How India Fought Polio — and Won

A sprawling country with a massive population pulled off one of the greatest public-health coups in history

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Saurabh Das / AP

A child is administered polio drops during an antipolio drive in New Delhi on Jan. 15, 2012

A few days ago, Ramesh Ferris took his first ride on a motorbike. Born in India and raised in Canada, Ferris made the journey into rural India to meet Ruksa Khatun, the 3-year-old girl who is the last child in India known to have contracted polio. This weekend, as the nation quietly marked two years without a single infection by the wild poliovirus, that child’s parents wondered how they were going to manage the surgery her doctors say she needs on a foot crippled by the disease.

Ferris would understand the gravity of their situation better than most. After he was paralyzed by polio as an infant, his birth mother was unable to provide him with the care he needed and placed him in an international orphanage. He was adopted by a family in Canada’s Yukon territory, where he grew up, eventually becoming an advocate in the global drive to end polio. India was once considered the center of the crippling disease — and was expected to be the last place it would be eradicated. But last year, the World Health Organization (WHO) confirmed that polio was no longer endemic in India. Next year, if no new cases arise, the country will be declared polio-free, perhaps the greatest public-health feat it has ever achieved, saving hundreds of thousands of children from paralysis and death.

India’s accomplishment was a triumph of consistent and strong political will as well as international coordination and has given a huge lift to the global fight against polio, a disease that as recently as 1988 claimed 350,000 people each year. In 2012, the global caseload was just 222. When India came off the WHO list last year, the number of countries where the virus is still endemic came down to three: Nigeria, Pakistan and Afghanistan. “Given India’s complex circumstances in terms of where people live and its topography, it’s astounding it came off the list before other countries,” says Ferris.

(Read TIME’s cover story on how geopolitics may threaten the global effort to fight polio.)

Understanding how a country so huge, so diverse and so poor managed to stop polio transmission offers important lessons both for the complicated international effort to eradicate the disease for good and for India’s own health care system. The oral polio vaccine was introduced in India in 1978, a year before the U.S. was declared polio-free. In 1985, Rotary International launched its global effort to end polio everywhere. India was a signatory to the 1988 WHO treaty committing participating nations to be part of that effort. But on the ground in India, “there was not much happening,” says Dr. Naveen Thacker, a past president of the Indian Academy of Pediatrics and a member of the expert advisory group to the Indian government for polio eradication.

It wasn’t until 1994, when the local government of the New Delhi capital region conducted a hugely successful mass immunization campaign targeting children, that the idea began to gain momentum that India might actually be able to tackle this disease. Though other Indian states like Kerala and Tamil Nadu had conducted similar campaigns before, it wasn’t until the national government saw tangible progress that officials were sufficiently convinced they could make a difference. “That’s when India decided to go after polio in a big way,” says Thacker. Routine immunization — in which patients sought out the vaccine themselves — had reduced polio but couldn’t stop it from spreading. Reported immunization coverage across India was officially as high as 90%, but the disease was still being transmitted.

In 1995 and ’96, the government started to organize annual national immunization days, and in 1997, India established the National Polio Surveillance Project. In 1999, it set up an expert advisory group that monitored the program and provided continuous evaluation of how the disease was behaving around the country. Eventually, that group, which Thacker was a part of, decided the best way to fight the disease was to focus on the states of Uttar Pradesh and Bihar, two of the poorest areas in the country where polio transmission was uninterrupted. Crucially, the group also decided to target migrant workers moving in and out of those states and started vaccinating along the trail that migrants followed.

(PHOTOS: Pakistan’s Fight Against Polio)

It worked. By 2009, 741 cases of polio were reported in India, says Thacker. By 2010, that number dropped to 42, and by 2011, only one case — as of today, India’s last — was reported in the entire country. Today, officially 71% of children in India are immunized against polio, with 98% of children in the highest-risk areas having been immunized. In the process, the National Polio Surveillance Project became India’s most extensive public-health surveillance system. There are currently 27,000 reporting units across the country, run through a combination of funding from the government, WHO, UNICEF, the Bill & Melinda Gates Foundation and the CDC, among other groups. India has become one of the world’s largest donors to global polio eradication, putting billions of dollars into fighting the disease at home and also lending its hard-won expertise to Pakistan, Afghanistan and Nigeria, where the virus is still being actively transmitted. (Here’s a graphic of how the global polio program is funded.)

