Polio's End Depends On Three Tough Countries

Guests

Joe Neel, health editor, NPR
Jason Beaubien, global health and development correspondent, NPR

Vaccination campaigns have erased polio in almost every country in the world, but the disease persists in Afghanistan, Pakistan, and Nigeria. Obstacles in each country, including religious extremism, difficult terrain and transient populations, make eradication efforts difficult.

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NEAL CONAN, HOST:

Sixty years ago, polio was a national terror, but we scarcely remember. The last cases of the dread disease in this country date back to 1979. By the early '90s, polio no longer existed in the Western Hemisphere. A few years ago, we seemed to be on the brink of worldwide extermination, but opposition to vaccination continued in a few places.

NPR News is tracking the effort to eradicate polio in Nigeria, Pakistan and India for a series called "Chasing Down Polio." Jason Beaubien, NPR's global health and development correspondent, and NPR health editor Joe Neel join us here in Studio 3A. And thanks to you both for coming in.

JASON BEAUBIEN, BYLINE: It's good to be here.

JOE NEEL, BYLINE: Hi, Neal.

CONAN: And Jason, you just returned from Nigeria earlier this month, which was sort of the epicenter, currently, of polio. Do some people there continue to oppose vaccination?

BEAUBIEN: People are not actively opposing it at this point. At this point basically the imams who were coming out and saying don't get your children vaccinated, this is a Western plot, that has completely changed. And the religious community is really behind - the Muslim leaders are behind the vaccination. So you don't have that.

But what you are running into now is the fact that polio is almost eradicated. It's very rare that you're having polio. So the sense of urgency isn't there, particularly amongst ordinary people. They're like, why should we be going out for these vaccination campaigns? The vaccine doesn't have to just be given once, it has to be given repeatedly. So there's sort of a lack of really - ort of a sense of urgency about trying to get wiped out there, and I think that is more of a problem now than direct opposition to it.

CONAN: A couple of years ago, I remember there was also criticism, we've got more important problems like, oh, malaria, why all the attention here on polio?

BEAUBIEN: Absolutely, and the situation continues in Nigeria, that - we went to some health clinics, there's absolutely nothing in these health clinics. And then you've got polio campaigns showing up, and they're passing out a drug that people are saying we don't really need the vaccine for polio, we need something to help us with malaria, with Dengue, with yellow fever, with these other diseases that we're dealing with right now.

So overcoming that is a big challenge, and getting at these last few cases that are out there is the problem. And in Nigeria, that is the only place in the world where polio is now expanding. You're getting more cases this year, and kids right - you know, we went and saw some kids that were infected and were paralyzed a month ago, and just last week two more new cases of paralysis in Nigeria from polio, a disease that's been, you know, pretty much wiped out for decades almost everywhere else.

So I think Nigeria is really going to be the - sort of a really important fight, you know, battleground over polio. Clearly Afghanistan and Pakistan is also going to be tough, but I think right now the focus on Nigeria makes sense.

CONAN: All three of those areas you mentioned, of course conflict zones as well. There's the fault line between the Christian and Muslim communities in Nigeria and sadly a lot of unrest and violence.

BEAUBIEN: Absolutely, and you've got some Islamic extremists that have been - you know, the weekend before we got there, there was a suicide bomber at a church there in Kano(ph), in the town that we were visiting. The police are out in force and the military - which also really makes things difficult for people trying to do a major operation to get every kid vaccinated when you've got roadblocks, you've got - the police have barricaded the streets in front of every police station so that traffic is now rerouted in ways and people are getting lost.

It just makes things much more difficult. And there's curfews, and sometimes the curfew's at 4:00, sometimes the curfew's at 6:00. It makes it really difficult to carry out this campaign, which has to go and vaccinate every child repeatedly in order to completely wipe out the virus.

And so the security is definitely affecting the efficacy of this campaign.

CONAN: Nevertheless, that - convincing the imams who opposed it a few years ago, that is extremely important. What worked?

BEAUBIEN: In terms of what worked, I mean, people just basically - there's a big contingent of public health officials who absolutely want this to work. And they went in and sat down with them, showed them that the vaccine is safe, you know, put them point-by-point through some of the rumors that were going on, and just basically overcame their fears and managed to overcome those fears among the very top leaders of the Muslim faith in northern Nigeria. And that's really what turned the tide and got the public behind it.

CONAN: Public health officials from Nigeria?

BEAUBIEN: Not necessarily from Nigeria, but from elsewhere in the world. You're getting a surge of people coming in from all over the world into Nigeria to try to work on this. From Geneva, people - the Bill and Melinda Gates Foundation is sending in extra people. They're paying for staff to get out there and actually do some of this - some of the grassroots mobilization in actual slums and neighborhoods. The World Health Organization, UNICEF, all of these organizations are pouring extra people in. Some of them are bringing people from India, showing what has happened in India, showing that type of model can work there. So there is a lot of focus. And the big question is, you know, can they do it?

