POST 01353E: STOPPING POLIO ERADICATION WILL BE A HUGE BLOW TO INTERNATIONAL HEALTH FOLLOW UP ON POSTS: 01339E
, 01345E, 01346E
19 NOVEMBER 2008
I apologize if I have to repeat points I thought I had made rather clear, but Anthony's message necessitates some response.
In general, I think Anthony confuses two issues:
1. Should the WHA have decided in favour of polio eradication in 1988? Clearly Anthony thinks that was a bad decision. I think it was not, but in any case the decision was taken, we are 20 years further and it cannot be turned back. All my Technet contributions so far have therefore not addressed this issue, but focused on the second;
2. Where do we go from here?
For the last question I have laid out the three options:
1. Finish the job. Progress in India has convinced us again that even in that most difficult country eradication is possible. Both the infected states, Uttar Pradesh and Bihar, have interrupted transmission of type 1 for considerable lengths of time. Recent and planned SIA and its visible impact on type I transmission convinces us that it can be done. All experience shows that type 3 is much easier to deal with.
2. Forget about the eradication goal, but maintain the current level of transmission. That would take almost the same level of supplementary immunization as is taking place currently and would therefore merely eternalise the costs, without mentioning the rapid decline in surveillance.
3. Stop supplementary immunization. Contrary to what Anthony says, I never suggested this would bring us back ante. In POST 01341E
I wrote "that polio incidence will rise to the pre-eradication level, although not quite due to better routine, perhaps 200 000 cases compared to the estimated 350 000 cases before 1988. Of course we would not see all those cases, because surveillance would collapse rapidly". If Anthony has a better estimate as to what level polio incidence would rise in case of interruption of SIA, I will be happy to hear it and adapt my numbers, but it can hardly be denied that without SIA, incidence would increase dramatically and rapidly compared to the current level. Recent outbreaks have taught us how fast population immunity declines in absence of SIA and in a context of anything less that excellent routine EPI. People in favour of stopping SIA should therefore clearly state that they find the consequent rise in polio incidence an acceptable price to pay for this change of policy, rather than silently hope the current level can be maintained without SIA. Even the idea that stopping SIA will be cheaper may be very wrong viewed from a longer term perspective, as was shown in a study in this regard comparing long and short-term costs and benefits of eradication and control strategies.
Even the most fervent opponents to polio eradication recognise at least some of the spin offs: planning and coordination structures well beyond polio, polio staff always working for other programmes, massive investment in cold chain and means of transport, establishment of a surveillance system of which the functioning has greatly helped surveillance of other diseases, surveillance laboratories, micro plans resulting in considerably better knowledge of target populations and under served populations used for other interventions, much better knowledge of social mobilization and communication strategies for reaching a variety of ethnic and religious groups, etc.. I think the comments from Dr Dewan (POST 01345E
) speak for themselves.
The example of a few badly placed freezers in Kano to contest the spin offs is quite disappointing and fully supports my point that, where it occurs, incorrect planning is a general problem, affecting routine as well as polio eradication rather than making one the victim of the other.
Regarding Nigeria, I worked in Anambra state in 1987 and health staff was complaining about the declining funds and interest for routine immunization. That was more than 10 years before Nigeria started doing polio SIA.
Stopping polio eradication before the job is done would be a huge blow to international health. Whether people agree or disagree with the initial decision in 1988, we are where we are and there is no way back, unless we are willing to face the consequences in terms of a dramatic increase in incidence of polio, widespread frustration among health workers and public who have given so much to achieve the goal, a negative fall out on other programmes way beyond polio and rapidly declining AFP surveillance. If I hear mothers in Uttar Pradesh and Niger say they clearly see the difference with the old times with young crippled children in every village and begging beside the traffic lights in the cities, I think we owe it to them to finish the job. This is not cheap emotional blackmail, but the hard reality. If we stop, we have to be willing to explain those mothers why the crippled children return. Perhaps less than before eradication due to improved routine, but a whole lot more than right now or when eradication is completed.
Technical officer, EPI
IN THE CURRENT ECONOMIC SCENARIO CAN DONOR GOVERNMENTS SUSTAIN THEIR COMMITMENTS?
The debate between control and eradication is older than the Initiative, I believe, and still going on. At this point, it should not be carried without having the global context in mind. We have entered a period of severe economic disturbances. And we have to admit that the answer to the debate may finally be imposed on us regardless of critical consequences. If the recession is as bad as many economists forecast, how can donor governments sustain their commitments at present levels, even any commitment at all. Having been involved personally with the contribution of significant funding a few years ago (so you know which side I stand), I would be very sad indeed to see all these efforts go up in smoke. But we have to be realistic.
While most governments of the world are making plans to face the situation, I just wonder how WHO in general, and the PEI in particular, are planning to weather the storm? Maybe Dr. Aylward could share his thoughts with us. And Technet members may have good ideas and suggestions.
Thank you very much
Claude Letarte ([[email protected]
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