Policy & practice

The human qualities needed to complete the global eradication of Dermot Mahera

Abstract Although the 99% decrease seen in global polio incidence between 1988 and 2000 represented remarkable progress towards , tackling the last 1% of polio has proved tantalizingly difficult. Pockets of endemic currently persist both on the border between and and in northern . These pockets have permitted the reinfection of countries that were previously polio-free. Global strategic plans for polio eradication set out the activities, resources and financing needed to overcome the managerial, technical and security challenges faced by those tasked with the interruption of transmission. However, polio eradication also depends on the less tangible but equally important human qualities of energy, realism, articulacy, determination, imagination, collaboration, adaptability, tactical awareness, innovation, openness and nimbleness (the initial letters of which give the acronym “ERADICATION”). By paying attention to these human qualities, the stakeholders involved may be more likely to achieve global polio eradication.

Introduction The GPEI has concentrated on the technical consider- ations for stopping poliovirus transmission, to the neglect Progress towards polio eradication has been remarkable. of the key human qualities that will also be needed. The The annual number of polio cases recorded worldwide fell Independent Monitoring Board has advised that “the style by 99% between 1988, when the Global Polio Eradication and approach to management of the global programme need Initiative (GPEI) was established, and 2000.1 However, tack- reorientation”7 and has warned that the GPEI runs the com- ling the last 1% of polio has proved difficult.1 Although the mon risk “for change management programmes to pay too little number of countries where polio was endemic fell rapidly attention to the human factors, to over-orientate themselves to after the launch of the GPEI, from at least 125 in 1988 to 20 the technical elements of a challenge”.7 The aim of this paper is in 2000,1 progress in eradicating polio has since slowed. In to help redress the balance by identifying the human qualities 2006 polio was still endemic in Afghanistan, , Nigeria that have contributed to the progress made so far and that need and Pakistan and only India has been declared polio-free, in to be highlighted in attempts to eradicate polio. These qualities 2012.1,2 In the last few years, travellers from the few countries are considered first in relation to embracing the goal of polio where polio remains endemic have carried poliovirus into eradication and second in relation to overcoming the main countries that were polio-free.2 Such reintroduction of the roadblocks to the interruption of poliovirus transmission. was detected in 23 previously polio-free countries in 2009–2010, in the World Health Organization’s (WHO’s) Embracing the goal European Region (which was certified as polio-free in 2002)2 in 2010, and in in 2011.3 All landmark achievements in and its application Since 2009, efforts have intensified to identify what it require imagination. For example, although the enthusiasts will take to interrupt poliovirus transmission in the coun- for human genome sequencing in the 1980s were often con- tries where polio is still endemic or where transmission has sidered wildly optimistic or hopelessly deluded, sequencing recently reappeared. In an independent evaluation conducted of the human genome was completed in 20019 thanks, in large in 2009, the main managerial, technical and security challenges part, to the imagination and vision of the enthusiasts. Similar faced by those attempting to clear the remaining pockets of imagination and vision – as well as a sound strategy and a transmission (then on the Afghanistan–Pakistan border, in strong likelihood of technical feasibility – are needed by those northern India and in northern Nigeria) were identified.4 The attempting to globally eradicate an infectious disease. Efforts GPEI’s Strategic Plan for 2010–2012 subsequently set out the to eradicate , and yellow fever all foundered on activities, resources and financing needed to overcome these the “rock” of doubtful technical feasibility. Polio eradication challenges.5 In 2010, the GPEI established the Independent is, however, based on a sound and adaptable strategy, similar Monitoring Board to monitor and guide the plan’s progress. to the one used to eradicate polio in the in 1994 The Board’s chairman, Sir , stated that (Table 1), and on technical feasibility.10,11 although “polio eradication is on a knife edge”, it was “still A few years ago, the persistent pockets of poliovirus feasible, but more urgency is needed to complete the task”.6,7 transmission in the Indian states of and Reflecting this urgency, the World Health Assembly declared were regarded as a “stress test” of the technical feasibility of in May 2012 that the completion of polio eradication consti- polio eradication. Certain technical difficulties in achieving tuted a “programmatic emergency for global ”, high enough levels to halt poliovirus transmission and an appropriate Emergency Action Plan for 2012–2013 in the affected areas were observed. One was low was developed.8 immunogenicity. These problems had been exacerbated by

a The Wellcome Trust, 215 Euston Road, London, NW1 2BE, England. Correspondence to Dermot Maher (e-mail: [email protected]). (Submitted: 20 August 2012 – Revised version received: 3 December 2012 – Accepted: 6 December 2012 – Published online: 24 January 2013 )