CONAN: Jason Beaubien just mentioned India. Joe Neel, that is the success story.

NEEL: Yes. The most recent, big success story is India. They had - they - the government finally organized around this one effort. Health services in India are still quite chaotic and not well-developed. But the government, working with some of the same organizations Jason just mentioned, including Rotary International, just a group called the Global Polio Eradication Initiative, put together a $1.5 million program and really just hit it hard. And they assembled armies of vaccinators, two million vaccinators to go out across the country on multiple days, because it takes multiple doses to provide immunity. And they vaccinated 175 million children against polio. And I don't think every single child has been immunized at this point, but when you get to a certain point, you've really quashed the disease.

And so far, for the last 21 months - I think it's 21 months - there haven't been any cases of paralysis - polio paralysis in the country. And once they get to the 36-month mark - I think that's in January 2014...

BEAUBIEN: Correct.

NEEL: ...it'll be declared eradicated in India. And that is a huge public health success story.

CONAN: And, again, were people there saying, what about our other priorities? We've got a load of problems in India. Polio is almost insignificant.

NEEL: Well, like we've seen with other public - with other diseases, like AIDS in Africa, taking one disease and attacking it can start to build up a public health infrastructure where none existed. AIDS is a problem in India, but not the problem it is in many countries in Africa. Polio was killing, in 1995 - I mean, in 1995, Polio was paralyzing 55,000 kids a year in India. That's a huge number. And over time, you're looking at millions of people with paralysis. So it was a major health problem, one of the top problems in the country. So you didn't quite have the same debate going on.

BEAUBIEN: And there was a lot of skepticism of: Can India do it? And the fact that India managed to do it has inspired other people to say, OK. If you can do it in India, yes, you can do it in Nigeria. Yes, you should be able to do it in the Afghan-Pakistan border region. It is doable. Here's a system. Here's a way to do it. You just need to break it down. You need to have enough foot soldiers on the ground to get in and actually get it done at each one of these little communities.

NEEL: And if you don't do it - one estimate, I think, the Global Initiative that I just mentioned, their estimate is within 10 - if you don't completely eradicate it this time around, and the push is to get it done this year or next, you know, you'll have an explosion of polio again, like we did earlier in the 2000s. And within 10 years, you'll have 200,000 cases a year again worldwide, and then it just keeps marching on. It's a very, very contagious disease.

CONAN: And the other region you just mentioned, the border between Afghan and -Afghanistan and Pakistan, well, talk about...

NEEL: Well, that's the hardest. I mean, that - in Pakistan, the situation is a little bit different than what Jason just described. There's still a lot of rumors going around that this is a U.S. plot against Muslims, that the drone strikes have not helped that. The Taliban has not allowed any vaccinators - Pakistani vaccinators into the region. Just - they just don't want any kind of Western medicine there at all.

And there have been negotiations going on. Just in September, a team was able to get into the tribal areas on the Pakistan side, and they immunized 30,000 kids, or they administered 30,000 doses. So there is the possibility that they'll penetrate, but, I mean, these people are working under enormously brutal conditions there. One vaccinator was killed some time this last summer. There was a report last week that another vaccinator may have been killed just because they were vaccinators.

CONAN: Vaccinators, yeah.

NEEL: Yeah. And that wasn't - that hasn't been confirmed, but they're - they've been attacked. And a lot of these comes out of the Osama bin Laden episode, where a vaccinator went to the house under the guise of vaccinating the kids to gather information, and that has really set back the effort in Pakistan.

CONAN: There are also, obviously, logistical problems, and not just in Pakistan. We'll to get to Nigeria in just a minute. But this is a very rugged country, and there are, you know, problems. You - the vaccine, as I understand it, has to be kept cold.

NEEL: Oh, that's right. I mean, in India, for example, it's not unusual for the temperature to get up to 110, and you have to keep the vaccine at - almost near-freezing, somewhere between 30 and 40. So you've got to carry around ice chests with ice packs, and that's just not an easy thing to do in developing countries where you don't have refrigeration.

BEAUBIEN: Yeah. And in Nigeria, I mean, you've got people who are nomadic, some nomadic people coming through there.

CONAN: Especially in the northern parts.

BEAUBIEN: Especially in the north. And it's in the north that you're still seeing these cases. It just in Northern Nigeria, a lot of traffic going through to Chad, through to Northern Cameroon, up into Niger. Some of these people are nomadic. Some of the people are truckers that are going around. And getting the children of these nomads vaccinated is very difficult, knowing where they are, and knowing if they have gotten them in the past. Some places simply - just getting to these actual settlements is a challenge. It's, you know, it takes going in boats. It takes going, you know, sometimes on a horseback or in - on four-by-four to get to these places.

