How to End a Disease

What is Polio?

A child looks on during a National Immunization Day in India. Photo: Devin D. Thorpe

One evening, a child would go to bed feeling fine, and awake to discover that he or she had lost the use of their legs. This is polio, a devastating disease, most common in children, that has existed for thousands of years.

If you’re reading this, you’re probably wondering why we’re still even talking about polio today. But thanks to an effective vaccine (which you would have received as a child) polio was eliminated from the Western Hemisphere in 1994.

Despite this milestone, polio is still a threat to global health, and epidemics from the late 19th century through the mid- 20th century struck thousands of victims in Europe and North America, and caused widespread panic. There is no cure for polio, but it can be easily prevented through immunizations that are safe and effective.

Passed from person-to-person, it can strike young and old, rich and poor alike. Franklin D. Roosevelt, the United States’ 32nd president, contracted polio in 1921, when he was 39 years old. For most people who get infected, it is a disease with no visible symptoms, and many recover fully. But for a small proportion of unlucky victims, it wreaks havoc on the human body, reaching the brain and spinal cord, causing paralysis, and even death.

At its peak in the U.S., more than 21,000 paralytic cases of polio were reported in 1952, with more than 3,000 deaths.
As polio could paralyze chest muscles used to breathe, a device known as the iron lung was used to help respiration while patients recovered. In the 1930's, an iron lung cost about $1,500 — the average price of a home.

Fearful parents kept their children away from swimming pools and movie theaters in summers, which was the high season for polio.

But thanks to effective vaccines and a remarkable global partnership, its reign of terror is close to an end. This is the story of how we have reached this stage, what still needs to be done, and the lessons we have learned to protect the world against other infectious diseases.

Finding a Vaccine

For a long time, little was known about the cause of polio, how the virus spread, and what could prevent it.

In Vienna in 1908, Dr. Karl Landsteiner, and his assistant E. Popper first discovered that polio was caused by a virus. This discovery, along with the invention of the electron microscope in 1931, facilitated the study of polio in the laboratory, and raised the possibility that a vaccine could be found to prevent it, like other viruses.

But progress in the search for this vaccine was slow, and many misunderstandings about polio’s transmission resulted in strategic mistakes. In New York in the summer of 1916, tens of thousands of cats were put down, as health officials feared that they were carriers of the virus.

Two American scientists, both hailing from Russia, focused on two different kinds of potential vaccine for polio. Jonas Salk led research into a vaccine using a killed (inactivated) form of the virus (IPV) that was injectable; and Albert Sabin developed an oral vaccine (OPV) using a live but weakened form of the virus.

Salk was the first to create officially a safe and effective vaccine, conducting the largest medical experiment in history from 1954–55, to test its effect on 1.8 million children in the U.S., Canada and Finland.

Salk (left) and Sabin administer their respective vaccines. When you were a child, you may have received Sabin’s live vaccine with a sugar cube, or Salk’s inactivated vaccine as an injection, if you were born after 2000 (in the U.S.). H

The Need for a New Partnership

Salk’s vaccine was a triumph, and combined with Sabin’s live vaccine (from 1961) mass vaccinations had a dramatic effect in reducing polio cases in the industrialized, wealthier nations in North America, Australasia, parts of South America and Northern Europe.

Unfortunately, merely possessing a safe vaccine is not enough to eradicate a disease globally. Polio still devastated developing countries, which possessed neither the health systems, infrastructure, nor resources to buy vaccines.

By 1985, polio paralyzed about 400,000 children a year — nearly 1,000 children every day, and was endemic in 125 countries.

That same year, Rotary, a global, nonprofit membership organization, decided to launch its audacious PolioPlus program to take on polio through the mass vaccination of children.