Bull World Health Organ 2013;91:283–289 | doi:10.2471/BLT.12.111831 283 Policy & practice Human qualities for global polio eradication Dermot Maher

Table 1. Key elements of the global strategy for polio eradication, 1994 campaigns of supplementary immuniza- tion activities with exceptionally high Element Details coverage. Although the aim in Africa is also to achieve high coverage with Improved Population immunity against is optimized by ensuring that as routine many children as possible receive the recommended three or four doses of supplementary activities, immunization as early as possible in infancy. these will have to be run over relatively Supplemental Pools of susceptible children accumulate. Such children were either not few campaigns and a relatively wide mass reached by routine immunization or did not develop adequate immunity area to decrease the risk of recurrent immunization despite receiving the recommended three or four routine doses. The outbreaks following importation of po- prevention of polio outbreaks depends on delivering multiple supplemental liovirus into previously polio-free areas. doses of polio vaccine each year through supplementary immunization In some settings, particular popula- activities, such as national immunization days and large-scale house-to- tion subgroups and communities – e.g. house “mop-up” campaigns. nomads, migrant labourers and other Poliovirus Nationwide surveillance for acute flaccid paralysis involves the reporting surveillance and virological investigation of all cases in children. Surveillance provides highly mobile groups of people, those information for programmatic action through early identification of with relatively poor access to public outbreaks, assessment of programme effectiveness and guidance of services and those (often minorities) eradication efforts. who otherwise make scant use of pub- Outbreak- An effective outbreak response requires adequate public health lic services – play an important role in response infrastructures, logistics and vaccine supply in each country, coordinated sustaining polio transmission. In discus- capacity globally by the WHO. sion with relevant local leaders, tailored WHO, World Health Organization. approaches have been developed, for Source: Hull et al. 10. implementation by special polio-erad- ication teams, to address the special Table 2. Key lessons learnt from the Global Polio Eradication Initiative and tactical needs of such groups. The implications, 1998–2008 of travellers at crossing points between polio-endemic and polio-free countries, Key lessons What is different in 2010–2012? and on the border between the polio- endemic countries of Afghanistan and Immunity thresholds needed to stop Oral vaccine campaign and monitoring strategy polio differ geographically, being tailored to local circumstances in different countries. Pakistan, is a useful approach. higher in Asia than in Africa. The GPEI has shown tactical aware- Immunity gaps allow virus to persist District-specific plans and capacity ness by recently taking on board the in smaller areas and subgroups than Special tactics for underserved populations lessons learnt through more than 20 thought. Independent monitoring of campaigns years of experience in strategic planning. Routes of poliovirus spread Immunization systems strengthening For example, the GPEI’s Strategic Plan and outbreaks are now largely New outbreak response standards for 2010–2012 reflects four key lessons learnt (Table 2), each with a specific predictable. Preplanned, synchronized campaigns tactical implication.5 Optimizing the balance of the Use of bivalent of types 1 and 3 monovalent oral vaccines is much Balancing supplementary immunization activities more difficult than anticipated. involving monovalent, bivalent and/or trivalent Interrupting transmission vaccines The stakeholders’ determination to Source: Global Polio Eradication Initiative5. overcome operational barriers to the interruption of poliovirus transmission behaviours and conditions that dramati- siderable inter-country variation in the is complemented by key human qualities cally enhanced the local populations’ progress made towards polio eradication that are relevant to each of the technical, vulnerability to poliovirus infection, is that the level of population immunity managerial and security challenges iden- such as indiscriminate defecation, con- needed to halt the transmission of wild tified during the independent evaluation taminated water supplies, high popula- poliovirus can differ substantially be- conducted in 20094 in the then-endemic tion densities, malnutrition, unclean tween geographical areas. The GPEI’s areas in northern India and northern supplementary infant feeds, high birth Strategic Plan for 2010–2012 reflected Nigeria and on the Afghanistan–Paki- rates and inter-birth intervals of less the observation that, to stop local trans- stan border (Table 3). than 1 year.4 Despite all of these condi- mission of poliovirus, the percentage tions, India was declared polio-free in of the population that needs to have Technical challenges February 2012; this provided definitive poliovirus-specific immunity is higher Need for more research evidence of the technical feasibility of in Asia (> 95%) than in sub-Saharan polio eradication.12 Africa (80–85%).5 Eradication efforts The success of global polio eradication Within the overall strategy, tactical in Asia are currently focused on the hinges on innovation for several reasons. awareness is needed to harness the full few districts and subdistricts where First, when adapting an older strategy, benefits of an improved understanding transmission, though highly localized, such as that developed in the Americas of the relationship between population persists. The aim is to achieve the high in the 1990s, for current use in other immunity and interruption of poliovirus immunity thresholds needed to halt settings, not all of the obstacles that may transmission. One reason for the con- transmission in Asia through frequent be encountered can be anticipated. An

