Smallpox is captivating.
It assumed the role as one of humanity’s greatest enemies, bringing death and famine wherever it reared its ugly head. When it was prominent, three out of ten people who contracted it died. Sitting on beds of the infected, touching their clothes, or being in the range of their coughs were enough to initiate the appearance of the dreaded pea-like bumps. And this disease managed to survive for thousands of years, toiling throughout humanity (Centers for Disease Control and Prevention [CDC], 2016).
But smallpox is not enthralling because of these atrocities. Everyone can agree that it is one of the most devastating diseases in history. What is amazing, though, is how we eradicated a disease that has wreaked havoc on humanity for 2,300 years in just a little over 20 years (CDC, 2016).
In 1980, the World Health Assembly officially declared smallpox to be globally eradicated, which meant that the disease could no longer occur naturally anywhere in the world (CDC, 2016). And as you can probably imagine, this was a breathtaking moment in human history. We had gone from cowering in the wake of smallpox to organizing a long-term commitment to fight back, and ultimately defeating it.
Fast forward to 2017, and we are once again on the verge of a similar achievement: eradicating polio.
Eradicating a globally present disease is no small feat. It requires the attention of world leaders and endless collaborations between health institutions in various countries. The initiative, officially dubbed the Global Polio Eradication Initiative (GPEI), consists of health workers and agencies across the world who monitor the disease and ensure that efforts around the world are sustained. Core partners of the GPEI include UNICEF, Rotary International, the Bill and Melinda Gates Foundation, and the World Health Organization (WHO).
According to Christopher Maher, the Manager of Polio Eradication and Emergency Support in the Eastern Mediterranean, partners of the GPEI have also supported the initiative financially, contributing around $1 billion a year. The initiative is supported mainly through external funding from multiple institutions. Over the last 30 years, national governments and international communities have invested significantly in the initiative, often contributing funds directly through the WHO.
However, what does eradication mean, exactly? The word choice used to describe our victory over smallpox was deliberate. Why not say we “eliminated” smallpox instead, and are going to “eliminate” polio as well? To the average person, one would probably not find much difference between the two words.
As it turns out, in the world of public health, the two mean fundamentally different things. Eliminating a disease means to reduce its incidence, or risk of contracting a disease, below a certain limit. However, the agent that causes the disease, which can be a type of bacteria or virus, could still be circulating in the global environment. With eradication, the agent has been destroyed; in other words, the virus can no longer be found naturally in the human environment. This is the goal of the polio eradication initiative.
This distinction was explained to me by Dr. Maher himself, when I had the pleasure of interviewing him when he was working in Amman, Jordan and discuss the final stages of polio eradication. Dr. Maher has worked with the initiative under the WHO since 1993 and has helped advance polio eradication in China, Somalia, Syria, and Iraq.
In the Eastern Mediterranean – and in the world – Pakistan and Afghanistan are the only two remaining endemic countries that have currently reported cases of polio. In 2016 alone, there were 20 cases in Pakistan, and 13 in Afghanistan – a huge decrease from the 20,000 cases that were reported back in 2000, and the lowest number of cases ever reported in the two countries. So far in 2017, each has reported only two cases, or four cases total. One reason that the cases of polio have decreased is that poliovirus, like many viruses, follows a seasonal pattern of transmission, and the current cold climate offers a perfect environment to battle the disease.
I began my conversation with Dr. Maher, who emphasized the importance of immunization, or vaccination.
“The fundamental theory for eradication is immunization,” Dr. Maher stated. “Polio is a virus that has only one host, and that’s humans. Not having a having second host and not having the capacity to survive very long by itself in the environment means that it’s a good candidate for eradication.” The targeted age group for polio vaccination, he elaborated, is children under the age of five because they are the most commonly affected, and therefore the most important in the survival and transmission of poliovirus.
“What you see now in the final stages of eradication in Pakistan and Afghanistan is a series of large-scale eradication targeting in the whole country or regions with highest risk of sustaining transmission. So it’s a lot of activity – in the two countries, they probably used in the region about 200 million doses of vaccination to immunize kids multiple times.”
The polio eradication initiative faced three main challenges: the sheer scale of the operation, communication, and disease surveillance. “If I said to you, ‘I’m going to give you an assignment. If you’re in a suburb in D.C., and now you’re responsible for visiting every household in the suburb and identifying children under five years, communicating with parents, vaccinating kids, etc., it might take you a bit of time to organize that, to raise the workforce, and to train people,” said Dr. Maher. “It’s a very big operational challenge as much as anything else.”