The eradication of smallpox in 1979 proved that an infectious disease could be wiped out. An effective and safe polio vaccine already existed, and the World Health Organization’s Expanded Programme on Immunization (EPI), launched in 1974 (and universally adopted by the early 1980s) intended to build on the smallpox infrastructure to target 6 diseases, including polio. So Rotary figured: Why not join forces and accelerate the efforts to end a deadly disease?

Rotary had already tested its capacity to work on a large-scale immunization campaign with other partners. Rotary worked closely with UNICEF to target polio when it led a program to immunize 6 million children in the Philippines in 1979, which then had the highest polio caseload in the western Pacific.

However, getting buy-in from other organizations was not easy. Many health experts thought that it was too costly to pursue the eradication of a single disease, when weighed against the benefits of boosting basic health services. But Carlos Canseco, then Rotary’s President, saw no conflict between the two. The “plus” in Rotary’s PolioPlus program reflects the idea also foreshadowed in the EPI, that by fighting infectious diseases such as polio, the global infrastructures to fight other diseases would also be strengthened.

With persistent advocacy, Rotary leaders managed to gain the endorsement of other major players in the health and development world.

So in 1988, following the unanimous adoption of a World Health Assembly Resolution on “Global eradication of poliomyelitis”, Rotary spearheaded one of the most successful public-private partnerships in history, the Global Polio Eradication Initiative (GPEI).

The Global Polio Eradication Initiative in Action

The GPEI spearheading partners faced a formidable task. To achieve the global eradication of polio, and to assist primary care services at the same time, had never been accomplished before on this scale.

The Initiative had to encompass research and innovation, advocacy, political leadership, and grassroots activism to raise awareness and ensure that every child, no matter how remote, was reached by vaccinators.

The project would not only have to win over heads of state, but populations of every culture, from the boat-dwelling fishing communities in Cambodia and Vietnam, nomads in Pakistan, Afghanistan and Somalia, to construction workers in Delhi, and even those who resisted the vaccine in wealthy countries.

Since the launch of the GPEI in 1988, more than 13 million people, mainly in the developing world, who would otherwise have been paralyzed, are walking because they have been immunized against polio. More than 2.5 billion children have received the oral polio vaccine, and the global polio caseload has been reduced by 99.9%, with only Pakistan and Afghanistan remaining as the last two polio-endemic countries.

To reach a point where we are on the cusp of eradicating a human disease for only the second time in history, the Initiative employed a variety of strategies:

1) Mass Vaccination Combined with Broader Health Interventions

The aim of mass campaigns was to interrupt circulation of poliovirus by immunizing every child less than five years old. For example, in Pakistan, this meant five nationwide campaigns in 2015 targeting all of the more than 35 million children under the age of five.

In many countries polio vaccination campaigns were linked with other badly needed health interventions. In Nigeria and elsewhere, health clinics set up as part of the polio program infrastructure have served as a staging post for multiple medical interventions, including measles vaccination, treatment of intestinal parasites, distribution of Vitamin A, and bed nets to protect against malarial mosquitos.

2) Advocacy

With competing priorities, not least other infectious diseases, it was imperative to keep polio eradication at the top of the agenda for heads of state, health ministers, and for multilateral organizations such as the U.N. As the only GPEI partner which is comprised of citizens in more than 170 countries around the world, Rotary was uniquely positioned to urge officials from the local to national level to focus on polio eradication.

The Sydney Opera House shine bright with the End Polio Now message to raise awareness for the global effort to end polio.

Advocacy has resulted in more than US$7.2 billion in contributions and commitments from donor governments to the GPEI. In combination with private sector partners, NGOS and development banks, over $11 billion has been invested in the Initiative. Rotary alone has contributed over $1.5 billion to the effort. Advocacy has also resulted in important declarations to bolster and extend support for eradication, from the European Union, the African Union, the Organization of the Islamic Conference, and many others.

Grassroots advocacy to reach local social, religious and cultural leaders was also vital. Rotary and its partners have appealed to Ulemas (specialist bodies of Islamic scholars) to support polio vaccination. In Pakistan, Islamic leaders have issued 28 fatwas promoting the safety of the vaccine and the importance of vaccinating children.

