The InterDependent

It took nearly two decades and a billion dollars, but on January 13, 2012, India celebrated its first-ever year without a single case of polio. India is one of just four countries in the world where polio—long ago eradicated in the West—has remained stubbornly endemic, thwarting a global eradication effort that began back in 1985. If this South Asian country of roughly 1 billion people remains polio-free this time, India's last ever polio case will have been Rukhsar Khatoon, an 18-month-old girl from Howrah in the Indian state of West Bengal.

But apparent success in India signals a wider international breakthrough in fighting polio, argue experts such as Tim Peterson, a polio specialist at the Bill and Melinda Gates Foundation. “India has always been thought to be the hardest place to eradicate the disease,” he explained. “If we can do it in India, we can do it anywhere.”

With India under its belt, the 27-year Global Polio Eradication Initiative will be left to tackle epidemics in Nigeria, Pakistan, Afghanistan and China. Lessons learned in India could help. Still, the fight will be far from over. The world has been here before—close to eradication—when another epidemic has broken out. Ensuring that the highly contagious disease has indeed been routed in India and the rest of the world has confounded public health officials for close to three decades.

The numbers in India make clear just how challenging the task is: India had to immunize 170 million children a year. In the worst affected areas in the state of Uttar Pradesh, 500,000 children are born every month, and many of these must be immunized up to seven times each to build up enough immunity to the virus. Without immunity across the entire community, a few cases can quickly spread, re-igniting polio for years.

For the last several years, this is the message that Bill Gates has been delivering to donors over and over: Any gaps in the campaign will set back decades of progress. The annual cost of running the global program is around $850 million, and Rotary International states that the current funding shortfall is around $500 million. Those dollars, say public health officials, could make the difference between ending the epidemic and watching it re-erupt across Africa and developing Asia.

A setback would also be costly. The immunization efforts, led by the World Health Organization (WHO), the UN Childrens' Organization (UNICEF) and the Centers for Disease Control and Prevention (CDC) in the United States, have cost over $8 billion so far. Much of the funding has come from the public service organization Rotary International, which began the campaign in 1985. U.N. agencies joined three years later, as did the CDC and the United States Agency for International Development (USAID). More recently, in 2010, Bill Gates pledged $10 billion over the coming decade to help immunize children against deadly and debilitating diseases, including polio.

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India is a perfect case study for understanding why polio has proven so difficult to eradicate. Three decades ago, the country had the worst infection rate in the world. According to WHO figures, there were 150,000 cases of polio in 1985. As recent as 2010, India had the highest number of cases of polio in the world.

The polio virus is usually transmitted through contact with the feces of an infected person. It incubates in the gastro-intestinal tract and can reside there for up to a month with little or no evidence of illness. This makes the disease extremely easy to transmit. “Each child exposed to the polio virus can infect around 200 others, and those 200 can infect 200 more,” explained Lieven Desomer, the chief of the polio unit at UNICEF’s office in New Delhi.

In about 1 percent of cases, the polio virus also attacks the central nervous system, causing the paralysis commonly associated with the disease. The risk of paralysis is far greater among children and others with weak immune systems.

Since polio targets very young children, the disease devastates families and communities. While rarely fatal, it can spread extremely quickly. Containing an outbreak of polio requires three rounds of community immunizations, known as mop-ups. For those suffering from the disease, little can be done except to provide pain relief and hope that their young immune systems can fight off the disease and prevent paralysis.

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A few years into the vaccination campaign, the global rate of polio infection has decreased by around 99 percent. But the disease hung on stubbornly in India. Although India’s vaccination campaign was one of the best in the world, it failed to take into account the underlying problems that helped to spread the disease, such as poor sanitation, infected drinking water and lack of proper nutrition. Regular contact with the virus also lessens the efficacy of polio vaccines. Children in areas with a high concentration of the virus often need up to seven doses of the vaccine to ensure they do not become infected.

Those structural troubles meant that once polio broke out, it was almost impossible to contain. In the summer of 2008, a single case of polio infection in the city of Badaun in northern Uttar Pradesh, for example, created an epidemic. The source of the infection was a child who had been exposed to the polio virus in the neighboring state of Bihar. A year and a half later, the epidemic was contained, but not before infecting around 1,000 children and leaving many of them paralyzed.

