On Monday, I had the pleasure of attending an event hosted by the Gates Foundation called “Polio Eradication and the Power of Vaccines” hosted by Bill Gates at the newly restored Roosevelt House here in New York. At the event, Bill Gates released his 2011 Annual Letter from the Gates Foundation. The main focus of his letter – and of this event – was on polio eradication. Also present at the event were historian cum-author David Oshinsky, representatives from the Sabin Institute, the WHO, and – oddly – a very uninformed Diane Sawyer, who hosted the panel discussion during the event.

The story about polio eradication is a long complicated one. Launched in the late 1980s, buoyed by the successful smallpox eradication program, the international effort had as a goal to eradicate the disease globally. Eradication, as opposed to eliminate or control, means to eliminate it everywhere in the world. It is worth pointing out that eradication is an extremely difficult undertaking and just because one disease has been successfully eradicated, it does not mean that others will be as well. Epidemiologists have argued that some diseases, including some diseases for which global eradication efforts have been launched in the past, are not biologically eradicable (if that is even a word). For example, if there are non-human reservoirs of the infectious agent the agent could easily be reintroduced making eradication nearly impossible. This appears to be true for both malaria, yellow fever, and yaws – all three of which have been targets of failed global eradication efforts. Eradication efforts against these agents are unlikely to be successful if one takes true eradication as the goal.

Fortunately polio is biologically eradicable – in fact one strain of the virus has already been eradicated. Plus, also like smallpox, there are effective vaccines available to target polio, which was the reason why smallpox could have been eradicated. But although we have a vaccine against polio it is not as effective as the smallpox vaccine. In general, we need to give 3 doses of the vaccine and even then we don’t get full protection. There are different strains of the virus circulating and not all vaccines are equally effective against all of the vaccines. Plus, in rare cases, the use of the live version of the vaccine can also cause a mutated and virulent form of the virus – using the live polio virus has been described by some as using fire to fight fire.

Perhaps more importantly, however, is the fact that polio is a largely invisible disease. Most people who get polio are largely asymptomatic. They might have flu like symptoms but for the most part it is impossible to know when someone is infected or not – smallpox victims were easily detected from the rash and poxes that appeared on their body. Only a small fraction of those infected with polio develop paralysis or more severe symptoms. So for every reported case of polio there are literally hundreds or thousands of undetectable infections. By the time we can respond using supplementary immunization – the disease has likely spread.

Does that mean that polio should not be targeted for eradication? There has been a lot of chatter about this this past week, including some comments from experts like Donald Henderson’s whose opinion on this matter I take very seriously. The truth is we don’t know – no one, no matter how much of an expert you are on this matter knows for sure. It is feasible from a biological standpoint, but challenging due largely to issues related to poor health infrastructure in endemic countries, weak institutions, and conflict – stuff public health has not done a great job addressing in the past. Polio has been eliminated in a number of geographic regions around the world but that does not mean it can be eliminated everywhere. But the simple truth is polio will never be eradicated if we don’t try. Plus, given the progress that has been made to date, there may never be a better time than now to try.

Polio eradication is the perfect example of what economists call a public good – while most of us will benefit from polio eradication in some way, the truth is that the benefits to most people will be very small. As such, very few of us have the incentive to pay for this and so we won’t. This is a big reason why I disagree with what author David Oshinsky proposed during his talk on Monday – let’s replicate the March of Dimes efforts from 50 years ago in the United States to raise money for polio eradication. People don’t see polio anymore and as such there is very little constituency to support such efforts. Instead, I believe, it is up to governments, and fortunately for us, rich computer geeks to pay for this effort. We should be thankful, and not be too critical of Bill Gates on this issue. Polio eradication efforts were floundering a few years ago. It is because of him, and his tireless efforts that we are even talking about polio eradication today.

It has been estimated that it will cost about $1 billion a year for the next few years to move ahead with the polio eradication efforts. Some have argued that this is not a lot of money because, for example, Americans spend $18 billion a year on dog food. But that is not the right way to look at this issue. It is a lot of money. The IHME estimated that in 2010 the world allocated about $25 billion a year for development assistance for health, what will ultimately finance most of the eradication efforts. So it is a lot of money in that perspective. Some have argued that this cannot be justified on the basis of disease burden, but again this is not the right comparator. Eradication needs to be considered in a dynamic sense, investments today may lead to cost savings in the long run (actually, I believe all development assistance efforts should also consider the long-run). Investments in polio eradication are a risky investments that may or may not pay dividends in the future. We don’t know if it will be successful, we don’t know if and when we might actually be able to cease polio vaccinations – where most of the savings will come (in fact, we already know that we will likely need to switch from OPV to IPV in the near future and that may need to continue to vaccine for a long time due to that fact that some people continue to shed polio virus and will for years to come).

Bill Gates comes from a different world – he is not a public health person at heart – he is an entrepreneur. He became the worlds richest man not by playing it safe – but by taking risks. This approach has carried over to his work at the Foundation. His donations are like an investor’s portfolio with a balance of safe and risky investments. Polio eradication is certainly one of the risky investments but the high-risk-high-reward model has paid off for him in the past, and it might play out here as well. Of course, we should not just let the mission of one individual highjack the global public health apparatus but I truly believe that this is one program where it might be worth taking the risk.

