News Focus

Years of effort and billions of dollars have driven to just a few impoverished corners of the world. The campaign is intensifying, but the virus is tenaciously resisting Polio: The Final Assault?

WASHINGTON,D.C., ATLANTA, AND DELHI—As in India, Pakistan, and Nigeria—the two had virus fighters well and say that the odds are he wrapped up his PowerPoint presentation, come to vet an aggressive new plan to wipe now as good as they get—and that this may fielded questions, and readied his papers for a out the disease by 2005. And this time, they also be the last, best chance. quick departure, Bruce Aylward sneaked one stressed, no halfway measures would suffice: last peek at his e-mail. “Bingo,” he said, They were going to “whack” the virus with Uphill battle pushing back his glasses and rubbing his per- everything they had. As devastating as it is, the Nigeria outbreak petually jet-lagged eyes. “We just got a con- Two days later, Aylward and Heymann is by no means the worst setback for the core firmed case in Togo.” David Heymann, flew into the Nigerian capital of Abuja in an partners in the eradication campaign: WHO, Aylward’s new boss and newly appointed czar attempt to stanch the hemorrhage in the CDC, Rotary International, and UNICEF. In- for at the World Health Or- northern state of Kano. Within days, national deed, when WHO and its partners set out in ganization (WHO), greeted the news with a governments, the United Nations Children’s 1988 to eradicate the disease by 2000, they single word: “meltdown.” And with that the Fund (UNICEF), and WHO announced a had no idea how tough it would be. Only one two closed up their laptops, grabbed their $10 million emergency campaign to vaccinate other disease has ever been eradicated— backpacks, and rushed out in the pouring rain all children under age 5 in the adjoining coun- smallpox, with the last case seen in 1977— to catch their flight home to Geneva. tries that were now at risk. Essentially, they and, by comparison, that campaign was a The e-mail confirmed their worst fears. would cordon off the disease in Nigeria— breeze, says Henderson, who led that effort. Fueled by rumors about tampered vaccines where the number of cases has now soared to For starters, the logistics have been unprece- and a general distrust of things Western, the at least 355 (almost half the worldwide total dented. Polio eradication entails, theoretically at poliovirus had staged a comeback in Nigeria in 2003) and eight neighboring countries least, administering two drops of oral vaccine —racing through the sparse and largely have been reinfected—and lay the ground- to every single child in every remote, even Muslim population in the northern states work for an all-out vaccination assault once war-torn, corner of the world at least twice a and reinfecting the southern megacity of the political situation cooled down. year until the disease disappeared. Moreover, Lagos. And now, Aylward’s e-mail con- Since then, the two have been largely air- even after a country is declared polio-free, firmed, the virus had leaped across the bor- borne, flying from one trouble spot to the it must continue vaccinating until the virus is der into yet another country that had been next to put out brushfires or generally rally wiped out everywhere, to guard against re- polio-free for years. the troops to meet their target: Stop trans- introduction. The challenge has consumed Aylward and Heymann had spent that mission of wild poliovirus in 2004 or per- more than $3 billion and involved some 20 rain-soaked September day last year in a re- haps the early months of 2005. After years million volunteers over the past 15 years, as treat with colleagues from the U.S. Centers of slipping deadlines and expanding budg- naysayers have questioned whether the goal is for Disease Control and Prevention (CDC) in ets, that goal is lauded even by longtime worth the cost or even feasible. Atlanta, Georgia. With the poliovirus cor- skeptics such as Donald A. Henderson of the If the logistics were not daunting enough, nered in just seven countries and hunkered University of Pittsburgh’s Center for Bio- just as the program was finally gathering

down in five key hot spots of transmission— security. Henderson and others wish the steam in the early 2000s, it was dealt three CREDIT:WHO

