Children receiving polio vaccine drops, Kano, Nigeria, Aug. 5, 2010. Mary F. Calvert/ZumaPress/Corbis
no one knows exactly how long polio has been around, malformed bones of
Egyptian mummies and stone carvings from around 1400 BCE suggest the disease
has dwelled among human populations for thousands of years.
irony about polio is that, while it was probably more prevalent in Pharaonic
times, it only became a terrifying epidemic in ours. One reason offered by
scientists is that in ancient times, infants were protected by maternal
antibodies and likely developed lifelong immunity. But as hygiene improved in a
rapidly modernizing world, people weren’t exposed to the virus until later in
life, when they were no longer protected by their mother’s immune system.
Although the introduction of polio vaccines in the mid-twentieth century
quickly stalled major polio outbreaks in wealthier countries, it remained
endemic in many parts of the world as late as 1988. That year, the World Health
Assembly (WHA), the decision-making body of the World Health Organization (WHO),
passed a resolution supporting the global eradication of polio. At the time,
the virus was still circulating in 125 countries, where it paralyzed 1,000
people a day—filling parents with terror and hospital wards with children who,
in many cases, would never walk again.
eight years of the WHA declaration, polio cases worldwide dropped almost 90
percent. In 2006, Egypt and Niger were declared polio-free. Last year, India
was declared polio-free as well, demonstrating success is possible even in the
most difficult circumstances. These accomplishments are part of a steep decline
in remaining cases worldwide; there were fewer than 250 new cases reported in
2012. Today, we are seeing the fewest number of polio cases in the fewest
countries ever. We have almost succeeded at wiping the virus off the face of
“almost” is not good enough. Polio is a stubborn, highly-contagious disease
that is easily transmitted as people move across borders, as they do frequently
today. In 2006, people living in thirteen countries that had already achieved
polio-free status became infected by travelers from the handful of countries
where the disease remains endemic. These importations led to large polio
outbreaks in several countries, including Indonesia, Somalia, and Yemen.
latest evidence of polio’s propensity for travel turned up in sewage samples
collected last December at two different sites in Cairo. Polioviruses detected
in these samples were found to be closely related to the poliovirus circulating
no new cases of polio have been reported in Egypt since 2004, the Ministry of
Health and Population quickly geared up to conduct mass polio vaccination
campaigns to ensure high immunity levels. Within four months after the virus
samples were confirmed, fifteen million children under age five will be
recent discovery of the poliovirus samples in Cairo underscores the
difficulty—and the urgency—of the global effort to eradicate polio. Until the
poliovirus is completely eradicated everywhere, no country is safe from
reinfection. It also reminds us of the incredible power of vaccines to solve
some of the world’s biggest health problems.
smallpox vaccine is one of the most impressive examples of what the world can
achieve with life-saving vaccines when backed by political commitment and
public will. As recently as 1967, the WHO estimated that ten to fifteen million
people a year were contracting the disease, two million died, and millions more
who survived were left disfigured or blind. After thirteen years of dedicated
vaccine campaigns, smallpox was completely eradicated—the first successful
global vaccination effort.
have reduced the number of children dying from diphtheria by 93 percent, cut
child deaths from tetanus by 85 percent, and lowered measles deaths by 74
percent. In Sub-Saharan Africa, more than 100 million young people have
received the new MenAfriVac vaccine. It is the first vaccine created
specifically to address a disease in the developing world, and it is putting a
fast end to the dreaded Meningitis A epidemics that have, for more than a
century, left death and devastation in their wake.
are an especially important tool in reducing the burden of disease, which takes
such a disproportionately heavy toll on developing countries. The problem of
global health inequity became visible to me about fifteen years ago, when my
wife, Melinda, and I saw a chart in the newspaper breaking down the major
causes of death among children. One of the largest sources was something called
rotavirus. It was killing 500,000 children a year, yet neither Melinda nor I
had ever heard of it. As I quickly learned, rotavirus is the leading cause of
diarrhea and it’s preventable with a vaccine that only children in rich
countries were getting.
realization is what prompted both of us to decide to focus on global health and
to do everything we could to get the rotavirus vaccine out to every child who
needs it. Now, twelve of the world’s poorest countries are giving the rotavirus
vaccine to children. By 2015, the number is scheduled to climb to forty
simple fact is, vaccines work wonders. They prevent disease from striking,
which is more efficient and effective than treatment after the fact. They are
also relatively cheap and easy to deliver. Yet millions and millions of
children—more often in poor countries—don’t get them.
started the Bill & Melinda Gates Foundation, we assumed that all the
obvious steps were already being taken to protect children from
vaccine-preventable diseases. But in fact, our first big health initiative was
devoted to delivering basic vaccines, because even that is not a simple matter.
