Polio’s end game

A fter more than two decades of hard work, Rotary and its partners are on the brink of eradicating polio. They celebrated another milestone in February, when India was removed from the list of polio-endemic countries after a year without any cases of the tenacious disease. In honor of World Polio Day, 24 October, we asked leaders of the partners in the eradication effort about the successes, challenges, and future of the campaign to end polio. Take action at www.endpolionow.org.

Q: What’s the most striking difference between running a humanitarian campaign and running a business, when both have the same challenges in terms of money, logistics, and outcome expectations?

THOMAS R. FRIEDEN, U.S. Centers for Disease Control and Prevention (CDC): In both business and public health, success depends on good management, and good management depends on leadership and good data. The major difference is that for polio eradication, we must eliminate the risk of failure rather than balance calculated risks.

JEFF RAIKES, Bill & Melinda Gates Foundation: The mix of stakeholders is different in a humanitarian campaign, but the biggest challenge is similar: multiple players with multiple agendas. How well you work out those differences – whether in business or in a humanitarian campaign – is often the key to success or failure.

JOHN HEWKO, Rotary International: In a business, you’re focused on the bottom line. In the humanitarian field, there is a double or even triple bottom line. It is important to run the operation efficiently – we are accountable to our donors and members, just as businesses are to shareholders. But more than that, we are accountable to those we are working to serve.

Q: Let’s think of humanitarian efforts as if they were a financial portfolio. How do you advise a client – in this case a donor – how to allocate his or her resources for the best return?

ANTHONY LAKE, UNICEF: Donors are interested in achieving the greatest possible return on their investment, which means they should invest in programs and initiatives that are effective and cost-effective. Targeting the hardest-to-reach communities is the best way to achieve that return. There is strong evidence to support this. In 2010, UNICEF put a team of our best analysts to work on a modeling exercise to test the cost-effectiveness of an equity-focused strategy to reduce the death rate of children under five. We found that in countries with the highest burden of under-five mortality and the worst poverty, such an approach can save up to 60 percent more children than current practices.

JOHN HEWKO: Polio eradication is a good investment. Although the global investment in a polio-free world exceeds US$9 billion, an independent study published in the medical journal Vaccine estimates the net economic benefits to be $45 billion to $50 billion over the next 20 years. Of course, the return on eradicating a disease forever and preventing the suffering of countless children is impossible to calculate.

Q: How do you best describe the leveraging power of cooperation?

JEFF RAIKES: A shared sense of commitment can solve problems that are bigger than any one individual or organization can take on.

ANTHONY LAKE: Effective, efficient, sustainable. The Global Polio Eradication Initiative [GPEI] is a powerful example of how cooperation produces results. The partnership works because we leverage comparative advantages to achieve our common goals, with each partner investing time and resources in our own area of expertise.

THOMAS R. FRIEDEN: Each of us knows our respective roles and supports one another. Together, through the efforts and cooperation of more than 200 countries and 20 million volunteers, we have immunized more than 2.5 billion children.

JEFF RAIKES: The campaign to eradicate smallpox showed what cooperation can achieve at the global level. In 1967, when the World Health Organization launched a new plan to eradicate smallpox, the disease was striking an estimated 10 million to 15 million people a year, killing one in four, and scarring or blinding most survivors. Twelve years later, smallpox was gone because governments and organizations worked together.

Q: What are the inherent dangers of your partnership? Does it have natural enemies, and what are they?

THOMAS R. FRIEDEN: Our enemies are fatigue and complacency. On bad days, the decades-long battle seems like it will never end, or we congratulate ourselves on how far we’ve come and don’t reach deep for the ingenuity needed to finish the job. Fortunately, our partnership has weathered those bad days because of our commitment to protect every child, and [because of] the faithfulness of our donors.

MARGARET CHAN, World Health Organization: The polio eradication partnership brings massive benefits to the organizations involved, and to the people we are working to help. Only by acting in partnership have we been able to get as close as we are to a polio-free world. With the benefits of partnerships come challenges, such as the need for consistent communication and information sharing, coordination among the different teams, and a clear understanding of the roles and responsibilities of each organization. Partnerships are not necessarily the easier way to work, but a good partnership is often a more effective way to work.

JEFF RAIKES: All kinds of forces can threaten a partnership: cultural beliefs, economic forces, political differences, egos. But the consequences of inaction are a much greater risk.