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gut-wrenching blows that added fresh com- Caused by an enterovirus that enters personnel to administer it. And, like the wild plications. The first was the 2000–01 polio through the mouth and multiplies in the poliovirus, the live vaccine virus sets up shop outbreak in the Caribbean, which made throat and gut, polio is easily spread through in the gut and is excreted in stool several starkly clear what experts had suspected: The fecal contamination. Fewer than 1% of in- weeks after administration. So even unvacci- live virus used to produce the vaccine can, in fections result in paralysis (that occurs only nated children were likely to receive the pro- rare circumstances, not only revert to a viru- when the virus invades the nervous system), tective virus through “passive” lent form but also trigger an outbreak. In but even asymptomatic carriers shed the as it spread among family members. Sabin short, the only tool effective at wiping out virus in their stool and are able to transmit postulated that if the vaccine were adminis- the disease might also perpetuate it. the disease for weeks. tered in massive campaigns to virtually all Into this complex brew came 11 Septem- With the 1955 introduction of Jonas children within a few days, transmission ber, which changed forever the concept of Salk’s injectable vaccine, made from a killed within a region would stop, as the wild virus disease eradication. Until then, the sine qua virus, and then in 1961 Albert Sabin’s oral would have no susceptible population in non of any eradication effort was to stop vaccine, made from a live but weakened which to hide. vaccinating, reap the financial windfall, and virus, polio all but disappeared from Cuba’s Fidel Castro was the first head of most likely destroy the virus itself. But now, wealthy countries, except for the occasional state to buy into the vision, instituting so- with the threat of bioterrorism looming importation. (Both vaccines can confer life- called National Immunization Days twice a large, it’s no longer clear if countries will long immunity.) year in 1962 and soon ridding Cuba of the ever stop vaccinating. Polio continued to exact a horrific toll in disease. In 1980, Brazil launched an all-out Aylward and the partners took a deep many developing countries, especially in the attack on polio, immunizing 20 million chil- breath, redefined and extended the deadline poorest areas, where again, and forged ahead, only to be hit with diarrhea was rampant a devastating outbreak in India in 2002. That and water and sanita- “dreadful” epidemic year, as Chris Maher, tion were lacking. who runs WHO country operations from WHO estimates that Geneva, describes it, was one of the lowest roughly 500,000 chil- points of the entire campaign. Donors were dren, and perhaps impatient, governments were fed up, and the many more, were para- troops both on the ground and in Geneva lyzed every year by po- were bone tired and disheartened. lio as late as 1980. But Then, in 2003, came two unexpected despite its prevalence, boosts. After its second major fundraising polio was less visible in campaign, Rotary International brought an these areas, lost against additional $100 million to the table. And Lee Jong-wook, an old polio hand from the West- ern Pacific, took over as head of WHO and immediately announced polio eradication as one of the agency’s two top priorities. He created a new position, special adviser on polio to the director general, and appointed Panic years. Polio epidemics swept through the Heymann to fill it. United States each summer in the early 1950s. An internationally acclaimed infectious- disease expert who cut his eyeteeth eradicat- dren in 1 day and inspiring Ciro de Quadros, ing smallpox and most recently had led the then a young epidemiologist and smallpox team against severe acute respiratory syn- veteran in charge of immunization for drome (SARS), Heymann brought a much- WHO’s regional office, the Pan American needed jolt of energy to the weary troops Health Organization (PAHO). “I thought and, most important, a willingness to make maybe we could do that in every country in bold decisions. “It is like the old days,” says the Americas,” recalls de Quadros. Aylward. “The excitement is back.” Although WHO officials were “very the backdrop of other devastating childhood skeptical,” says de Quadros, PAHO resolved A silent crippler diseases such as malaria, diarrhea, measles, in 1985 that it would rid the Americas of Throughout the 1940s and 1950s, polio was and tuberculosis. When the oral Sabin vac- polio by 1990. In El Salvador, Haiti, and one of the most feared diseases in the indus- cine, dubbed OPV, was introduced as part of Venezuela, PAHO officials honed the strate- trialized world. An insidious virus that can routine in developing coun- gy that would later become the mainstay of sweep silently through the population with- tries in the 1970s, numbers began a slow but the global eradication program. They estab- out being detected, polio caused crippling steady decline. lished a “cold chain” of refrigerators and ice epidemics every summer, affecting some From the outset, Sabin touted his oral chests to deliver polio vaccine to every cor- 21,000 children each year in the United vaccine as a tool for ridding entire regions, if ner of the continent—by truck, motorcycle, States alone in the early 1950s. In wealthy not the world, of polio. He later donated the horse, or on foot. They created a surveil- countries such as the United States, where vaccine to WHO. Compared to Salk’s in- lance system for rapid investigation of any many other childhood diseases were in de- jectable vaccine, Sabin’s oral formulation case of acute flaccid paralysis—a hallmark cline, polio stood out as particularly horrify- had several advantages, especially for devel- of several diseases, including polio—and a ing, leaving its young victims paralyzed or oping countries. It was cheap, was easily de- network of labs that could analyze stool

