Betrayals of Trust

I wish I’d been wrong about polio eradication. Really, I do. Against the ever-extending deadlines, outbreaks of vaccine-associated poliomyelitis, and deadly violence, there’s no comfort in having anticipated failure.

Way back in 1997, when Vincent Racaniello and I penned the first major scientific criticism of the World Health Organization’s polio eradication campaign, we were actually naïve enough to think that our objections might make a difference. Instead, we were waved aside and assured that everything would work out fine.

But the goalposts had already started moving. The original plan was to eradicate polio by the year 2000. When Vincent and I wrote our critique of the campaign’s reliance on oral polio vaccine (OPV), the WHO had already adjusted the deadline to 2005. As that year approached, the date slid further. Bill Gates now thinks that his foundation can help the WHO finish the job by 2018, continuing a longstanding tradition of keeping the goal at least five years in the future.

Don’t get me wrong, there is a chance we might eventually eliminate this virus. There’s even a tiny chance we might get it done with just OPV, but I wouldn’t bet a dollar on it, let alone the billions of dollars the WHO’s funders have pumped into that dream.

The problem is that OPV, originally developed by Albert Sabin, contains live attenuated viruses that routinely revert to wild-type, paralytic strains in vaccinated people. It’s the only vaccine in general use that can cause exactly the disease it’s meant to prevent, and it does so in one of every few million vaccinees. For the eradication effort, a bigger problem is that many, if not all vaccinees secrete the reverted virus for some time. Kids take the vaccine, and a few days later they’re pooping out live, potentially paralytic virus. That’s not a big deal if everyone around them is vaccinated, but in areas where vaccine coverage is spotty it can – and does – lead to outbreaks of polio caused by vaccine-derived strains.

There’s no obvious way to end an OPV-only campaign. People with immune disorders can excrete vaccine-derived poliovirus indefinitely. Eradication mandates eliminating OPV because it’s a source of new infections, but if we stop vaccinating then the existing reservoirs of infection will start new outbreaks. That’s why even the eradication campaigners now admit, more than a decade after we told them so, that switching to the inactivated vaccine may be an essential step.

Unfortunately, inactivated polio vaccine (IPV) is much more expensive to make, transport, and administer than OPV. The price differences aren’t noticeable in developed countries with plenty of pediatricians, but they become prohibitive if your goal is to vaccinate the whole world right now. Getting IPV to every child would require building a functional public health infrastructure everywhere, but we can get OPV to them without having to make that commitment.

In other words, the WHO and its supporters have made a deliberate choice to value the quick elimination of a single disease over establishing lasting improvements in public health.

Back in 1995, when I first heard a presentation about the eradication campaign from a WHO/CDC representative at a conference, the rationale was that eradication is much easier to “sell” to developing countries than the hard, unglamorous work of building public health infrastructure. Eliminate polio in five years and you can claim a distinct, easily defined victory. Spend the same time and money building rural clinics and covering urban sewers, and nobody will notice. I was told that polio eradication was an achievable goal that politicians could understand. I also inferred the subtext: that it was the kind of career-defining accomplishment that WHO and CDC officials would love to put on their resumés. I had a problem with that rationale then, and I still do.

I’m certainly in favor of people advancing their careers, and I’d love to see infantile paralysis eliminated from the world. Public health is chronically strapped for cash and people, though, and pouring huge sums and millions of person-hours into a quixotic charge against one disease inevitably entails shortchanging other, more pressing needs.

There’s also another price that’s only become clear recently. In order to make the eradication campaign work, the WHO has enlisted thousands of volunteers all over the world. The Rotarians committed themselves to the effort early, and have provided an astonishing amount of logistical support. But in the last polio-endemic countries, the real ground troops are local volunteers, mostly women, who’ve had a short course in vaccine delivery. These dedicated individuals are motivated by nothing but a desire to help their neighbors. Their reward is a mother’s thanks, a child’s smile … or a bullet:

Nine female polio vaccinators have been killed in two shootings at health centres in northern Nigeria, police have told the BBC. In the first attack in Kano the polio vaccinators were shot dead by gunmen who drove up on a motor tricycle. Thirty minutes later gunmen targeted a clinic outside Kano city as the vaccinators prepared to start work.

Some Nigerian Muslim leaders have previously opposed polio vaccinations, claiming they could cause infertility. On Thursday, a controversial Islamic cleric spoke out against the polio vaccination campaign, telling people that new cases of polio were caused by contaminated medicine.

This is the latest in a string of such killings, but it’s the first I’ve heard of in Nigeria. It’s become fashionable to blame the CIA for causing this spate of anti-vaccinator violence, but as I’ve pointed out before that’s an oversimplification. The latest incident underscores that point.

If any agency is to blame for these deaths, it’s the WHO. They’ve recruited women to do a job that makes them stand out, in places where armed religious fundamentalists fly into a rage whenever women stand out. Then the WHO has trained these women to administer a vaccine that can cause the very disease it’s meant to prevent. When a local cleric claims that new cases of polio were caused by “contaminated medicine,” what are these volunteers supposed to say? He’s sort of right. Finally, all of this is being done in the service of a public health campaign that’s probably doomed. Meanwhile, malaria, tuberculosis, and HIV remain rampant and vaccines for other preventable diseases can’t be distributed because of a lack of infrastructure.

Perhaps it is much easier to convince politicians to back an eradication campaign than to build real public health systems. But it’s not cheaper.