In the end, will the world-wide eradication of polio go down in the "grand success" or "dismal failure" side of the global health ledger book? That was the basic question faced by World Health Organization Director-General Margaret Chan and a host of polio experts at a conference held this week to review the international polio program's progress and problems. As reported by the Associated Press, "some leading experts asked a grim question: Is it time to abandon the goal of eradication and focus instead on containing the disease? The answer, for most, was no - even though many had doubts." Those doubts seemed to touch on a range of concerns: How can additional spending on polio eradication be justified in the face of problems that are larger (in terms of the burden of illness)? Do the countries where polio is still endemic, Nigeria, India, Pakistan and Afghanistan, have the political will and institutional capacity to push back against the disease? Do we really have the technology to do the job, or do we need to move away from the inexpensive, easy-to-administer oral vaccine to an injectable version that has less risk of generating new cases?
From the outside, the polio eradication program has always seemed like an effort that had some blindspots: It's been heavily promoted by true believers, who haven't always seemed open to questions about strategy. Targets and timetables used for advocacy and fundraising have become dissociated from the ground realities. And in many countries that program has been implemented largely through specialized personnel, reporting and logistics systems in a way that seemed at times to compete with routine immunization and other health system priorities. But the achievements are indisputable, and it just might be that what's called for now is redoubled effort (with some modifications) rather than abandoned hope. Since the program started in 1988, the incidence of polio has declined by 99 percent, and many countries have been polio-free for years. Paradoxically, one of the reasons polio doesn't look like a major priority is because it's already been largely tamed. The remaining cases, something like 2,000 per year, are coming from some of the most challenging places on the planet, so it is little surprise that the ambitious target dates set for eradication come and go.
The way forward might be inspired by the bumper sticker phrase: Think global, act local. Any progress in the countries where polio continues to be found depends on the engagement of local leaders, both in the health sector and in the broader community. These are leaders who, frankly, may not care very much about globally-set polio eradication targets, but who do care about something - maybe the refurbishing of their health infrastructure, or the creation of surveillance systems for infectious diseases that they are worried about, or better transportation to higher-level health facilities. With a bit of creativity, surely the international funders and technical agencies that see the benefits of finishing the job of polio eradication can find ways to respond to the local priorities in ways that reinforce progress on the polio front.