CREDIT: (RIGHT) WHO kept alive inside an iron lung. livered, and didn’t require trained medical samples from AFP cases for the presence of

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chasing a single disease, he and other skep- 8000 tics argued, when those funds could be used Total cases 7000 instead to boost routine immunization or oth- erwise improve child health? 6000 During those “sleepy” days in the early 1990s, as Aylward calls them, not much 5000 happened globally, and what did was at the 4000 instigation of countries such as China where the disease was rampant. The cam- 3000 paign in WHO’s Western Pacific Region, 1988 2000 which includes China, would prove to be a turning point. 1000 Compared to Latin America, the West- 0 ern Pacific Region was a messy, sprawling 1999 2000 2001 2002 2003 place, devastated by poverty and conflict and divided by myriad languages. Maher remembers the Mekong Delta as the The Noose Tightens toughest, and most inspiring, place he ever When the World Health Organization worked. When he went there in 1992, the and its partners set out to eradicate 2001 United Nations had just pulled out and the polio in 1988, the disease was endemic Khmer Rouge would remain active for in more than 125 countries, and some years. The WHO folks didn’t have much 350,000 children were paralyzed. By money or resources, and the climate, envi- 2001, the number of cases had dropped ronment, huge number of children, and to 483 in just 10 endemic countries. high traffic along the river all conspired to After a resurgence in 2002, when the keep poliovirus alive. disease remained localized in seven “And the psychological scars people countries but cases soared to 1918, bore,” recalls Maher, in that “everyone had a cases dropped again in 2003 to 748, member of their family killed, or their entire 2003 and the number of endemic countries family disrupted. Plus, they were so bloody was down to six. By 16 March 2004, poor. The amazing thing is despite all the nas- Endemic Nonendemic Polio-free just 32 cases had been confirmed. tiness and terrible trauma, we could find peo- ple interested in working and doing a good job. And they did it.” Under the guidance of Lee, at that time a 45-year-old physician and the virus. And they implemented vigorous sion,” recalls WHO’s Maher, an Australian bi- public health specialist who was head of the house-to-house “mop-up” vaccination cam- ologist who fought polio in the Western polio eradication initiative in the region, the paigns once a case was detected. (Because Pacific for 8 years before joining Aylward in team pulled it off in 6 years. polio can circulate silently, a single con- Geneva. “I can’t overstate the magnitude of In Cambodia, Maher was sometimes firmed case is treated as an outbreak.) The what we are trying to do. To wipe out a virus. helped out by a young Canadian physician last indigenous case in the Americas oc- It’s only been done once”—with smallpox. and epidemiologist fresh out of Johns Hop- curred in Junin, in northern Peru, in Septem- Moreover, “so many things about small- kins University: Bruce Aylward. With his ber 1991, involving a 3-year-old boy named pox were easier than Luis Fermín Tenorio. polio,” adds Hender- son, who questioned Early days the polio enterprise Lobbied hard by a small coterie of “eradica- from the get-go. “With tionists” such as de Quadros, Sabin, and Ro- smallpox, protection tary International, which Sabin had enlisted in comes with one dose of the fight in the mid-1980s, WHO member vaccine. And even a states resolved at the World Health Assembly villager can diagnose it. in 1988 to eradicate polio worldwide by 2000. And smallpox doesn’t At WHO headquarters in Geneva, how- spread all that readily.” ever, the reception was tepid at best. The Nor was polio as big agency was already confronting a huge list a problem, Henderson of health problems, many more severe than argues. “Has polio ever polio. And the new directive came with an been one of the major infinitesimal budget, just enough to support problems of the devel- one staff person. “WHO was told to eradi- oping world? No. One cate polio with one hand tied behind its in 200 gets it. And one back,” explains Aylward. in 2000 of those die. It Role model. Received skeptically at first, the Pan American Health Or- Moreover, it was by no means clear scien- doesn’t begin to touch ganization’s plan to eradicate polio in the Americas showed the world tifically that the goal was attainable. “It was measles or malaria.” So it could be done. Here, schoolchildren in Mexico City participate in im-

always a huge risk, never a foregone conclu- why pour money into munization activities circa 1986. SOURCE:CREDITS: BOTTOM) TO WHO; (TOP PAHO

