PHILADELPHIA – Polio broke out in Central Asia this year, with 560 cases reported in Tajikistan. Cases have also been diagnosed in Russia and Uzbekistan, apparently transmitted by infected but asymptomatic people traveling from Tajikistan.
The Tajikistan outbreak is especially troubling, because the country had been certified by the World Health Organization as polio-free. Indeed, the drive to eradicate polio, as the Tajikistan tragedy shows, may be putting the entire world at risk. It makes no sense to talk about eradicating diseases like polio if a small outbreak in a remote part of the globe can rapidly spread and imperil billions.
That scenario is not merely hypothetical. The Western Hemisphere was certified as polio-free 20 years ago, but there were cases in Haiti and the Dominican Republic as recently as 2000. Four cases were reported in an Amish community in Minnesota in 2005, and many others have been reported in recent years in Angola, Nigeria, Uganda, Kenya, Benin, India, Nigeria, Somalia, Pakistan, Sudan, and elsewhere.
For many in the field of public health, the greatest triumph achieved by medicine in this century was the eradication of smallpox. This astounding accomplishment has played a key role in leading various national and international governments and organizations, including the WHO, Rotary International, and the Gates Foundation, to mount efforts to eradicate many other infectious diseases, such as measles, malaria, and polio.
Eradicating diseases that have killed or disabled untold numbers of people is a goal that is easy to understand and support. As WHO Director Margaret Chan told an audience of Rotarians at the group’s international convention last year, “The international community has so very few opportunities to improve this world in genuine and lasting ways. Polio eradication is one.” Moreover, talk of disease “eradication” is unparalleled as a means to command funding, engage the attention of politicians, and garner positive media coverage.
But there are reasons to wonder whether continued efforts at polio eradication – as opposed to aggressive and effective disease management and control – is the right course to follow.
If polio eradication is the goal for current public-heath campaigns, it is important to recognize exactly what target is being set. Talk of eradication means permanent relief from a disease, and thus permission to let down our guard against it. But the consequences of replacing vigilance with indifference regarding polio are too risky in today’s world.
For starters, the surveillance required to establish eradication is a huge challenge. Political instability, wars and civil breakdown, and balky governments sometimes make access nearly impossible in some parts of the world.
Moreover, it is not clear that all polio cases can be detected, because some infected people do not show symptoms. And the challenge of ensuring adequate surveillance appears insurmountable when one considers that polio can suddenly reappear out of the blue in a so-called wild-type form.
Chasing down the last cases of polio is very costly. Fragile health-care infrastructure and community support are being strained by the eradication effort, as government budgets and resources in poor countries are diverted from more pressing local problems.
In other parts of the world, the emergence of respect for a patient’s right to refuse vaccines creates a difficult challenge for those seeking to eradicate diseases such as polio. Vaccination rates in many parts of the United States have fallen well below 90% for polio, meaning that the risk of an outbreak is very high should a case be introduced. And, in an age of mass air travel, a case in Tajikistan can be in Utah in a day.
Finally, there is the ever-present possibility of bioterrorism. For this reason alone, no trust should be placed in claims of eradication of diseases like polio.
Of course, the eradication of polio is a noble goal. But it is not the right one. The best that can be done is to seek to control polio, and to hope that politics, economics, and ethics allow us to get that far.
Those involved in efforts aimed at complete eradication should rethink their goal, lest faith in the unattainable leads to disaster.
Arthur Caplan is Professor of Bioethics and Director of the Center for Bioethics at the University of Pennsylvania.
Copyright: Project Syndicate, 2010.