Members of the national surveillance team have gone to Nigeria and Pakistan in particular to help those countries set up similar systems. It’s an especially complicated task in Pakistan, where the effort to immunize children has become highly politicized, as anti-Western hard-liners have scared parents in high-risk areas into refusing the vaccine by spreading rumors about its safety and, worse, by attacking the vaccinators themselves. In December, the murder of nine health care workers during a polio-vaccine drive was linked to the Pakistani Taliban. It’s part of what makes this stage of the fight against polio — so tantalizingly close to being over — such a crucial one. As TIME’s Jeffrey Kluger wrote in a recent story on polio and politics: “All viruses fight back against their eradication. Polio is the only one with a propaganda wing and an armed militia on its side.”

The wisdom gained during the long years of hard work in India will not go to waste there. Infectious diseases like tuberculosis could benefit hugely from the kind of political will and national coordination that the government has shown in fighting polio. The infrastructure of the national surveillance project is already being used to deliver other health services to people living in hard-to-reach parts of the country.

(MORE: What’s Blocking the Final Stand Against Polio?)

Whatever the disease, it’s people like Ramesh Ferris who can do the most to persuade the public to take action. Last July, he went to Karachi to help educate parents about polio immunization. He climbed six flights of stairs on his crutches to reach a family on the top floor and show them firsthand the risk to which they are exposing their kids by refusing to let them get the vaccine. After a long, tense moment, the family opened the door and let him in, and Ferris personally administered the vaccine. “We have invested so much time and money into this fight. We can’t let hostility and misconceptions veer off our journey,” he says.

In India, too, Ferris cautions that the fight isn’t over just because the country has gone two years without new transmissions. “There is something called the polio endgame,” says Thacker. “You have a war, and once you declare the war is over, you take your weapons back and just survey.” India isn’t there yet. Children need to keep getting vaccines, and surveillance can’t stop, especially with a neighboring country in which the disease is still on the move. Says Ferris: “We’re not out of the woods yet.”

15 comments
RobBob
RobBob like.author.displayName 1 Like

It is so discouraging to forever seeing articles about the global polio eradication initiative that "mention" Rotary or only refer to Rotarians' efforts as part of an unknown "others".  Get it straight, news media:   Members of Rotary International, through their (our) Rotary Foundation, after six years of trials and planning, INITIATED and then funded the global eradication effort, following with over an uninterrupted  quarter century of implementation of national, regional and local support for vaccine production, distribution network delivery system implementation, and testing facilities --- combining all that with literally hundreds of thousands of on-the-ground volunteers in 130 countries to actually administer vaccine to BILLIONS of children.    

Not to overlook the awesome efforts in all other countries, the Rotary Polio Task Force in India alone has conducted dozens of National Immunization Days (NIDs) where as many as 175 MILLION children have been delivered vaccine in any given NID week of concentrated effort.   Their work, all volunteer and without any public recognition stands as a testament to the incredible dedication of Indian Rotarians who all too long have labored in anonymity whilst devoting uncounted hours of effort leading the NIDs.    People I know personally, have worked with, and/or have gloriously shared in the experience of participating in an NID in 2003:   Manjit Sawhney,  "Pandu" Setty, Sudarshan Agarwal, Sushil Gupta, Deepak Kapur, Ashok Mahajan, P. C. Thomas, O.P. Vaish,  Ravi Vadlamani,  Ranjan Dhinga, and of course, Past Rotary International Presidents Kalyan Banerjee and Raja Saboo.  This list of just the Indian leadership should include many, many others known and unknown to me, but with the exception of the visionary Motilal Doshi, and Indian Freedeom Fighter who walked with Gandhiji, those above have served for DECADES of uncompromising efforts to deliver the polio vaccine to every child in India.  These are but names to the world, but to me they are real people with real lives who have gone so far beyond what is expected that they should be enshrined as examples of  service and sacrifice to the world.  