284 Bull World Health Organ 2013;91:283–289 | doi:10.2471/BLT.12.111831 Policy & practice Dermot Maher Human qualities for global polio eradication

vaccinated, and the optimal utilization Table 3. Main challenges to the interruption of poliovirus transmission, 2009 of new oral and con- structs. In the eradication of polio from Category Challenges the areas of persistent transmission in Technical Need for more research on immunological basis of multiple , ages of Asia, a key research challenge is to im- children to be vaccinated, and optimal use of new oral and inactivated vaccine prove vaccine effectiveness and reduce constructs the thresholds of population immunity Too little attention paid to post-eradication strategies that may ultimately required to stop poliovirus circulation. determine the success of the GPEI Operational research to improve pro- Managerial Low levels of routine immunization, with inadequate collaboration between gramme performance should be tailored GPEI and the Extended Programme on Immunization to the specific challenges of each remain- Inadequate commitment and deployment of resources at local, grass-roots level ing endemic area (e.g. improving lot Little GPEI authority or control over poorly-performing local programmes, and quality assurance sampling in Nigeria) complicated GPEI administrative structure globally and within countries and the resolution of key eradication Disparities in country support by GPEI issues such as the use of short-interval Security Need to develop programme capacity to adapt tactics to operate with sufficient additional doses of oral vaccine for safety in conflict-affected areas and reach target groups outbreak response.4 Improvements in GPEI, Global Polio Eradication Initiative. the GPEI’s capacity for social science 4 Source: Global Polio Eradication Initiative . research could help to obviate the prob- lems arising from unfounded fears over example of such an unexpected obstacle From its base at WHO’s headquarters vaccine safety, particularly the persistent is the relatively low efficacy of oral polio in Geneva, a dedicated GPEI research myths, rumours and misconceptions in vaccine observed in northern India.13 and product development team has Nigeria and Pakistan that contribute This obstacle was, however, successfully successfully coordinated the network to vaccine refusal.4 Further focus on overcome by an innovation: the develop- of vaccine manufacturers, academic practical programmatic research is ment of a new bivalent vaccine. Second, research institutions, not-for-profit re- needed to improve the quality of vaccine the decades needed to achieve eradica- search groups, public health laboratories campaigns and surveillance. Although tion provide time for important devel- and regulatory agencies worldwide that we may have the data that show where opments in, for example, diagnostics, has facilitated the development, testing vaccination coverage is poor, we still vaccinology and cold-chain technology and licensing of new vaccines, diagnos- need to understand why coverage is that can enhance programme effective- tics and related technologies, as well as poor in certain areas and to identify and ness and reduce costs. Third, potentially operational research. implement effective solutions.7 important aspects of the or its The importance of fast-track vac- Post-eradication strategies control that were unrecognized at the cine development was shown by the outset of the eradication programme successive appearance of new vaccines The interruption of wild poliovirus trans- (e.g. vaccine-derived polioviruses) can aimed at enhancing the impact of each mission globally is not the end of polio, be investigated and identified as the immunization contact in areas of highly but it is the beginning of the end. Two programme progresses. In the late stages efficient poliovirus transmission. In important risks will need to be managed: of polio eradication, as the transmission the early 2000s, despite high vaccine the reintroduction of wild poliovirus and of wild poliovirus is interrupted, the coverage through a combination of the re-emergence of circulating vaccine- proportion of polio cases caused by cir- routine and supplementary immuniza- derived polioviruses. The success of culating vaccine-derived polioviruses is tion activities, transmission was being post-eradication strategies, like that of expected to increase.14 To try to resolve sustained in areas of Egypt and India the pre-eradication strategies, hinges this problem, the plan is to switch from where population densities were par- on innovation. In leading the GPEI’s trivalent oral vaccines to the bivalent ticularly high and sanitation was poor. programme of work on post-eradication vaccines that are more genetically stable. Monovalent oral polio vaccine of type 1 risk management, WHO is continuing its The use of all oral polio vaccines will be was found to confer substantial gains in multi-pronged programme of research, stopped once the transmission of wild immunity compared with the trivalent new product development, strategy poliovirus is interrupted. vaccine15 and, after fast-track develop- formulation and policy development.5 Since the GPEI’s inception, the ment, testing and licensing, was in use This programme has four main aims: key stakeholders have built the GPEI’s in Egypt and India by 2005. A similarly (i) to characterize in detail the primary capacity to pursue an active and wide- rapid response to the recent demonstra- risks that may threaten polio eradication ranging research agenda. For example, tion of good immunogenicity induced in the long term; (ii) to develop strate- the United States Centers for Disease by bivalent vaccines of types 1 and 316 gies for mitigating each of the long-term Control and Prevention have contrib- has resulted in rapid deployment of such risks; (iii) to establish the mechanisms uted epidemiological and virological vaccines in the field. needed to coordinate these risk man- expertise, and the Bill & Melinda Gates In the late stages of polio eradica- agement strategies internationally; and Foundation and the Global Alliance tion, the GPEI will need to promote (iv) to develop new products to manage for Vaccines and Immunization have and support innovation to address the risks associated with a halt in the use financed several important research remaining problems and issues, such of oral polio vaccines. In 2013, WHO projects, particularly for the develop- as the immunological basis of multiple will finalize the Polio Eradication and ment and testing of new vaccines. vaccinations, the ages of children to be Endgame Strategic Plan for 2013–2018.

