THOMAS ABRAHAM , the author of Polio: The Odyssey of Eradication , tells us “this book is driven by an outsider’s desire to understand one of the most ambitious acts that human society can undertake: to permanently rid the world of a disease by exterminating the pathogen that causes it”.
On the face of it, disease eradication appears to be a noble undertaking worthy of the effort and funds expended on it. Abraham says: “In 1988, before the eradication campaign was launched, the WHO [World Health Organisation] estimated there were around 350,000 new cases of polio every year, spread over 125 countries. By 2000, there were only an estimated 2,880 cases a year, spread over twenty countries.”
Right from the book’s first pages, the author gives details of the Global Polio Eradication Initiative (GPEI) that make one question the wisdom of eradication as a means to tackle disease. Having made this point clear early on, the author proceeds to tell the polio story. In a way it could be said that Abraham is treading familiar ground; his earlier book was on the severe acute respiratory syndrome, or SARS.
Although he says in his author’s note that this book is not meant to be a comprehensive history of polio eradication, chiefly because the disease is still present in three countries, for all practical purposes it is a more than adequate account of the disease, the virus that causes it and the efforts being made to eradicate both. (The notes and select bibliography will be of help to those who want more information.) His experience in the profession of journalism, both as an academic—he once taught health and science journalism at the University of Hong Kong—and as a foreign correspondent for The Hindu , and his stint at the WHO headquarters in Geneva have stood him in good stead.
There is a clear distinction between disease-control programmes and eradication. Success in the first instance means a reduction in the number of cases so that the disease is no longer a threat, and for this situation to persist immunisation is a must. The second instance entails complete elimination of the pathogen from humans and the environment; if this goal is attained, then it means that at some point immunisation for the disease can be stopped as happened with small pox, the only disease that has been eradicated so far. Thus, eradication is an ambitious target to aim for.
The book is divided into three parts. The first section tells us about the virus and the disease and outlines the history of vaccine development. The impetus behind the search for the vaccine was President F.D. Roosevelt of the United States. He had contracted the disease, or at least that is what a doctor diagnosed it as. Abraham says that there is an ongoing debate about whether Roosevelt had polio or Guillain-Barre syndrome. But it matters not what he actually had. It is sufficient that he believed he had polio, and the foundation he set up, the National Foundation for Infantile Paralysis, ended up funding the research that came up with the two polio vaccines available today: Jonas Salk’s killed virus vaccine, which has to be injected, and Albert Sabin’s live attenuated virus vaccine, which has to be administered orally. Sabin’s oral polio vaccine (OPV) became the vaccine of choice for the GPEI.
A significant aspect about the GPEI was that it broke new ground when it came to funding: it was the first time private organisations—Rotary International and, later, the Gates Foundation—joined the WHO, UNICEF and the U.S. Centres for Disease Control and became involved in a global health programme. This in effect gave private players, and their donors, enormous say in deciding the priorities of the campaign, perhaps more than the governments whose citizens were its target.
The second section delves into the push for eradication of polio and the progress of the campaign.
The book turns the spotlight on the inequalities between rich countries and poorer ones and the part these played in making the polio eradication programme a global initiative rather than one focussed in the West where polio epidemics started becoming a routine occurrence sometime in, ironically, the late 19th century, when there was a general improvement in public hygiene standards. We get the answer to the question why countries tackling the challenges posed by various diseases utilised their scarce resources to focus on one disease, one that was not more of a problem for them than the others, and especially when they were still grappling with the basics of public health: sewerage systems, treatment plants and provision of drinking water. Like in so many areas of human endeavour, one’s station in life decides how one’s concerns are taken care of and how one is treated. For instance, in poorer parts of the world, the polio eradication campaign routinely threatened parents with jail if they refused to allow their children to get the polio drops. The author points out that if such tactics had been used in the West, they “would have been met with horror and public protest”.
The final section of the book brings the story closer home—an entire chapter is devoted to India—and up to date, discussing the current status of the global polio campaign, which has missed its eradication deadline by almost 20 years as Afghanistan, Nigeria and Pakistan have still not been declared polio-free.
Abraham highlights a lurking impediment to eradication: the OPV in numerous instances has itself caused disease. And this was not confined to a case of just a vaccinated child or its immediate contacts getting infected. The vaccine “went rogue” and caused disease in the general population in the same way the wild poliovirus did. The author says: “Thus in 2015, nearly a third of all polio cases globally were caused by vaccine-derived viruses…. Of these vaccine-derived cases, Laos, Madagascar, the Ukraine, Guinea and Niger had been previously declared polio-free by the WHO…. Studies showed that vaccine-derived polio broke out in areas with low vaccination rates, high population density and poor sanitation…. This set of conditions described large parts of the developing world.” Abraham reports that there was a vaccine-derived outbreak in June 2018 in Papua New Guinea, a country that was declared polio-free in 2000. The worrying aspect of this reality is that though it is debated and written about in technical and scientific circles, it is not something the polio campaign chooses to publicise. Indeed, its public face is one of unremitting optimism. This is exactly the sort of thing that is grist to the mill of the anti-vaccination movement. The alarming rise in recent times of the number of cases of diseases that were thought to have been consigned to the past in the West, such as measles, whooping cough (pertussis) and diphtheria, is proof of the growing antipathy towards vaccination there.
The book discusses the historical, political and technical issues relating to polio eradication. But this is no dry as dust narration. Much like Siddhartha Mukherjee does in his two medical opuses on cancer and the gene, Abraham gives us some insight into the personalities of the important people in the polio story. All along, one gets to understand their motivations and why they did things the way they did. One is pulled into the story because he presents the human aspects of it every step of the way.
No one, least of all the author, wants to detract from the remarkable achievements of the polio eradication campaign. However, he does hope that those involved in setting and funding public health agendas will take the time to ponder the enormous effort and the considerable amount of money (“[t]he world has already spent close to US$15 billion”) that was spent on tackling just one disease and think twice about embarking on another such exercise. He says: “If the money spent by the polio eradication campaign had gone into broader vaccine programmes (including polio vaccination), perhaps the world’s children would be better off today.” The book makes the general reader ponder this point as well.
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