TIME global health

What the Gates Foundation Has Achieved, 15 Years On

Sunny days: Melinda and Bill Gates in 2014, one year before their self-imposed deadline arrived
Sunny days: Melinda and Bill Gates in 2014, one year before their self-imposed deadline arrived Scott Olson; Getty Images

Jeffrey Kluger is Editor at Large for TIME.

Much has been done over the foundation's first decade and a half — with more still to do

There are a whole lot of things you may or may not get to do in the next 15 years, but a few of them you can take for granted: eating, for one. Having access to a bank, for another. And then there’s the simple business of not dying of a preventable or treatable disease. Good for you—and good for most of us in the developed world. But the developed world isn’t the whole story.

The bad—and familiar—news is that developing nations lag far behind in income, public health, food production, education and more. The much, much better news is that all of that is changing—and fast. The just-released Annual Letter from the Bill and Melinda Gates Foundation makes a good case for hoping there is still more to come.

The 2015 letter represents something of a threshold moment for the Foundation. It was in 2000 that the Gateses began their work and set themselves a very public 15-year deadline: show meaningful progress in narrowing the health, income and resource gap between the world’s privileged and underprivileged people, or be prepared to explain why not. So far, nobody—neither the Gates Foundation nor the numerous other global health groups like the World Health Organization and UNICEF—have much explaining to do.

The number of children under five who die each year worldwide has been nearly cut in half, from a high of nearly 13 million to 6.5 million today. Polio has been chased to the very brink of extinction, and elephantiasis, river blindness and Guinea worm are close behind. Drought-tolerant seeds are dramatically increasing agricultural yields; economies in the once-desperate countries in sub-Saharan Africa are now matching the developed world in rate of annual growth. Up to 70% of people across the developing world now have access to wireless service, making mobile banking possible—a luxury in the West but a necessity in places there is no other banking infrastructure.

The trick of course is that progress isn’t the same as success. The 13 million babies who were dying a year in the years before the Foundation began, for example, factored out to a horrific 35,000 every single day. Slashing that in half leaves you with 17,500—still an intolerable figure. For that reason and others, the Gateses are turning the 15-year chronometer back to zero, setting targets—and framing ways to achieve them—for 2030.

The most pressing concern involves those 17,500 kids. The overwhelming share of the recent reduction in mortality is due to better delivery of vaccines and treatments for diseases that are vastly less common or even nonexistent in much of the developed world—measles, pneumonia, malaria, cholera and other diarrheal ills. Those are still the cause of 60% of the remaining deaths. But the other 40%—or 2.6 million children—involve neonates, babies who die in the first 30 days of life and often on the very first day. The interventions in these cases can be remarkably simple.

“The baby must be kept warm immediately after birth, which too often doesn’t happen,” Melinda Gates told TIME. “This is basic skin-to-skin contact. Breast-feeding exclusively is the next big thing, as is basic cord care. The umbilical cord must be cut cleanly and kept clean to prevent infections.”

HIV may similarly be brought to heel, if not as easily as neonate mortality. A vaccine or a complete cure—one that would simply eliminate the virus from the body the way an antibiotic can eliminate a bacterium—remain the gold standards. But in much of the world, anti-retrovirals (ARVs) have served as what is known as a functional cure, allowing an infected person to live healthily and indefinitely while always carrying a bit of the pathogen. Gates looks forward to making ARVs more widely available, as well as to the development of other treatment protocols that we may not even be considering now.

“We’re already moving toward an HIV tipping point,” she says, “when the number of HIV-positive people in sub-Saharan Africa who are in treatment will exceed the number of people becoming newly infected.”

Food security is another achievable goal. Even as Africa remains heavily agrarian—70% of people in the sub-Saharan region are farmers compared to 2% in the U.S.—yields remain low. An acre of farmland here in America may produce 150 bushels of corn; in Africa it’s just 30. The problem is largely rooted in our increasingly unstable climate, with severe droughts burning out harvests or heavy rainstorms destroying them.

“Millions of people eat rice in Africa,” says Gates, “and rice has to be kept much wetter than other crops. At the equator it’s staying drier longer, but when the rains do come, they hit harder.”