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in 1997, the operation Hard lessons consisted of four peo- By 1999, polio cases had dropped about ple in Geneva and 70 98% to just 7000 worldwide. The campaign worldwide. By 2000, it knocked off the easy areas first in rapid suc- had grown to 50 in cession: Europe, the Pacific Rim, and large Geneva and 3000 parts of Africa. Other places—the Indian worldwide. “When I subcontinent, west and central Africa, and took over, it was clear the horn of Africa—proved much tougher. that we could never The differences remain puzzling. A range of eradicate polio by factors conspire to keep the virus alive, chief 2000. My goal was to among them poverty, population density, convince the world tropical climate, poor sanitation, political in- that it could be eradi- security (which makes any operation per- cated, period, and to ilous), and indifferent or minimal support get the world to com- from the local community. mit to 2005,” says Along the way, it became clear that the River of transmission. In the Mekong Delta region of Vietnam and Aylward. three to four doses of OPV that confer life- Cambodia, wracked by poverty and conflict, the poliovirus thrived in the “He was tremen- long immunity to most vaccine recipients in early 1990s, testing the mettle of Chris Maher (left) and his colleagues. dously hard-working, the United States and other “clean” environ- very talented, and kind ments would not suffice in poor tropical set- wiry build and mop of red hair, he looked of obsessed,” says Maher, who joined Ayl- tings. Perhaps it is the pervasive diarrhea, even younger than his 32 years, and he had ward in Geneva in 2000. Aylward could also which means that the vaccine flows right such impossible energy that he was soon be brusque and impatient. “Bruce’s natural through the children before it can take, but dubbed Tigger. Working as a consultant to instinct is full speed ahead and damn the tor- in most “low-hygiene” environments, at WHO, Aylward organized the first mass pedoes,” notes Maher. “He trod on a lot of least eight doses per child are needed. vaccination campaigns in Cambodia in 1994 feet.” Easily as driven as Aylward, blunt, and Equally puzzling, in some of the toughest and 1995. He moved on, but Maher stayed physically imposing—he’s seen the insides areas, transmission persisted even when the in the region until 2000, several years after of most hotel gyms across the globe— country managed to immunize 85% or 90% the last case—a 15-month-old girl named Maher has evolved over the years into Ayl- of the children, whereas in some parts of Mum Chanty in Cambodia’s Mekong Delta ward’s unofficial “han- region in March 1997—and just shy of the dler,” smoothing ruffled date the region was certified polio-free. feathers and bandaging Their success provided the proof of con- damaged toes. cept other regions needed. “The Americas During those early showed we could do it,” says Aylward. “But years, the somewhat un- Cambodia and the rest of Western Pacific wieldy core partnership showed we could do it without infrastructure.” was coalescing, with Momentum began to build around the WHO taking the lead idea of polio eradication. In 1995, for in- for overall technical di- stance, the European and eastern Mediter- rection and strategic ranean regions of WHO pulled off the first planning and CDC for synchronized vaccination campaign across vaccine supply, out- 18 countries, immunizing more than 56 mil- break investigations, lion youths. Aylward was often called in to and genetic fingerprint- jump-start a country’s campaign, darting ing of viral strains. from Cambodia to Europe, Turkey, Iraq, the UNICEF took care of “Stans,” and what was then Burma in the the on-the-ground logis- Obsessed. With his abundant energy and tenacity, Bruce Aylward, course of 6 or 7 years. tics of organizing mas- shown here immunizing a child in Angola in 2002, helped turn a sleepy But global coordination was lacking. sive campaigns and enterprise into the biggest public health project in the world. That began to change, says de Quadros, training and mobilizing when Lee was appointed head of immu- the vaccination teams. “And there was al- Africa it stopped with just 70% to 80% cov- nization programs in Geneva in 1994. He ways Rotary,” says Aylward, who lauds erage. “I think we will eradicate polio with- brought in Bjørn Melgaard, who in turn the group for its “tireless advocacy.” Over out really understanding how,” says Aylward. convinced Aylward to forsake his no- the decades, Rotary International has In some places, such as India, polio days madic lifestyle and move to headquarters contributed more than $500 million and were major celebrations. Schoolchildren in late 1997. A half-year later, Aylward countless volunteers. Throughout, the flocked to the booths to get their polio drops. was running the program and “making a partners have also been aided by a net- In others, such as Mogadishu, Somalia, the lot of noise,” says Maher. “He is not a work of national governments, non- vaccine had to be delivered during lulls in the shrinking violet.” governmental organizations, humanitarian shooting. “As you can imagine, polio is prob- Immediately, Aylward began building his organizations, international agencies, and ably not the most urgent priority in these team: experts in business, management, “some very big heroes,” such as the Unit- countries,” says Elias Durry, who heads polio communication—young people who could ed Nations Foundation and, more recently, and other immunization operations in Soma- match him in stamina, says Maher, at 44 the the Bill & Melinda Gates Foundation,