To this list must be added that of Dr. John Sever, a Washington DC pediatrician and Rotary leader who actually is responsible for the very idea of eradicating polio.  To John, who has served tirelessly in virtually every position of leadership in this effort and who is globally recognized throughout the health community for his contributions and who has assiduously avoided any recognition or praise for his ongoing efforts, I only note that my respect and awe of your accomplishments finally has overcome my reluctance to finger you as the great man you are to the world.    

Without Rotary, Rotary International, The Rotary Foundation, and an untold number of Rotarians who have contributed their time, talent and treasure to this effort, there never could have even been a polio eradication programme.   Without Rotary's leadership, WHO and the 130+ national health agencies would not have had the muscle to even contemplate the awesome undertaking that has occurred with Rotarian volunteers leading the charge again and again and again for over 25 years!  Without Rotary's success, there never would have been a polio eradication programme for Bill & Melinda Gates to plug into with their vast resources at a critical time when we were so close to success but burdened with all-but-insurmountable challenges they have helped so mightily to overcome.

 So why doesn't someone publicize the Rotary story?  Good question, asked a million times over by the Rotarians who funded the vast majority of early efforts, stimulated national and corporate support --  and who continue to this day to provide ongoing financial support, as we know we still have miles to go in the three remaining countries endemic with the wild polio virus, as well as cleaning up resurgent hotspots in a dozen other countries.

A question well worth answering!  And the news media which has so long minimized Rotary’s role can be an agent of positive change as the world finally finds a way to properly thank Rotary for being so effective in orchestrating the largest health campaign ever mounted in the history of the world.

halaszchristina
halaszchristina

@RobBob: I stopped reading the minute you wrote, "awesome".

RobBob
RobBob

@halaszchristina @RobBob Whilst I did not post this message for those who cannot comprehend the scope of what Rotarians have accomplished, I will admit to having edited the message after posting and replaced the word to which you objected with "tireless" -- as that word more accurately depicts just how onerous and consuming this task has been.  Although I must say that never in the past 20 years have I ever heard a single word of complaint from my Indian Rotarian friends engaged in the polio eradication effort.   

 And As I perused the length of my posting, realizing that many would falter at having to exercise their brains long enough to achieve receiving a complete thought from a thoughtful person on a most worthy subject.   They are the ones who lose by living partial lives with partial thoughts and partial deeds -- unlike my Rotarian friends who have persevered to the completion of an "impossible" task -- and "awesome" achievement indeed!  And certainly unlike the millions of children who have been spared the horror of crippling polio -- of which my brother is one -- who deserve to know just who they should recognize for their good fortune. 

halaszchristina
halaszchristina

@RobBob: Why the haste? We all have hours a day to devote to tedious commentary proffered free in online newspapers and magazines. 

RobBob
RobBob

@halaszchristina@RobBob 

 further to both my reply above and then to your original comment below:

In my haste to reply, I failed to edit my second paragraph, to wit:

And As I perused the length of my posting, I realized that many would falter at having to exercise their brains long enough to achieve receiving a complete thought from a thoughtful person on a most worthy subject.   They are the ones who lose by living partial lives with partial thoughts and partial deeds -- unlike my Rotarian friends who have persevered to the completion of an "impossible" task -- an "awesome" achievement indeed!  And certainly unlike the millions of children who have been spared the horror of crippling polio -- (strike "of which my brother is one", for he IS a polio victim, not one who has been fortunately spared as I have) -- who deserve to know just who they should recognize for their good fortune. 

One liners are great, especially when meaningful.  But in the global health community's efforts to eradicate polio there are no snide asides nor irrelevant comments needed; the task in itself consumes every possible ounce of energy.   Get as life, halaszchristina, you just might find it rewarding.

Now,  back to my work on Rotary service projects.

gracechiou88
gracechiou88

More developed nations could try combating the transmission of hepatitis viruses A, B, and C.  The eventual goal would be greater life expectancy.

kdv666
kdv666

@Leftcoaster  

Rotary was indeed mentioned in the story, as having started the global effort in 1985.


