An Old Friend Returns

Polio_physical_therapyNobody seems to think about polio anymore. In the collective consciousness of the Western World, it’s an affliction associated with old presidents and grainy, black-and-white pictures of children in leg braces. The imagery is always archaic — the braces are old-fashioned and primitive; the iron lung, an iconic representation of the disease, is synonymous with impractical and outdated medical technology. Yet as is common with many infectious diseases, what is old news in the United States is still a harsh reality in much of the developing world.

Polio, indeed, is a disease that exploits conditions of physical isolation, cultural distrust, economic disparity, war, and social upheaval. According to Dr. Robert Heimer, a professor of epidemiology and pharmacology at the Yale University School of Public Health, “Polio crops up in places where social dislocation is ongoing.”

In many ways, preventable infectious diseases provide an interesting and disturbing means of assessing social, political, and cultural divides. They are a visible demonstration of the inequality and neglect that is still pervasive in many parts of the developing world. While relatively recent eradication campaigns have reduced the total number of worldwide cases by approximately 99 percent, the disease is still endemic (i.e. has never been eradicated) in three countries: Pakistan, Afghanistan, and Nigeria. Eliminating that last one percent of cases continues to be an uphill battle.

Polio (or poliomyelitis) is an acute, viral, infectious disease spread primarily through fecal-oral transmission. In approximately 99 percent of cases, the infected individual shows no symptoms but still sheds virus. In the one percent of cases where the virus enters the bloodstream and central nervous system, however, it can destroy critical motor neurons, leading to muscle weakness and the disease’s characteristic paralysis, particularly in the legs.

The disease has existed within human populations since prehistoric times. Egyptian paintings and carvings occasionally show otherwise healthy individuals with withered limbs and walking canes. Until the introduction of higher sanitation standards, however, the disease rarely reached pandemic proportions. Children were usually exposed to the virus in low, constant doses, resulting in a passive immunity that kept the disease in check. But towards the end of the nineteenth century, the advent of improved sewage disposal and clean water supplies radically decreased the number of children exposed to the virus, drastically increasing the number of individuals at risk for paralytic polio.

Localized epidemics began to appear in Europe and the U.S. around 1900, and reached pandemic proportions in several instances throughout the first half of the twentieth century. 1952 was the worst year in American history: 58,000 cases were reported, with 3,145 deaths, and 21,269 cases of mild to severe paralysis. Even today, polio has no cure, but with the advent of two different types of vaccines in the 1950s, the prospect of eradication became feasible. Because there is no animal host or reservoir for the infection, it is theoretically possible to do away with polio completely. That the disease often affected prosperous communities unfamiliar with the ravages of infectious disease made polio an ideal candidate for eradication.

Today, the remaining one percent of polio cases are located in some of the most geopolitically unstable regions of the world. This, experts contend, is no coincidence. “I don’t think its possible to look at the goals [of disease eradication] in the absence of the political situation,” said Dr. Michael Cappello, a professor of pediatrics and epidemiology at the Yale School of Medicine. “What we’re seeing in places like Nigeria, Pakistan, and Syria, are examples of how short-term breakdowns in infrastructure lead to resurgence in disease incidence.” While there may be similar themes that run throughout the regions where polio still exists (namely armed conflict, physical remoteness, suspicion of western influence, and lack of political will), the underlying problems themselves are highly particular and defy universal solutions.

“If you immunize enough kids with effective doses, polio disappears,” said Oliver Rosenbauer, a spokesman for the Global Polio Eradication Initiative, “The reason why that hasn’t happened is very different, and different for each area within each country.”

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Syria is an interesting test case, insofar as it represents a country that had the disease mostly under control until its civil war began in 2010. Prior to the conflict, approximately 95 percent of children under five were vaccinated.  But, as a result of a fundamentally inoperable healthcare system and a breakdown of basic sanitation services during the civil war, there are now an estimated 500,000 unvaccinated children who are vulnerable to infection. Twenty-two cases of polio-like paralysis (ten of which have been confirmed as poliovirus) have been reported throughout the country. Undoubtedly, the re-emergence of polio traces the development of conflict.

