Lung: An Interview with the World Health Organization's Sona Bari
As a way to add some context to"Lung" I thought it would be appropriate to interview an enlightened mind about the subject. In the third issue of "Love Machines" Harvey's struggle with illness was something I wanted to treat responsibly, and as a result I have done a lot of research into iron lungs, and the history of polio itself.
As a result I found myself discussing polio, iron lungs, and global epidemics with none other than the World Health Organization's (WHO) Senior Communications Officer, Sona Bari. Bari has been involved in polio eradication for over a decade, and works closely with the ongoing efforts of the WHO's Global Polio Eradication Initiative (GPEI). In late September of this year I conducted an interview with Bari about the fight to eradicate polio worldwide. (This interview was conducted via e-mail in September, 2014. Sona Bari is based in Geneva, Switzerland.)
(This interview was conducted via e-mail in September, 2014. Sona Bari is based in Geneva, Switzerland.)
Please tell me about yourself and the Global Polio Eradication Initiative (GPEI.)
My name is Sona Bari. I have worked on polio eradication for 10 years now, coming in as a former journalist. The GPEI was set up back in 1988; smallpox had become the first virus ever to be permanently removed as a threat back in the 1970s, and it became clear that we could do the same with polio. There was a vaccine, there was the motivation, and this is a virus that survives only in humans (meaning that if everyone is immune, it will die out for good).
The GPEI was inspired by Rotary International, and set up as a partnership between Rotary, the World Health Organization (WHO), UNICEF and the United States Centres for Disease Control and Prevention (CDC), bringing together all the different mandates and skills that we needed- technical expertise, the ability to mobilise and educate communities, and to generate the funds and political will to get the job done.
In the story Harvey finds himself in an uncomfortable iron lung as treatment for his polio. How is treatment different today for those who are afflicted vs. the 1940s?
Back in the 1940’s, polio was one of the worst nightmares of every parent even in wealthy countries. In a day, your child could go from being healthy to lying in an iron lung, potentially for the rest of their lives, unable to breathe without a machine because the muscles in their chest had been paralysed. There was no way to protect them, and no cure.
Things have changed dramatically since then. While there is still no cure for polio, there is a vaccine, which means that no child needs to suffer from polio ever again- so long as we make sure they are reached by vaccinators. Because there are so few cases of polio now compared to the 1940s, cases such as Harvey’s where the lungs become paralysed – rare to begin with – are even rarer now. But because polio strikes in the least protected, often poor communities, polio is still debilitating, stigmatised and life-altering. If it affects the lungs, it will very likely kill, as there are no respirators in such places. If it paralyzes the limbs, the only available treatment is to alleviate the symptoms, by stimulating and relaxing the paralysed muscles. Through rehabilitation, those afflicted can learn to move as best they can- but when you remember that this is a disease we can prevent by simply putting droplets of a vaccine into the mouth of a child, it seems a high price to pay.
How has our understanding of polio changed since then?
Back in the 1940’s, there was no way to protect children or adults from polio. However, just 10 years later, one of the greatest medical breakthroughs of the 20th century was made with the discovery of a vaccine. Following this, polio disappeared rapidly from industrialised countries. We now have several vaccines with which to fight the disease. In countries with strong health systems where polio has been eradicated, inactivated polio vaccine is used. This is given through an injection, and develops immunity more slowly. In countries where polio is more of a threat or health systems are weak, the oral polio vaccine is used. It can stop circulation of the virus within the community, and it can be administered with very little training just by putting two drops into a child’s mouth, meaning that reaching every individual becomes a much more achievable task. And our understanding of polio and how to prevent it is still growing- we now know that giving both of these vaccines together stimulates immunity faster and more effectively.
What does a polio outbreak look like? When an outbreak is diagnosed in a previously "healthy" region, how does your organization respond?
Polio is what we call a ‘silent’ disease, with only 1 case in 200 showing symptoms. Outbreaks only occur where immunity levels are not high enough to stop the virus before it can pass between people. This means that in regions where systems are strong and immunity is high, we do not see outbreaks. Polio has become a strong indicator of poverty and conflict, occurring only where vaccinators can’t get to children because of insecurity, or where the systems that are meant to protect children are not strong enough to do so.
For example, in 2013 we saw a polio outbreak in the Middle East, starting in Syria and spreading to Iraq. While Syria once had a very strong health system, two years of conflict meant that levels of immunity had dropped, and the virus was able to gain a foothold. The response of local health partners to the outbreak was strong and rapid, with GPEI support: repeated campaigns were held to reach children with the vaccine. This year, we haven’t had any cases since April, so we are hopeful the rapid response has stopped polio in the area.
What resources does your organization provide to afflicted nations and individuals?