In the case of rice and corn and all other crops, the answer is seeds engineered for the conditions in which they will have to grow, not for the more forgiving farmlands of the West. In Tanzania, site-specific seed corn has been made available and is already changing lives. “That seed,” one farmer told Gates when she visited in 2012, “made the difference between hunger and prosperity.”

Finally comes banking. Across Africa, only 37% of people are part of the formal banking system, but up to 90%, depending on the area, are part of the M-Pesa network—a mobile banking link accessible via cellphone. The Pesa part of the name is Swahili for money and the M is simply for mobile.

“Today too many people put their money in a cow or in jewelry,” Gates says. “But it’s impossible to take just a little of that money out. If someone gets sick or you have another emergency, you simply sell the cow.” Mobile banking changes all of that, making it much easier to save—and in a part of the world where even $1 set aside a day can mean economic security, that’s a very big deal.

Nothing about the past 15 years guarantees that the next 15 will see as much progress. The doctrine of low-hanging fruit means that in almost all enterprises, the early successes come easier. But 15 years is a smart timeframe. It’s far enough away that it creates room for different strategies to be tried and fail before one succeeds, but it’s close enough that you still can’t afford to waste the time you have. Wasting time, clearly, is not something the folks at the Gates Foundation have been doing so far, and they likely won’t in the 15 years to come either.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME Pakistan

Militants Gun Down Pakistan Health Workers as Polio Crisis Intensifies

Hospital staff stand near the bodies of anti-polio drive campaign workers who were shot by gunmen, at a hospital morgue in Quetta
Hospital staff stand near the bodies of antipolio campaign workers who were shot by gunmen, at a hospital morgue in Quetta, Pakistan, on Nov. 26, 2014 Naseer Ahmed—Reuters

There have been 260 new cases of polio diagnosed in the South Asian nation this year

Public-health workers continue to be gunned down at will by Islamic militants across Pakistan, where ongoing attacks against vaccination teams have hampered the government’s ability to rein in a spiraling polio crisis.

On Wednesday, heavily armed militants in the Baluchistan region capital of Quetta mowed down members of an antipolio campaign, leaving four public-health workers dead and three others injured. Survivors of the ambush chided government officials for failing to provide sufficient security for the team.

“Two men on a motorcycle stopped our car and started shooting. No security arrangements were made,” one of the victims told the Pakistani newspaper Dawn. “We called everyone, but no one came to our rescue.”

The bloody scene in Quetta this week has sadly become all too familiar in conflict-riven Pakistan. On Monday, near the city of Peshawar, gunmen mounted on a motorcycle shot and injured another polio health worker. A Taliban splinter group later claimed responsibility for the attack and issued a statement deriding the polio vaccine as “dangerous to health” and “against Islam,” according to the Los Angeles Times.

The uptick in brazen attacks against health workers has saddled Pakistani Prime Minister Nawaz Sharif’s embattled administration with renewed criticism, after he made boisterous promises during his campaign in 2013 to make peace with Taliban forces.

“Such cowardly attacks against our goal of polio-free Pakistan will further strengthen our resolve to stamp this menace out of the country,” Ayesha Raza Farooq, the Pakistani Prime Minister’s focal person on polio eradication, said in a statement on Monday. “I urge the provincial government to take all measures necessary to protect the polio teams and ensure safe conduct of polio campaigns.”

The militants’ suspicion of vaccination programs has been fueled in large part by the bogus hepatitis B campaign crafted by U.S. clandestine officials searching for Osama bin Laden in Pakistan in 2011, which later lead to the dramatic killing of the al-Qaeda chief by Navy Seals.

In 2012, Taliban forces operating in the country’s tribal belt banned polio vaccinations and began openly attacking public-health officials trying to administer inoculations. More than 60 public-health workers have been killed in the country since the declaration.

Since 2012, transmission of the virus has been most intense in the country’s restive Federally Administered Tribal Areas (FATA). But following an offensive launched by the Pakistani military against insurgents in FATA’s North Waziristan in June, close to 1 million people fled the area. As a result of the exodus, the polio epidemic has spread to other parts of Pakistan that had previously been unexposed to the highly contagious virus.

