UPDATE ON POLIO ERADICATION

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(This article appeared in the April 23, 2010 edition of the Wall Street Journal)

Gates Rethinks His War on Polio

Bill Gates walked into the World Health Organization's headquarters in Geneva—for a meeting in an underground chamber where global pandemics are managed—and was greeted by bad news. Polio was spreading across Africa, even after he gave $700 million to try to wipe out the disease.
That outbreak raged last summer, and this week a new outbreak hit Tajikistan, which hadn't seen polio for 19 years. The spread threatens one of the most ambitious health campaigns in the world, the effort to destroy the crippling disease once and for all. It also marks a setback for the Microsoft Corp. co-founder's new career as full-time philanthropist.
Next week, the organizations behind the polio fight, including WHO, Unicef, Rotary International and U.S. Centers for Disease Control and Prevention, plan to announce a major revamp of their strategy to address shortcomings exposed by the outbreaks.
Nigeria is ground zero for the reemergence of polio. Now the country is making surprising headway against the crippling disease, in part thanks to an unlikely meeting of two leaders: Microsoft mogul Bill Gates, and the Sultan of Sokoto, the spiritual leader of Nigeria's 70 million Muslims. WSJ's Rob Guth reports.
Polio is a centerpiece of Mr. Gates's charitable giving. Last year the billionaire traveled to Africa, one of the main battlegrounds against the disease, to confer with doctors, aid workers and a sultan to propel the polio-eradication effort.
"There's no way to sugarcoat the last 12 months," Bruce Aylward, a WHO official, told Mr. Gates in the meeting in the underground pandemic center last June. He described how the virus was rippling through countries believed to have stopped the disease.
Mr. Gates asked: "So, what do we do next?"
That question goes to the heart of one of the most controversial debates in global health: Is humanity better served by waging wars on individual diseases, like polio? Or is it better to pursue a broader set of health goals simultaneously—improving hygiene, expanding immunizations, providing clean drinking water—that don't eliminate any one disease, but might improve the overall health of people in developing countries?
The new plan integrates both approaches. It's an acknowledgment, bred by last summer's outbreak, that disease-specific wars can succeed only if they also strengthen the overall health system in poor countries.
If successful, the recalibrated campaign could shape global health strategy for decades and boost fights against other diseases. A failure could rank the effort as one of the most expensive miscalculations in mankind's long war with disease. Already, polio has evaded a two-decade-long, $8.2 billion effort to kill it off.
Big donors have long preferred fighting individual diseases, known as a "vertical" strategy. The goal is to repeat 1979's victory over smallpox, the only disease ever to be eradicated. By contrast, the broader, "horizontal" strategy has less well-defined goals and might not move the needle of global health statistics for years.
The polio fight is a lesson for Mr. Gates's foundation, which is funding other vaccines that could face similar setbacks. In the polio fight, his foundation backed a program that was following an outdated playbook. Polio's resurgence last year forced a major rewrite.
The shift on polio was informed by Mr. Gates's trip last year to Nigeria, a nation with a history of exporting the virus to other countries. Mr. Gates was accompanied by a Wall Street Journal reporter.
Mr. Gates has forged himself as a global-health diplomat following his 2008 retirement from Microsoft. He is using his star power and $34 billion philanthropy to try to push businesses, health groups and governments to improve health in developing countries.
In the Nigerian city of Sokoto, the dusty center of a once vast Islamic empire, Mr. Gates drove to a palace, walked past a row of trumpeters and found himself looking up at a man on a throne wearing a flowing robe and turban—the Sultan of Sokoto, spiritual leader of Nigeria's 70 million Muslims.
Just as Mr. Gates introduced himself to the sultan, the lights flickered out.
"I want to welcome you to the real world—to the real third world," the sultan said to Mr. Gates from his gilded chair in the darkened room.
Men like the sultan are important allies. In 2003, Islamic leaders in northern Nigeria spread rumors that polio vaccines sterilized Muslim girls. Leaders halted vaccinations, allowing the virus to spread. The WHO said the virus eventually infected 20 countries.
By the start of last year, Nigeria was home to half of the world's 1,600 polio cases. The sultan could help get the campaign back on track.
Speaking to Mr. Gates and a room of religious leaders, the sultan declared his support for the polio fight. "We want to show you our commitment," he said. "The time you have taken to come here will not be in vain."
But he, too, questioned the wisdom of targeting one disease. "Other health issues should be looked into," the sultan said, "instead of just facing one direction with polio eradication." He ticked off tuberculosis, HIV and AIDS, malaria, cholera and a parasitic infection known as "snail fever."
After the global victory over smallpox 30 years ago, a rush of energy went into similar "vertical" attacks on single diseases. The polio program followed that approach and made great gains. Led by WHO and donors such as Rotary, the campaigns by the year 2000 slashed the world's polio cases to under 1,000 from 350,000 in 1988. Polio fighters planned to eradicate the disease by 2000.
That date came and went. But polio persisted, eating up billions of dollars.
Critics argued for a shift away from killing polio to free up money for controlling multiple diseases. In some countries, polio campaigns became an example of a functioning vaccination system even as other diseases were missed. Mr. Gates saw that himself in Nigeria.
Arriving at a Sokoto health clinic in a Toyota minivan stocked with Diet Coke, Mr. Gates stepped inside and was soon leaning on a wooden desk, flipping through children's vaccine records. "Do you know if this child had the first dose of DPT?" he asked, pointing to a record of a diphtheria vaccination of a boy who appeared to have missed a treatment. A health worker beside him didn't have an answer.
The clinic also had no hepatitis B and yellow fever vaccines, the workers said, because the government's system for supplying medicine wasn't working.
