Opionion article by the Representative of the World Health Organisation (WHO) in Pakistan Dr. Michel Thieren in connection with World Polio Day
It is inevitable that polio will be stopped, will all likelihood even by the year’s end. Wherever the virus is still actively transmitting, mostly in Afghanistan and Pakistan, the core polio epidemiological indicators attest that this virus is actually on the run. The number of new cases – and the virus’ presence in the environment – is facing an historic decline, with low results in both countries. The last reservoirs of polio are almost cleared of polio cases and cleansed from the endemic strain of indigenous poliovirus. More, the genetic sequences of the collected viruses show unprecedented uniformity, stemming for its near-extinction. All trend lines are swiftly heading for zero, with no return possible to the dark ages of the crippling disease.
This World Polio Day 2016, which by all means is very likely to be the last one celebrated in a polio endemic world, is less an opportunity to set a final date for viral elimination, than it is to reflect one last time on the three meanings of a polio-free world for the next generation of children.
First, there is the moral imperative to end polio. Forty years ago, smallpox vanished from earth and created an historical precedent by removing the immense sufferings it had caused for centuries all around the world. Next came polio, with the unequivocal claim on the World Health Day on April 7, 1995: “Target 2000: A World Without Polio”. The decision to eradicate polio once and for all was taken not only on scientific evidence as being more cost effective than to control it
The decision to eradicate polio once and for all was taken not only on scientific evidence as being more cost effective than to control it indefinitely, but also as a global conscience that polio, like smallpox, represents absolute evil to public health. Poliomyelitis, few decades back, was a singular childhood horror repeated in millions of households across the world: the sudden and brutal withdrawal by the virus of the basic physical skill a child learns to master during his/her first twelve months, “to walk”. Eradicating polio is therefore exactly this: freeing the world from a crippling disease which condemns the most underserved children to a lifelong social death. This moral imperative is the prominent legacy of a polio-free world.
The second is the epidemiological imperative of ineluctability of eradication. No matter how entrenched the virus is and how hard it still is to find the last vulnerable, unprotected child, there will be no way back in the effort. Eradicating polio is a target that, by definition, bears no variance: no child will be left unattended. Utilitarians may view this otherwise. Half a billion USD, the annual cost of the program in Pakistan, may better be re-invested in interventions with much higher impact on child survival, such as routine immunization or breastfeeding feeding. Let us remember that Pakistan ranges among the lowest achieving countries on Millennium Development Goals 4 and 5 associated with child and maternal mortality. But such a resource shift, right now, from polio towards other public health programs would signify a dangerous indulgence to a “near eradication” target, which actually would be an “epidemiological oxymoron”.
Eradicating polio is a target that, by definition, bears no variance: no child will be left unattended. Utilitarians may view this otherwise. Half a billion USD, the annual cost of the program in Pakistan, may better be re-invested in interventions with much higher impact on child survival, such as routine immunization or breastfeeding feeding. Let us remember that Pakistan ranges among the lowest achieving countries on Millennium Development Goals 4 and 5 associated with child and maternal mortality. But such a resource shift, right now, from polio towards other public health programs would signify a dangerous indulgence to a “near eradication” target, which actually would be an “epidemiological oxymoron”.
There is no room for a 99.9% decline in eradication: the goal is zero cases everywhere and no more viruses anywhere. Because polio cannot be ‘controlled’, it can only be eradicated. The handful number of cases, and their ten thousand times less frequent occurrence compared to many other lethal illnesses doesn’t provide any justification for the world to surrender the fight.
Any lost terrain would irremediably re-open sage heavens for the virus to transmit freely again. The 23 cases of this year would quickly trigger a dominos effect, with thousands of new cases falling down in just a few years only.
Global polio eradication is unstoppable, and failure to eradicate would lead to 200 000 cases of polio per year, worldwide. Once achieved polio eradication will leave an immense legacy of practices that will benefit public health initiatives for generations.
And then comes the third meaning: is eradicating illnesses a messianic vow? As we enable the ‘sixth great extinction’ of species on earth, the small string of DNA that the poliovirus is shows remarkable resilience, having for long defied the most powerful and technically equipped individuals and entities in the world. The road from half a million polio cases per year decades ago to 23 cases today hasn’t been easy, and along that long night, the program had to reset its global target at least three times. Eradicating a disease is by any means “extreme public health practice”.
In Afghanistan and Pakistan, this year alone, the Global Polio Eradication Program has delivered half a billion doses of OPV (Oral Polio Vaccines) to approximately fifty million children during nine monthly national campaigns through mobilizing 300 000 vaccination workers each time. This represents the backbone of an even bigger logistical and operational system, with the field presence of the world’s finest polio eradication experts. The story of the collective, sustained endeavor complemented with hundreds of thousands of individual narrative accounts has yet to be told.
The take-home message however, for all of us on the ground in Pakistan and Afghanistan is very simple: Polio eradication works; polio eradication is much more than just a medical jargon and a “doctor thing”; it belongs to religious leaders, army personnel, security experts, peace negotiators, policy makers, the legislator and the executive; it stands on the shoulders of courageous anonymous professionals who, every morning are not going out to work, but with a resolve to fight.
Most importantly even, polio eradication in its last mile requires the integral ownership and undertaking of the tasks by the community, in disregard to any top down programmatic intrusion from the outside. The “community based vaccination” approach is at the core of our count down to zero strategy in the next several weeks.
It is paradoxically when there will be no more polio virus, that the world will have reached its top capacity and savoir-faire to eradicate it. This ability will transfer to future eradication efforts in malaria and measles eventually. Eradication overall is a humanitarian and epidemiological imperative, and it is an imperative in its own. It reassures a constantly worried world about emerging health threats that actually deadly diseases can also be forced out. This is what the world is celebrating today.