The cost of war: Polio rises again in Syria

The outbreak of polio in the Syrian Arab Republic announced by the World Health Organization a few weeks ago is a troubling reminder that global conflicts threaten the public’s health. Violence, like the 2-1/2-year-old civil war in Syria, can lead to significant disruption and/or long term damage to the public health infrastructure, including basic sanitation efforts, maintenance of a safe water supply, basic nutritional needs, and disease monitoring and prevention.

Because of the Global Polio Eradication Initiative, this latest outbreak is especially troubling. But it should not be surprising. The displacement of so many Syrians fleeing the fighting has devastated the county’s once robust public health infrastructure and stymied immunization efforts. Syria had been polio-free for a decade. Ten polio cases, with many more likely to be reported, are now confirmed.

Polio, technically known as poliomyelitis, is a viral disease that can lead to full or partial paralysis, and sometimes death. The United States experienced periodic local polio epidemics until the development of the Salk and Sabin vaccines, introduced in 1955 and 1963 respectively. Before the vaccines were introduced, tens of thousands of Americans contracted the virus, which could leave them either partially or completely paralyzed. Dr. Jonah Salk’s birthday, Oct. 24, is now celebrated as World Polio Day.

Syria isn’t, of course, the only nation in conflict where polio threatens the health of the population. But there's a theme: In Pakistan, a Taliban ban on vaccination in the North Waziristan region under its control has resulted in the crippling of many children whose health and mobility might have been preserved by inoculation with polio vaccine. The CIA’s use of a fake vaccine campaign in its effort to hunt down Osama bin Laden didn’t help, fomenting distrust and leading to the murder of polio vaccine workers. For similar reasons polio remains endemic in portions of Afghanistan and in portions of Nigeria.

Israel, where no cases have been reported, has confirmed presence of polio virus in its sewers, indicating that vaccinated individuals have likely been exposed to the virus and are shedding it through their feces, putting unvaccinated people at grave risk. Almost all Israelis have been immunized with the inactivated polio virus (IPV), which protects people from getting sick. But individuals vaccinated with IPV can, if exposed to polio, still shed the virus in the feces. Only the oral polio vaccine (OPV), a live but weakened form of the virus, is effective at preventing the fecal spread of polio.

Historically, efforts at disease eradication began at the local level--isolation and quarantine practices prevented ships from plague-ridden regions from landing. Next came regional attempts, such as the crusades against hookworm and malaria (now back in the US. with rates the highest they have been in 40 years) in the southern United States. The first global effort at disease eradication led to the triumphant announcement that smallpox had been eradicated in 1980 after an intensive effort that began in 1967, when smallpox could still be found in 12 countries or territories. Over the 20^th century, smallpox took the lives of an estimated 300 million people. The Global Polio Eradication Initiative, underway with support from 80 countries and 40 leading universities and schools of medicine and public health, aims to eradicate the disease by 2018.

The political, medical, and cultural challenges threatening the polio eradication effort and questions about whether disease eradication is a viable and achievable goal or whether disease-control is a preferable pathway are ones the world is confronting today. While these issues are discussed and debated, the polio outbreak threatening the Middle East serves as a potent reminder of how epidemics can spread and of the difficulties faced by global health leaders attempting disease eradication or control.