Chasing Polio in Pakistan: Why the World's Largest Public Health Initiative May Fail

6. Geneva

151 ChAPter 6 Geneva I am an optimist. —Bill Gates The Shift from International to Global Health I began a master’s program in international health in 2003 but graduated in 2005 with a degree in global health.2 The change in the moniker of my department reflected a larger trend: the term “global health” is replacing the previously dominant “international health” in the language of academics and bureaucrats working toward improving health in poor countries (Brown and Fee 2006). This change in appellation is intended to reflect the nature of disease in an increasingly globalized world, and to shift focus from individual nations to linkages across boundaries. While international health has sought to make systematic comparisons across national frontiers, global health views health and disease in a comprehensive, world-wide, integrated manner. This change in perspective on the world’s health and health problems has emerged as a result of the establishment of newer and closer physical, economic, social, cultural, financial, and political linkages between nations, collectively referred to as globalization. One of the results of globalization is that morbidities and mortalities, once geographically unique, are no longer so confined. (Imperato 2001, 77) The focus on global health carries with it an increased emphasis on the ideal of collaboration. This is framed as essential to the success of health initiatives in the new millennium: “Health problems today truly are global, and do not lend themselves to narrow parochial solutions. Cooperation, collaboration, and communication are more than a trendy 152 Chasing Polio in Pakistan shibboleth; they are ignored at the peril of genuine pandemic” (Banta 2001, 75). Partnerships are the preferred mode of collaboration in this new global health. They provide a way of taking on projects too large for a single government or agency. The Global Alliance for Vaccines and Immunizations (GAVI); the Global Fund to Fight AIDS, Tuberculosis, and Malaria; the Stop TB Partnership; the Measles Initiative; and the Roll Back Malaria Partnership—all are extremely large partnerships that include some combination of multilateral and bilateral agencies, governments, and privatesector organizations. Many of these projects are modeled, more or less explicitly, on the Polio Eradication Initiative, the first global partnership of this type. In the current climate of collaboration, even partnerships need partners; for example, the Global Fund, itself a partnership, is listed as a partner of the Roll Back Malaria Partnership. This proliferation of partnerships marks an important conceptual and cultural shift in the field of what is now global health. The conceptualization of the relationship between organizations such as the World Health Organization and the governments of poor countries like Pakistan as “partnership” and “collaboration” has important implications for the ability of international organizations to exert the power needed to carry out ambitious goals like eradication. The extent to which the culture of global health differs from the culture of international health thirty years ago, and the implications of this cultural shift, are clear when one compares the methods of the Polio Eradication Initiative to the single successful attempt at eradication, the Smallpox Eradication Program. The Smallpox Era The last naturally occurring case of smallpox was that of a Somali cook in 1977.3 The eradication of smallpox is widely and justifiably regarded as one of the great achievements of international health, cited by thinkers of widely divergent philosophies as an example of the best of international assistance (Easterley 2006, 242; Sachs 2005, 260). In the world of development , where progress is often all too elusive, smallpox eradication was an unqualified success. Many of the challenges would-be smallpox eradicators faced were similar to those that have proven so formidable in the attempt to eradicate polio. The following description of the Pakistani government’s efforts in smallpox eradication details problems different in specifics, but not in nature , from the obstacles to eradicating polio in that country: Geneva 153 By December 1968 major problems had become apparent. The government did not increase the budget [as it had promised] but, in fact, decreased it by 30%—to 1 million rupees. The plan envisaged the use of local body vaccinators as part of the complement of personnel but they were responsible to their own union councils (administrative units each responsible for a population of about 10,000) and the councils, in turn, to the Ministry of Basic Democracy. As the WHO adviser was to report: “A number of vaccinators have been appointed under political pressure and many...