In the onslaught’s wake, public-health officials claim to have vaccinated more than 1 million people in the past few months, including 850,000 children under the age of 10, who were previously inaccessible, according to the Global Polio Initiative. Still, polio continues to spread across the country.

Public-health officials confirmed this week the existence of 260 new polio cases in Pakistan this year — a fourfold increase since the same duration in 2013, according to the New York Times. Pakistan is one of just three countries where polio remains endemic.

TIME Infectious Disease

Africa Nears Polio Eradication, CDC Says

German Minister Mueller Travels Nigeria
German Development Minister Gerd Mueller vaccinates a child against polio in a hospital on June 11, 2014 in Abeokuta, Nigeria. Thomas Imo—Getty Images

Health officials credit successful vaccination efforts in Nigeria

Correction appended, November 21, 2014

Wild poliovirus has nearly been eradicated in Africa thanks to successful vaccination efforts in Nigeria, the Centers for Disease Control and Prevention revealed in a new report Thursday.

No case of polio has been recorded on the continent since August, the report finds. There have been 22 cases of polio in Africa overall since the beginning of 2014, six of which were in Nigeria, one of the last three endemic nations alongside Pakistan and Afghanistan. The latest tally marked a drastic reduction from 49 cases in Nigeria the previous year.

That drop has been credited to vaccination campaigns in the country’s restive northern states, where a decade of periodic outbreaks had reintroduced the virus to 26 polio-free countries. “Interrupting all poliovirus circulation in Nigeria is achievable,” the report finds, but only with expanded vaccination coverage to some of the region’s most remote and hard-to-reach communities.

Correction: The original version of this article misstated the total number of polio cases across Africa and how many countries were affected. There were 22 cases in Africa since the beginning of 2014 and the virus was reintroduced to 26 polio-free countries since 2003.

TIME Internet

Google Doodle Celebrates Jonas Salk, Scientist Behind Polio Vaccine

Google

Dr. Jonas Salk made polio nearly extinct in just two years

Tuesday’s Google Doodle celebrates the 100th birthday of the American scientist behind the first effective polio vaccine: Dr. Jonas Salk.

“Thank You, Dr. Salk!” reads a sign in the homepage animation, which depicts joyful, fully mobile children dancing and running around with dogs and balloons. Polio largely impacted children.

The Washington Post reports that according to the Salk Institute, “In the two years before [the] vaccine was widely available, the average number of polio cases in the U.S. was more than 45,000. By 1962, that number had dropped to 910.”

Salk was also depicted on the March 29, 1954 cover of Time Magazine:

Time Magazine, Cover Credit: Boris Artzybasheff
TIME Health Care

The Price of Staying Alive For the Next 3 Hours

Stayin' alive—and cheap at the price
Stayin' alive—and cheap at the price ZU_09; Getty Images

A new study suggests a little spending now can buy you a lot of time later

How much do you reckon you’d pay not to be dead three hours from now? That probably depends. If you’re 25 and healthy, a whole lot. If you’re 95 and sickly, maybe not so much. But for people in one part of the world—the former East Germany—the cost has been figured out, and it’s surprisingly cheap: three hours of life will set you back (or your government, really) just one euro, or a little below a buck-thirty at current exchange rates.

That’s the conclusion of a new study out of Germany’s Max Planck Institute, and it says a lot about the power of a little bit of money now to save a lot of suffering later—with implications for all manner of public health challenges, including the current Ebola crisis.

The new findings are a result of one of the greatest, real-time longitudinal studies ever conducted, one that began the moment the Berlin Wall fell, on Nov. 9 1989. Before that year, there were two Germanys not just politically, but epidemiologically. Life expectancy in the western half of the country was 76 years; in the poorer, sicker east, it was 73.5. But after unification began, social spending in the East began rising, from the equivalent of €2,100 per person per year to €5,100 by the year 2000. In that same period, the difference in lifespan across the old divide went in the opposite direction, shrinking from 2.5 years to just one year as the east Germans gained more time. Crunch those numbers and you get the three extra hours of extra life per person per euro per year.

“Without the pension payments of citizens in east and west converging to equivalent levels,” said Max Planck demographer Tobias Vogt in a statement, “the gap in life expectancy could not have been closed.” Increased public spending, Vogt adds, is often framed as an unfortunate knock-on effect of longer life. “But in contrast,” he says, “our analysis shows that public spending can also be seen as an investment in longer life.”