CREDITS:WHO oldest of the group. When Aylward arrived says Aylward. Continued on page 1966

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So, despite stepped-up regain its ability to move from person to MALI rounds and increasing sums person and cause an outbreak. Since then, NIGER of money thrown at it, polio outbreaks caused by “back mutants” of the remained stubbornly en- vaccine virus have been documented in the trenched in various corners Philippines, Madagascar, and Egypt—the of the world. As target dates last one recognized retrospectively. BURKINA CHAD F ASO slipped, the goal was re- “We now think it circulated for about defined—from certifying 7 years in Egypt in the late 1980s and early BENIN NIGERIA the world polio-free by 1990s,” says Paul Fine of the London School 2005 to having all the re- of Hygiene & Tropical Medicine, who has

OGO gions be in the process of studied the issue for WHO. (And there may GHANA T certification to stopping have been others, he adds, that went un- CENTRAL AFRICAN transmission of wild virus. detected in part because the viruses were not REPUBLIC CAMEROON The program was perpetu- routinely sequenced until very recently.) ally cash strapped; every These vaccine-derived outbreaks proved 2002 year, Aylward had to lobby fairly easy to stamp out with massive mop- for more money, trying to ups using OPV (28 children were paralyzed convince donors that just before the Hispaniola outbreak was con- MALI one more push would do it. tained in 2001). However, they illuminated NIGER an unsettling Catch-22. OPV was the only Triple whammy vaccine guaranteed to stamp out an out- BURKINA As the partners struggled to break. But because of the potential for back F ASO CHAD make that final push, the mutation, its use sowed the seeds for future campaign was dealt the outbreaks of vaccine-derived polio, unless BENIN three blows that threatened countries could be persuaded to continue NIGERIA its very survival. First came massive, costly campaigns when the disease the outbreak in Hispaniola, had all but disappeared. That’s unlikely, says

