Eliminating polio requires global, coordinated effort -- Health Affairs article highlights risks, rewards of eradication

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Eradicating the wild polioviruses was supposed to have been achieved by 2000, but the effort to fight the disease is still ongoing. Polio cases reached an all-time high this century --1,997 cases -- in 2006. In 2008 there were more than 1,600 cases identified in 18 countries. For polio eradication efforts to succeed, countries must focus on several "weak links" to sustain population immunity from the virus, argues Scott Barrett, an economics professor at Columbia University in New York City.

Barrett's paper is one of many articles on global health in the new Health Affairs issue, which is supported by a grant from the Bill and Melinda Gates Foundation. Other issue highlights include a discussion of an innovative new international approach to providing affordable antimalarial drugs; an examination of the extent to which people, particularly in low- and middle-income countries, are forced to borrow money or sell assets to afford health care; a study of whether donor funding supplements or substitutes for health care spending by governments in developing nations; and a discussion of diplomatic efforts to combat a boycott of polio immunization. A full table of contents follows, and all articles are available to reporters upon request.

Papers Examine Challenges Of Eradicating Polio

Barrett describes the "weakest links" that must be strengthened if the world is to eliminate the spread of polio. Barrett says global health leaders need to focus on the following:

* Stopping the transmission of the wild polioviruses in countries such as Afghanistan and Pakistan, where war and the resulting upheaval hinder efforts to control the virus, and regions such as the northern Indian states of Uttar Pradesh and Bihar, where the presence of other health conditions appears to weaken the ability of certain forms of polio vaccine to stimulate immunity;

* Making sure that wealthy countries and private foundations continue financing anti-polio initiatives;

* Coordinating use and eventual termination of the oral polio vaccination among countries because weakened live virus strains in the oral vaccine can occasionally mutate and circulate as vaccine-derived poliovirus;

* Securing stocks of wild poliovirus stored in laboratories all over the world;

* Promoting effective surveillance and reporting of polio outbreaks; and

* Making sure countries are prepared to respond to outbreaks even after the wild polioviruses have been eradicated.

If poor countries could get access to IPV more cheaply and eventually stop use of the oral vaccination, many of the post-eradication "weakest links" would fall away, Barrett argues.

"Although the world's attention today is understandably focused on eradicating the wild viruses, the ultimate success of the initiative will depend as much on the steps being taken now to improve the economics of inactivated polio vaccination," he concludes.

In a related paper, Judith Kaufmann and Harley Feldbaum, of the Global Health and Foreign Policy Initiative of the Johns Hopkins School of Advanced International Studies, examine the diplomatic actions taken by the Global Polio Eradication Initiative, the United Nations, and the U.S. government to address the 2003-2004 northern Nigeria boycott of polio vaccination. The boycott had a strong political component and was fueled by rumors that the polio vaccine was contaminated with antifertility drugs intended to sterilize young Muslim girls. This boycott led to a global outbreak of polio, with cases spreading to 20 countries across Africa, the Middle East, and Southeast Asia, and it eventually cost more than $500 million to control.

Kaufmann and Feldbaum examine the diplomatic actions used to resolve this global health crisis, and draw conclusions about the processes and importance of health diplomacy.

"Flexibility, coordination among multiple actors and a willingness to mix politics, public health, and diplomacy were all a part of the effort. All must be part of the toolbox to address future global health challenges," they conclude.

A New Approach To Delivering Antimalarial Treatments

The global fight against malaria faces the ongoing challenge of making effective medicine affordable in developing countries. Growing resistance to traditional antimalarial drugs has made treatment more difficult, and newer, artemisinin-based medications -- the only drugs to which resistance has yet to develop -- are at least 10 times more costly than older, less effective drugs. In developing countries, most antimalarial medication is purchased at small drug stores in rural villages -- places where conventional development assistance and public-sector channels do not reach.

In 2001, in an effort to delay resistance, the World Health Organization issued a recommendation that artemisinins be used only in combination with another effective antimalarial -- as artemisinin-combination therapies (ACTs) -- for the treatment of malaria. However, artemisinin monotherapies continue to be used widely around the world. In their paper, Ramanan Laxminarayan and Hellen Gelband of Resources for the Future discuss a global subsidy that uses the distribution channels of the public and private sectors to make effective drugs accessible to those who need them while simultaneously reducing the risk of the development of resistant strains of malaria.

Laxminarayan and Gelband describe the barriers to creating such a subsidy, which challenged "orthodoxies of development assistance and medical care." "By recognizing that perfect systems would not be built in time to save malaria patients or artemisinins, the [Affordable Medicines Facility - malaria] AMFm carved out an alternative path for effective drugs to get to patients in the meantime," they write.

"The most lasting indicator of success is that with stronger public health systems, the success of malaria elimination, and lower-cost ACTs through technological innovation, the need for the AMFm will disappear," they conclude.

Borrowing And Selling To Pay For Care

Health care costs burden families all over the world, but a new study shows that people in low- and middle-income countries are hit especially hard. Out-of-pocket payments account for 70 percent of health financing in low-income countries, compared to 14.9 percent in high-income countries. In an analysis of data from the World Health Survey, Margaret Kruk of the University of Michigan and colleagues found that one in four families in these countries borrow money or sell assets to pay for health services. Survey respondents represented 40 countries and a combined population of 3.66 billion, or 58 percent of the world's population.

Kruk and colleagues suggest that by using prepayment systems -- such as tax-based health financing and social insurance -- to increase spending on health services, governments can protect families from economic hardship due to health care-related expenses.

Donor Funding And Government Spending

Donor funding from government and private sources of health aid to developing countries has increased significantly in the last two decades, reaching $13.7 billion in 2006. In a new study of donor spending in low- and middle-income countries, researcher Marwa Farag of Brandeis University and colleagues found that a 1% increase in donor funding was associated with a 0.19% decrease of government health spending in low-income countries, holding everything else constant. Donor funding is thereby partly replacing, rather than simply supplementing, government health spending, as "donors seem to regard the health sector as more important than governments do." This can have negative long-term consequences if donor funding is reduced or stopped and governments have committed their resources elsewhere.

Farag and colleagues point to how this funding substitution "requires the agencies responsible for donor coordination to pay special attention to what happens to the government share of health funding and to understand the influence of their efforts on national health systems."

Burness Communications