Eradication, Interrupted

XIAN ZHANG

For the first time in six years, the wild poliovirus has been recorded in Somalia. The first reported case occurred in a 2-year-old girl near Mogadishu, who became paralyzed on May 11th. According to the World Health Organization (WHO), Somalia has the 2nd worst polio vaccination rate in the world, leaving immunity gaps – swathes of susceptible and unvaccinated people. This one case quickly became what is currently the worst polio outbreak in the world, with 65 cases reported since May. After genetic testing, the WHO concluded that the strain in Somalia was linked to those circulating in Nigeria.

Infamous for its rapid transmission rate, the virus quickly crossed borders. A week after the Mogadishu case, a 4-month-old girl in eastern Kenya became paralyzed by polio, with two caretakers testing positive for the virus as well. Kenya’s last recorded case was in 2011. Before these outbreaks, it seemed the end of polio was within reach.

In 1988, the WHO set the ambitious goal to eliminate polio. Since then, the reported number of transmissions have been decreased by 99%. By 2012, there were just 223 cases reported worldwide, a record low. Since 1988, $9 billion has been poured into this global effort, with another $5.5 billion needed to finish the job. Why does it cost so much at the end? Those last few hundred people are the hardest to reach, and have missed previous waves of vaccination efforts. Spreading through the fecal-oral route, polio is a disease of access – vaccination workers can’t get to at-risk populations, who in turn can’t get to adequate sanitation infrastructures.

However, when India – previously accounting for 50% of all polio cases – was taken off the list of endemic countries in 2011, the end became tantalizingly close. If such a large country, with a high migrant population, urbanization, and marginalized populations could do it, there was promise that others could follow. That year, polio cases were reported in 11 countries. Promisingly, by 2012, only 4 countries reported cases, with polio endemic in just two regions: northern Nigeria and the border between Afghanistan and Pakistan.

That is why the new cases reported in Somalia and Kenya have been such a huge setback for global eradication efforts. The issue is not only the individual case numbers, but how they will spread. When Nigeria stopped vaccinating from 2003 to 2004, 21 previously polio-free countries became reinfected. From just a few cases, the Horn of Africa, a region with extensive migration, refugee movement and large immunity gaps, is now at high risk for a polio outbreak.

The disease also highlights the complex ties between global health, diplomacy, development and security. It acts as a common thread through India and Pakistan, bringing the arch-rivals into bilateral cooperation that would have been previously unfathomable. In Pakistan, the CIA made the decision to send a polio vaccination team into the suspected town where Osama Bin Laden resided. Those efforts and positive DNA samples led to his eventual capture, while simultaneously harming legitimate efforts to reach rural communities. While the Taliban renounced their war on polio health workers – even encouraging its fighters to aid in efforts when possible – two polio volunteers were shot in Pakistan last month.

To reach the global target of eradicating polio by 2018, every single stakeholder must work seamlessly together: the United Nations as coordinators, donor governments as financial backers, engineers as facilitators of sound sanitation systems, armed groups that respect the neutrality of health workers, and the dedication of the communities themselves to stamp out this virus once and for all. After smallpox, polio is poised to become just the second infectious disease ever eradicated. With so much at stake, its future lies upon the ability of the international community to work together in this pivotal moment.