Polio on the Brink
March 01, 2011 | By Bill Gates
My Annual Letter: End Polio Now
Polio, once a worldwide scourge, threatens to make a comeback unless all countries do their part to eliminate it. Eradication is tantalizingly close but funding to fight the disease still falls short.
Aid for the poorest has already achieved a lot. For example, because of donors’ generosity, we are on the threshold of ending polio once and for all.
Polio is a terrible disease that kills many and paralyzes others. Fifty years ago it was widespread around the world. When you talk to people who remember polio in the United States, they’ll tell you about the fear and panic during an outbreak and describe grim hospital wards full of children in iron lungs that maintained their breathing. At its peak in the United States in 1952, polio paralyzed or killed more than 24,000 people.
As a result of mass mobilizations to administer the polio vaccine, polio was eliminated in the United States and most developed nations decades ago. Most people who live in rich countries assume the disease is long gone and that it doesn’t kill or paralyze children anymore. But it is still a frightening presence in a number of places around the world.
In 1988 the global community adopted the goal of ending polio altogether. At that time more than 350,000 children a year worldwide were killed or paralyzed by the disease. Since then, vaccination coverage has increased significantly and the number of cases has gone down by 99 percent, to fewer than 1,500 last year. There are now just four countries where polio transmission has never been stopped: India, Nigeria, Pakistan, and Afghanistan.
That’s incredible progress, but the last 1 percent remains a true danger. Eradication is not guaranteed. It requires campaigns to give polio vaccine to all children under 5 in poor countries, at a cost of almost $1 billion per year. We have to be aggressive about continuing these campaigns until we succeed in eradicating that last 1 percent.
Therefore, funding is critical to success. Organizations such as Rotary International and the governments of India, the United States, the United Kingdom, and Japan are all major contributors to the polio campaign. Our foundation gives about $200 million each year. But the campaign still faces a 2011-12 funding gap of $720 million. If eradication fails because of a lack of generosity on the part of donor countries it would be tragic. We are so close, but we have to finish the last leg of the journey. We need to bring the cases down to zero, maintain careful surveillance to ensure the virus is truly gone, and keep defenses up with polio vaccines until we’ve confirmed success.
Why is it so important to end polio? Eradication will have three huge benefits.
The first is that getting rid of polio will mean that no child will die or be paralyzed by the disease in the future. One thing most people don’t realize is that if we don’t finish the job on eradication, we will lose a lot of the ground we’ve gained over the past two decades. The disease will not stay at its current low level. If we don’t get rid of it, it will spread back into countries where it’s been eliminated, and it will kill and paralyze children who used to be safe. Only eradication will guarantee that all children are safe.
The second benefit is that the money that will be saved by eradicating polio far exceeds what we are spending on eradication efforts now. The long-term benefits of the last couple of billion dollars spent on eradication will be truly phenomenal. A recent estimate added up the cost of treatment that won’t be necessary and the enhanced economic contribution of adults who won’t get polio. Eradication could save the world up to $50 billion over the next 25 years.
The third benefit is that success will energize the field of global health by showing that investments in health lead to amazing victories. The eradication effort illustrates so well how a major advance in the human condition requires resolve and courageous leadership. To win these big important fights, partnerships, money, science, politics, and delivery in developing countries have to come together on a global scale.
The history of polio and polio eradication is fascinating. (One of the best books I’ve read on the subject is David Oshinsky’s Polio: An American Story.) Polio was the first disease that raised significant money from the broad public. The March of Dimes was created to combat the disease. Although President Roosevelt and lots of Hollywood stars helped the campaign, its huge success came from neighborhood-based fundraising. I remember March of Dimes volunteers ringing our doorbell when I was growing up and asking for a donation. By any measure, the public’s generosity in supporting that charity made it one of the most successful health-related fundraising campaigns ever.
The March of Dimes funded research into the first polio vaccine, which was invented by Dr. Jonas Salk and introduced in 1955. It was such an important priority to get the polio vaccine out widely that the U.S. government sponsored the campaign, which it had never done before. The campaigns of the late-1950s were wildly successful, and by 1961 the number of cases in the United States was down to just 161.