3) Innovative Tactics

The GPEI has also implemented innovative tactics to reach more children. For example, the creation of strategically placed Permanent Transit Posts (PTPs) at entry points to international borders, provinces, and big cities across Pakistan have reached mobile populations with the vaccine. Staffed by polio eradication teams, the Posts provide safe spaces to keep the vaccine, and immunize children in transit, reaching migratory and nomadic populations.

A carefully crafted communications strategy expressed the importance of frontline health workers to parents as vital for their children’s health, and assuaged fears about the vaccine’s safety.

And the Initiative has also overcome hurdles in reaching remote communities through its use of technology. In the age when high quality data is of paramount importance, the GPEI has worked hard to replace traditional written paper reporting of polio and maternal and newborn health data from the field with cell phone reporting. The use of cell phones has facilitated communication with, and payment to, vaccinators, especially in remote communities. GPS monitoring of vaccination teams and missed communities has enhanced immunization coverage, and improved upon the hand drawn maps that were previously used in house-to-house campaigns.

4) Female Health Workers

Hundreds of thousands of health workers, mainly women, carried and delivered the vaccine to billions of children. Women had a greater level of trust with mothers and thus were able to enter households and have the interactions with mothers and children necessary to deliver the polio vaccine.

Female health workers immunize children against polio in the streets of Karachi, Pakistan.

They also provided other services, such as health education, antenatal care, routine immunization, and maternal health. They worked bravely in difficult conditions, and persevered despite the threat of violent resistance to the polio vaccine. The Taliban in Pakistan and other extremists, such as Boko Haram in Nigeria, have waged a brutal campaign against vaccination teams. More than 70 polio workers (including several men and security guards) were killed in Pakistan from 2012–2016. The contribution of these health workers was a vital part of the success in fighting polio.

What’s Next? Building a Legacy

The GPEI offers several valuable lessons for global health. It shows the value of finding good partners who persevere over many years with disciplined adherence to a set of clearly defined roles. It shows the importance of constant communication and coordination between partners to track down a formidable threat to public health. It engages voluntary support with creative advocacy, extending its reach and appeal. It also uses clear metrics for success and independent oversight to keep a massive undertaking on track, with a singular focus.

True to the ambitions of the PolioPlus program, the global effort to eradicate polio, involving 200 countries, and 20 million volunteers, has strengthened routine immunization coverage against multiple diseases, trained thousands of health workers, and implemented infrastructures vital to national public health systems, and built resilience against outbreaks.

We now have a global network of 145 laboratories established by the GPEI, which also tracks measles, rubella, yellow fever, meningitis and other deadly infectious diseases, and will do so long after polio is eradicated.

The GPEI infrastructure is already being used to counter other health threats. For example, Nigeria managed to thwart the deadliest Ebola virus in history in 2014, by repurposing its polio eradication infrastructure and technology to track all cases, and implement a rapid and effective outbreak response.

A polio-free world will reap financial savings and reduced healthcare costs of up to US$50 billion through 2035. In fact, we’ve already saved $27 billion since the GPEI’s inception, and low-income countries account for 85% of the savings. This achievement will prove what is possible when the global community comes together to improve children’s lives.

If we succeed, we will have gifted the world a new blueprint for disease eradication, on a scale never before attempted. But if we don’t see this effort through to the finish line, polio would easily see resurgence, leading to 200,000 cases of paralysis a year within 10 years.

The day will come soon when we see no new cases and live in a polio-free world. That will be a day to celebrate. The feat of eradicating polio will be one of the most important this century. But when it is defeated, it will also empower our belief in the potential to reach new milestones for global public health.

Join Rotary on 24 October for a live broadcast on World Polio Day featuring CDC Director Dr. Tom Frieden and TIME Editor Jeffery Kluger. Watch live:

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