The idea that generous, tactical spending now can be both a money-saver and lifesaver is one that health policy experts tirelessly make—and that people in charge of approving the budgets too often ignore. Bill Gates often makes the point that $1 billion spent to eradicate polio over the next few years will save $50 billion over the next 20 years, not just because there will no longer be any cases of the disease to treat, but because the global vaccination programs which are necessary just to contain the virus can be stopped altogether when that virus is no more.

As TIME reported in September, British inventor Marc Koska made a splash at the TEDMed conference in Washington DC when he unveiled his K1 syringe—an auto-destruct needle that locks after it’s used just once and breaks if too much force is used to pull the plunger back out. That prevents needle re-use—and that in turn not only reduces blood-borne pathogens from being spread, it does so at a saving. According to the World Health Organization (WHO), $1 spent on K1 syringes saves $14.57 in health care costs down the line—or $280 for a $20 order of the shots.

All across the health care spectrum, such leveraging is possible. Critics of the Affordable Care Act have slammed the law for the cost of the preventative services it provides, and while it’s way too early to determine exactly how successful the law will be, the encouraging stabilization in the growth of health costs suggests that something, at least, is working.

Global health officials are making a similar, though more urgent, preventative argument concerning the Ebola epidemic in West Africa. Americans are rightly jumpy over the few cases that have landed on our shores, but the 1,000 new infections per week that are occurring in the hot-spot nations of Liberia, Guinea and Sierra Leone make our concerns look small. Frighteningly, according to the WHO’s newest projections, that figure will explode to 10,000 cases per week by December if the resources are not deployed to contain the epidemic fast.

“We either stop Ebola now,” WHO’s Anthony Banbury said in a stark presentation to the U.N. Security Council on Sept. 14, “or we face an entirely unprecedented situation for which we do not have a plan.”

Suiting up and wading into the Ebola infection zone is a decidedly bigger and scarier deal than spending an extra euro on public health or an extra dollar for a new syringe. But the larger idea of intervention today preventing far larger suffering tomorrow remains one of medicine’s enduring truths. We lose sight of it at our peril.

TIME Disease

What It Will Take to End Polio

President Franklin D. Roosevelt leaves his home at 49 East 65th Street for a short visit to his family estate at Hyde Park, north of New York City on Sept. 27, 1933.
President Franklin D. Roosevelt leaves his home at 49 East 65th Street for a short visit to his family estate at Hyde Park, north of New York City on Sept. 27, 1933. Martin Mcevilly—NY Daily News/Getty Images

Jeffrey Kluger is Editor at Large for TIME.

Franklin Roosevelt never knew the Pakistani babies battling polio today, but he knew their pain. The world is fighting to end that suffering forever

You can still see the ramps and rails at Franklin Roosevelt’s house on East 65th Street in Manhattan—even though they’ve been gone for decades. They’re easily visible in the pictures that decorate the home. They’re visible, too, in the popular iconography of Roosevelt, who was photographed standing countless times after being paralyzed by polio in 1921, but always with a hand on a bannister, an arm on an aide, a cane in his grip—and ramps and rails at the ready.

The six-story Roosevelt house, where the family lived from 1908 until their move to the White House in 1933, is now owned—and was restored—by New York’s Hunter College. These days it’s a place of learning and policy conferences. But it is also a place of historical serendipity.

“When the house was built, it was one of the first private residences in New York that had its own elevators,” Hunter president Jennifer Raab told me as we toured the building this morning. Those became indispensable once FDR became paralyzed, and it was in that house that his kitchen cabinet thus gathered in the four months between his election in 1932 and his inauguration 1933. “The New Deal was born here,” Raab says.

For FDR, there were abundant compensations for polio. As Ken Burns’ documentary The Roosevelts makes clear, the disease deepened and grounded him. It made him a champion of children with polio—an effort that led to the March of Dimes and the later Salk and Sabin vaccines—and for that matter a champion of all people who suffered hardship. It was polio that gave Roosevelt a fuller temperament—and in turn gave the nation a fuller Roosevelt.