Polio Vaccination
Polio Vaccination

Dr. Bruce Aylward, Assistant Director-General for Polio, Emergencies, and Country Collaboration at the WHO, recently discussed the disease in Syria with The New York Times. “The virus is the kind of virus that finds vulnerable populations,” he said, “and the combination of vulnerability and low immunization coverage, that is a time bomb. There is a real risk of this exploding into an outbreak with hundreds of cases.” The international nature of the conflict has generated a perfect storm of sorts — up to 4,000 people cross from Syria into neighboring countries every day, each one a possible carrier of the disease.

“This is a virus that travels with population movements across great distances. It got to Syria through population movements. That’s very clear,” Rosenbauer told The Politic. A Pakistani strain of the disease has already been found in several children in Syria’s Deir ez-Zor province, as well as in sewage samples taken in Israel and Lebanon.

A recent article in the medical journal The Lancet reported that even Europe might be at risk from a polio outbreak in Syria. If, because of lax vaccination practices in non-endemic areas, the disease finds a niche, the number of cases could explode. As a result, the international community has quickly mobilized around the suspected outbreaks. “Everybody knew that Syria was a risk,” explained Rosenbauer. “Health ministers [from various countries bordering Syria] declared this a regional public health emergency, and each country is going to launch their own immunization campaigns aimed at rapidly boosting immunity levels.” Massive immunization drives have been initiated, with the goal of vaccinating over ten million children in Middle Eastern countries over the next several weeks.

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In contrast to the dramatic nature of the events leading to the re-emergence of polio in Syria, the continued presence of the disease in Nigeria, Pakistan and Afghanistan is a result of deeper, more entrenched cultural forces.

According to Rosenbauer, the traditional problem areas of Pakistan “have been greater Karachi, the Quetta area of Baluchistan in the south, and then the federally administered tribal areas in the northwest.” Each area experiences particular problems, and there seem to be two different underlying causes for the difficulties experienced by eradication campaigns. In Karachi and Quetta, it was primarily what Rosenbauer termed “operational issues,” linked to a lack of political commitment or insufficiently planned operations — simply put, “kids were being missed.”

In the tribal areas of North Waziristan, however, the issue can be traced in part to Taliban influence. In June of 2012, the group denounced vaccines as a Western plot to sterilize Muslims and imposed a ban on inoculations. Suspicions also rose after a failed CIA attempt to identify the location of Osama bin Laden included a fake vaccination campaign in the city of Abbotabad. “It was a serious blow to polio efforts in many areas,” said Imtiaz Ali, a Yale World Fellow and Karachi-based reporter. “Since there was already ignorance about polio it was a big dent.”

Ali’s assessment of the prospect of eradication in Pakistan was far less optimistic than Rosenbauer’s projections for Syria. “Polio, particularly in the tribal region and the Waziristan region, has become a victim of geopolitics,” Ali said. “The problem is politics. And there is no easy solution to this.”

While there have been attempts to de-stigmatize vaccination efforts, including ad campaigns featuring prominent religious scholars and politicians, the tribal areas’ physical isolation and fundamentally conservative nature make any real attempt at eradication incredibly difficult. Ali explained, “If the Pakistani military could control the entire region, they could give security to the polio workers. When that will happen? I don’t know.”

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Kano, a northern state in Nigeria
Kano, a northern state in Nigeria

Nigeria’s situation is much more comparable to that of Pakistan than Syria. “If you look at Nigeria, the main problem there has been getting strong political commitment at the local level, making sure the immunization campaign is properly implemented and properly run,” Rosenbauer said. The situation has improved markedly since 2003, when five states in the predominantly Muslim northern region (Kano, Zamfara, Kaduna, Niger, and Buachi) boycotted vaccines on the advice of religious and local leaders, who reportedly endorsed rumors that the polio vaccine was an American conspiracy to spread HIV and cause infertility.

