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

2. Polio Eradication in Policy

25 ChAPter 2 Polio Eradication in Policy We will no longer have to live in a two-tiered world. And I think that may be the single most important legacy of polio eradication, the end of acceptance of what shouldn’t be acceptable. —Olen Kew, CDC The only way to protect every child from polio is to eradicate this crippling and potentially fatal disease completely. —Bill Boyd, president, Rotary International The eradication of a disease is the ultimate contribution for sustainable health development. —Margaret Chan, director-general, WHO Eradication, the permanent obliteration of a disease, is a powerful ideal.1 Its supporters are impassioned and eloquent. It also has a number of clear advantages as a public health strategy. Because the goal is unambiguous and progress toward that goal is measurable—the case count—monitoring performance and ensuring accountability are relatively simple. If an eradication program succeeds, the disease in question ceases to be a human problem, and in theory at least, the money and energy thus saved can be used to address other health problems. Not least, as what Dr. Margaret Chan calls the “ultimate” in public health, eradication attracts supporters that more mundane control programs do not. But achieving eradication is extraordinarily difficult. 26 Chasing Polio in Pakistan Eradication as a Strategy Eradication is a very difficult endeavor, different from the usual public health goal of disease control. Control programs, the routine strategy in public health, aim to reduce incidence of disease to an “acceptable level.” In contrast, eradication is the “permanent reduction to zero of the worldwide incidence of infection caused by a specific agent as a result of deliberate efforts; intervention measures are no longer needed” (Dowdle 1999, emphasis added).2 When discussing eradication, health planners often also mention “elimination,” a slightly different benchmark. Elimination refers to the reduction to zero of the regional incidence of an infectious disease; in the case of elimination, importation of infection from other regions of the world is possible, and so control measures must be continued.3 Polio has been eliminated from the Western Hemisphere, but not yet eradicated from the globe. Eradication programs are of necessity global in scope. They must also be vertical in design, meaning that they focus solely on a single disease. Supporters of eradication and other vertical programs have long been at odds with those in global public health who advocate the delivery of primary health care: the provision of comprehensive health services, ideally with the active participation of the communities being served. Proponents of primary health care often argue that eradication programs, and other vertical programs, do little to address the most pressing health issues of the poor. The debate is of long standing and continues today. As far back as 1969, John Bryant criticized vertical programs because “the most serious health needs cannot be met by teams with spray guns and vaccinating syringes” (quoted in Cueto 2004, 1864). More recently, Laurie Garrett argued in Foreign Affairs that because the current increase in funding for global health is “directed mostly at specific high-profile diseases—rather than at public health in general—there is a grave danger that the current age of generosity could not only fall short of expectations but actually make things worse on the ground” (Garrett 2007, 14). However, vertical programs have some major strengths: they usually have clear goals, fairly straightforward methodologies, and measurable indicators of progress. And certainly, proponents of eradication and other vertical programs would never argue against the simultaneous provision of primary health care. But in a world with somewhat limited funding and—more to the point—limited staff for health interventions in poor countries, emphasis on an eradication program in a given area may come at the expense of activities aimed at improving the general health of that Polio eradication in Policy 27 population. These tradeoffs may well be worth it if the eradication program succeeds—but attempts at eradication are by nature risky. Eradication Programs in the Twentieth Century Eradication programs come with a high risk of failure and a high degree of difficulty. The Polio Eradication Initiative carries the promise and the risk of this approach to public health. In the twentieth century, seven human diseases—hookworm, yellow fever, yaws, malaria, smallpox, polio, and guinea worm—were targeted with large-scale campaigns for eradication. Only one project succeeded. The Rockefeller Foundation’s Sanitary Commission launched a hookworm “eradication” program in the U...