Was 2013 the year of the ‘Almost Eradicated’?
By Iruka N Okeke
Eradication, the complete annihilation of a disease, is a rare goal and a rarer accomplishment. The World Health Assembly has signed onto only seven such programs in history. Three were terminated in failure (malaria eradication in the mid 20th century, yaws and yellow fever) and only two – smallpox and rinderpest – have succeeded so far. Good progress has however been made for guinea worm disease and polio. Both guinea worm and polio eradication programs are lagging more than two decades behind their original target dates but eradication is in sight and therefore programs must continue in spite of the challenges. Sadly, Nigeria is among the handful of countries that has struggled in the endgames of both eradication programs. Nigeria was the source of re-introductions to Cameroon in the 1990s and the principal reason why elimination in our neighbor was delayed. In 2008, with Ghana, Mali and Sudan, Nigeria was one of only four countries endemic for guinea worm. The story is similar but more drawn out for polio, where Nigeria, Afghanistan, Pakistan and India (the last now polio-free) were the last bastions and vaccine boycotts in Nigeria led to resurgence of the disease as well as export to polio-free countries.
If one follows and comments on eradication programs in general, and Nigeria in particular, it is easy to become the dispirited bearer of bad news. However Nigeria has a long history of elimination successes. Yaws was never globally eradicated but in Nigeria, it went from being hyper-endemic to eliminated (Eradication implies a worldwide incidence of zero and takes away the need for control measures, wile a disease is eliminated when the incidence is zero within a stated geographical area and control measures need to be implemented to prevent resurgence). The Yaws eradication program was also the precursor to today’s rural health programs. Similarly, Nigeria was not one of the endgame countries in Smallpox eradication. The disease was eliminated across West Africa several years before global eradication was achieved. More recent elimination challenges with Guinea worm and polio lead us to ask what works in Nigeria (and what doesn’t)…and why?
One thing that works in country after country is strong leadership and a well-coordinated program. Leadership by former minister of state Muhammad Ali Pate were recently chronicled in Science (Registration required for link) and many more dedicated foot-soldiers have made elaborate contributions to the polio and guinea worm eradication programs in the last few years. In 2012, Nigeria saw 101 polio cases. In 2013, the number is 49. The news is even better for guinea worm. Nigeria was in precertification for elimination in 2011 and was certified guinea worm-free by the WHO in 2013.
Eradication programs typically begin with large success stories and end in difficult challenges. It is much easier and cost-effective to get from 90% to 9% than from 0.9% to zero. But a program that makes progress towards eradication and does not achieve it is often a resource waste. Therefore the high investments needed for a successful endgame are worth it.
The difficulties Nigeria has seen are not entirely unpredictable. It is hardest to make progress in highly populous countries with weak health systems. But all countries that struggle with disease control have everything to benefit from eradication. Once we have crossed guinea worm disease and polio off the lists forever, Nigeria can focus its resources on more intransigent infections such as malaria, the many other diseases that kill and maim our children, and HIV. Eradication is an all or none event and so we never say ‘almost eradicated’. However, given these recent successes, Nigeria’s public health workers deserve some early applause now.
This post is dedicated to the memories of health workers in Borno and Kano states who were shot last year while distributing polio vaccines.
Iruka N Okeke
Never doubt that a small group of thoughtful committed people can change the world; indeed it is the only thing that ever has…Margaret Mead