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Managerial challenges from Nigeria and the consequent rein- Commitment of resources Levels of routine immunization fection of 18 countries (directly or via another country) by mid-2005.18 Little Those involved in GPEI at all levels, Global eradication of any disease that progress appeared to be made in Afghani- from global to local, must show articula- crosses national borders requires inter- stan, India, Nigeria or Pakistan between cy in advocating for the full deployment national collaboration. The solidarity 2004 and 2008, and 11 new outbreaks of of the required resources at the local, between nations that has permitted tre- polio occurred in 2010.19 These setbacks grass-roots level. Operational barriers mendous progress to be made towards proved a test of both the stakeholders’ at the grass-roots level can only be over- polio eradication must be reinforced energy and their enthusiasm. come if the GPEI’s stakeholders fulfil in the late stages of eradication and Although transmission of wild their financing commitments, which the post-polio era.17 Such solidarity poliovirus had not been interrupted include the filling of the GPEI’s budget is a common strand running through globally by the initial target date of 2000, shortfall for 2012–2013 – estimated to several health initiatives, including the the substantial progress made initially be 700 million United States dollars Expanded Programme on Immuniza- in implementing strategies and reduc- (US$) – by increasing domestic and in- tion. In the independent evaluation ing the number of countries with polio ternational funding.20 At the global level, that was conducted in 2009, low lev- endemicity reinvigorated eradication the justification for further financing is els of routine immunization – which efforts. However, any prolonged eradi- sound, as failure to achieve the GPEI’s were partially attributed to inadequate cation effort runs the risk of fatigue at ultimate goal would have significant and collaboration between GPEI and the international and national levels. At the adverse humanitarian and economic Expanded Programme on Immuniza- local level, community and health staff consequences. If the GPEI’s activities tion – were identified as one of the fatigue may be worsened by difficulties had to be halted early, hundreds of main challenges to the successful inter- in the efficient delivery of routine GPEI thousands of children would be para- ruption of poliovirus transmission.4 By and other immunization activities in lysed for life by polio within a decade exploiting all of the opportunities for dangerous environments, the often high and billions of dollars would have to collaboration between the GPEI and the frequency of supplemental activities, be spent on outbreak response activi- Expanded Programme on Immuniza- and the proliferation of vertical donor ties, the rehabilitation and treatment of tion, it should be possible to improve initiatives that directly or indirectly af- polio cases, and the associated loss of the performance of both initiatives. fect .4 Fatigue often leads economic productivity. The incremental Such collaboration will be essential in to poor campaigns and then to a vicious net benefits of achieving global polio the polio “endgame strategy” and also in circle of lack of progress and waning eradication, aggregated over the period the post-eradication era, when reliance confidence. In contrast, the energy 1988–2035, have been