It’s extraordinarily difficult. Nevertheless, universal coverage with today’s
vaccines is achievable. And it is possible that new vaccines will be developed
in the future for diseases such as malaria.
achieve both of these goals would save millions of lives, and they are a major
focus of our foundation and the work we are doing with partners such as the
Islamic Development Bank (IDB) and His Highness General Sheikh Mohamed bin
Zayed Al-Nahyan, crown prince of Abu Dhabi, as well as leaders in other Middle
Eastern and Islamic countries.
Sheikh Mohamed committed $50 million to polio eradication and vaccine delivery.
Last fall, the IDB, a new donor to the polio eradication effort, announced an
innovative $227 million financing package to Pakistan that will cover the
majority of the country’s polio vaccination campaign costs. It also announced a
$3 million grant for polio eradication activities in Afghanistan.
of innovative collaboration between traditional donors, rapidly-developing
countries, and emerging economies can take us closer to ending polio and
reaching all children, no matter where they live, with the vaccines they need.
Another is the Global Vaccine Summit that is taking place in Abu Dhabi in April
this year. Under the patronage of Sheikh Mohamed, the summit will unite the world
in reaffirming support for the Decade of Vaccines, a commitment endorsed at the
World Health Assembly in May 2012 to save more than twenty million lives by
2020. The Global Vaccine Summit also will underscore the importance of building
and maintaining effective routine immunization systems to keep all children
healthy, no matter where they live.
the most incredible examples of the power of vaccines is how close we are to
declaring the world polio-free. Fully funding the Global Polio Eradication
Initiative’s strategic plan is a critical step in achieving this historic goal,
and will help us reach mothers and children with other life-saving vaccines and
important health services. Vaccines can protect children for a lifetime, but
reaching all children will take a sustained effort. It is this tension, between
how much the world has achieved and how much is left to achieve, that causes me
to be both optimistic and impatient—an impatient optimist. And polio is the
subject about which I am most impatient—and the most optimistic.
we have successfully eradicated polio from most countries, many people believe
it is a disease of the past, and no longer a risk. As a result, it is sometimes
difficult for donors in developed countries to understand why their continued
support is so important.
fact, polio still strikes and paralyzes children today. Until it’s eradicated
everywhere, it remains a risk everywhere. And getting to that remaining 1
percent is much harder than anyone ever imagined. The best way to illustrate
the challenge we still face with polio is to compare it to what it took to stamp
out smallpox worldwide.
smallpox, every individual infected with the virus got an unmistakable rash on
the skin. As soon as someone saw a new case, vaccinators moved aggressively
into nearby towns to “ringfence” and contain the virus. Once immunized, people
never needed another smallpox vaccination.
the other hand, is transmitted silently and just 1 percent of infected people
show symptoms. The other 99 percent are contagious without knowing it. When
symptoms do appear, they may not be definitive. Symptoms often start with a
fever and headache. A few days later, ordinary muscle aches may get
increasingly severe and the patient’s reflexes can start to slow down. Only
then does paralysis sets in. But, even when a health worker sees a child with
paralysis, it takes another two weeks to collect and analyze stool samples. By
the time a diagnosis is confirmed, the poliovirus may have traveled hundreds of
miles in any direction.
an effective “population immunity,” polio vaccinators must reach at least 80
percent of the population, sometimes as much as 95 percent, depending on a
number of factors. Achieving 95 percent coverage is very difficult, even in
wealthy countries. It is far more challenging in the developing world.