JOHN HEWKO: The Global Polio Eradication Initiative has been described as the gold standard of public-private partnership, and it’s been working now for over 20 years – which is itself quite amazing. The biggest danger to a partnership that is tackling a major global health initiative over several decades is loss of focus and purpose, particularly as the leadership of the partners changes over time. The fact that this danger has not plagued this partnership can be attributed to the nature of the goal toward which we are all working – a gift to the children of the world that will live on in perpetuity.

Q: What’s the most serious threat facing the effort to eradicate polio?

THOMAS R. FRIEDEN: The challenge of getting over the finish line in Nigeria, Pakistan, and Afghanistan. The good news is that India has shown other polio-endemic countries what is possible with commitment and perseverance.

JEFF RAIKES: When you’re working on big problems that take a long time, the greatest threat is losing the sense of urgency. This really hit home for me on a recent trip to India, when I met a little girl named Arshi who had contracted polio despite receiving many doses of the oral vaccine for type 1 polio and a few doses of the vaccine for type 3. If we had been able to roll out a new bivalent vaccine just six months earlier, Arshi wouldn’t be one of the last children in India to contract polio. So I keep asking myself and others: Are we doing absolutely everything we can, today, to innovate and think of new ways to finish the job?

Q: What went right in India? How do you account for India’s success?

MARGARET CHAN: India demonstrates that our strategies work, even in the most technically challenging places, provided they are fully implemented and the vaccine gets to all children. And it underscores the importance of political commitment at all levels, from central government to local communities. It is truly about the incredible perseverance of the government of India, supported by Rotarians from across the country. It is an incredible achievement.

JEFF RAIKES: What they accomplished is even more remarkable when you think about the country’s huge and growing population, hard-to-reach migrant communities, and sanitation and health conditions that limit the effectiveness of polio vaccines. Twice a year, two million volunteers prepare 800,000 vaccination booths around the country. They immunize more than 172 million children, one at a time. And with partners like Rotary, WHO, CDC, and UNICEF, they have built an impressive infrastructure for delivering health services to some of the most underprivileged children in the world.

THOMAS R. FRIEDEN: The scale of the effort is mind-boggling. The people of India deserve enormous credit.

JOHN HEWKO: The government of India has invested over $1 billion; Rotarians advocated with government, traditional, corporate, and community leaders; UNICEF developed strategies to identify populations of children that might otherwise have been missed; and WHO, with the support of CDC, helped develop the world-class National Polio Surveillance Project that was able to identify all cases of possible polio.

ANTHONY LAKE: The volunteers – who, importantly, included children – are the true heroes and heroines of the polio campaign. The success of India is also living proof of [the effectiveness of] the equity approach – prioritizing the hardest-to-reach, most-disadvantaged children. That’s how India was able to protect every child.

Q: If you could do one thing to hasten the end of the transmission of polio, what would it be?

MARGARET CHAN: At its core, polio eradication is very simple. If all children are immunized with multiple doses of polio vaccine, then transmission of the virus stops. To make that possible, if I had a magic wand, I would bring instant peace and security to Afghanistan, Nigeria, and Pakistan. That would be a huge boost to progress.

JOHN HEWKO: Rotary, if it could, would remove all the barriers to reaching children with the polio vaccine – be it the successful brokering of Days of Tranquility in areas of armed conflict or persuading the governments of the world to exhibit the political will and provide the funding needed to finish the job.

THOMAS R. FRIEDEN: My hope is that the leaders of countries with endemic polio recognize that they are instrumental in ending the tragic effect that continued polio transmission means for their people and their future. Only with their leadership can polio be eradicated. And there are reasons to be hopeful. Leaders in these countries are engaging with us and other partners.

Q: What drives your optimism, given that you’ve been trying to eliminate the final 1 percent of cases for so long?

ANTHONY LAKE: What drives our optimism is the progress we have made in some of the most difficult operating environments – and the promise of building on it. The global progress in eradicating polio since 1988 is truly remarkable. And in 2011, that “1 percent” was the lowest [number of reported cases] we have ever had. India has proved we can do this – and if we can achieve this there, we can do so everywhere.

JOHN HEWKO: Over the past 25 years, eradication efforts have weathered economic downturns, conflict, natural disasters, and varying levels of political will. Fights worth winning are usually not easy or quick – but we stay the course until the goal is achieved.

