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A Priceless Legacy: The Global Campaign

NIDs are not unique to Bangladesh, but are part of a global effort that has brought the world remarkably close to its goal of eradicating polio by the year 2000, a priceless gift from the 20th to the 21st century.

In 1998, NIDs protected 450 million children — more than two thirds of all the world's under-fives — against polio. In 1997/98, 36 countries in Africa held NIDs and most immunized more than 80 per cent of under-fives. Some 32 million children were vaccinated in the Middle East, the Russian Federation, the Caucasus and the Central Asian republics during March through May 1999. By early 1999, virtually all countries where polio is endemic had held NIDs.

In a number of instances, exceptional efforts were made. In Tanzania and Zambia, boats and planes were used to reach villages on islands and in the mountains. In an area of Sudan the size of the United Kingdom, but with just 40 km of paved roads, bicycles were flown in for delivering vaccines. In China — where two thirds of the country's terrain is either mountain, highland or plateau — health workers carried vaccines on horseback to remote settlements.

But perhaps most remarkable and moving has been the agreement of warring parties to silence their guns — in Afghanistan, Cambodia, the Philippines and Sri Lanka — in order to allow children to be immunized.

Regionally, we in Bangladesh and our neighbours in Bhutan, India, Myanmar and Nepal have worked together to hold NIDs on the same day, for maximum impact. In India, where WHO reported 70 per cent of the world's polio cases in 1998, 127 million children were vaccinated on a single day in January 1997 and even more — 134 million — in 1998, in the largest and most spectacular health events ever organized by any country.

I would like to take this opportunity to say a few words about my country. Bangladesh is a young nation in all senses of the term, except in our tradition and heritage, which are centuries old. Bangladesh came into being as a sovereign, independent State only a little over 25 years ago.

Nearly half of our people are under the age of 18, a demographic reality that helps explain our concern for and firm commitment to the welfare of our children, adolescents and youth, expressed at the World Summit for Children in 1990 and later reflected in our National Plan of Action. We were also among the first 20 countries to ratify the Convention on the Rights of the Child, thereby bringing it into force.

In our country, 370,000 children under the age of five still die each year, primarily from diarrhoea, acute respiratory infections, measles, neonatal tetanus and other vaccine preventable diseases. To reduce this loss, we have worked through the Expanded Programme of Immunization (EPI) to achieve a near-miraculous increase of immunization coverage for our children. Spurred by EPI, we have set up a delivery system that reaches every corner of our country, with 108,000 EPI outreach sites now being used for immunizations and for other life-saving interventions, including health education and counselling, information on oral rehydration therapy (ORT), and micronutrient supplementation.

Thus, we are working to eradicate polio and eliminate vitamin A deficiency, our two most important public health concerns. We are also waging an offensive against major childhood diseases, malnutrition — affecting more than half of our children virtually from their very first year — and micronutrient deficiency. Victory is still a long way off but we are determined to win.

The fight against polio is global, led by WHO, in partnership with UNICEF, Rotary International, the US Centers for Disease Control and Prevention and literally thousands of groups around the world. The mass vaccination campaigns are the latest breakthrough against this elusive and ancient disease.

Polio has been known for at least 3,000 years — its immobilizing power was depicted on an ancient Egyptian engraving. It paralysed or killed about half a million people every year at its peak, before the development of a vaccine in 1955.

The disease can, thankfully, be completely eradicated, and NIDs are crucial in attaining this goal. By vaccinating all of a country's children at the same time with the oral polio vaccine, NIDs ensure that the wild virus is driven out of this large pool of hosts. This leads to its extinction, since it has no animal or insect reservoir in which to hide and can survive only briefly in the environment. It will follow smallpox, the first disease ever eradicated (in 1979, after a 12-year global campaign), into the annals of history.

But polio is a more elusive enemy than smallpox. Although it is highly infectious, polio rarely causes distinctive symptoms. Paralysis occurs in fewer than 1 per cent of cases; about 90 per cent produce virtually no symptoms at all. Some 200 people can be infected before a paralytic case finally signals an outbreak.

Another complicating factor is that the polio vaccine needs to be administered several times to attain adequate immunity — unlike the smallpox vaccine, which had to be given only once.

Despite these obstacles, a four-stage strategy against polio is working well. First, as many infants as possible are routinely immunized four times in their first year of life, as part of a series of vaccinations against the six major childhood diseases. Next, through NIDs, all children under five receive an additional two doses of polio vaccine, spaced about a month apart. Third, a surveillance system is set up to ensure that no polio case goes unidentified. Teams then go house-to-house to immunize every last child in areas where the virus is known or suspected to be circulating.