example of India, the most recent country to eliminate polio. India started
with the same approach as the United Kingdom: vaccinating children when they
came into the clinic for routine visits. But too many Indian children never see
the inside of a clinic, so the Indian government added a supply-side approach
to the demand-side approach. That is they started going out into communities,
finding children, and vaccinating them house by house.
about what this requires. India has more than a billion people. Geographically,
it is three times larger than Egypt. It also features some of the most severe
terrain and weather in the world. During a flood in 2007, for instance, health
workers in Bihar state had to walk for miles in water up to their waists to vaccinate
children living in a remote area along the Kosi River. Not only did they have
to carry the vaccines in a box on their head to keep it out of the water, they
also had to keep the vaccines cold the whole time. Similar efforts of courage
and commitment happened over and over, since every child has to be vaccinated
three or more times to ensure full immunity.
polio program employed two million people and was almost entirely paid for by
the Indian government, which speaks volumes about the political commitment that
went into the program. Its accomplishment of wiping polio out of the country is
the most impressive global health success I’ve ever seen.
A Moral Quest
challenges in the remaining three endemic countries—Afghanistan, Pakistan, and
Nigeria—are just as daunting, though for different reasons.
Nigeria, a decade ago, some leaders in the northern part of the country started
the rumor that the polio vaccine reduced fertility in the children who received
it. Campaigns were suspended for a year while officials disproved the
allegations. A large epidemic sliced through Northern Nigeria, and polio spread
back into about twenty nearby countries where it had been eliminated. All those
countries had to ramp up again to win the fight for the second time. The rumors
persisted even after the campaigns were restarted, and to this day some parents
refuse to let their children be vaccinated.
Afghanistan and Pakistan, militants in some areas won’t give vaccinators access
to local children. Even in the places where vaccinators can go, there is no
guarantee that they will be safe.
surprisingly, when I lay out these facts, people usually ask me two questions.
First, given all the challenges, is complete eradication of polio really
possible? And secondly, should we bother putting in the work it’s going to
to both is yes. We can eradicate polio, and we should. Why? In a word, because
the long history of the disease. Though it’s been around for thousands of
years, we only figured out that it is contagious 200 years ago. It was just one
hundred years ago that we learned it is a virus. Fifty years ago, we developed
the vaccine to prevent it. Twenty-five years ago, the world resolved to
eradicate it. At each step along the way, a breakthrough—in medical knowledge,
diagnosis and treatment technology, global collaboration, and delivery—changed
how we think about the problem.
innovations are continuing to help us overcome remaining obstacles to
eradication. In the past year, Nigeria started using a new technology to solve
an old problem: How do you vaccinate every child when you don’t know how many
program uses what they call “microplans” to assign routes to vaccinators, with
the goal of covering every part of the country. Previously, the maps weren’t
accurate or detailed enough to drive universal coverage. Thousands of
settlements were simply overlooked. Distances could be off by many miles,
meaning that what the microplan said was a twenty-mile trip and a day’s worth
of work might end up being a forty-mile trip and two days-worth.
innovations in mapping technology have enabled polio teams to identify areas
that vaccinators previously missed. The question is no longer, “How many
children are there and where might we find them?” It is now, “How do we most
efficiently vaccinate every child?”
like this are the inspiration for my optimism. But to make sure innovation in
technology transforms our world in positive ways, human beings need to point it
in the right direction. That takes public will, as seen in people,
organizations, and their governments coming together to drive polio into
organizations helped push the eradication resolution through the World Health
Assembly, but the one you wouldn’t expect is Rotary International. Rotary is a
service organization with 1.2 million members who live in almost every country
in the world.
Rotarians pledge to put service above self, they have no specific global health
mandate. They are neither polio experts, nor policy leaders. But they are
regular people who go to work and spend time with their families. For three
decades, they have also spent time advocating for polio eradication, raising
money to support vaccination, and giving kids all over the world polio drops.
partners include the Centers for Disease Control, UNICEF, and the WHO. We rely
on them to advance polio eradication, but that is still not enough. We also
need people whose jobs have nothing to do with the health of poor people to
act. That is public will in the face of global health inequity.
strong commitment from leaders in all three endemic countries. When I went to
Nigeria for the first time four years ago, I met with two groups of leaders:
the religious leaders in the north, who are in the best position to encourage
anxious parents to vaccinate their children, and the state governors, who have
the power to hold the health system accountable for results. At the end of our
two-hour meeting, the governors signed a document committing them to the goal
of eradication and spelling out their personal obligations.