There are no such compensations for the handful of children around the world who still contract the crippling disease. On the same morning I was making my visit to the Roosevelt house, word came out of Pakistan that the country is on target to top 200 polio cases in 2014, its biggest caseload since 2000. Pakistan is one of only three countries in the world where polio remains endemic—the other two are Afghanistan and Nigeria, with 10 and six cases respectively so far this year—and it’s the only one in which the caseloads are moving in the wrong direction.

As recently as 2005, Pakistan’s case count was down to just 28, helping to push polio to the brink of eradication. That same year, however, religious leaders in northern Nigeria declared a boycott of the vaccine, claiming that it contained HIV and was intended to sterilize Muslim girls. This led to a wildfire spread of the Nigerian strain that stretched as far southeast as Indonesia.

But Nigeria got its house in order, and the hot zone now—a more challenging one—has shifted to Pakistan, particularly in the tribal areas in the north and in the mega-city of Karachi. Some of the problem is simply the crowded, unhygienic conditions in Karachi. But the bigger piece is the fighting in the tribal regions, which have made vaccinations difficult or impossible. That’s been exacerbated by Taliban gunmen, who have shot and killed 59 polio field workers and police officers trying to protect them since 2012.

“It’s a very sad thing,” Aziz Memon, head of Rotary International’s PolioPlus team, told TIME by phone from Pakistan today. “We’re trying to get vaccinators on the ground and into the field despite the ban. And now rains and flooding that have broken 100-year-old records are creating more problems.”

Rotary, which has been the point-organization for the eradication of polio for more than 25 years, is being assisted by the Gates Foundation, Save the Children and multiple other international groups, all working to push back against the Taliban blockade. Vaccinators routinely wait at bus stops around Pakistan, climbing aboard and looking for kids who have no vaccination records and administering the drops on the spot. Refugee camps in the war torn tribal regions provide another way of standing between the virus and the babies.

“When the virus is contained like this it’s a good opportunity to step in and control it,” says Memon. “We can also take advantage of the low-transmission season, which starts soon.”

The effort to snuff out polio altogether is more than merely the moral thing, it’s also the practical thing. Bill Gates repeatedly stresses that $1 billion spent per year over the next few years can save $50 billion of the next 20 years, money that would otherwise be spent treating polio and constantly fighting the brushfire war of vaccinating against outbreaks. Eliminate the disease for good and those costs go with it. What’s more, the delivery networks that are put in place to do the job can be easily repurposed to fight other diseases.

None of this long-range thinking makes a lick of difference to the 187 Pakistani children—or the 10 Afghanis or six Nigerians—who forever lost the use of their legs this year. They are paralyzed, as they will be for life. For them, there is no offsetting wealth, no townhouse with an elevator, no path to global greatness. There is only the disease—a pain FDR recognized and fought to fix. In Pakistan, that same fight is being waged today.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME History

FDR’s Polio: The Steel in His Soul

Jeffrey Kluger is Editor at Large for TIME.

Disease can break a lot of people. As a new film by Ken Burns and an exclusive video clip show, it helped make Franklin Roosevelt

No one will ever know the name of the boy scout who changed the world. Odds are even he never knew he had so great an impact on history. It’s a certainty that he was carrying the poliovirus—but he may not have known that either since only one in every 200 infected people ever comes down with the paralytic disease. And it’s a certainty too that he had it in late July of 1921 when he and a raucous gathering of other scouts had gathered on Bear Mountain in New York for a summer jamboree. So important was the event in the scouting world that it even attracted a visit by the former Assistant Secretary of the Navy and 1920 Democratic Vice Presidential nominee, Franklin Roosevelt.

This much is painfully certain too: somehow, the virus that inhabited the boy found its way to the man, settling first in his mucus membranes, and later in his gut and lymph system, where it multiplied explosively, finally migrating to the anterior horn cells of his spinal cord. On the evening of August 10, a feverish Roosevelt climbed into bed in his summer cottage on Campobello Island in Canada’s Bay of Fundy. It was the last time he would ever stand unassisted again.