The GPEI partners work mainly to prevent the spread of polio so that in the future, no child will grow up unable to walk, to play, to go to school and get a job and live a normal life due to the paralysis that polio causes. WHO works with governments worldwide to set up strong routine immunization systems so that every child is vaccinated. On top of this, we coordinate immunization campaigns to reach all the children in areas where these health systems are not strong enough or where conflict and instability makes it hard for the health system to function.
Polio can spread very quickly. We have a very strong global surveillance system to make sure that we know in a very short time every time there is a case of polio, so that we can rapidly increase immunity in the area and stop anyone else being affected. From inspiring commitment from those at the very top of the system to explaining to parents why this vaccine is so crucial, we provide technical expertise to countries all over the world.
There are many parts of the world without access to electricity. How does the WHO handle the distribution, operation and maintenance of respirators in such isolated pockets of the world?
First of all, polio very rarely leads to paralysis of the muscles necessary for breathing. But when it does, if the patient is in an area without electricity, it will very likely lead to death. My boss tells a story of a family in rural Ghana who took turns throughout the day and night to pump by hand the father’s respirator.
While iron lungs are rarely needed these days to respond to paralysis caused by polio, even the distribution of vaccine presents its own challenges. Vaccines need to be maintained at a particular temperature for them to remain effective. Each vaccine has to make a long and complicated journey along what we call the cold chain, from factory to country capital to village, using all sorts of modes of transportation. This can make it very difficult to keep the vaccines cool- making enough ice to fill cool boxes before they are sent off on the backs of donkeys, carried on foot for hours, or many other remote and challenging journeys is a logistical challenge that health workers face daily. Each vial of vaccine has a vaccine vial monitor which enables health workers to be sure that the vaccine has been kept at the right temperature and is therefore still effective.
The GPEI currently lists polio as being "endemic" in three nations: Afghanistan, Nigeria and Pakistan. What is limiting the success of your efforts in these nations? What are the major obstacles to containment?
There is a false narrative that communities in these countries refuse vaccine: they are no more or less trustful of vaccination than some communities in the US. It’s important to remember that this is mostly not because parents refuse vaccine; it is because they don’t even get the chance to have their children vaccinated. The challenges faced by vaccination programmes in the endemic countries are three fold: operational, management-based and political.
In 2012, Pakistan was close to achieving eradication with cases consistently falling. However, due to immunization bans imposed by local leaders in one part of the country and violence affecting health workers, access to children needing vaccines was restricted. This led to a massive rise in polio in the past 18 months – today, 9 out of every 10 children paralyzed by polio in the world is a Pakistani child. This is not only because of insecurity – it is also because of a lack of political commitment and strong oversight. Pakistan is the greatest challenge to global polio eradication right now, and it has ‘exported’ virus to conflict zones in the Middle East.
In Afghanistan, there have been improvements in program operations and intensive community outreach to encourage vaccination. Most cases in Afghanistan were linked to cross-border transmission from Pakistan, making the movement of refugees and internally displaced persons the greatest challenge faced in Afghanistan.
In Nigeria, WPV cases have continued to steadily reduce in number in the past few years. This is due to measures taken to address the biggest challenge in Nigeria, which was the fact that children were being missed in campaigns. Factors contributing to this success are the use of highly accurate mapping to locate children previously missed by vaccinators, and a surge in the number of field personnel working to achieve eradication.
In the years since the polio vaccine was first developed a fringe anti-vaccination movement has formed in the west. How large of a risk does this pose to your organization's mission?
In my travels in Nigeria, Pakistan and many other countries, nearly every parent I have met is desperate to vaccinate their child. When you see the disease around you, you think being anti-vaccination is a luxury. The worst – and in my view the most shameful – effect of the anti-vaccination movement in the west is its influence in countries where a vaccine-preventable disease presents a real threat of lifelong disability or death. Misinformation spreads far and wide these days. The anti-vaccine movement of say, the western US, bears a real responsibility for its influence on the few communities in the eastern Democratic Republic of the Congo where children were paralyzed a few years ago by polio.
Any child that goes un-immunized is at risk of being infected by polio. The virus does not distinguish between children who are unprotected because of insecurity, bad health systems, or because of anti-vaccine sentiment.
With only so much manpower and funding, the World Health Organization's resources are split between ongoing health crises around the globe. Does the WHO still have an imperative to fight polio when other, deadlier diseases are spreading so quickly?
Absolutely. Being able to completely stop this disease, now and for every future generation, is a unique opportunity. Being able to create a world in which every parent knows their child is protected from what used to be the leading cause of disability worldwide should be imperative enough to see the job through to the end.
But there are other reasons too. The GPEI currently estimates that it will cost US$5 billion to fully eradicate polio globally by 2018. This will pay for the vaccination of more than 250 million children multiple times each year, for monitoring and surveillance in more than 70 countries, and for expanding the polio infrastructure for other health and development programmes. It is estimated that this investment now will generate net benefits of US$40-50 billion for the world’s poorest countries in avoiding treatments and the contributions that people who would otherwise have been paralysed will make to the economy. In addition, the human and technical infrastructure that currently supports polio eradication will be repurposed for other health and development systems.
