the diverse communities, priorities and geographies of the world that have presented the biggest challenges. The protracted eradication campaign has had to face a perhaps unexpected task – to justify the prioritisation of a receding disease to not one but several generations of some of the world’s most poorest people. This has frequently put the campaign in conflict with evolving political landscapes and also perhaps with some parental desire for self determination – a wish to decide which diseases to protect their children from, not to have it thrust upon them by distant decision-makers from the 1980s.
As the global conversation casually drifts towards eradication campaigns for measles, malaria and other diseases, I hope the technocrats of tomorrow remember this and more, for the sake of the health workers, the children they aim to protect and ultimately their own success.
Featured image © CDC Global
Emily Loud is co-founder and communications manager at The Diagonal, and has a master’s in Global Health and Development from UCL. She is particularly interested in the “demand-side” of health interventions and global health security. Emily is currently based in London, doing communications for two global health and development organisations, shoehorning in research when she can find a moment. You can find her on Twitter @eloudness