estimated at no on inactivated polio vaccine will make and enthusiasm arising from positive less than US$ 42 billion.21 Successful house-to-house supplementary immu- developments, such as the declaration eradication will ensure that the 21-year nization activities more difficult. Careful that India was polio-free in February financial investment made so far will be consideration of the merging or overlap- 2012, can promote a virtuous circle that protected in perpetuity. ping of the initiative with the encourages further progress and the At the national level, GPEI’s ad- final and post-eradication phases of the confidence to overcome any remaining vocacy efforts have often focused on GPEI might identify potential gains in barriers to eradication. engaging national and subnational efficiency for both initiatives. The human quality of realism en- leaders, especially in countries with Following the GPEI’s launch in ables the translation of what is feasible weak health systems. Such efforts help 1988, energy and enthusiasm were ini- in theory into what is achievable in the GPEI to obtain access to the mul- tially maintained by the dramatic early practice. It was the successful adaptation tisectoral (e.g. human, transport and successes achieved in those parts of the and implementation of the GPEI’s main communications) resources that it needs world where polio eradication efforts strategy in the WHO’s Western Pacific to meet the logistical challenges it faces were rapidly scaled up. In these areas, Region that convinced many decision- in running rapid and widespread polio the mean time from strategy initiation makers of the “operational” feasibility of vaccination campaigns. By focusing to the interruption of the transmission polio eradication. However, a key lesson political engagement on the national of indigenous wild poliovirus was only arising from the late stages of the GPEI leaders of countries in which political 2 to 3 years. The few areas of the world is that proof of technical feasibility in power is highly centralized, account- where polio remained endemic by the one setting does not necessarily equate ability for the progress of the vaccination mid-2000s were the exceptions to this to operational feasibility in all settings. campaign and the resources used can rapid progress. There were serious set- Evidence of the technical feasibility of often be promoted. In large federated backs in subsequent efforts to eradicate a particular eradication strategy in any republics (e.g. India, Nigeria and Paki- polio from the endemic areas of southern area does, however, provide the basis for stan), however, the subnational leaders Afghanistan, northern India, northern realistic application and adaptation of who control resources at the regional Nigeria and Pakistan, as well as from the that strategy to the conditions in differ- level also have to be important targets of nearby countries where transmission was ent settings. In the final drive towards the GPEI’s advocacy. Such subnational re-established. For example, the suspen- global polio eradication, such tailored leaders may ultimately control the fate of sion of polio vaccination in Kano state in approaches will be needed in polio- a global eradication effort, as famously northern Nigeria in 2003 was followed endemic areas and any countries where demonstrated by the prolonged suspen- by the international spread of poliovirus poliovirus transmission reappears. sion of polio vaccination by the leaders