Routine immunization, the first stage of the strategy, has been widely embraced. By 1990, 4 out of every 5 infants worldwide were routinely immunized — up from just 1 in every 20 in the 1970s. But the proportion of the world's under-ones who are routinely vaccinated has fallen slightly in this decade (though the actual numbers have risen along with population increases), and the coverage rates in a number of countries and in specific areas remain far lower than the average. NIDs, by supplementing routine immunization, are vital in breaking this impasse.

The results speak for themselves. The number of polio cases worldwide has been cut dramatically in a decade. In 1988, according to WHO, there were an estimated 350,000, of which only 10 per cent were reported. In 1998, with improved surveillance, just over 5,000 cases were reported. North and South America have been officially certified polio-free, and in Europe, only Turkey has reported cases in the last year. Polio is rapidly disappearing from North, Southern and Eastern Africa and the Arabian Peninsula; in East Asia and the Pacific, the last case was reported in Cambodia in March 1997. Less than a decade ago, 10,000 children were paralysed in an epidemic in China; now, after a series of NIDs, no cases are reported there at all.

Polio has retreated to a few final strongholds — Afghanistan, Bangladesh, India, Nepal and Pakistan in Asia, and Somalia, Sudan and parts of West and Central Africa. But even there, the world is winning.

We must maintain the momentum for eradication for the sake of our children. The gains have already been enormous. In all, 2 million to 3 million children worldwide are able to run, jump and play normally who — but for the campaign — would have been paralysed by polio.

As long as polio exists, the world has to spend $1.5 billion total each year to stop its spread. In the Americas, for example, more is spent to remain polio-free than is needed to eradicate the disease permanently throughout the world. We can all imagine how such resources could be better used.

Another dividend that is already benefiting children is the experience gained from NIDs in reaching children with other vital health interventions. In our case, as I have described, vitamin A is given along with the polio vaccine.

Vitamin A deficiency, which affects about 100 million children under five, impairs a child's resistance to disease and contributes to nearly a quarter of all deaths among those under five. It is also the leading cause of blindness in children in developing countries. And there is growing evidence that inadequate vitamin A in women greatly increases their risk of death in pregnancy and childbirth.

NIDs have proven to be true 'life-savers' in getting vitamin A to children in Bangladesh: Before we started having NIDs we were unable, despite our best efforts, to reach more than 55 per cent of our children. Now, over 90 per cent receive vitamin A as they are immunized.

The protection is powerful and inexpensive: A capsule costing just two US cents protects a child for up to six months.

Ending vitamin A deficiency is considered as effective in saving lives as two of the great success stories of recent years — immunization against the six major diseases and the use of ORT in treating diarrhoeal dehydration.

For much of the world, progress towards the goal of eliminating vitamin A deficiency, set at the 1990 World Summit for Children, has been good. By 1996, more than half of all young children in countries where deficiency is a public health problem were receiving vitamin A supplements, up from a third just two years before. Now, 35 countries are 'on track' to meet the goal.

Still, there is a gap that must be closed: In some countries rates of vitamin A supplementation are significantly lower than rates of polio immunization. Using NIDs to deliver both, as is done in Bangladesh and another 42 countries, is just the type of strategic advance needed now.

Indeed, both UNICEF and WHO have recommended that all countries with high under-five mortality and where vitamin A deficiency is a public health problem should combine the interventions. Supply is not an issue, since the Government of Canada is generously providing the vitamin A required.

NIDs, originally conceived as a short-term measure to finish off polio, have demonstrated an unsuspected long-term benefit. Studies show they improve cooperation between sectors of government, and that, in conducting NIDs, community organizations gain more central roles in health matters, leading to better communication with health services staff. These developments have already benefited other health programmes. And the 'culture of immunization' that NIDs helped create may also raise levels of vaccination against diseases other than polio.

All these gains can be preserved and actually extended by turning NIDs into broader Child Health Days. Such Days would be used to give vaccinations other than polio and to distribute vital micronutrients and antiworm medicines, as well as to promote mosquito nets treated with insecticide in areas where malaria is a threat. During Child Health Days, activities could be organized to promote breastfeeding, hygiene and the control of diarrhoea, and mothers and other caregivers could be informed about supplementary feeding and the psychosocial stimulation through play and interaction with adults that are vital for a child's healthy development.

The battle against polio has fired the imagination of governments worldwide and mobilized their will as few other causes have done, producing one of the greatest mass efforts in history. During its dramatic course it has also helped to pinpoint, and fill, gaps and weaknesses in existing health services; it has led to better management capacities and communications systems; it has strengthened surveillance systems for diseases; and it has inspired new ways of transporting vaccines while keeping them cool. In these ways, the polio campaign has given governments the confidence, will and capacity to tackle other major health concerns.

These victories, it is clear, need to be the beginning not the end of the story — the opening of a new chapter in ensuring the health of children all over the globe.