A second polio vaccine—this one in the form of liquid drops that children swallow instead of an injection in the arm— was invented by Dr. Albert Sabin and licensed in 1963. By 1979 there was no more poliovirus in circulation in the United States. Dr. Salk’s and Dr. Sabin’s vaccines are still the key tools used for eradication today.
To this day, the smallpox campaign is the only successful human disease eradication campaign in history. At its peak, smallpox killed over 2 million people every year and also blinded and disabled large numbers. The eradication campaign started in 1967, the last naturally acquired case of smallpox was in 1977, and the world was certified as being free of smallpox in 1979. (Two excellent books on the smallpox eradication are Dr. D.A. Henderson’s Smallpox: The Death of a Disease and the forthcoming House on Fire by another key smallpox warrior, Dr. Bill Foege.)
Smallpox had a number of characteristics that made it easier to eradicate than polio. Almost everyone who got smallpox developed a distinct rash. In contrast most polio infections are not noticed because less than one in 100 people infected are paralyzed, even though all those infected can transmit the virus. This means by the time a paralytic case is found, the poliovirus has probably spread.
Also, the vaccines against polio are not as effective as the smallpox vaccine, which was so powerful that a single vaccination protected almost everyone. In the case of the most common polio vaccine, at least three doses are required to get 85 percent of children fully protected. In many countries of the developing world, even more doses are needed to reach the immunity levels needed to stop transmission of the virus.
But the polio campaign also has some huge advantages that the smallpox campaign did not have. The advanced science we have today lets us sequence the DNA of the polio virus and develop an understanding of the history of transmission, which guides our work. We also have far better communications and modeling tools than were available in the 1970s, and those are being used in smart ways to respond rapidly to every outbreak.
In 2003 I would have said we were just a couple of years away from ending polio, and I would have been wrong. That year there were false rumors in Nigeria that the polio vaccine caused women to become sterile. This allowed the disease to have a resurgence and to spread to many other countries. The experience of 2003 serves as a reminder to be humble as we move forward. But humility does not mean fatalism.
Fortunately those false rumors have been almost completely eliminated through the leadership of key political and religious figures. In 2009 when I visited Northern Nigeria to meet with the most important traditional leader, the Sultan of Sokoto, he committed to the campaign. It was fantastic to see him publicly giving his support. (He also gave me a horse to thank me but I told him I couldn’t take it.)
Last year both India and Nigeria had substantially fewer cases than ever before. In India the number of cases went down from 741 in 2009 to just 41 in 2010. In Nigeria, thanks in large part to the renewed leadership in the northern part of the country, the number went down from 388 to just 18. But alongside the phenomenal progress was another reminder that gains can be lost without sustained action.
The majority of cases in 2010 were in countries that had been polio-free until the virus travelled back across borders and caused outbreaks in areas where people had gotten lax about vaccination. There was a large outbreak in Tajikistan in the first half of 2010 and another in Congo in the second half. In both regions there were a number of immunization campaigns organized as a response. Today the outbreaks appear to be under control.
What those outbreaks in formerly polio-free countries prove is that eradication is a global project requiring every country to do its part. Very few projects demand global participation. In most areas each country can pursue its own approach, and countries can compare outcomes to see which approach is the most successful.
Philosopher and historian Will Durant once observed that the only thing that could get countries to join forces would be an alien invasion. To my mind, terrible diseases are surrogates for an alien invasion. If we are to succeed, the world needs leadership from a global institution and significant, coordinated resources from rich countries to fund activities in the poorest countries.
For polio, the World Health Organization (WHO) has played the central role with Rotary International, the Centers for Disease Control, and UNICEF as key partners. Polio eradication has benefited immensely from having Rotary’s support. Rotary had the vision to get involved in 1985 and has kept polio eradication as its top priority. Everywhere I go to learn about polio, I see Rotary members helping out with the hard work.
I feel sure that with continued support we will be able to show significant progress building on this year’s work. The site www.polioeradication.org tracks the key parts of the campaign including fundraising and the latest cases. I will make a number of trips focused on polio this year, including additional trips to India and Nigeria, and will write a report for the foundation website. For anyone who wants to support the polio campaign, which would be fantastic, visit www.rotary.org/endpolio and click on the EndPolioNow logo.