Such outbreaks can also easily cross borders. Last year, there were over 180 cases in nearby Pakistan and more than 70 in Afghanistan. With such outbreaks comes the chance of exporting the disease. There was a small outbreak in China last year linked to Pakistan in which 21 children were infected with polio. China had not had a case of polio since 1999.

Even if the disease is eradicated in India, meaning that there are no more infections from so-called “wild polio virus,” Desomer cautioned that it can still be imported from neighboring countries.

The Badaun epidemic seems to have served as a wake-up call for India. “In 2009, the government re-examined its strategy,” said Desomer. Data from UNICEF helped make Indian officials aware of the gaps in their efforts to eradicate the disease. “We examined the Badaun area and found 60,000 manually scavenged toilets,” he explained. These open latrines, perfect vehicles for the spread of polio, had been outlawed, but they continue to exist in rural India where the government had little oversight and the rule of law was only loosely enforced.

UNICEF brought evidence of these primitive toilets to the district magistrate, who then mobilized government resources to put an end to the practice. Small efforts such as upgrading rural toilet facilities have done more to achieve India’s current success against the disease than more than a decade of vaccinations. The reason, explained Desomer, is that preventing infection is often as easy as washing your hands. “The chances of catching polio are very low with access to basic necessities.”

Part of the newfound success may come from the increasing importance that global health campaigners have put on involving local governments in the fight. “This has been an example of a successful private-public partnership,” said Desomer. “Over 80 percent of the contributions to polio eradication in India have come from the government of India.” That figure comes to around $2 billion in the last decade and a half, most of it in the past few years. “That level of government contribution is unique to India,” he said.

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In the coming months, Desomer cautions that India cannot become complacent. “India has beat the odds through the blood, sweat and tears of thousands of people. They can’t let this slip now.” He has good reason to worry. Over the past decade, India has reduced the number of annual infections to single digits only to see them skyrocket a year or two later.

Maintaining a polio-free India will also mean policing its borders better. Pakistan and Afghanistan remain hotbeds for the disease. The Pashtun community, which is the worst hit, travels fairly freely back and forth across the porous border between the two states. As happened in China last year, a single child infected with polio can create outbreaks in areas thought to be free of the disease.

Carol Pandak, the manager of Rotary International’s polio eradication program Polio Plus, argues that some of the successful initiatives undertaken by India could now strengthen the fight in China, Pakistan, Afghanistan and Nigeria. Much of India’s success came through leveraging traditional structures of community leadership. “Rotary engaged with the ulema and other traditional and religious leaders to help encourage participation in the vaccination program,” she explained. “That could be replicated in places like Nigeria and Pakistan.”

Desomer agreed. “A decade ago, it was not uncommon for rumors to spread about the vaccines being some kind of plot,” he explained. “Our vaccinators would be chased out of homes and have stones thrown at them.” Reports to the Independent Monitoring Board, which audits the success of polio eradication efforts, showed that failure to immunize sufficient numbers of children to stop the cycle of transmission was often due to parental refusal to participate in the immunization program.

That changed when health workers approached religious and village leaders and educated them on the benefits of vaccination. Now, polio vaccination teams tend to work through, rather than around, traditional leadership. The same imams and clerics who once resisted inoculation in Afghanistan and Nigeria are now at the center of global health officials' campaign.

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The world will probably not meet the July 2012 deadline set to eradicate polio. The disease is on the rise in Afghanistan and Pakistan. Ongoing conflict in western and northwestern parts of Pakistan, where the disease is most prevalent, makes it difficult to reach enough children to halt the spread of the disease. The recent specter of civil conflict in Nigeria threatens to endanger the real gains that country has recently made against the disease.

However, the organizations and people that have devoted billions of dollars and years of their lives to eradicating this disease are refusing to be discouraged. “We eradicated the disease in South Sudan, we interrupted transmission in Somalia,” said Peterson. “We are usually even able to negotiate with the Taliban. The key to getting back on track is reaching the children.” And that's not free.