So close, yet so far.
That well-worn expression summarizes perfectly the status of polio eradication, one of the most ambitious public health initiatives ever undertaken.
In Monday’s Globe and Mail, former prime minister Paul Martin presented the optimistic view in a commentary entitled, “We Are On The Cusp Of Ending Polio.”
His outlook stands in stark contrast to last week’s stinging report from a blue ribbon panel that stated polio eradication won’t come “any time soon.”
So, who’s right?
Well, they both are, except that we should pay a lot more attention to the independent monitoring board of the Global Polio Eradication Initiative.
As the board rightly points out, pie-in-the-sky optimism has been a major impediment to success, and the panel offers concrete proposals for what needs to be done to close the deal.
The eradication effort, a partnership among Rotary, the World Health Organization, Unicef and the U.S. Centers for Disease Control and Prevention, began in 1988. (The Gates Foundation became a partner and major financial contributor later.) At that time, polio – the Great Crippler – killed 350,000 people and disabled millions more each year, most of them children.
At the outset of the global eradication campaign, success came quickly. The annual number of cases fell to a low of 483 in 2001.
But the final push to control an infectious disease is always the most difficult (and expensive.) That’s why smallpox is the only disease that has ever been eradicated.
For the past decade, we have been counting the days until the last case of polio. But the goal has remained frustratingly elusive as the numbers of cases yo-yoed. More than $8-billion (U.S.) in spending has not been enough.
Of course, there have been excuses: War and natural disasters have interfered with vaccine campaigns; greater ease of travel has brought polio back to countries where it had been wiped out, and the logistics of mass vaccination in the developing world remain difficult.
But the new report, written by an eight-member expert group headed by Sir Liam Donaldson, Britain’s former chief medical officer, has concluded that the major obstacle to eradication is not political or scientific or monetary, but something seemingly mundane – bad management.
They say the program is riddled with “tired and ineffective” managers who lack commitment and are not accountable. Worse yet, incompetent managers are being left in their jobs, mostly at the country level, where nepotism and corruption can be common. The problem is particularly acute in Pakistan, which has become the global epicentre of the polio epidemic. Recently, polio even returned to China, via Pakistan.
“Pakistan’s progress now lags far behind every other country in the world. Without urgent and fundamental change, it is a safe bet that it will be the last country on Earth to host polio,” the expert group wrote.
The beacon of hope is India, which has not had a single case of polio recorded for a year.
The fundamental problem though, according to the expert panel, is that the global eradication effort is overeager to celebrate the successes (like India) and ignore the failures (like Pakistan).
That’s why the target date for global eradication has repeatedly been missed and reset. The latest goal, ending all polio transmission by the end of 2012, will likely not be met without a dramatic change in philosophy and management.
The panel says so in blunt language, uncustomary in this type of report: “Fifteen months remain. We continue to genuinely believe that this is long enough – that success will be attained. But this will not happen through more of the same, nor will it happen by sharpening performance here and there. It will only happen if the program seizes on the most fundamental problems this report identifies and deals with them as real organizational, national and global priorities. Some of the problems identified run so deep that nobody should believe that ‘more time’ is the solution to them. The focus needs to be on solving the problems themselves. More time may be a requirement but is not the answer in itself.”
There is, of course, a dilemma for boosters of polio eradication. They have to maintain a facade of optimism if they are going to keep the money flowing from donors, from philanthropists like Bill Gates through to countries like Canada.
But, as the expert panel points out, the “narrative of positivity” has become Pollyannaish and counterproductive.
After years of stumbling, it has become clear that the culture and approach of the global program need to change.
What these donors need to do, though, is not abandon hope, but rather make their continued support contingent on the type of change the expert panel is demanding.
The worst thing that could happen is for the 23 years of effort to go to waste when we are indeed on the cusp of eliminating ending polio.
Instead of despair and anger at what has gone wrong, there need to be urgency and focus on what needs to be done right.
As the expert panel writes in its cri de coeur for leadership: “To fail now would unleash widespread suffering and death on the world’s most vulnerable children.”