September, I went to New York to attend a United Nations polio meeting.
Nigerian President Goodluck Jonathan, Afghanistan President Hamid Karzai, and
Pakistan President Asif Ali Zardari all came to talk about their commitment to
eradication. Their presence, as much as the content of their remarks, showed
that the initiative has unprecedented momentum.
important for wealthier country governments to be involved and generous with
their aid as well. The proof of great leadership is the ability to be
long-sighted and keep the big picture in mind. A number of donor governments
have decided to prioritize foreign aid, even in the face of great financial
challenges, which is exactly the kind of commitment I’m speaking of.
leaves the second question to answer: Why is it worth it? Polio doesn’t kill
anywhere near as many people as AIDS, tuberculosis, malaria, or rotavirus, so
why should the world focus on eradicating it?
there is no such thing as keeping polio at its current, low levels. We have
gotten to this point because of our shared commitment to work together until
the job is done. Vaccinators are wading through flooded rivers,
developing-country governments are investing scarce resources, and the global
health community is on high alert. These are not sustainable approaches, but
they are what is required if we are to be successful. If we don’t keep
investing, cases will shoot back up to the tens of thousands annually in dozens
of countries—precisely at a moment when we are at the brink of seeing polio go
successfully eradicating polio will generate lessons that benefit all of global
health. We are on the verge of doing something we’ve never been able to do
before—reaching the vast majority of children in the remotest places in the
world to help secure their health and future. We are building systems,
developing technology, and training workers that make it possible to help
people who have never received any help. When polio is gone, we can use the
same systems, technology, and people to deliver other lifesaving solutions,
especially routine vaccinations for diseases like rotavirus and measles.
practical arguments, and I believe they are convincing. However, the argument
that really moves me is more idealistic. By facing together what at times seems
like an insurmountable challenge, we will demonstrate what is best about
humanity. Ending a disease that affects people disproportionately just because
of the region they live in will inspire us to be more ambitious about what is
possible to achieve in our world and in our lifetime.
months, vaccinators and other health workers have been targeted and killed by
militants in Nigeria and Pakistan. To me, the nihilism behind these coordinated
attacks—seeking out goodness to destroy it—is the opposite of what the
eradication fight is about. The vaccinators were trying to stop disease and
ease suffering so that even people they would never meet could have a better
heroes, and there are two ways to honor their memory: do our best to ensure the
safety of those who continue the campaigns; and finish the task they gave their
committed to doing whatever it takes to win this fight. Ending polio is my top
personal priority and the top priority of our foundation. But even the generous
resources of our foundation are nowhere near enough.
global polio community has a detailed plan for getting from here to
eradication. The plan is based on a careful analysis of what countries have
accomplished in the past, and what still needs to be accomplished in endemic
countries in the future. This plan says that, if the world supplies the
necessary funds, political commitment, and resolve, we will certify the
eradication of polio by 2018.
commitment, and resolve. These are the key variables for success. If the world
delivers, then we will eradicate polio within five years. It will be a
remarkable success that can be added to the growing list of improvements to the
human condition. We’ve cut the child mortality rate by 75 percent in the past
five decades. We’ve cut the poverty rate by 50 percent in the past two decades.
We’ve eradicated smallpox. These are mind-boggling successes. Adding the end of
polio to the list will be one of the great moral and practical achievements of
Bill Gates is the chairman of Microsoft Corporation, the world’s largest
computer software maker, which he founded in 1975. He launched the Bill &
Melinda Gates Foundation in 2000 to support philanthropic initiatives in the
areas of global health and learning. The Foundation has since dispersed $26.1
billion in more than one hundred countries focusing on endeavors such as
expanding childhood immunization, providing microfinance for small farmers, and
supporting college education. In developing countries, it concentrates on
improving people’s health and giving them the chance to lift themselves out of
hunger and extreme poverty. In the United States, it seeks to ensure that all
people—especially those with the fewest resources—have access to the
opportunities they need to succeed in school and life. On Twitter: @BillGates.