A bad immunization decision

Dr Shakeel Afridi  made a very bad immunization decision. Although his decision involved hepatitis vaccination it has implications for polio.

Eradication of polio would be a great human achievement. Only once before have human beings work together successfully to eliminate the disease from our planet. In many ways we are making progress in the efforts to eliminate polio. In January of this year India past the one-year mark for being polio free. So far this year there have only been 60 confirmed cases mostly in the three remaining endemic countries Afghanistan, Pakistan, and Nigeria. Last year at this time there had been 165 cases. 

The original plan was to eliminate polio by the year 2000. A couple of years later the war in Afghanistan made the efforts to eliminate polio all that much more difficult. Successes are often followed by failures.  In 2010 devastating flooding in Pakistan led to major outbreaks.  Many places that have been polio free become reinfected from time to time. Most of the polio cases in Pakistan and Afghanistan are in the border regions between the two countries where infections in the knocked back and forth like a volleyball. 

Although we may be closer than we have ever been to the goal of eliminating polio this last bit may prove to be exceedingly hard. There is a problem of donor fatigue. The budget for the next few years stands at just over $2 billion, nearly $1 billion still need to be raised. The 2012 world polio eradication budget is $270 million short. Even the unfunded $2 billion budget is lacking resources for funding ongoing polio immunization in areas that are vulnerable to reinfection.

Beyond the financial struggle there is the very real challenge of conducting an immunization campaign in a war zone. At times the polio eradication campaign has been seen by some communities as a Western conspiracy. One of the stumbling blocks in Nigeria has been acceptance from some local Islamic leaders. Similarly the Taliban has an uneasy relationship with immunization efforts. Some Taliban have believed that immunization efforts were really a conspiracy to sterilize Muslim populations. Even though both the Taliban and local Islamic leaders in Nigeria have more recently supported immunization campaigns, “immunization efforts” are not always innocent and free of conspiracy.

Dr Shakeel Afridi was recently convicted of espionage by the Pakistani government. Afridi was involved in CIA efforts to look at DNA samples that were acquired from immunization needles in Abbottabad. The target of that search was DNA of children of Osama bin Laden. When the CIA identified that his children were in the area that helped in confirming their belief that they had found the compound where he was dwelling.  Although this DNA search apparently involved giving real hepatitis vaccinations Dr. Afridi acted in a way that violated multiple principles of medical ethics. One might try to justify many of these violations on the grounds of stopping Osama bin Laden. Patient privacy, for instance, is broken for much smaller police investigations. 

What is particularly objectionable, is that this fraudulent campaign has the potential to undermine polio eradication efforts. There has already been some suggestion of fear of immunization by people in tribal regions of Pakistan. The concern these people have is that the immunization campaign may be a front for an effort to track down Taliban leaders. Even a small amount of nonparticipation in the polio eradication campaign could allow the virus to harbor, and later breakout. We need to be vigilant against the possibility of even a small number of cases spreading to other countries and then like dominoes spreading beyond. At this point, such an outbreak could put back the eradication efforts by years, if not even leading to the collapse of the efforts altogether. Political enemies come and go, wars do not eliminate them. On the other hand, if eradicated, polio will not come back. 

Let's do a cost comparison. According to the website “cost of war” the cost of the Afghanistan war is now over 500 billion, so the ratio between the amount spent on this useless war and the amount still needed to eliminate polio, is greater than 500:1. Let's look at it another way, the Center for Defense Information estimates the cost of a team of four drones to be about $120 million (they typically fly in teams of4) a little more than two teams would cover the unmet polio eradication budget needs for 2012.

The CIA's program that used immunization to engage the DNA of children in tracking down and killing their father may have unforeseen ramifications regarding the effort to eliminate polio. The American war machine is not much on apologies, or paying for their mistakes, but in relationship to the Pentagon budget a couple hundred million dollars is hardly anything.