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In 1988, the World Health Organization (WHO) announced an ambitious campaign to the world of polio by 2000. It's 2018, and the disease still persists in pockets, including cases of vaccine-derived polio in India. But it is no longer a major health hazard, the campaign continues to cost a billion USD annually. So why did the campaign fail to achieve its target? In his new book Polio: The Odyssey of Eradication, journalist and academic Thomas Abraham looks at what went wrong; from the murder of vaccinators, to resistance from parents, to how it became a casualty of geo-politics in the post-9/11 world. Abraham, who was previously editor of the South China Morning Post and worked at the United Nations, spoke on the campaign, the disease and the vaccine, on the sidelines of the Global Investigative Journalism Network's third Asian Investigative Journalism Conference in Seoul.
Following are the edited excerpts from the conversation:
How did this idea to look at this campaign start? And what in essence led to the campaign's failure?
The polio program started in 1988 and was released in 2000. Now it is 2018 and it still has not finished. The obvious first question is why has it taken so long? That was one interesting question that in turn to a whole bunch of other issues. The three remaining countries in 2011 (which still had polio) were India, Pakistan and Nigeria. War and conflict was one issue, lack of confidence was another.
A boy receives polio vaccine drops, during an anti-polio campaign, in Karachi, Pakistan. File image. Reuters / Akhtar Soomro
Eradication, if you look at it from a scientific point of view, is like a moon shot; putting a man on the moon. What is the cause of death? And in polio, the cause is a virus. You are trying to drive that to extinction, globally. That itself is an amazing thing. Even for human beings, it is hard to drive other life forms to extinction. And you are trying to get rid of a vaccine. Lots of questions jump up when you start tracking. First of all, why was polio chosen for this? Polio is a global program, the vaccine was coming straight to people's doorsteps. You have not had these repeated doses of polio vaccines. So parents started shouting and saying 'When we're going to be kids', we're going to give you that. And polio, to be honest, was a really, really small cause of childhood death. So there was a natural pushback. From India, it started in the 2000s.
The old polio vaccine was amazing but it was not effective when you had a high population density. It can persist for a long time along with poor sanitation. This was happening in India and Pakistan. The vaccine did not work that it was needed again vaccination campaigns. That led to some suspicions.
In Nigerian Muslim Communities, there was also a rumor that the polio vaccine was the West's revenge for 9/11. They do not care about your kids, they want to make sure they are sterile. This article is available in the United States and Pakistan where the polio campaign fell into this crevbade in the global divide that opened up after 9/11 between the West and parts of the Muslim world.
How did that happen?
In parts of Pakistan, you had American drone attacks, and the Taliban figured this campaign is important to the government and the Americans, and said unless you stop the drones we will not allow vaccination here. This was around 2007. Another thing was the Talibanization of the north-west frontier that polio workers were being targeted. And unless you have women vaccinators it's difficult to get access to homes. Prominent mullahs were doing propaganda against the vaccine. That was part of it. Why did it go so wrong, why did it take so long? These are all the things: bad vaccines, lack of demand, geopolitics.
Though the campaign was not fully successful, it is not correct?
Oh yes. But the goal was not to succeed to a large extent. So the question was, should we have a manageable level? But here you are going to be polio-free in nature. And you can not step away.
Why was 2000 chosen as the cut-off date?
They thought it would be an easy thing. And eradication programs need to be time-bound, because they are very intensive. In eradication, as opposed to a vaccination program, you have a lot of effort for a short period of time and wipe it out permanently. But if it persists and you can do this huge effort, then you can afford it any more.
How did you approach the writing? Did you have any doubts about whether or not they were overturned in the process?
It was about five years to report and write. The story kept changing. As you dig deeper, the story becomes more complex and more interesting. The whole thing is a learning process. Why were vaccinators being murderinated? Why are rational parents refusing vaccination? Once you start with these questions the answers get a lot more interesting. If you do not ask the questions you do not get the answers.
Polio: The Odyssey of Eradication, by Thomas Abraham
You also mentioned the ethical dilemma in parenting, when parents are resistant, for instance.
There is a huge ethical dilemma. For examples, parents were threatened with jail in Pakistan. That would be completely unacceptable in other parts of the world. Why do you have two standards? Then this idea of an informed consent ingrained into medical practice. Here there was no consent, informed or otherwise. Do parents know the risk? In the United States there was a compensation program because there is a known risk [of vaccine-derived infection]. Another ethical point, if vaccinators are getting killed is it worth to adult human life to save a child from paralysis? Where does the balance lie?
Is eradication the only way to approach a public health issue?
Only certain diseases are capable of being eradicated. It means the virus must be removed from society. And those are diseases where the bug exists only in human beings. Even if you ensure every one is flu-free, it can be reintroduced. And most diseases are like that. The exceptions are smallpox, measles, Guinea worm disease. Technically very few diseases can be eradicated. The feeling in the 1970s and 80s was a great belief in the power of science to achieve a lot of things. If we can, let's go for it.
What about the argument that it is better to focus on simple things?
That's valid. Public health has many religions and sects within it. Some would say focus on single diseases, others say it's a waste of time, There is this continuous argument in public health. Here was some way was chosen. At point in time, they thought we could finish in it 12 years. Rotary International was willing to provide money. And everyone thought it would be pretty easy. The whole idea in 1988 was a gift from the 20th to the 21st century.
What were the lessons learned in this general public?
The big issue is, as a government, do you focus on your infrastructure or infrastructure? sanitation, primary health care centers etc? And the answer to me is [the latter]. If you look at the child as a whole, you are preventing the child from getting polio but the same child can die of measles or malaria or diarrhea or all these childhood killers. You are saving the child from paralysis and polio but what happens after that? There are arguments on this side of the question that are needed.
So what do you think is a realistic date for the world to become polio-free?
The earliest according to the WHO is 2022. Will they meet it? I do not think so. I think it will take a lot longer. If you look at the rate at which vaccine-derived polio cases are springing up, it's hard to put a date on this. And neither can you stop; you've reduced it to about 30 globally. If you take your foot off the gas, the danger is it could explode. It's a point of no return at the moment.
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