286 Bull World Health Organ 2013;91:283–289 | doi:10.2471/BLT.12.111831 Policy & practice Dermot Maher Human qualities for global polio eradication of Kano state in northern Nigeria in 22 Box 1. The needs identified by the Global Polio Eradication Initiative in conflict-affected 2003. In the early phases of the GPEI, or insecure areas, 2012 ’s establishment of National PolioPlus Committees in most • Support the key humanitarian “actors” (e.g. Red Cross and Red Crescent) who can provide poliovirus-infected countries greatly invaluable assistance in negotiating access and vetting potential local collaborators. Recruit individuals with expertise in conflict, political mapping, and associated skills facilitated the GPEI’s efforts to establish strategies, advocates and processes to ac- • Build the capacity to support teams and workers in conflict-affected areas cess and engage subnational leaders. In • Identify and engage non-traditional partners and decision-makers the late stages of polio eradication – as • Refine tactics (e.g. “Days of Tranquillity”, “access negotiators” and use of oral polio vaccines the impact of polio becomes less visible in “short interval additional dose” campaigns) and technologies (e.g. hand-held jet injectors and concern over vaccine-related polio for administering vaccines) to facilitate immunization grows – it will become harder for local • Develop local administrative processes to contract services and move resources community members involved in mobi- lization and immunization to articulate convincing reasons for the immuniza- Disparities in country support the development of site-specific tactics tion of each child. that allow health personnel to reach Fast-changing epidemiology and cash target groups safely. The current chal- GPEI’s authority and control flows often require nimbleness in the lenges in southern Afghanistan and the reallocation of funds. Responding Openness and accountability at all levels federally administered tribal areas of to resource constraints, the GPEI of the GPEI will promote effective and Pakistan are considerably different from has developed new mechanisms to efficient performance. At the national those previously addressed in countries evaluate and prioritize activities for level, GPEI has had little authority or such as the Democratic Republic of maximum effect. Financial tracking control over those local implementing the Congo and .24 In practice, allows identification of weaknesses entities that are performing poorly. This success in eradicating polio from one and disparities in country support, has been a huge constraint on progress.4 conflict-affected or insecure area does such as the inadequate funding given Greater openness on the part of nation- not “prove” the overall operational to some countries where transmission al and subnational authorities would feasibility of the global task, but it does had been re-established, such as put the spotlight on areas in which provide invaluable experience to take in 2009 and South in 2008.4 A the quality of eradication activities is to the next such area (Box 1). Given nimble reaction to outbreaks can limit currently insufficient to interrupt polio- appropriate attention and investments, their spread and decrease the risk of virus transmission. This would enable adaptability can overcome the barriers re-establishment of poliovirus circula- collaborating partners to concentrate to polio eradication posed by conflict. tion. GPEI is developing a two-pronged extra resources and enhanced technical In the context of the Emergency Ac- approach to enhance the speed, qual- assistance where they are most needed. tion Plan for 2012–2013, the GPEI’s ity and impact of outbreak response The Independent Monitoring Board Independent Monitoring Board has activities for both wild poliovirus and already monitors the progress of the recognized the effectiveness of, for ex- circulating vaccine-derived poliovi- Strategic Plan for 2010–2012 against ample, Afghanistan’s polio eradication ruses. There will be closer international major milestones and process indica- programme’s adaptability and ingenuity monitoring of response activities to tors and advises countries and partner in gaining access to children eligible for manage risks associated with new polio agencies on any corrective actions that vaccination in the face of considerable outbreaks, and new, international, out- are needed.23 Independent quarterly security challenges. break response guidelines informed by assessment of indicators of programme the results of pilot studies, operational performance for each polio-infected research and clinical trials.4 Conclusion country will enable prompt remedial action wherever underperformance is Security challenges Attention to the key human qualities identified. In treating polio eradica- Programme adaptability needed for success is as important for tion as a global health emergency, the polio eradication as it was for Independent Monitoring Board pres- The solving of operational problems eradication.25 The global eradication of ents its reports “frankly, objectively, requires both adaptability and learn- polio depends on increasing herd im- and without fear or favour”.7 Evidence ing from experience. Myths need to munity, through mass vaccination, to of the Board’s frankness can be seen be overcome, the standard of outbreak counterbalance the factors that favour in its recommendation that “Pakistan response needs to be improved, and persistent poliovirus transmission and should fundamentally rethink its na- children in conflict-affected or insecure the vulnerability of a population to tional emergency plan, focusing on areas need to be vaccinated. Insecurity poliovirus (i.e. poverty, overcrowd- what can be done to enhance meaning- and conflict pose difficult challenges to ing, conflict, political instability, low ful accountability”.7 Openness on the operational feasibility. Although adults levels of education and sanitation and part of the GPEI’s senior management in conflict-affected areas are often very high fertility). To tilt the balance and is a requirement for the consultation keen to improve their children’s future stop poliovirus transmission, various and decision-making needed for the and can be readily engaged in the de- human qualities need to be enhanced, GPEI to streamline its administrative livery of basic health services, they are highlighted, invigorated and intensi- structure, and to promote effective and often also very difficult to reach. The fied. These human qualities, which efficient performance. complexity of conflict may necessitate can be remembered as the acronym