GHANA OGO an island shared by Haiti polio expert David Wood, coordinator for T CENTRAL and the Dominican Repub- quality assurance and safety of biologicals at AFRICAN REPUBLIC lic, in the summer of 2000. WHO. “Many countries are saying that once CAMEROON It was not immediately ob- wild polio is eradicated, it will be difficult vious that something was for them to spend part of their health dollar 2003 terribly amiss. Although the on a disease that doesn’t exist.” region had been polio-free The second hit came on 11 September Type 1 Type 3 for years, Hispaniola was 2001, when two jetliners crashed into the Breakout. Rumors about vaccine safety derailed vaccination activities ripe for an importation. twin towers of the World Trade Center in in Nigeria in 2003, and the disease exploded, reinfecting eight polio- Routine immunization had New York City. That event drove home many free countries and endangering the global eradication effort. fallen to an alarming 20% to unexamined vulnerabilities. “The whole idea 30%, says de Quadros, leav- that we could eradicate a disease and be done lia and south Sudan. Quality operations are ing a huge cohort of kids susceptible should with it, that is over [now],” says Walter Oren- key, he says, because “you can’t go in twice, the virus enter from an endemic country. stein, a polio veteran at CDC. “We should you can’t take your time.” In other conflict- But when Olen Kew of CDC and col- eradicate the word ‘eradication,’ ” declared ridden areas (for example, Afghanistan, An- leagues sequenced the viral DNA obtained Henderson at a meeting shortly thereafter. gola, and the Democratic Republic of the from stool samples of several of the affected Although poliovirus would not be an ef- Congo), the core partners, sometimes with children, they found that it was not an import- fective bioweapon, its potential for inciting help from the U.N. secretary general, bro- ed wild virus but a derivative of the Sabin terror was immediately clear. “We know kered cease-fires, known as “days of tranquil- strain used to make OPV ity,” so that children could be immunized. (Science, 12 April 2002, p. Progress was steady—by year-end 2000, 356). Judging from the polio cases dropped to about 3500—but frus- number of genetic muta- tratingly slow. Some problems arose when the tions, they surmised that vaccination teams were poorly trained or un- the virus had been circulat- supervised or simply not paid. And the entire ing in the largely unvacci- concept of disease eradication was mystifying nated population for at least to many communities, especially the poor 2 years before reverting and minority populations, for example, in In- and triggering an outbreak. dia and Cambodia. Mostly they didn’t under- Scientists had known stand why the “polio people” kept coming since the 1960s that in back when the government provided no other rare instances, the attenu- health services. “They had so many other ated Sabin strain could needs,” says Maher. “This fostered suspicion, regain its neurovirulence resentment, paranoia, … [the suspicion that] and cause disease. But ‘they must be up to no good. The vaccine this was the first evi- Cold chain. Some 20 million volunteers have helped deliver OPV,

must be dangerous.’ ” dence that it could also which must be kept cold, to remote corners of the world. SOURCE:CREDITS: BOTTOM) TO CDC;WHO (TOP

