Dissent in the face of success
After mounting the most widespread and intensive campaign in history for the eradication of a disease, no new case of poliomyelitis was reported in India in 2010. This seemingly impossible goal was achieved by repeatedly dosing some 150 million children — up to 25 times in the first five years of their lives — with the Sabin Oral Polio Vaccine (OPV). But has this unprecedented public health effort actually eradicated polio; how will the ‘endgame’ of polio play out; was the eradication strategy based on good science and appropriate for what is essentially a problem of poverty and sanitation; has the unprecedented dosing of Indian children with OPV placed them at risk in order to achieve a supposed “global good”; and, were valuable national resources misdirected to polio, a “minor” disease, instead of being invested in routine immunisation aimed at “health for all”? These are the core questions raised by the “Discontents” in William Muraskin’s monograph.
The jubilation accompanying the eradication of smallpox in the 1970s led a group of influential American public health specialists to push the concept of eradication as a global goal. The declaration of the World Health Assembly emphasising primary health care to bring “Health For All by the Year 2000” did not deter the ‘eradicationists’ from pursuing their cause; culminating in the same World Health Assembly in 1988 calling for the global eradication of poliomyelitis.
Tracing the debates among experts and reinforcing his account with personal interviews with many of them, Dr. Muraskin, who is a Professor at Queens College, New York, and who specialises on the politics of international health, provides insights into how critical decisions were reached. At the outset, drawing on the experience of the Americas, eradication efforts were seen as a means for strengthening primary health services in general. Talking about eradication was seen as “the only way to get key political leaders to support the routine systems that good public health actually required”. Such political will would be created — especially in the developing world — through well-applied pressure on decision-makers, the lure of external financial resources, and the promise of eradication’s “infinite benefits”.
Thus, the arugument goes, “a network of interested scientists” supported by “eradication entrepreneurs” developed the contours of the polio eradication campaign by pressuring and “shaming” national governments to participate despite their divergent priorities. The single-focus, top-down approach was thrust on developing countries although polio, for many of them, was a low-priority disease and scarce resources had to be diverted from more pressing problems like malnutrition, diarrhoea and malaria. Muraskin observes that it was clear “that the larger benefits of eradication accrued to the industrial world rather than developing countries” and “that a ‘condescending attitude’ toward the developing countries is built into the whole enterprise of global eradication schemes”. The most contentious decision was the adoption of OPV over the Salk Inactivated Poliovirus Vaccine (IPV).
The monograph devotes its most substantial chapter to “The Case of India”, where the views of ‘Indian Dissenters’ are discussed to make the case that “the polio eradication campaign is based on highly questionable science — science that has been unjustifiably manipulated by the politics of the global policymakers”. The lack of transparency in the Government’s approach was accompanied by a sense that nothing must be allowed to undermine the momentum of the campaign.
The polio eradication campaign in India might have set routine immunisation systems back by years. Repeated National Immunisation Days not only occupied health bureaucracies for weeks on end, but also demanded work-forces of other branches of government, volunteers etc. The self-fulfilling logic of the campaign insisted that the intensity could not be slackened till the virus was eradicated. It appears, however, that the overall outcome of the campaign is at best “elimination” of polio, and that some sort of vaccination must continue (indefinitely?) to ensure sustained immunity.
POLIO ERADICATION AND ITS DISCONTENTS — A Historian’s Journey Through an International Public Health (Un)Civil War: William Muraskin;
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