And what I thought was interesting was people there were telling me one of the biggest problems isn't the different countries, you know, Niger or Chad. It's the borders between different states inside Nigeria and just getting those types of cross-border communication worked out so that - they were finding that most of the cases are turning up somewhere between two political entities, between a city and another area, between a slum and another area, or between - and basically, there just wasn't a coordination across different governmental strata. And just getting those types of logistical things worked out is incredibly complicated when you're trying to reach every child in a particular area, in an area that's not very well-developed to begin with.

CONAN: Jason Beaubien is NPR's global health and development correspondent. He's been reporting on efforts to eradicate polio in Nigeria under the guidance of NPR health editor, Joe Neel. They're both with us here in Studio 3A. You're listening to TALK OF THE NATION, from NPR News. And, Joe, just as Jason was describing, travel by horseback or four-wheel vehicle, at the same time, some of these people who might have this disease, might be carriers, can get on a plane and go anywhere.

NEEL: Well, that's right, and that's where the - I mean, every disease is a risk to - is a worldwide risk. And that's why Western countries have recognized the importance of global health, in the past decade, especially. There's been bipartisan support in the U.S. Congress, and President George W. Bush and President Obama have backed global health because it's recognized that - look at SARS. It spread around the world within six weeks, seven, eight weeks. The flu, it can, you know, it's a matter of hours that a disease can really go some place and take off.

BEAUBIEN: But one of the things that's really interesting about polio is that most of the carriers are asymptomatic. They're not showing any signs. They're not getting paralyzed. Most of them are perfectly healthy, perfectly fine, and they can move somewhere else, spread the disease to other people who will then end up actually getting paralyzed by it. So it's a very difficult disease to contain, a very difficult virus to contain, because so many of the carriers - I think more than 90 percent of the people who are carriers aren't completely asymptomatic.

CONAN: Were you able to find - visit a child in Nigeria with polio?

BEAUBIEN: Yes. We went and saw a couple of children who had just gotten polio in the last couple of months, who were paralyzed in the last couple of months. And they were - six of them all happened in sort of a cluster just outside of Kano, in a small village. It wasn't really clear. We also went - and it was a very clean little village, you know, farming village. And then we went to this other place that was a complete dump, that actually, the sewer was pouring into this open concrete thing. And there weren't - hadn't been any right around there, and they were monitoring right there, next to the sewer and thinking that's where it's going to be. But it turned out it popped up out in the countryside in a very tidy, little farming village.

CONAN: Joe Neel, if polio should be eradicated, if this goal is met, what does that mean?

NEEL: Well, it means that the world won't have hundreds of thousands of cases of paralysis every year. It also - like I was saying earlier, it builds infrastructure. It allows countries to then start tackling these other diseases. As we've seen in Africa, putting AIDS drugs out into various places has really - and prevention efforts there has really helped elevate the health on many levels in these countries, and is something that just hadn't taken place before. I just want to go back to one thing that Jason said about the - how it spreads out. In Pakistan, the - one of the major ways it's spreading into the population is from these tribal areas.

And one way they're trying to attack it is they set up checkpoints around cities, like Rawalpindi, Islamabad, where when they see people with children coming into the - past the checkpoint, if the child doesn't have a mark on their finger that they've been vaccinated, they give them the vaccination right there. And that's the only way they can attack it. And - because it's from these areas that you cannot get into, that you cannot reach that polio is going to remain for - it seems like at least another year or two.

CONAN: And obviously, the cases of these children you visited in Nigeria is - this could've been prevented just a couple of years ago.

BEAUBIEN: And it should've been prevented even this year. I mean, if these kids had gotten the vaccinations earlier in the year, vaccinators were out in that area. You know, one of the most kind of unclear whether or not he'd been vaccinated or not, the other one said that basically he had been opposed to - the father said he'd been opposed to vaccination. So, you know, there is still some opposition to vaccination. And unfortunately, that child, you know, now is not going to be able to walk.

CONAN: And you were talking about sort of the multiplier effect that these kinds of global health programs can raise health all around in other circumstances. Did you see evidence of that? That the efforts by these outside groups, has it - have they been working malaria, dengue fever, AIDS?

BEAUBIEN: Well, not directly. But you do see that there's an overall improvement in sort of health structures. You see that there's better coordination between different groups. Also, most health clinics in that part of Northern Nigeria don't have electricity. And so into these different clinics, they were bringing in solar-powered refrigerators to keep the vaccine. So, obviously, they can keep other vaccines, keep other medical supplies in them. So there is a building up of some of that infrastructure. And I was struck, working on this story just by - it is kind of a - it's a global effort to do this, and it crosses boundaries. It can only be done if Afghanistan and Pakistan, you know, sort of work on it together. And that's what I was really struck by the most, that this could be an amazing global success story.

CONAN: Jason Beaubien, Joe Neel, thank you both very much for your time.

Tomorrow, TALK OF THE NATION: SCIENCE FRIDAY. Ira Flatow will be here. TALK OF THE NATION, from NPR News.

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