On top of that, communication posed challenges as well. For the initiative to be effective, the communities at risk must be engaged and informed about what is happening with the disease. “You have to engage communities in all these different settings and you have to persuade them by saying, ‘Yes, you have to get your child immunized and immunized multiple times.’” Overall, the persuasion component of communication is essential. It is most important in convincing families, who may live in regions with poor healthcare access, to put their children’s health in the hands of the initiative.
Lastly, constant disease surveillance evaluated how effective the initiative was in multiple stages. The basic and arguably the best mechanism for all disease surveillance for polio eradication is documenting kids who exhibit a symptom called acute flaccid paralysis, which is the current evaluation tool used in disease surveillance for polio. Dr. Maher elaborated, “What you want to know from immunization campaigns is basic info on quality. Are you reaching a high proportion of children you’re trying to reach? Did we get as many children as we could? Those that we missed, why did we miss them?” According to him, an eradication initiative cannot function without surveillance. Randomly immunizing as many people as you can find, without keeping track of who has been afflicted and who has received the vaccine, is understandably not the best way to tackle the disease.
There is another more obscure component that is equally vital to eradication. Before working with communities, health workers cannot assume that all families will be accepting of their work, or even know what the initiative is about. They must evaluate how willing the communities are in seeking this health service, and if the communities are not as willing, health workers must devise a strategy to build demand for such services. Dr. Maher exemplified this challenge by comparing his previous work in Southeast Asian countries with solidified health infrastructures to countries that lacked them.
“There were unquestionable challenges and sheer size difficulties in China, but there was a basic solid capacity to deliver services, and there was a pretty strong health-seeking behavioral ethic in the population. I found out over time that these two go together: if there are services being offered, they are eventually met by expectation services by both the population (omit comma) and their desire to seek services if they’re available. That worked in our favor to great extent, as we could run our campaigns even in huge logistical nightmares. We could get very high levels of coverage, because there was an infrastructure of coverage to offer service in difficult circumstances, and there was a strong engagement of community to accept and seek that service.
“As we got further and further into the eradication program, we got down to places that became more difficult. We saw certain patterns emerge: the places where polio hung on were the places that didn’t have as well-developed health infrastructures. They didn’t have a well-developed public sector or tradition of offering public services to population, and didn’t have a certain level of demand for health services. So part of this initiative is really about building the demand in the community so that people accept that service.”
The initiative was also caught up in politics as well. From 2011 to 2012, Pakistan experienced a period of turmoil: militant groups attacked governors, disastrous floods displaced thousands of civilians, and tensions with the U.S. heightened (Human Rights Watch, 2012). As a result, distrust of foreign officials and government workers manifested and violence against health workers arose, which temporarily caused eradication efforts to wane. When I asked about this, Dr. Maher stated, “The rejection was a political one rather than a community one. Polio for a while there was used as a political foothold. It’s a visible program; there are people moving from house to house during the course of the year, which means polio workers were a good target. There were concerns about vaccine safety and whether or not they were religiously acceptable.”
The polio eradication initiative has experienced several bumps along the path to the final phase, which is happening right now. Fortunately, it has the support of numerous countries, including the U.S., Japan, U.K., Germany, and many others, as well as their major health institutions. Dr. Maher commended that agencies such as the CDC have contributed integrally in terms of logistics and technicalities. UNICEF has also driven the initiative forward with creating communication and engagement strategies. Rotary International, the Bill and Melinda Gates Foundation, and the WHO have all performed massively in eradicating polio. Thanks to their efforts, the initiative has currently advanced to a historic, unprecedented point, as we become one step closer to the eradication of a second major disease.
Dr. Maher hopes that polio will be eradicated this year, given the intensity of current immunization efforts during a low transmission period. With continued international support, the initiative may be finished sooner than we expect. Without a doubt, global health will soon make history again.
Centers for Disease Control and Prevention (2016). History of Smallpox. Retrieved from https://www.cdc.gov/smallpox/
Centers for Disease Control and Prevention (2016). Transmission. Retrieved from https://www.cdc.gov/smallpox/transmission/index.html
Centers for Disease Control and Prevention (2016). Smallpox Virus. Retrieved from https://www.cdc.gov/smallpox/history/history.html
Human Rights Watch (2012). World Report 2012: Pakistan. Retrieved from https://www.hrw.org/world-report/2012/country-chapters/pakistan