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what it was like in the 1950s when people campaigns in several polio-free countries Apathy hardened into resistance in July were afraid to go into swimming pools,” considered at high risk for an outbreak be- 2003, when several Muslim leaders began to says Orenstein. cause of their proximity to the reservoirs, protest that the vaccine was tainted with the Polio eradication had been sold to coun- large populations, and low levels of routine AIDS virus and sterility drugs, part of a U.S. tries on the premise that it would enable OPV coverage: Angola, Bangladesh, the plot to decimate the Muslim population. Re- them to stop immunization and devote Democratic Republic of the Congo, sponding to growing alarm, the Kano state scarce resources to other diseases. But after Ethiopia, Nepal, and Sudan. government cancelled the vaccination 9/11, it became clear that countries worried It was a risky decision that left much of rounds planned for 4 and 5 September. Wor- about bioterrorism were unlikely to leave the world vulnerable to a reintroduction, ex- ried that funds would be misused or wasted, their populations vulnerable to dangerous plains Aylward. But they had no choice. the European Union declined to pay for the agents—as even U.S. citizens now are vul- “Our financial partners are saying they planned national rounds in October and De- nerable to smallpox. That raised the unset- want the job done.” Adds Maher: “You can’t cember. Cases skyrocketed. tling prospect that rich countries that could go on protecting yourself everywhere; that Maher says the partners were resigned to afford inactivated polio vaccine (IPV)—less the likelihood that the virus would effective but unable to cause disease—would continue circulating in Nigeria and continue immunization, while the poor neighboring Niger throughout 2004 countries would be left vulnerable to polio. and possibly into 2005, but not to its To Fine, who favors universal IPV, such in- escape to neighboring countries. “We equities are “intolerable.” Others see them as did not anticipate losing ground in regrettable but inevitable. Nigeria. We didn’t anticipate that at The third blow came in a country where this late stage, we would be respond- the campaign had seemed on the verge of ing to a widespread outbreak again.” success: India. With just 200-odd cases in India in 2001, it looked as if the campaign A jolt of energy had finally cracked the deep-rooted reser- On 29 July 2003, just 8 days after he voir in Uttar Pradesh. But then in 2002, wild took office, Lee reiterated his vow to poliovirus exploded in India, starting in eradicate polio and appointed Hey- Uttar Pradesh and racing through the coun- mann as his special adviser. try. When the partners reanalyzed the data, Heymann brought a razor-sharp they realized that the problem was largely in mind, a sense of urgency, his trade- the minority Muslim community in Uttar mark decisiveness, and fresh tactics Pradesh (see p. 1964). from his fight against SARS. From The outbreak shook the partners and now on, he declared, each new case donors to the core, raising doubts that they of polio would be treated as an inter- would ever pull it off. “The wheels fell off national public health emergency. the trolley,” says Maher. “We took a long Heymann’s “just do it” approach step back in 2002.” was evident in spades in Atlanta in “We were so close, and we botched it,” September, where he and Aylward says Aylward. “We got complacent. We let met with CDC and UNICEF officials down our guard.” Polio czar. David Heymann learned about disease eradi- for a strategy session. Over the objec- Reeling from these blows and even more cation in India during the smallpox campaign in the tions of some of the CDC polio veter- strapped for cash, the partners made a con- 1970s; in 2003 he turned his sights on polio. ans, Heymann insisted they could scious and some say overdue decision in wipe out wild transmission in 2004— April 2003 to focus their resources on India is not an eradication strategy. We spent a lot if they were bold enough. The window of op- and the remaining endemic countries. Polio of money on the global effort, and we need portunity was narrow, and time was short: If was now cornered in just seven countries; to concentrate on finishing.” they didn’t halt transmission soon, polio three major reservoirs in India, Pakistan, and would break out again and reinfect countries Nigeria accounted for 95% of the cases. And Breakdown in Nigeria that were now vulnerable because they had within those three countries, transmission That vulnerability became all too apparent a stopped mass campaigns, as was already oc- was restricted to five major hot spots that couple of months later in Nigeria. Vaccina- curring in west Africa. “There isn’t time to accounted for 75% of the global total. tion teams had scoured the country earlier, make a perfect program now,” said Heymann. The problem was that, although the virus wiping out polio even in the sprawling city “Just whack it.” was on the run, it had retreated to the worst of Lagos, which posed the biggest chal- Another example of how Heymann is corners of the world—poor, crowded, chaot- lenge. But even before the rumors started, pushing the envelope is the bombshell ic, unsanitary places where it could really the quality of the vaccination campaigns in buried in an otherwise bureaucratic docu- hunker down, notes Stephen Cochi of CDC. the north were lapsing. “In some parts of the ment, the global polio eradication strategic The partners stopped mass campaigns in north, there is a sense that this is a program plan for 2004–08. For years, the partners some 100 polio-free countries, enabling that comes from the outside,” explains Ma- had been agonizing over whether and how to them to redeploy forces to the endemic areas, her. “They don’t necessarily buy into the stop immunizing after the world was certi- which they planned to blast with repeated idea that this is a good thing they are doing fied polio-free (see p. 1969). Once Hey- rounds of immunization. At the same time, on their own.” Vaccinators often did not mann came on board, they made a remark- they would try to guard their flanks by step- show up, and those who did often weren’t ably fast decision. In a final draft, the fuzzy ping up surveillance in the polio-free re- paid. They were reaching less than 50% of language of earlier versions about “develop-

CREDIT:WHO gions. And they would continue national the children, creating a tinderbox. ing post eradication vaccination policy” was