These responses were set against the backdrop of U.S. military engagement in Muslim countries, and court proceedings against Pfizer for ethics violations during antibiotic trials in Kano. But despite initial resistance, polio in Nigeria has been eliminated from all but two states, Kano and Borno. In Borno, the problem is still insecurity, mostly as a result of activity by the terrorist group Boko Haram.

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Though these situations seem wildly diverse, they do share distinct similarities. First, the epicenters of the disease are generally isolated, economically disadvantaged, predominantly Muslim communities. Second, rumors about Western conspiracies often do play a role in widespread distrust of vaccinators and vaccination efforts. The question then becomes: how do you eradicate a disease that spreads easily through asymptomatic carriers and now exists primarily in some of the most conflicted and dangerous areas of the world?

It seems that the consensus on effective polio eradication points towards education and local, micro-level planning. “The scientific work demonstrating the impact is an important component,” explained Robert Heimer, of Yale’s School of Public Health, “but only a small component of what is necessary to make these programs acceptable to politicians and the broad public.” Most of these issues are what he calls “data proof problems” — issues where, no matter how much information one gets, it’s very difficult to change policy without significant cultural or political shifts.

However, every researcher and health worker interviewed for this story spoke to the importance of this type of local engagement. Dr. Elijah Paintsil, an epidemiologist from Yale who works on mother-to-child HIV transmission, explained his version of international medical cooperation: “Do not write an agenda. That has been a mistake over the years, in terms of global donations to resource limited countries. We are trying to reverse that and provide a model that works, that is sustainable, and that is based on mutual trust.” Paintsil’s work in Ghana is based on this notion of intensely local engagement. “They [the locals] know the local structure and government better than we do. We are just helping them craft the message,” he explained.

Imtiaz Ali put forward a similar notion in discussing Pakistan. “You have to put a very indigenous and local shape to the program. If you send outsiders, they will be suspected [of being informants].” Taliban forces continue to kill vaccinators when they attempt to reach children in many regions. After all, the U.S. and Western nations have a vested interest in both eradicating the disease and also carrying out military operations.

Though a proponent of education efforts and local involvement, Ali also spoke to the strategies’ limitations, as vaccinators are often unable to reach those most affected by the disease as a result of insecurity. “As long as the Taliban are calling the shots and not allowing the polio workers there, I don’t see anything happening,” he said. The solution seems to lie in a tripartite structure of security, protection, and education.

A study in the international research journal Nature put forward an appealing course of action. First, integrate social and political analyses into feasibility assessments (the scientific research side), strategic planning, and steering. Second, find out what is driving rumors and resistance. And third, design and monitor communication and engagement strategies that enable local populations to take ownership of their immunization program. “You engage local leaders, local traditional and religious leaders to speak on behalf of the program, to speak on behalf of the need to protect children from polio,” said Rosenbauer.

Nevertheless, there does not seem to be a single “right way” to deal with these problems. Engaging the public requires strategic approaches sensitive to regional differences. The involvement of high-level figures in government, for instance, was useful in increasing vaccination rates in Nigeria and Kano. But in Afghanistan, the visibility of political figures proved too polarizing. Neutrality was needed in order to effectively convince community members to take ownership of the process.

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The unexpected difficulties involved in eliminating the last crop of polio cases have raised questions about the feasibility of doing away with the virus once and for all. The number of diseases that are eligible for eradication is small, and many have questioned the reasoning behind devoting so much energy to one disease, arguably to the detriment of other containment efforts.

“It’s extremely difficult to eradicate a disease,” Dr. Cappello explained, “but once its done, you never have to spend again. The decision at the policy level can be very challenging.” This debate has been ongoing for much of the past few decades. Should the international community really be pursuing the eradication of polio? Or should the focus be on the mere containment of the disease? The complexity of these issues in the face of 99 percent elimination has undeniably dulled political will in the past.

Nevertheless, when the threat of explosive outbreaks emerges, the international community rallies. Rosenbauer is resolute. “If you look at Syria and Somalia at the moment, that should put that argument right to rest,” he said. “You eradicate this disease, or in ten years time you’ll have 200,000 new cases every year. Those are the choices you have. This is not a disease that can be contained.”

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