But yes, this is a really good news story for India, and for the rest of the world too.  The suffering that polio has caused is incalculable.  If it really does follow smallpox into oblivion, what a wonderful bonus for future children.   Seems like the only ones who hope to see polio still causing suffering and death are the Taliban and the anti-vaccination freaks, and to be frank, they deserve each other.



serene123
serene123

I find it interesting that WHO keeps spreading how they eradicated Polio in India, which is simply not true...not to mention the millions of dollars they waste trying to get rid of it. WHO goes to great links to get children in the poorest areas vaccinated, but it's astounding they do absolutely no recall to see if children in these areas are dying of polio. In the poor villages, if their child gets sick, they can't afford to go to the hospital. Their children die, get cremated and people are none the wiser that it very well may have been from polio. Also, as an Indian living in America, I visited India in February and could not believe what happened to me. I was standing in front of a family member's house when an WHO rep gripped me by the arm and another tried to FORCE the polio vaccine on me. There are so many wrong things with this scenario: 1) To be the most effective, the polio vaccine should be given to children before the age of 3. I'm almost 30 and they tried to give me the vaccine and were giving it to many teenagers. 2) Absolutely no background check was done on whether or not a child had received the vaccine already. Although it doesn't hurt to get it twice, it's a gross waste of money. Imagine how many others in need could benefit from the wasted vaccines. 3) You don't go around grabbing people! I know very little Hindi and was yelling at the woman and man to let me go and asking them what they were doing, in English, and not once did that raise flags to them? I have zero accent. It should have been a clear indication I was not some poor villager in desperate needs of a vaccine. Not to mention I was dressed as a westerner, completely out of place in the village. Although I applaud WHO's efforts to eradicate polio, they aren't doing it correctly and need to stop giving India a false sense of security that it has been eradicated until they refine their  sampling strategy.

GauravSingh
GauravSingh like.author.displayName 1 Like

@serene123 Lecture Lecture Lecture...Thats all you NRIs are good for.....Please Enjoy Life in America...and dont downplay this staggering achievement of millions of volunteers.

serene123
serene123

@GauravSingh I most definitely said I applaud their efforts, but it needs to be revised and done properly. Try reading my entire comments before making an assumption. Not to mention, more than 90% of my family lives in India and they agree with my feelings above.

Kniola
Kniola

 @serene123 Sure, you can rant all you want. However, you must surely appreciate that in a country as maddeningly diverse and chaotic as India, the controlled methods of the west need not necessarily apply. Yes, I'm sure there have been human rights violations. And as a person of Indian origin not living in India, used to western standards of living and very liberal value systems, I do not support the complete disregard for privacy and rights that the implementation of this program has had just as surely as sugar is sweet. However, in a chaotic country, you sometimes need chaotic methods. Maybe there is some sampling error, maybe, as you pointed out, there are deaths from polio still happening. But it is contained for now, and surely that is quite an achievement considering how brownian everything about India is. In my books, containment in a society as varied, changing and myriad as the Indian one is nearly as good as eradication. And in the end, you must put some trust in statistics, or else the entire world will be a lie. 

GauravSingh
GauravSingh

@serene123 @GauravSinghYou dont need to be defensive.But see India is a very very very Complex country.This may be its strength and its weakness.But to understand india travelling is more required rather than reading.Western methods to analysis dont work for india.

That is why Foreign journos posted in India are constantly confused and criticised.Documentation/Graphical Analysis/Behavorial Function trying to frame such things to describe india is a waste exercise.
I also agree with the problems you posted.But thier solution is so complex and would take so much time that lets not dilute the overlying success achieved.
The Mistake for an India Analyser to commit is to Predict/Draw a graph of India.

jambouburgess
jambouburgess

Incredible

This toilet paper is as good as its boss Mr Murdock....

4 days in and nothing about the french intervention in Mali!

nothing bad to say about it Mr murdock?

Leftcoaster
Leftcoaster like.author.displayName like.author.displayName 2 Like

"WHO, UNICEF, the Bill & Melinda Gates Foundation and the CDC, among other groups."

Rotary International is among the "other groups" that should be mentioned.  Since 1985, Rotary International has contributed over US$1.2 billion, with more yet to come.  Without WHO, the Gates Foundation and UNICEF, the battle would not be nearly so close to being won; without Rotary's dollars and volunteer manpower, it would not have the strong international support it has. 

Thanks to all who have been involved - we are almost there!