Roosevelt’s polio, which struck him down just as his political star was rising, was supposed to be the end of him. The fact that it wasn’t is a self-evident matter of history. Just why it wasn’t has been the subject of unending study by historians and other academics for generations. This year, Roosevelt and his polio are getting a fresh look—for a few reasons.

October 28 will be the 100th birthday of Jonas Salk, whose work developing the first polio vaccine was backed by the March of Dimes, which was then known as the National Foundation for Infantile Paralysis and which itself grew out of the annual President’s Birthday Balls, nationwide events to raise funds for polio research, the first of which was held on FDR’s 52nd birthday, on January 30, 1934, early in his presidency. That initial birthday ball raised a then-unimaginable $1 million in a single evening, a sum so staggering Roosevelt took to the radio that night to thank the nation.

“As the representative of hundreds of thousands of crippled children,” he said, “I accept this tribute. I thank you and bid you goodnight on what to me is the happiest birthday I have ever known.”

This year too marks one more step in what is the hoped-for end game for the poliovirus, as field-workers from the World Health Organization, Rotary International, UNICEF and others work to vaccinate the disease into extinction, focusing their efforts particularly on Pakistan, one of only three countries in the world where polio remains endemic.

Then too there is the much-anticipated, 14-hr. Ken Burns film, The Roosevelts: An Intimate History, which begins airing on Sept. 14. It is by no means the first Roosevelt documentary, but it is the first to gather together all three legendary Roosevelts—Franklin, Theodore and Eleanor—and explore them as historical co-equals. It’s the segments about FDR and his polio that are perhaps the most moving, however—and certainly the most surprising, saying what they do about the genteel way a presidential disability was treated by the media and by other politicians in an era so very different from our own.

“We think we’re better today because we know so much more,” Burns told TIME in a recent conversation. “But FDR couldn’t have gotten out of the Iowa caucuses because of his infirmity. CNN and Fox would have been vying for shots of him sweating and looking uncomfortable in those braces.”

That’s not a hard tableau to imagine—the competing cameras and multiple angles, shown live and streamed wide. And what Americans would have seen would not have been pretty, because never mind how jolly Roosevelt tried to appear, his life involved far, far more pain and struggle than the public ever knew, as a special feature from the film, titled “Able-Bodied,” makes clear. That segment, which is not part of the broadcast and is included only on the film’s DVD and Blu-Ray versions, which are being released almost contemporaneously with the film, was made available exclusively to TIME (top).

Concealing—or at least minimizing—the president’s paralysis was nothing short of subterfuge, the kind of popular manipulation that wouldn’t be countenanced today. But it’s worth considering what would have been lost by exposing the masquerade that allowed FDR to achieve and hold onto power. Roosevelt, as the Burns film makes clear, was a man whose ambition and native brilliance far exceeded his focus and patience. It was a restlessness that afflicted cousin Teddy too, causing him to make sometimes impulsive decisions, like pledging in 1904 that he wouldn’t run again in 1908—an act he regretted for the rest of his life and tried to undo with his failed third-party presidential bid in 1912.

“Who knows what would have happened if Teddy had had the great crises Franklin had—the Depression and World War II?” Burns says. “I do know he was unstable and always had to be in motion. It fell to FDR, who could not move, to figure out a way to outrun his demons.”

George Will, in an artful turn in the “Able-Bodied” clip, observes that when the steel went onto Roosevelt’s legs it also went into his soul. That may have been true in FDR’s case, but it’s true too that suffering is not ennobling for everyone. Some people are broken by it; some are embittered by it. As polio nears the end of its long and terrible run, the things FDR achieved despite—even partly because of—his affliction remain nothing short of remarkable.

TIME Ideas hosts the world's leading voices, providing commentary and expertise on the most compelling events in news, society, and culture. We welcome outside contributions. To submit a piece, email ideas@time.com.

TIME Infectious Disease

Polio’s Two Vaccines Are More Effective When They’re Combined

For decades, there’s been a tug-of-war between the oral and inactivated polio vaccines over which is more effective at preventing the paralyzing disease. Researchers have now resolved the dispute and say that pairing them are better than either alone

When it comes to fighting a virus, having as many weapons as possible, especially in the form of vaccines that can prevent infection, is certainly welcome. And that’s always been the case with polio, which has not one but two effective immunizations that can stop the virus from causing debilitating paralysis. Which is more effective in preventing illness and which is better at stopping transmission of the virus? Scientists report in the journal Science that neither is ideal, but that together, the vaccines are powerful enough to achieve both results. The results “revolutionize our thinking about how to use polio vaccines optimally,” says Hamid Jafari, director of polio operations and research at the WHO, who led the research.

