community-oriented primary health care (horizontal programmes), donor funded ‘disease specific’ vertical projects, immunisation, non-polio acute flaccid paralysis (NPAFP), polio eradication, Synthetic polio
Polio programme: let us declare victory and move on
NEETU VASHISHT1, JACOB PUlIYEl1
Department of Paediatrics, St Stephens Hospital, Delhi 110054 INDIA Author for correspondence: jacob Puliyel: e-mail: firstname.lastname@example.org
It was hoped that following polio eradication, immunisation could be stopped. However the synthesis of polio virus in 2002, made eradication impossible. It is argued that getting poor countries to expend their scarce resources on an impossible dream over the last 10 years was unethical.
Furthermore, while India has been polio-free for a year, there has been a huge increase in non-polio acute flaccid paralysis (NPAFP). In 2011, there were an extra 47,500 new cases of NPAFP. Clinically indistinguishable from polio paralysis but twice as deadly, the incidence of NPAFP was directly proportional to doses of oral polio received. Though this data was collected within the polio surveillance system, it was not investigated. The principle of primum-non-nocere was violated.
The authors suggest that the huge bill of US$ 8 billion spent on the programme, is a small sum to pay if the world learns to be wary of such vertical programmes in the future
[. . .]
The polio eradication programme epitomises nearly everything that is wrong with donor funded ‘disease specific’ vertical projects, at the cost of investments in community-oriented primary health care (horizontal programmes)(38). Gilliam has described how vertical programmes undermine broader health services through duplication of effort (each single disease control programme requires its own bureaucracy), distort national health plans and budgets and, because salaries of donor-funded vertical programmes are often more than double those of equally trained government workers, lead to a diversion of skilled local health personnel from primary healthcare, causing an ‘internal brain drain’ (39). We have seen how polio, that was not a priority for public health in india, was made the target for attempted eradication with a token donation of $ 0.02 billion. The Government of india finally had to fund this hugely expensive programme, which cost the country 100 times more than the value of the initial grant.
De Maeseneer and colleagues suggest that vertical programmes have unwittingly increased the incidence of other diseases and broken the first rule of medicine – primum non nocere – first do no harm. They cite the example of HiV and hepatitis caused by WHO-endorsed immunisation programmes against other diseases (40). With polio eradication there was a huge increase in non-polio AFP, in direct proportion to the number of doses of the vaccine used. Though all the data was collected within an excellent surveillance system, the increase was not investigated openly. Another question ethicists will ask, is why champions of the programme continued to exhort poor countries to spend scarce resources on a programme they should have known, in 2002, was never going to succeed.
In the final analysis, if the right lessons have been learnt and the world does not repeat these mistakes, the costs may yet be justified.
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