A Nigerian Sultan Helps Gates Rethink His Polio Strategy

In 2000, the picture of polio around the world looked pretty good: just 1,000 cases were reported that year. Bill Gates saw this as an opportunity: a chance to invest a little bit of his money and not just control a disease, but eradicate it.

Last year, though, that rosy picture looked both bleak and expensive. As Bruce Aylward of the World Health Organization said, “There’s no way to sugar-coat the past 12 months.” During 2009, we saw a resurgence of polio in 20 countries — many of which had previously eradicated the disease.

The Gates/WHO strategy to fight polio was based on the success of the 1979 smallpox vaccine campaign. In this campaign, though Bangladesh was seen as a last stronghold of the disease, the virus was finally eliminated when a policy of forced vaccination was implemented (which many consider a human-rights abuse). The polio campaign used a similarly simple playbook: vaccinate, vaccinate, vaccinate. And for awhile, it seemed that strategy might work. Now, though, it’s failing. Like the case of smallpox, polio is still deeply entrenched in one place: Nigeria. The country made up half of the world’s polio cases last year, in part due to rumors that have circulated about how the vaccine induces sterility, and in part because of the risk of Vaccine-Associated Paralytic Poliomyelitis, which causes paralysis in about one in a million people who receive the oral polio vaccine.

That’s where the Sultan of Sokoto, ruler of 70 million Muslims living in northern Nigeria, comes in.

In April, Gates flew to Nigeria to talk with the Sultan to try and figure out how to make a campaign against polio work. During that meeting, one of the Sultan’s advisors suggested a mandatory vaccination campaign, but the idea ruffled Gates’ anti-authoritarian feathers. Accordingly, in the absence of such a strategy, the duo agreed to build infrastructure, instead. After all, containment of a disease depends on more than just vaccination — it requires the early recognition, treatment and quarantine of infectious individuals. Fighting a disease like polio requires people to be nutritionally stable and avoid fecal contamination of their food and water (which is how polio is spread).

To describe this focus on infrastructure, the Sultan used a metaphor of a train whose cars are labeled “eduation” and “disease control.” According to the Sultan, polio eradication is just a single car in that train, and the whole train was needed to save lives. While the metaphor may be simplistic, what it represents echoes the long-standing debate between “vertical” (disease-specific) programming and “horizontal” (primary care infrastructure) investment. Though Gates — traditionally a “vertical” approach guy — agrees that an overall health system is necessary, he’s long been rooted in the belief in the need to prioritize, especially in this tight financial climate.

Still, though, when it comes to polio, at this point, Gates seems to be bucking his former support of a strictly “vertical” polio eradication program, in favor of a more comprehensive and holistic approach. How this new thinking will be manifest is yet to be seen.

Photo Credit: World Economic Forum

Caitlin Cohen