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Death of a Virus: Eradicating Polio in Bangladesh
by Matthew De Galan, Writer
DHAKA, Bangladesh -- At the tender age of 13 months, Dolly is certainly Bangladesh's youngest and most unlikely celebrity. Last year she was featured in newspapers and on television throughout the country. And today health officials and journalists from around the world venture into the sprawling slums of Dhaka to visit her family's one-room home on the edge of a garbage dump.
At first glance, Dolly seems much like any other Bangladeshi toddler: big brown eyes, a mischievous smile, a playful laugh. Mentally, she is bright and alert. But physically, one leg is markedly weak, and she will likely be disabled for the rest of her life.
Dolly's ailment is not a new one. It's polio -- the fearsome virus that has killed or disabled millions. Polio put Franklin D. Roosevelt in a wheelchair and struck fear into the hearts of families in the industrialized world until a vaccine was developed in the 1960s.
While progress in the developing world came more slowly, in the past 15 years, governments and organizations worldwide have embarked on a massive global effort to wipe out polio. Since 1988, the number of polio cases has dropped from 35,000 a year to slightly more than 5,000 last year.
Global eradication could come in the next five years, and dozens of countries already have been declared "polio-free." Others, like Bangladesh, are tantalizingly close -- so close that Dolly made headlines last year with the dubious distinction of being the only Bangladeshi child confirmed to have contracted polio in 2000.
"A decade ago, Dolly would have been one of many hundreds of Bangladeshi children with polio," says Dr. Wahidula Islam, project coordinator of CARE's child health programs in Bangladesh. "But now we believe she will be one of the last children ever in Bangladesh to have polio. She is a reminder to us of why it is so important to finish the job [we have started]."
'Finishing the job' in Bangladesh involves a large, complex public health initiative including the Ministry of Health, UNICEF, the World Health Organization, the Centers for Disease Control, Rotary International, the U.S. Agency for International Development, and a coalition of nongovernmental organizations consisting of CARE, Plan International, Save the Children and World Vision. The cornerstone of the initiative is "National Immunization Day" -- a twice yearly event which aims to administer the oral polio vaccine to each of Bangladesh's 20 million children under the age of 5.
The strategy behind National Immunization Day is simple: the best way to kill the virus is to deny it a place to live. The virus can survive only a short time outside the human body and can't survive in animals or insects. This weakness gives health officials a distinct advantage.
"Immunizing all children on the same day is like locking all the doors at once, trapping the virus outside, where it can't live," says Dr. Tahsinul Anam, CARE's assistant project manager for the polio eradication project. "Doing this in one day is vital because it builds a sudden and secure wall of immunization. The virus simply has nowhere to go."
Last November's National Immunization Day began with a massive awareness-building effort. Radio, television and newspaper announcements carried the message for days beforehand, urging parents to bring their children to health centers. The prime minister made a special appearance on television. Parades, rallies, soccer games and other community events brought the message to villages across the country.
All the while, hundreds of thousands of volunteers and thousands of government and international health officials planned the massive logistical effort required to distribute 20 million doses of oral polio vaccine across a nation the size of Wisconsin. Pre-positioning the vaccine isn't possible because it must be kept cold and most rural communities lack refrigeration facilities. Roads are rough, and much of the country is criss-crossed with canals, rivers, ponds and swamps.
Coordination Brings Results
Last November, just before daybreak on National Immunization Day in the northern city of Sylhet, hundreds of bright red coolers packed with ice and vials of vaccine were stacked in a health clinic near the center of town.
A young man on a motorcycle pulled up, draped three coolers around his neck and roared off into the darkness. Next, a woman in a bicycle rickshaw arrived. A worker handed her six coolers and the driver pedaled away with the cargo.
For the next two hours, volunteers fanned out across the city and neighboring villages, bringing vaccines to community health centers, schools, markets, the train station -- anywhere that was easy for parents to bring their children. On the main road from Dhaka to Sylhet, volunteers stopped buses and administered the vaccine to children on board. In rural areas, volunteers walked miles in the hot sun to reach isolated villages, hoping they would arrive before the ice in their coolers melted.
With similar efforts taking place around the country, by the end of the day, an estimated 18 million children had been vaccinated -- nearly 90 percent of the target group.
But health officials worry about the niche groups that were missed: homeless street children, the poorest families in urban slums, and children living in the isolated hill tribe region along the border with Myanmar. Year after year, these hard-to-reach groups are the least likely to be vaccinated. They thus represent a fertile pool in which the virus can survive.
Hill tribe residents pose a particular challenge in immunization efforts. They are a different ethnic group than the rest of Bangladesh. After years of tension, economic isolation, and occasional conflict, they have little trust in the government. Some communities have reportedly opposed immunization campaigns, fearing it is actually an effort to poison their children.
This fear, combined with rugged terrain, create a formidable obstacle for health officials. But nowhere in the country are the stakes higher. Neighboring Myanmar -- impoverished and politically isolated -- still has incidences of polio. Unless a wall of immunization can, in effect, be erected, the virus could easily spread into Bangladesh through the hill tribe region.
For the other 19 countries around the globe that still are combating polio, the challenges are similar and, in some cases, more daunting: All are poor, and many are plagued by war, civil strife or political instability. In the Democratic Republic of Congo (formerly Zaire), health officials have to negotiate a cease-fire before immunization programs can be implemented.
In Bangladesh, there are no bullets to dodge. But the obstacles are still daunting. At a "lessons learned" meeting shortly after National Immunization Day, health officials discussed the difficulties ahead.
One official recommended the use of helicopters to reach the isolated hill tribes. Another objected: "The only people with helicopters are the army. Can you imagine the army landing in a village and saying 'Here, give this to your children. It's medicine. Really. Trust us.'"
The other topic of discussion was waning enthusiasm for the fight against polio. Precisely because of the success in reducing polio, it has become more difficult to convince governments, international donors and the public that the disease should still rank high as a public health priority. With AIDS emerging, and malaria, tuberculosis and other diseases re-emerging, why spend time, money and energy eradicating a disease that only affects a few thousand people each year?
Dr. Islam has his own answer.
"Eradication is forever -- forever," he says. "If we do not do this, when it is entirely in our power, what will the Dollys of tomorrow think of us?"
Facts on Polio
- Polio usually strikes children younger than 3 years old.
- The polio virus is transmitted orally and multiplies in the intestine before invading the nervous system. It slowly destroys the body's nerve cells, causing paralysis and in some cases death by asphyxiation as the muscles controlling the breathing process are cut off from the central nervous system.
- One in 200 polio cases leads to paralysis, usually in the legs.
- Five to 10 percent of polio victims die.
- Polio survivors suffer from post-polio syndrome, a further weakening of muscles affected by a previous polio infection. It can cause fatigue, progressive muscle weakness, muscle and joint pain, and muscular atrophy. Survivors also can have swallowing problems, breathing trouble, and progressive functional decline.
- The last reported case of polio in the U.S. was recorded in 1979. It has been gone from the Western Hemisphere since 1991.
- About two dozen countries are still at risk from polio. Among the remaining countries where transmissions are taking place, 16 are in Africa, many in armed conflict zones, and four are in Asia.
- Polio can be prevented through both orally administered drops and an injectable vaccine. Both work by introducing different strengths of the virus into the body, which reacts by producing antibodies and blood cells via the immune system that guard against any future contracting of the disease.
- Oral polio vaccines should be administered at 2 months; 4 months; 6 to 18 months and 4 to 6 years of age.
- The World Health Organizations and other humanitarian organizations including CARE have established a countdown for eradicating the virus from earth by 2005.
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