Bull World Health Organ 2013;91:283–289 | doi:10.2471/BLT.12.111831 287 Policy & practice Human qualities for global polio eradication Dermot Maher

ERADICATION, are energy, realism, polio eradication. The only alternative Acknowledgements articulacy, determination, imagination, to polio eradication is the indefinite I am grateful to staff of the WHO’s Polio collaboration, adaptability, tactical application of measures to limit the Eradication team for fruitful discussions awareness, innovation, openness and spread of, and harm caused by, polio, that informed this paper and critical nimbleness. Advocates, whether at the with indefinite costs incurred in both review of the manuscript. The views ex- global, national or local level, can use human and economic terms. A lack of pressed by the author are not necessarily ERADICATION as a rallying call in determination will consign the goal of those of the Wellcome Trust. their identification and promotion of global polio eradication to the fate of the qualities needed to achieve global Tantalus. 26 ■ Competing interests: None declared.

ملخص الصفات البرشية الالزمة الستكامل استئصال شلل األطفال عىل الصعيد العاملي عىل الرغم من أن االنخفاض بنسبة 99 % الذي لوحظ يف معدل من ُناطي هبم مهمة مقاطعة رساية شلل األطفال. ومع ذلك، فإن اإلصابة بشلل األطفال عىل الصعيد العاملي يف الفرتة من عام 1988 استئصال شلل األطفال يعتمد كذلك عىل صفات برشية أقل إىل 2000 مثل ًتقدما ًملحوظا جتاه استئصال شلل األطفال، إال أن مادية، ولكنها عىل نفس القدر من األمهية، وهي الطاقة والواقعية مكافحة نسبة 1% األخرية من شلل األطفال أثبتت صعوبة بالغة. والفصاحة والتصميم والتخيل والتعاون والقابلية للتكيف وتستمر جيوب رساية هذا املرض املتوطن يف الوقت الراهن عىل والوعي التكتيكي واالبتكار والرصاحة والفطنة )معاين الكلامت احلدود بني أفغانستان وباكستان ويف شامل نيجرييا. وقد سمحت التي تشكل أحرفها األوىل كلمة “ERADICATION” هذهاجليوب بإصابة بلدان كانت خالية من شلل األطفال يف باإلنجليزية(. وعن طريق إيالء االهتامم هلذه الصفات البرشية، من السابق بالعدوى من جديد. وحددت اخلطط االسرتاتيجية العاملية األرجح أن يقوم أصحاب املصلحة املعنيني بإنجاز استئصال شلل الستئصال شلل األطفال األنشطة وامل��وارد والتمويل الالزم األطفال عىل الصعيد العاملي. للتغلب عىل التحديات اإلدارية والتقنية واألمنية التي تواجه

摘要 实现脊髓灰质炎全球根除所需的人文素质 尽管在1988 年和2000 年间，全球脊髓灰质炎发病率减 病毒传播重任的人们克服所面临的管理、技术和安全方面 少99%，表明根除脊髓灰质炎工作取得了显著进步，但 的挑战。然而，根除脊髓灰质炎还依赖于虽然无形但同样 是经证明，消灭最后1%的脊髓灰质炎非常困难。目前， 重要的人文素质：精力、现实主义、表达能力、决心、想 在阿富汗和巴基斯坦的边界和尼日利亚北部都存在小片的 象力、协作、适应性、战术意识、创新、开放和灵活度（ 地方性传播。这些小块地区已经引起之前没有无脊髓灰质 这些词语的英语首字母缩写为“ERADICATION”）。通过 炎国家的二次感染。脊髓灰质炎全球根除战略计划设定必 关注这些人文素质，利益相关方可能会更容易实现脊髓灰 要的活动、资源和资金筹措，以帮助肩负切断脊髓灰质炎 质炎的全球根除目标。

