Polio eradication was an ideological projectBMJ 2012; 345 doi: http://dx.doi.org/10.1136/bmj.e8545 (Published 19 December 2012) Cite this as: BMJ 2012;345:e8545
- William Muraskin, professor and graduate adviser, Department of Urban Studies, Queens College, City University of New York
In the 1980s, why was polio, with its rather small mortality rate, chosen for a worldwide “eradication” campaign, when other infectious diseases such as measles, pneumonia, and diarrhoea causing infections each killed millions of children a year? It had little to do with the priorities of most developing countries where polio was endemic. It was more to do with the ideology of a small number of powerful and well placed players in global public health who were dedicated to the concept of so called eradication as perhaps the major tool for international public health.1
Many of these people had been involved in the successful campaign to eradicate smallpox. However, after that great achievement near consensus had formed in public health circles that primary healthcare (including routine immunisation) rather than vertical eradication campaigns should be the focus of global and national efforts. It looked as though smallpox would be the first and last human disease to be eradicated.
Those who I would call “eradicationists” had to find a disease that could be quickly and inexpensively disposed of to keep the concept of eradication alive in the face of popular indifference and active hostility from the World Health Organization. They considered many diseases, from rabies to neonatal tetanus, but only three seemed feasible: measles, yaws, and polio. To win support for a campaign against one they convened large meetings of experts.
In 1983 they held the largest conference of polio experts in the world, including Jonas Salk and Albert Sabin, but to the great disappointment of the organisers the meeting generally ignored eradication. In the one session that specifically dealt with the question, the anti-eradicationists, led by representatives of WHO, argued so well that even proponents admitted they had been defeated.
So the idea of polio eradication was not championed by experts in the disease. Nor did the idea arise from most of the developing countries that had endemic polio. But this lack of support did not deter those committed to finding a disease to eradicate. Once it became clear that measles, a disease that is remarkably easy to spread, was not a feasible option given the technology at the time, and given that yaws is a disease found primarily in Africa and part of Asia and is far less a high profile global disease, polio was the most attractive game in town.
Fortunately for the eradicationists, their group included three men well placed, with the help of allies, to push their agenda successfully against their far more numerous opponents. William Foege was former chief of the smallpox eradication programme at the US Centers for Disease Control and Prevention (CDC), later head of the CDC, and then leader of the highly influential Task Force for Child Survival. Not just a towering public health figure in his own right, Foege also had the ear of Jim Grant, the charismatic leader of UNICEF. Together they were a formidable force. Much less well known, but ultimately the most influential proponent of polio eradication, was Ciro de Quadros, head of immunisation at the Pan American Health Organization (PAHO).
PAHO, although technically part of WHO, was an older agency, often rivalrous with, and contemptuous of, its nominal parent body. De Quadros was committed to the idea of disease eradication and took WHO’s hostility to it as an affront. He was able to prove in principle that polio could be eradicated by eliminating it from the Western hemisphere. And it was widely believed that if a disease could be disposed of in Latin America and the Caribbean (areas with countries as poor as Haiti and as diverse as Brazil) it could be defeated anywhere. But the assumption was unfounded: Brazil could not stand in for places like India.
Unfortunately, it was not that difficult to get the members of the World Health Assembly to support a major global policy without fully understanding the implications for their own home countries. One of the costs was that national health priorities formulated by developing nations themselves (such as building routine immunisation systems, neonatal health, maternal mortality, controlling diarrhoeal diseases) may have been pushed aside in favour of an agenda that these countries didn’t even know existed. They would not only have had to subordinate their own public health goals to engage in a fight against a relatively minor disease, but they were doing it not merely for the stated goal of vanquishing polio, but to prove the point that disease eradication can be maintained as a major tool of public health. For eradicationists today it is polio, but tomorrow it may be measles, mumps, and rubella. And woe betide any country that should want to put its own health goals above these global aims.
Cite this as: BMJ 2012;345:e8545
Competing interests: The author has completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declares: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Provenance and peer review: Commissioned; not externally peer reviewed.