The second great eradication

WHO ceremoniously flagged off its Final Push for Polio Eradication in theYear 20008242; from New Delhi earlier this month. But the conspicuous absence ofUnion Health Minister Mr. N. T. Shanmugham from the launch function seems tohave sent the wrong signals about India8217;s commitment to meet the globaltarget of polio eradication within the year.

The WHO says that India, which has about 70 per cent of the 5,000 poliocases reported worldwide in 1999, holds the key to the success of a drive torid the world of the crippling virus. In fact, India stepped up eradicationefforts some three years ago with major all-India campaigns to administeroral polio vaccine OPV to children. In what is considered a world record,more than 140 million children took the dose on a single day last November.Now, it is understood that Bihar and Uttar Pradesh are the last remainingstrongholds of the virus.

WHO Director-General Gro Harlem Brundtland, on her maiden foreign visit inthe millennium, said in India while launching the final push: quot;We are in thefinal stretch of the polio campaign and India is the biggest and mostimportant area in that context. A major effort is necessary in the Indiansub-continentquot;. WHO launched the polio initiative in 1988, when there wereabout 350,000 cases reported from 125 countries.

Tempering the general euphoria, Brundtland herself admits that the WHO8217;spolio campaign is still short of about 300 million. She has written to allheads of state to contribute generously, and hopes for results soon.

However, funding is a relatively easy problem to resolve. The real issue isIndia8217;s choice of the Oral Polio Vaccine OPV route for the entirepopulation. Independent experts like Pushpa M. Bhargava, who was founderdirector of the Centre for Cellular and Molecular Biology, Hyderabad, havequestioned this policy and called it a quot;flawed decisionquot;. Bhargava says thatIndia should have adopted the injectible polio vaccine IPV route.

This view is based on a simple fact many Indians, especially 60 per centof India8217;s children, suffer from chronic diarrhea. Since the condition isalmost always present, many do not retain the critical immunity that theoral route provides because the vaccine does not stay long enough in thebody. Experts also say that OPV does not give enough blood immunity.

Bhargava recently said, quot;No one will be more delighted and satisfied than meif it can be shown, indisputably and without any question, that OPV hasworked in this country. Unfortunately, all evidence available as of todaygoes against this view.quot;

Little wonder that the US, on advice from the Centres for Disease Control,Atlanta, went in for a judicious mix of OPV and IPV while trying toeradicate polio. Experts here suggest that India should also have chosen theIPV route or at least a mix in its bid to eradicate polio.

But the WHO holds that the OPV route is to be recommended since it ischeaper and safer. But OPV needs a functioning cold chain since the vaccineis inactivated by high temperatures. Recently, health officials in Indiahave insisted that this problem has been largely addressed with theintroduction of vials with temperature-dependent colour codes and vaccinevial monitors. But it is well known that there have been many instances ofthe cold chain breaking down.

While the government tenaciously holds on to its optimistic estimate ofhaving covered over 90 per cent of the population, there are some worryingindependent estimates. The first really independent assessment, made in theIndia Human Development Report, 1999, talks of about 64 per centimmunisation against polio. Variations, as always, are huge from 92 percent in Kerala to less than 30 per cent in Rajasthan. If a third of thepopulation still remains un-inoculated, can the virus be driven out withinthis year? In Bihar, the post of the District Immunisation Officer DIO islying vacant in as many as eight districts. This is the officer who issupposed to ensure that the Pulse Polio program rolls on without a hitch atthe district level.

Such realities and more force experts to question the WHO8217;s ambitious plansfor eradication. Dr Indira Nath, an immunologist at the All India Instituteof Medical Sciences, New Delhi, believes it is very unlikely that the 2000target will be achieved. quot;WHO tries and makes simplistic global solutionsbut they seem to miss out on the regional variations and solutions,quot; shesays. Dr Nath8217;s hospital still sees numerous polio victims despite the factthat they have had the mandatory three polio drops, which shows that the OPVroute may not be working too well.

In the midst of all this introspection, Brundtland is bravely positive: quot;Weare on the verge of a major public health breakthrough after smallpox,polio will be the second disease ever to be eradicated. But we must notforget the fragility of an eradication effort and the danger of complacencyin the face of a disappearing disease.quot; She adds this caveat in view of thepolio outbreak in Angola last year, with over 1,000 cases. Also, twocountries that had been declared polio-free 8212; Iran and Myanmar 8212; sufferedrelapses.

So what might be in order? The WHO says it will continue to monitor areaswhich have undergone vaccination drives until 2005 to ensure the virus isrelegated to the history books. quot;The greater danger is not to be ambitious,quot;said Brundtland, when asked whether WHO would achieve its goal despitechances of outbreaks in areas thought to be polio-free. quot;At the dawn of thenew century, it is within our grasp to eradicate polio forever.quot;

She also had a very clear message for India and called for far greaterexpenditure on the health sector. quot;As a fraction of gross domestic product,too little goes towards health,quot; she said. But more worrying is the factthat India spends close to 100 million on each pulse polio day. We have had11 of them so far. If the political and administrative machinery does notget its act together, all this money just might go down the drain.