Furthermore, we are faced with the stark reality that if we fail to stop polio in the enclaves where it remains, we are handing down a terrible legacy to the next generation. In 2012, the world was the closest it had ever been to eradication. However, 2013 saw a rise in cases due to conflict, insecurity, and international spread of the virus causing new outbreaks. If we fail now, we will see as many as 200,000 new cases every year within 10 years. This is not a risk we can afford to take. And it is not an ethical choice when we have the means to prevent it.
For many in the first world, polio is little more than a history lesson. What are the biggest misconceptions you encounter about the virus?
For many born in the last few decades, polio is not a real and present threat. But ask your parents, your grandparents, and the story is very different. The fear that spread with this virus was very real, and lives were affected in long-lasting and devastating ways. This is not history. This is a reality lived by families in Pakistan, Afghanistan and Nigeria, and wherever polio re-emerges as an outbreak today. New cases are still reported nearly every week. This makes the perception that polio is a thing of the past dangerous to maintaining the political and social momentum that is so essential to these final steps.
UNICEF and WHO both work to engage and educate communities about the nature of the virus and the disease and the importance of vaccinating your child with enough doses to ensure immunity. From working with youth groups in Pakistan, with diasporas living on the other side of the world, with mothers who take to the streets with loud speakers, to Bollywood stars in India who inspire people to make that trip to the health centre- our colleagues and partners use innovative and culturally sensitive means to give people the information they need to protect the health of their children and to challenge misconceptions.
Finally we must remove the misconception that settling for the containment of the virus, rather than eradication, is a viable option. As I have described, the cost in both economic terms and the spread of the disease if we do not completely stop it is too high. Every child who grows up unable to play, to walk, to run, is a failure of the global community.
What does the decades-long struggle against polio say about containment efforts for other epidemics? Do you feel that governments and individuals are prepared for a true global outbreak of contagious disease?
In the 26 years since the initiative was set up, the polio programme has advanced our understanding of how to respond to the spread of infectious diseases. The lessons that have been learned in countries across the world have taught us a lot about the best scientific approaches for disease control, the need for tailored approaches for different cultural and political environments, and about tackling the incredible challenges we face in situations where there is conflict, insecurity and mistrust. These considerations and experiences are adding to the global knowledge base that enable responses to outbreaks of other diseases.
What factors could lead to a resurgence of polio? What should the public know?
Until polio is eradicated globally, no country is safe from outbreaks. This was demonstrated this year, when a virus from Equatorial Guinea in central Africa was found in the sewage system in Brazil. Luckily this did not cause an outbreak, but it highlighted how vigilant we need to be. In May 2014, polio was declared a Public Health Emergency of International Concern, and temporary recommendations were made to stop the international spread of the virus. This means that people travelling out of infected countries need to have proof that they are vaccinated. Other countries such as China, Australia and India are starting to adopt these pro-active measures to stop polio at borders. Each step we take to stop polio spreading and to end infection in endemic countries is a step closer to the endgame- and this can only be done by making sure that every single child is protected, no matter where they live.
Will we see a total eradication of polio within our lifetime?
I believe we will. Back in the 1940s, people like Harvey could not see an end to polio. This story that you have told through the pictures in this comic is an ancient tale - people have had their lives turned upside down by polio for thousands of years. The first historic reference to polio is believed to be from ancient Egypt in a stone-carved depiction of a priest with a withered leg from around 1580 BC. And yet, within the last decades, the landscape has dramatically changed, swinging the odds against this ancient virus. We now see a couple of hundred cases of polio a year. Compare this to the 1000s that were being infected each day in Harvey’s time and you can see how far we have come. But even one child paralyzed by polio is one too many.
The GPEI has a Polio Eradication and Endgame Strategic Plan which outlines the path to eradication by 2018. With financial, political and social commitment, we will be able to achieve this goal.
The drive to eradicate polio has led to the biggest social movement in history, with over 20 million volunteers, health workers, technical experts and government officials worldwide committed to seeing the job done. We have the vaccines, we have the knowledge, and it is just a question of holding ourselves accountable to serving every last child.
And finally, what is the next step? If you eliminate all forms of polio where does your group go next?
Eradicating polio will be a wonderful thing; with all the challenges faced within the world today, that polio can be ticked off the list is an inspiration.
One pillar of the endgame plan is to prepare the infrastructure for the future, so that all the lessons we have learned in the last decades, all the systems, assets and expertise that we have put in place and health workers we have trained continue to meet health and development needs in the future. When the GPEI is no longer needed, the skills that we have amassed since 1988 will be in great demand. We have shown how to reach the last child, the most vulnerable community – and these are the communities that we can continue to serve with their other health needs.