India was the problem, everyone agreed. Forty years ago, the World Health Organisation’s (WHO) apex body, the World Health Assembly (WHA), resolved to eradicate polio. It was a deeply controversial decision because, to many, it seemed wildly ambitious. There were at least 1,000 cases a day around the world and, of those, more than half occurred in India. In one part of Tamil Nadu, two of every thousand children under the age of five developed polio every year. The annual cost to the nation was estimated Rs 45,000 crores.
It was never said explicitly but the attitude of the global community hadn’t shifted much since 1948. India was vast, chaotic and often ungovernable. Democratic, yes; admirable, sometimes; infuriating, often; but evidently not capable of dealing with a hyperepidemic that was fiendishly complex and tied to intractable problems of poverty and sanitation. Controlling polio depended on reaching every child in every remote village with a series of polio drops or injections in coordinated campaigns.
India’s many gods seemed, to the gathered experts, the symbol of a country where no-one was in charge and no-one ever could be. Pakistan, on the other hand, was authoritarian but resolute and a firm ally of America in everything from defeating communism to defeating polio.
In a 1994 interview, officials from the US Centers for Disease Control (CDC) predicted total polio eradication in Pakistan within two to three years. And, they reassured themselves, Pakistan would soon oversee Afghanistan too.
This week marks World Polio Day (WPD) and things seem very different. At an international press conference today, all eyes will be on Pakistan and Afghanistan, the last two countries where polio is endemic.
As of today, there had been just 20 cases globally so far this year. The press conference will see videos of heroic women and men who struggle every day to reach every last child in the Federally Administered Territories and in Kandahar.
Some of these polio workers have died and others have been wounded terribly -- usually by criminal gangs claiming to act in the name of fundamentalist Islam. The would-be fundamentalists love polio - it is a magnet for international funds and it gives them leverage with embarrassed governments. Few of the polio workers are paid regularly and fewer still are recognised properly, but still they fight on. When polio is finally history, it will be thanks to these decent, dedicated men and women.
On our side of the border, Rukhsar Khatoon, of Shahpara village, near Kolkata was only eighteen months old when she made history. In January 2011 she was the last Indian child to contract polio. In 2014, the country was declared officially free of polio. Many rushed to claim credit -- in early 2012, the Gates Foundation dispatched an American writer to find Rukhsar who had had a mild case of polio, recovered fully and sensibly dived under her mother to avoid the attention. But, this was an Indian success story.
Polio showed what vast, chaotic fractious India could achieve when it wanted to. Epidemiologists plotted the epidemic and countered it like chess grand masters. Prime ministers such as Atal Bihari Vajpayee and chief ministers such as Dr Harsh Vardhan in Delhi cajoled and encouraged the health system. Geniuses like former President A.P.J. Abdul Kalam applied technology to helping polio survivors. And, after over 30 years of grind, it was gone.
Today, polio risks showing the other side of this kind of national resolve: what happens when the mission is over and the focus shifts.
There is this month, a continuing national scandal over “tainted” oral polio vaccine (OPV) from an Indian vaccine manufacturer, Biomed. The scandal is not that the vaccine was dangerous -- although it was -- or that Biomed’s directors immediately went on the run from investigators -- although they did. Rather, it is that India continues to use a vaccine designed to eradicate polio, rather than the one designed to keep the country polio free.
OPV may or may not have been the right way to eradicate polio. The WHO and India’s 'babus' convinced themselves that it was, even though the oral vaccine includes weakened but still living polio virus. So, it carries a small risk of causing polio-like disease, especially in some communities where many children miss some of the ten or twelve doses that are often necessary. (That’s why news reports always talk of “wild” polio; they mean cases that weren’t caused by the vaccine). Many say it was science that convinced the bureaucrats - some are more inclined to think that it was that OPV was produced by state-linked enterprises in many countries, including India.
Everyone agrees, though, that OPV will have to be ditched as soon as the last case of wild polio has occurred. Professor T Jacob John of Christian Medical College (CMC) Vellore, one of the world’s foremost authorities on polio, wrote five years ago, that Vaccine-Derived Poliovirus (VDPV) “…may silently circulate for many months, even 1-2 years, before showing up with polio cases … the day OPV is discontinued, silent transmission of VDPV may already be happening in the community.” The solution, he pointed out, was to start introducing the injectable, inactivated polio vaccine (IPV) that has been used for decades to protect children in Europe and North America. IPV can protect children from both wild and vaccine-derived viruses. Professor John was right as we still hear reports of VDPV every year in India.
IPV has been in India’s routine immunization programme for two years but I’m told that progress is achingly slow. Had every Indian child been protected by IPV, that Biomed error would have been much less of a threat.
Officials mutter about shortages but, in advance of the Monday press conference, I asked Sanofi Pasteur, the world’s largest IPV producer, if there were any supply problems. There aren’t - the vials don’t even have far to travel. They are produced in Hyderabad.
India has defied global expectations and achieved something remarkable. We cannot let bureaucratic inertia and prejudice undermine it.