By contrast, in front of the clinic, a polio campaign was in full swing. Health workers tended coolers filled with vials of vaccine for children gathered there.
At a meeting the next day in the capital, Abuja, Nigeria's head of primary health care, Dr. Muhammad Ali Pate, reopened the vertical-vs.-horizontal debate. Even if Nigeria lowers polio cases, he said, the gains "can't hold" without a broader health-care system, he said.
Mr. Gates listened, seated behind a name tag that read "Our Guest." Dr. Pate showed a slide of a cartoon steam-engine train with cars labeled "Education" and "Disease Control." Polio should be just one car in that train, he said.
Mr. Gates didn't disagree—certainly Nigeria needs a functioning health system, he said in interviews. But it was a matter of priorities, he said. With the world so close to killing polio, countries like Nigeria should make eradication a top priority, he said. Victory would free up millions of dollars to pay for broader health improvements.
"So the benefit of finishing is huge," he said.
On the plane, Mr. Gates strategized about what else would help win the fight, balking at one religious leader's suggestion: forced vaccinations. "Strap 'em, down, I say! Let's make it illegal" to not take the vaccine, Mr. Gates joked. Then he got serious again, citing failed attempts in the U.S. to enforce compulsory vaccinations.
In many respects, Mr. Gates remains a tech geek at heart. Aboard his plane, he expounded on an array of scientific topics: From developments in genotyping, to research showing that Bangladesh's high disease-immunity rates are due to "oral-fecal" transmission (when people build immunity by ingesting contaminated food or water).
In Nigeria, Mr. Gates scored a diplomatic triumph. He won commitments from the sultan, and from Nigeria's governors, to take a more active role in polio vaccinations. "We really stand at the threshold of global health success on polio," he told the assembled governors at the close of the trip.
However, just three days later, a new front opened 2,000 miles away in Uganda. There, a woman walked into a hospital to say her son couldn't move his left leg. It was Uganda's first polio case in 12 years.
Cases also popped up in Mali, Togo and Ghana and Cote d'Ivore, which hadn't reported polio for four years. A girl in Kenya became that country's first polio case since 2006.
Polio, which spreads through water contaminated by human feces, paralyzes just one person for every 200 infected. Discovering just a few cases could mean that thousands have been infected. That demands massive vaccination campaigns.
On Feb. 28, 2009, Mr. Aylward, the WHO official, was grocery shopping in Geneva with his wife and son when he got an urgent email about the Uganda case. For 30 minutes, Mr. Aylward stood next to a spinach display, working his phone and setting in motion a plan that 10 days later vaccinated 48,000 children in Uganda.
Costly emergency responses like this became increasingly common last year. The Gates Foundation had set $47 million aside for emergencies, Mr. Aylward said. By early June, the money was running down.
That month, Mr. Gates flew to Geneva for the meeting in the WHO's underground room.
Mr. Aylward came with good news to offset the bad news about polio's resurgence, he recalled later. After describing the outbreaks, he shifted to Nigeria's progress against polio and described positive results from a trial of a new vaccine.
But those positives didn't offset the risks of polio's revival, say several attendees of a follow-up meeting. "It was becoming evident that the virus almost knew no bounds," said Dr. Steve Cochi, senior adviser at Centers for Disease Control. "It kind of confirmed some of our worst fears."
A month later in Seattle, Gates Foundation officials paused at a PowerPoint presentation showing the foundation's polio grants were approaching $1 billion. It was a staggering amount for a program that appeared to be stalling. "We can't go to Tachi and Bill and ask for more money," without reviewing the program, one person said, referring to Mr. Gates and Tachi Yamada, a top foundation official, according to an attendee.
In August, experts commissioned by the WHO landed in Angola, Pakistan, Afghanistan, India and Nigeria to evaluate the polio program. In Africa, a team found that once polio had been ended in some countries, weak health-care systems let it return. In northern India, bad sanitation, malnutrition and other intestinal issues are believed to hurt the oral polio vaccine's effectiveness.
These findings echoed the message to Mr. Gates in Nigeria, and marked a turning point among the Gates Foundation and other backers of the polio fight in the debate over whether the strictly "vertical" polio strategy could succeed.
In October, the Gates Foundation summoned backers of the program, including Unicef, CDC and Rotary, to its Seattle headquarters for a major rethink. Two weeks later it called in independent experts for help. The outcome of those meetings will be reflected in the revamped plan coming next week. Polio backers say they are buoyed by reports of just 71 polio cases worldwide this year, vs. 328 in the year-earlier period.
If approved in May by member nations of the WHO, the new strategy will set ambitious goals for getting close to eradicating polio by the end of 2012. The plan bolsters the core "vertical" approach of polio program but also adds a "horizontal" strategy, including training for health workers on topics such as hygiene and sanitation.
Nigeria will be a key testing ground. The country has made strong progress against the disease since Mr. Gates's visit. But stopping polio there, and in at least one of the three other countries where it's deeply rooted, will be the main challenge in the next three years, Mr. Aylward says. Failure to achieve that goal will raise questions over whether the program continues, he says.
A big hurdle is money. The polio program is $1.4 billion short of the $2.6 billion it needs over next three years. The Gates Foundation will continue its polio grants, but says it can't make up the shortfall.
But funding is just one worry for Mr. Gates in his new career. He built his foundation on the promise of life-saving vaccines, reflecting his penchant toward finding technological solutions to problems. As polio shows, technology can be hampered by political, religious and societal obstacles in the countries where he's spending his money. He's still learning how to navigate through those forces.
In Nigeria last year, Mr. Gates sat on the lawn behind his hotel reflecting on that. Science can simplify the job, he said, but "the human piece is the ultimate test."