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22 Responses to “Polio’s last mile: the risky road ahead”

  1. Karen Grepin says:

    Why I support Bill Gates #polio eradication efforts (hopefully with working link): http://bit.ly/fcfZ70 #globalhealth

  2. Brett Keller says:

    RT @KarenGrepin: Why I support Bill Gates #polio eradication efforts (hopefully with working link): http://bit.ly/fcfZ70 #globalhealth

  3. Eilidh says:

    Great post. What is your opinion on the efforts to eradicate Guinea worm disease?

    • admin says:

      Admittedly, I know a lot less about Guinea Worm eradication than say polio efforts. But I think some of the same arguments hold: great progress has been made and if it might actually be feasible to go the last mile it might be a worthwhile effort. But each effort must be analyzed individually to know for sure.

      • Brett Keller says:

        I think an important difference with guinea worm eradication is that we’re trying to stop it by surveillance and prevention rather than vaccination. (Right?) My understanding is that if you stop the intensive surveillance program we have now, you might see a slight resurgence but not that much — someone please correct me if I’m wrong.
        In contrast, vaccination rates for polio through regular programs aren’t nearly high enough to keep rates where they are now — they’ve been driven down by intensive (and thus expensive) mop-up campaigns and region- and country-wide vaccination days. If we stop those efforts we’d theoretically go back to the level of protection we get through the regular vaccination programs, which means we’d have a lot more cases.

        • admin says:

          Yes, I think it is fair to say that polio would spread much more quickly if left unchecked than guinea worm – just look at how it has been spreading even with current surveillance efforts.

  4. RT @devisridhar: Excellent post by @KarenGrepin on polio eradication http://bit.ly/fcfZ70

  5. RT @KarenGrepin: Why I support Bill Gates #polio eradication efforts (hopefully with working link): http://bit.ly/fcfZ70 #globalhealth

  6. “We should be thankful, and not be too critical of Bill Gates on this issue.” Is it Bill Gates alone or the Gates Foundation that is funding the drive to eradication? If the drive fails, herd vulnerability increases, and more children are crippled and die as a result of the failed effort, will Bill or the Gates Foundation take the credit?

    • Austin says:

      One can see the current funding profile of the polio eradication program here:

      http://www.polioeradication.org/Financing.aspx

      Based on rough estimation, it looks like Gates funds less than half of existing efforts, and about 1/5 or of the total need.

      • admin says:

        Yes, but I think we also need to think about how they are encouraging other donors to pledge. Last week Abu Dhabi and the UK both made new pledges – likely because they were motivated to do so by Gates himself.

    • admin says:

      I do think you raise a good point: that of accountability. I think this is a big reason why the gates foundation has been reluctant to just come forward and say they are going to finance the whole thing. We need this to be a global partnership. Both credit – and blame – should be shared.

  7. RT @poliotoday: RT @devisridhar: Excellent post by @KarenGrepin on polio eradication http://bit.ly/fcfZ70

  8. Brett Keller says:

    Thanks for the informed commentary! I’m torn on eradication. I think it would be a capital G “Good Thing” to do, but I’m not sure the cost-savings are there. As you mentioned, people continue to shed polio virus and that — along with the threat of bioterrorism or accidental reintroduction since polio would be relatively easy to make from scratch — means that we’re unlikely, at least in the US, to stop vaccinating anytime soon even if it is eradicated. I’m not sure we have the methods we need to really make objective decisions when there is so much uncertainty.

    • admin says:

      There have been efforts in the past to calculate the cost-effectiveness of polio eradication. My sense is that no one really knows how much it is going to cost to get rid of it, so the cost-effectiveness calculations are not that useful. But if we do eradicate the virus, there will eventually be a point where we could likely stop vaccinating. Regardless, routine polio vaccination with IPV is probably quite doable for the foreseeable future.

  9. RT @KarenGrepin: Why I support Bill Gates #polio eradication efforts (hopefully with working link): http://bit.ly/fcfZ70 #globalhealth

  10. Great post on Bill Gates' #polio eradication efforts, @KarenGrepin! http://bit.ly/fcfZ70 #globalhealth

  11. RT @KarenGrepin: Why I support Bill Gates #polio eradication efforts (hopefully with working link): http://bit.ly/fcfZ70 #globalhealth

  12. Thank you for the informed account of polio eradication and vaccines. Gates and his foundation don’t just have a lot of money, they seem to have a lot of clout when it comes to raising money, too. So why do they not concentrate their efforts on improving water and sanitation? If people had access to clean water and good sanitation, things like polio, guinea worm, cholera and many other diseases would be reduced dramatically. Access to clean water and sanitation is a human right, so we don’t need to argue about cost effectiveness. But we can hardly justify vaccinating people against a handful of diseases and then sending them home to drink water contaminated with feces. We know that everyone is going to drink water sooner or later so why not concentrate on providing people with safe water supplies?

  13. NYU Wagner says:

    Prof. Karen Grepin on the journey to eradicate polio: Polio’s last mile: the risky road ahead: http://bit.ly/ggzzL6 via @addthis

  14. […] her blog, Karen Grepin thinks the gamble is worth trying, and points out that Gates became a rich entrepreneur by taking […]

  15. […] her blog, Karen Grepin thinks the gamble is worth trying, and points out that Gates became a rich entrepreneur by taking […]

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