Today (13th January, 2014) is a landmark day in the history of public health in India. It is exactly three years since the last Polio case was detected in India. Ruksha Shah, from the Subharara village in the Panchla block of District Howrah, West Bengal was the last recorded case of Polio in India. India has traditionally been a difficult country to eradicate polio from. There has been a steady trickle of cases despite massive efforts to control the disease and there have been pockets that have been difficult to reach, both due to geographic and cultural reasons. However, all of these are now slowly being pushed into the background as India is awakening to a new era: of official polio eradication status.
It is indeed a wonderful achievement simply because of the enormity and the logistic immensity of the issue. Imagine reaching every nook and cranny of a billion-strong nation, a cultural cornucopia, a polyglot of languages, a social-cultural-economic potpourri with one single message: two drops of life (the oral polio vaccine, of which two drops are given, was popularised with this catchphrase in India: do boond zindagi ki) and armed with a small vial of vaccine. Imagine meeting resistance from cultural pockets that believed that the vaccine was actually a vile ploy to cause sterility and control population; then trying to convince an entire community that it was not the purpose for the vaccine. Imagine the man-hours and the money that needed to be pumped in to ensure that the target groups were vaccinated, then a door-to-door round up was done to ensure nobody was missed; followed by an external monitoring system for quality assurance! And all of this concerted effort in order to bring down a disease that had almost been uprooted, but obstinately refused to be eradicated completely.
One must remember that this national-level concept of eradication, however, is slightly naive. Yes, it does bear testimony to India’s commitment to eradicating the disease, yet, the very concept of disease eradication at a national level remains pretty much redundant in today’s global village. A small example of the fact:
Globally, in 2013, it has been the non-endemic countries that have contributed more to the load of polio cases. That is, countries that had eradicated the disease (like India), were the ones which got re-infected with the stubborn virus. Importation of cases is a major problem that has been the bane of the eradication efforts. The three countries that still remain endemic for Polio, Pakistan, Afghanistan and Nigeria, have scaled up the efforts to reach eradication status, but that seems to be a distant dream. Especially true for ares in which there is political unrest and organised terrorism, for these countries, and many others in which polio is an emerging threat, the virus is but a mere part in the whole game. Social, political, economic and cultural determinants have become equally, if not more, important factors in the bid to eradicate polio.
A classic example of Polio becoming a biosocial phenomenon with aetiologies grounded in more than just biomedical issues is the case of the Syrian Arab Republic. The site of an ongoing political unrest, with the resultant breakdown of social and other security systems, this nation experienced an importation outbreak resulting in 17 cases in October 2013. What has to be noted is that Syria had not reported a single case of polio since 1999 and a decade and half long success crumbled in the face of a mere few months of instability. This does not bode well for any nation, globally speaking, as long as there is transmission of the virus and reporting of cases from the endemic nations.
Being a subclinical infection that can be carried around without any obvious symptomatic appearance, polio has managed to spread on a global level from a few foci. And though we have many reasons to laud the efforts in India, we still have to keep up our guard. The threat of importation is real, with the complex geopolitical issues at play. And the need to maintain a high level of herd immunity to ward off imported virus is self-evident. Also important is the need to have in place a strategy that phases out the live, attenuated oral vaccine and instead shift to the killed, injectable one. This is an important shift because this will have to use more trained personnel as an injection is a procedure with higher complication risks than just delivering drops orally.
There is no room for slackening. The fear is that, with the news and celebration of the eradication coming through, there will be some sort of a release phenomenon and some complacence will set in. There is, however, no room for slowing down. The momentum needs to be maintained and, if anything, an increased alertness should be instituted to keep up the morale of the workers who might want to slow down. It might be easy for the community to regress into a state of denial about vaccination and lose the ground gained in the past few years.
It has been a long time coming, and rarely does one have to wait for success to be served cold. However, the three years is up and India and her public health professionals are awakening again, it is the moment of our tryst with destiny. It is our unique opportunity to create a watershed line and mark the rise of a healthier nation.