The global public health initiative to eradicate polio is "not a done deal." That's the consensus at the 2016 World Health Summit in Berlin. There is plenty of potential for us to fail. On three counts.
If it weren't for the short-sightedness of business, we may not be in the situation we are with polio today. In the late 1990s we were heading towards a global public health goal of eradicating the disease by the year 2000.
By 1999, things were looking good. And the World Health Organization says one strand - poliovirus type 2 - was indeed eradicated that year.
But Suraya Dalil, the Afghan ambassador to Switzerland, suggests commercial concerns at the time may have led us to where we are now.
"We wanted to eradicate polio by 2000," says Dalil. "I remember I was at UNICEF. But the [stock of] polio vaccine was very low because the manufacturers weren't making it, thinking that by 2000 no one would buy it."
And sixteen years later, says Dalil, we still face a global threat. Her home country, Afghanistan, and Pakistan are listed by the WHO as the two places in the world where polio transmission has never stopped.
Polio cases have decreased globally "by over 99 percent since 1988, from an estimated 350,000 cases then to 74 reported cases in 2015," says the WHO.
It has, however, reemerged in countries at war, like Syria, where immunization levels were once at 80 percent but have dropped to 41 percent. Elsewhere, there have been what Stephen Matlin of Imperial College London calls "setbacks."
"We've seen new cases of polio in Nigeria in three regions under Boko Haram control," says Matlin. And "genetic matching" has shown it was not properly controlled in the first place.
Reaching the "missed children"
The WHO says polio mainly affects children under 5 years of age. In 1 in 200 infections, it leads to irreversible paralysis, and in some cases that paralysis can be fatal when the child's breathing muscles become immobilized. There are three strains of wild poliovirus (type 1, 2, and 3). "Failure to eradicate polio […] could result in as many as 200,000 new cases every year, within 10 years, all over the world."
Afghanistan has been running a vaccination program for 20 years, says Dalil. It is the only such program in the country that goes door-to-door to "reach every child."
Dalil says 60 percent of polio cases in Afghanistan are imported from Pakistan. The two countries share a "huge border" with the potential for a million children to cross. You could say it is a burden. But Dalil says it's also an opportunity. And that's why Afghanistan has set up vaccination centers along its southern and eastern borders.
Security a key challenge… and money
There are also significant security issues - even though, Dalil says, the Taliban is "okay" with polio vaccination programs. Security issues loom large in Syria and Nigeria to name two locations.
Matshidiso R. Moeti, the WHO's regional director for Africa, says security is a "key challenge" in eradicating polio. Nigeria, for instance, collaborates closely with the military on vaccination programs. The military goes in first and "cleans up," she says. "But I don't want to contemplate too closely what that means."
"We need to learn the lessons from polio so we know how and when to work in these insecure areas," says Moeti. "And we need to make sure eradicating polio is not just a commitment of a country's health minister, but also of its finance minister."
Often governments rely on private initiatives, like the Bill and Melinda Gates Foundation, to help with their vaccination responsibilities. They may in fact have to. But richer nations could also pitch in a little more, where there is the political will.
Nellie Bristol, a senior fellow at the Center for Strategic and International Studies, says foreign investment in the US is "better than most" even at 1 percent of the federal budget. But if Donald Trump wins the upcoming election, "all bets are off."
Many ways to fail on polio
There is a lot of talk about eradicating diseases by 2030 at this World Health Summit, whether it is polio, HIV, or tuberculosis. Eradication, however, is not inevitable - even with all the technology in the world. So what if we fail?
Ilona Kickbsuch, who heads the Global Health Center in Switzerland, says "people love to eradicate things, but we may fail to learn the lessons from polio. We have not learnt the lessons from smallpox, so what happens when we next try to eradicate measles."
Failure may be a badge of honor for technology entrepreneurs, who boast about blowing millions of venture capital. But as Silicon Valley moves increasingly into the area of health, it may like to take note there is no room for failure here.
And you got that message loud and clear when Kickbusch's colleague, Stephen Matlin, took the notion of failure to its ultimate conclusion with a simple question on Tuesday (11.10.2016).
He asked: "What if we fail to eradicate polio?"
Matlin says interest in disease always spikes during emergencies, and we saw with the Ebola outbreak in western Africa. So "what does polio need now" to ensure we eradicate it? Surely, not another global pandemic.