Polio Eradication: The Bad News Continues

When last we left the long asymptote of polio eradication, nine health workers in Pakistan who had been administering polio vaccine had been murdered, presumably by the Taliban or its sympathizers, because polio eradication has been cast by them as a plot against Islam in the wake of a CIA operation which used vaccinations as an attempt to get close to Osama bin Laden.

(If this story is new to you: Yes, really. For background, start with this post, and then read this, this, and this.)

So it's discouraging to say that, in the past few weeks, the news hasn't gotten any better — though some additional voices have joined the debate in an attempt to stress to the world how important this moment is.

First, news updates: On New Year's Day, an additional seven vaccinators — six female health workers and a male doctor — were ambushed and shot to death. For a week, polio eradication in Pakistan, one of three countries where the transmission of the crippling virus has never been interrupted, was at a standstill. On Tuesday, it relaunched with promises of high security (and in an attempt to signal that the government takes the crisis seriously, presidential daughter Asifa Bhutto Zardari administered drops to children in Karachi).

But: Worldwide, the polio campaign depends on the efforts of volunteer and low-paid vaccinators who work solo or in small teams, and there are signs that the Taliban intimidation has kept those teams at home. In Pakistan, both The News and The Frontier Post are reporting that "lady health workers" are staying home out of fear or as a result of family pressure. From The News:

A lady health worker, who identified herself as Shahana, a resident of Baldia town, said her husband and parents had disallowed her from taking part.

“Health officials say the police will provide security to vaccinators, but the cops was present in Baldia when armed men shot a lady vaccinator dead. Nobody trusts the police for security in Karachi anymore,” she maintained.

In a tough editorial, The Lancet warns that this is not just another routine setback:

The effect of the killing of polio vaccine workers in Pakistan will have repercussions for its neighbour Afghanistan, which, together with Pakistan itself and Nigeria, is one of the remaining polio-endemic countries. Genetic analysis shows that two of the three chains of polio transmission in Afghanistan are from Pakistan. Other neighbouring countries have also been put at risk. For instance, polio broke out in China in 2011 for the first time since 1999 after being imported from Pakistan; 18 people were paralysed and one died.

Heidi Larson, an anthropologist who studies public trust in vaccines and immunisation at the London School of Hygiene and Tropical Medicine, pointed out that the killings of health workers in Pakistan could be a “game changer” in the global efforts to eradicate polio, calling for a rethink of delivery strategies. She compared it with the 2003—04 immunisation boycott in northern Nigeria, led by religious and political leaders, who claimed that the oral polio vaccine could cause sterility. This boycott led to poliovirus not only rebounding in Nigeria, but also spreading to 15 African countries and to Indonesia.

Just to underline: The crisis in Pakistan is not just about the changeable fortunes of the polio campaign, which has waxed and waned in public opinion since its launch in 1988. It is specifically in response to the admitted-to ruse by the CIA, which used a pretense of administering injectable hepatitis B vaccine in an attempt to harvest DNA from children who were believed to be related to bin Laden, as a way of proving he was in a particular area. They did not succeed -- his location was proven by other means -- but the damage to public heath looks to be long-lasting.

So long-lasting, in fact, that the deans of 12 public-health schools in the United States (Columbia, Emory, Harvard and others) have sent an open appeal to President Obama excoriating the CIA attempt and asking that it never happen again. An excerpt:

...because of these assassinations of vaccination workers, the UN has been forced to suspend polio eradication efforts in Pakistan. This is only one example, and illustrates why, as a general principle, public health programs should not be used as cover for covert operations.

...contaminating humanitarian and public health programs with covert activities threatens the present participants and future potential of much of what we undertake internationally to improve health and provide humanitarian assistance. As public health academic leaders, we hereby urge you to assure the public that this type of practice will not be repeated.

International public health work builds peace and is one of the most constructive means by which our past, present, and future public health students can pursue a life of fulfillment and service. Please do not allow that outlet of common good to be closed to them because of political and/or security interests that ignore the type of unintended negative public health impacts we are witnessing in Pakistan.

Two of the deans, Drs. Lynn R. Goldman of George Washington University and Michael J. Klag of the John Hopkins Bloomberg School, have also published an op-ed which further fills in the Pakistan context and the damage done.

One final point: New Year's Eve -- the day before the third round of polio-worker murders -- was the latest deadline set by the international polio-eradication initiative for ending the circulation of wild polio virus anywhere in the world. It was not met. The goal is now to interrupt transmission by the end of 2014. It is worth asking, given this completely unnecessary setback, how much further along the effort will be by then.

Flickr/RIBI/CC