Résumé Qualités humaines nécessaires pour achever l’éradication mondiale de la poliomyélite Même si la diminution de 99% de l’incidence mondiale de poliomyélite et de sécurité que doivent relever les personnes chargées d’eradiquer la entre 1988 et 2000 a représenté un remarquable progrès vers l’éradication transmission du virus de la polio. Cependant, l’éradication de la maladie de la maladie, s’attaquer au dernier 1% de la polio s’est avéré terriblement dépend aussi de qualités humaines moins tangibles, mais tout aussi difficile. Des poches de transmission endémique persistent actuellement importantes, qui sont l’énergie, le réalisme, la faculté d’expression, la à la frontière entre l’Afghanistan et le Pakistan et au nord du Nigeria. Ces détermination, l’imagination, la collaboration, l’adaptabilité, le sens poches ont permis la réinfection des pays qui ne présentaient auparavant tactique, l’innovation, la sincérité et la vivacité (dont les lettres initiales plus aucun cas de poliomyélite. Les plans stratégiques mondiaux pour en anglais donnent l’acronyme «ERADICATION»). En prêtant attention l’éradication de la poliomyélite ont établi les activités, les ressources et le à ces qualités humaines, les parties prenantes pourront probablement financement nécessaires pour surmonter les défis techniques, de gestion réussir à éradiquer la poliomyélite à l’échelle mondiale.

Резюме Человеческие качества, необходимые для достижения цели избавления от полиомиелита в глобальном масштабе Несмотря на 99%-ное снижение уровня глобальной эндемической передачи в настоящее время сохраняются как заболеваемости полиомиелитом в течение 1988-2000 гг., на границе между Афганистаном и Пакистаном, так и на севере что является значительным прогрессом в деле ликвидации Нигерии. Именно они привели к повторному инфицированию полиомиелита, борьба с последним 1% заболеваемости стран, в которых ранее отсутствовал полиомиелит. Глобальные полиомиелитом оказалась мучительно трудной. Источники стратегические планы по ликвидации полиомиелита содержат

288 Bull World Health Organ 2013;91:283–289 | doi:10.2471/BLT.12.111831 Policy & practice Dermot Maher Human qualities for global polio eradication

описание мероприятий, ресурсов и финансирования, решительности, воображения, сотрудничества, способности необходимых для преодоления управленческих, технических к адаптации, понимания тактики, восприятия инноваций, трудностей и проблем безопасности, с которыми сталкиваются открытости и быстроты действий (начальные буквы этих специалисты, выполняющие задачу по предотвращению слов на английском языке образуют слово «ERADICATION» передачи полиовируса. Тем не менее, ликвидация полиомиелита (ЛИКВИДАЦИЯ). Уделяя внимание этим человеческим качествам, зависит также и от менее осязаемых, но столь же важных заинтересованные стороны смогут с большей вероятностью человеческих качеств: активности, реализма, убедительности, достичь цели глобальной ликвидации полиомиелита.

Resumen Las cualidades humanas necesarias para lograr la erradicación global de la poliomielitis Aunque la disminución del 99% en la incidencia de la poliomielitis a nivel las personas cuya tarea es interrumpir la transmisión del poliovirus. global observada entre 1988 y 2000 representó un progreso notable No obstante, la erradicación de la poliomielitis también depende de hacia la erradicación de dicha enfermedad, hacer frente al último 1% cualidades humanas, menos palpables pero igual de importantes, como ha resultado terriblemente difícil. En la actualidad persisten enclaves de la energía, el realismo, la capacidad de expresión, la determinación y la transmisión endémica en la frontera entre Afganistán y Pakistán y en el imaginación, la colaboración, la flexibilidad, los conocimientos tácticos, norte de Nigeria. Dichos enclaves han permitido que países que ya se la innovación, la franqueza y la agilidad (en inglés, las iniciales de estas habían librado de la enfermedad se hayan vuelto a infectar. Los planes palabras dan lugar a las siglas ERADICATION, erradicación en español). Si estratégicos globales para la erradicación de la poliomielitis establecen se presta atención a dichas cualidades humanas, las partes interesadas las actividades, los recursos y la financiación necesarios para vencer los implicadas podrían tener más posibilidades de lograr la erradicación retos administrativos, técnicos y de seguridad a los que hacen frente global de la poliomielitis.

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