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replaced with the simple words “stopping Nigeria and five other endemic countries Meanwhile, as the partners are waiting OPV.” Says Aylward: “That was David (Somalia had then gone a year without a out the political storm, Maher will be spend- [Heymann]. We knew the decision, but we case) flew to Geneva and reconfirmed their ing much of the next few months on the needed someone with his credibility to say it commitment to stopping transmission of ground in Nigeria, reevaluating everything was the right decision.” wild poliovirus in 2004—and risking pub- from the composition of the vaccination The year 2004 will see the most aggressive lic humiliation if they don’t. “We offered teams to how WHO and UNICEF divvy up push yet in the remaining reservoirs and at- them 2005,” said Heymann at a press con- tasks, so they can deliver the best possible risk countries. With full backing of the Indian ference. “And they all said they wanted to rounds when they finally get the chance. government, the partners are attacking the in- do it in 2004.” Transmission in Nigeria seems likely to tractable reservoir in western Uttar Pradesh Egypt may be first, then with relentless, repeated rounds to immunize India, then Pakistan. “Once every child—or at least 90%. Because of its India finishes, with God’s astronomical birth rate, there is a concerted ef- grace in 2004, the political fort to reach all newborns, who present a huge pressure will be immense,” susceptible cohort every month. says Maher. “Then Pak- In Pakistan—where worrisome, low- istan and Nigeria will be level transmission continues—as in India the only places left in the and Nigeria, more people are on the ground world with polio.” than ever before, devising microplans to Pakistan “is a bit of a identify every single house and ensure that risk,” says Aylward. And it is visited by a vaccina- tion team, and that each team has at least one woman or a member of the local community to help overcome resistance. Geneva declaration. At a meeting The teams are trying to on 15 January, health ministers from gain access to the tribal the polio endemic countries re- groups in Pakistan’s re- affirmed their commitment to wip- mote North-West Fron- ing out the disease in 2004. Above, tier Province at the same Bruce Aylward, Lee Jong-wook, and time that military forces David Heymann. are trying to root out Al Qaeda. And they are spill over into 2005. And CDC blasting the Cairo area, virologist Kew notes that the one of two lingering virus is now circulating inde- reservoirs in Egypt, pendently in Niger and Burkina where one challenge has Faso, a problem those countries simply been finding vac- will have to address. But Maher cinators willing to climb is fairly sanguine that Nigeria all the way to the top floors of the high-rise the situation in Nigeria remains dicey. The will come around. “Nigeria is not a huge apartments that dot the city. representatives from Kano who were sup- technical challenge,” he explains. They did it All this requires more money than ever posed to travel to Geneva didn’t—because of in densely populated Lagos, which was polio- before—WHO and UNICEF estimate the the weather, assured Minister of Health free for 2 years until being reinfected from initiative will spend $450 million in 2004— Eyitayo Lambo. Nor did Kano or the state of the north, he says. So the sparsely populated along with innovative ways to get that money Zamfara participate in the long-postponed north should be relatively easy, once they where it is needed. And it requires full sup- national immunization rounds on 23 Febru- gain access. “If we have three, four, five good port from political and religious leaders at ary in Nigeria and the nine other western rounds, that’s it. The game is over.” all levels. African countries now at risk. And if and when the world is declared Increasingly, the way to get that support Even so, as he looks ahead to the next polio-free, the partners have perhaps 1 year is to “name names”—a strategy informally synchronized rounds, scheduled for late in which to stop OPV. By then, the stock- referred to as shame and blame, much more March, Maher thinks he sees “some order pile should be ready with enough OPV to in evidence since Heymann’s arrival. If a emerging.” Several independent labs have vaccinate a region, or even much of the country or province is slacking off, tell pronounced the vaccine safe, as have Nige- world, should polio return. Excellent sur- them—and the world—that they are risking ria’s president and health minister. veillance will be crucial for detecting and a $3 billion investment and needlessly caus- Pressure on Nigeria is mounting. Dis- stopping an outbreak—and money to sup- ing more children to be paralyzed. If com- mayed by the results of the 23 February port it may be hard to find. mitment in a key country is flagging, Hey- rounds, U.N. Secretary General Kofi Annan But after the “long and very, very painful” mann will jump on an airplane or pick up sent in his undersecretary general for Africa, process of trying to halt transmission, as the phone. “It is very easy for him to call a Ibrahim Gambari, for private negotiations Maher describes, the endgame doesn’t minister of health and effectively say, ‘We with Nigerian leaders. And shortly after, on look so intimidating. There is an undeniable need to do a better job. And I will call next 17 March, the president released a long- psychological element here, he says: “If we week to see if we are,’ ” says Maher. awaited report from a federal and state com- do this, we can go on and do practically any-

On 15 January, ministers of health from mittee, again confirming the safety of OPV. thing we want.” –LESLIE ROBERTS CREDITS: P.VIROT/WHO

1968 26 MARCH 2004 VOL 303 SCIENCE www.sciencemag.org