MARGARET CHAN: We are optimistic because we know that the strategies to eradicate polio work. Eradication has been achieved in 99 percent of the world – often in highly challenging conditions.  That is from a professional perspective, as a public health professional. On a personal level, what really makes me optimistic is to see the universal desire of parents everywhere to provide a better life for their children.

Q: What might cause you to change your strategy?

THOMAS R. FRIEDEN: The basic strategy is to provide multiple doses of effective vaccines to large numbers of children, with efforts guided by precise virologic surveillance. Refinements in that strategy have occurred during the last decade when it was clear that many more doses of vaccine were needed in some areas, or that some risk groups were being missed. All of the partners in the Global Polio Eradication Initiative are open to innovative suggestions for getting the job done faster. Continuous innovation – such as bivalent vaccine and vial monitors that change color if the cold chain has been broken – is an integral part of the strategy to get over the finish line.

MARGARET CHAN: Our aim is not just to eradicate polio, but to do so in the most efficient and fastest way possible. We are constantly evaluating our strategic approaches to come up with new tactics, including some to overcome area-specific challenges. The ultimate, basic strategy does not change: to vaccinate every single child. Our job is to figure out how best to do this.

Q: All of you have been effective in dealing with donor fatigue. How will you prepare people for the significant costs that will be related to the certification of a polio-free world?

JOHN HEWKO: It’s important to continue to inform and educate Rotary club members, policymakers, and the public about the progress of polio eradication and what it will take to finish the job. Rotary club members have raised more than $1 billion in support of global polio eradication efforts and are committed to seeing the program through to certification. Rotarians are actively engaged in reaching out to governments and institutions to secure the resources necessary to complete this last lap in the race to eradicate polio.

MARGARET CHAN: Once polio is eradicated, the next challenge will be to ensure it remains eradicated. We will need to impress upon the global community the importance of investing in the eradication process right through to the very end – that is, through to certification. At the same time, we will need to take advantage of the polio infrastructure to ensure that the broader benefits of polio eradication are fully exploited.

THOMAS R. FRIEDEN: We know that poliovirus can lurk in high-risk areas unseen; we need to be sure this does not happen after the apparent “last” case. When we stop the current intensified effort because there are fewer outbreaks, funds will be freed for post-eradication activities. Part of our investment in eradication has been working with countries so they can eventually take over full responsibility for routine vaccination and monitoring.

ANTHONY LAKE: These costs are critical to achieving a sustainable victory in defeating a crippling disease. I think that donors who care about eradicating polio – and there are many – understand that we have to finish the job. We are working hard to make the program ever more efficient, and to support national efforts to keep countries polio-free until the day finally comes when polio no longer poses a threat.

Q: What do you say to people who think the resources spent on polio eradication would be better used elsewhere?

JOHN HEWKO: I would tell them five things. First, if we opt for polio control instead of eradication, experts say that polio could rebound to 10 million cases in the next 40 years. Second, we have the technical tools to end polio. The tools to eradicate other diseases, like HIV, are not available. Third, polio eradication is a good investment. Fourth, polio eradication activities strengthen the system for other health interventions. And finally, the successful eradication of polio sets the stage for the next major global health initiative.

MARGARET CHAN: Polio eradication is the best buy, any way one looks at it, from a health, economic, and a humanitarian point of view. Today, more than five million children are walking who otherwise would have been paralyzed. Upwards of $50 billion will be saved through 2035 – most of these savings in the lowest-income countries – once polio has been fully eradicated. This frees up urgently needed resources.

JEFF RAIKES: We need to finish the job we started. It makes no sense to stop at 99 percent. Experts agree that if we don’t stamp out every last instance of polio, the number of cases will go back up and the virus will spread to other countries where it has been eliminated. If this happens, the resources required to contain polio will come at the expense of other global health initiatives.

ANTHONY LAKE: I would encourage people to consider the cost of inaction: putting 200,000 of the world’s poorest children at risk of paralysis [every year].

MARGARET CHAN: Investments in eradicating polio benefit other areas of public health as well. The vast polio surveillance network helps detect and respond to other disease outbreaks, including measles, neonatal tetanus, yellow fever, avian influenza, and meningitis. Polio eradication infrastructure and staff are integral in strengthening routine immunization services.

THOMAS R. FRIEDEN: As long as polio exists anywhere, it remains a threat everywhere. Now is not the time to quit.