Recent efforts to erradicate polio has pitched the two vaccines against each other. Developed in the 1950s and 1960s, one was made by Jonas Salk using killed polio virus, and the other, developed by Albert Sabin, uses a weakened but still live virus that could replicate in the human gut to deliver immunity. Jafari and his colleagues, report that children vaccinated with the oral polio vaccine who then received a boost of the Salk vaccine showed the lowest amount of virus in their feces—one of the primary ways that the virus spreads from person to person—and excreted these viruses for a shorter period of time than children who had been immunized with the oral vaccine and received a boost with an additional dose of the same oral vaccine.

MORE: WHO Declares Health Emergency on Polio

The WHO’s global effort to eradicate polio has relied heavily on the oral vaccine, because it’s a liquid that can be eaily given to children orally, and it’s cheaper. Plus, the oral vaccine, because it contains a weakened virus that can reproduce in the human gut, helped to reduce the volume of virus excreted in the feces, and thus lower the chances that others coming in contact with the feces could get infected.

But in places where polio infections were rampant, such as northern India, the oral vaccines didn’t seem to be doing much good at reducing the burden of disease. Even when children were getting the recommended three doses, rates of infections remained high. “The transmission pressure was extremely high in these areas that were densely populated, had a high birth rate, poor sanitation and high rates of diarrhea,” says Jafari. In those regions, it took an additional 10 to 12 vaccination campaigns—about one a month to provide children with additional doses on top of the recommended three doses—to finally control the disease and limit spread of the virus. It turns out that the immunity provided by the oral vaccine wanes over time.

In order to eradicate the disease, public health officials knew they had to do better. So they tested whether adding in the inactivated vaccine would help. And among 954 infants and children aged five years to 10 years who had already received several doses of oral vaccine, adding a shot of the inactivated vaccine did help them to shed less virus compared to those who received another dose of the oral vaccine.

PHOTOS: Endgame for an Enduring Disease? Pakistan’s Fight Against Polio

With polio currently endemic in Pakistan, Cameroon, Equatorial Guinea, and the Syrian Arab Republic, the WHO declared the spread of polio a public health emergency of international concern, and issued temporary recommendations for all residents and long-term visitors to those countries to receive a dose of either the oral or inactivated vaccine before traveling out of the country. In other countries where polio has been found, such as in some sewage samples and fecal samples from residents in Israel, health officials have also advised residents living in those regions to receive a dose of inactivated polio vaccine in order to limit spread of the virus.

“The inactivated polio virus vaccine is becoming an important tool in preventing international spread of polio,” says Jafari. Whenever outbreaks of the disease occur, health officials are now recommending that even vaccinated individuals who could be infected but not get sick, receive an additional shot of the inactivated vaccine in order to limit the amount of virus they shed and spread to others.

TIME polio

The Battle to Eradicate Polio in Pakistan

A Pakistani health worker vaccinates a child in Islamabad
A Pakistani health worker vaccinates a child in Islamabad Anadolu Agency/Getty Images

Political unrest in Pakistan has been a gift to the poliovirus, with 99 cases reported there so far this year. But Rotary International, which has already vaccinated 2 billion children in 122 countries, is hitting back hard

Epidemiology can be all about geography—and that’s especially true when it comes to polio. If you live in the U.S., where polio was eradicated in 1979, the specter of the disease has faded almost entirely, though pockets of infections can occur among the unvaccinated. In Pakistan, however, things are moving in precisely the opposite direction, and have been for a while now.

One of only three countries in the world where polio remains endemic (the other two are Nigeria and Afghanistan), Pakistan had been close to joining the world’s polio-free nations, with only 58 infections in 2012. But thanks to bans on vaccinating—and deadly attacks on polio fieldworkers—by the Pakistani Taliban, the caseload rose to 93 in 2013. In 2014, the total reached 99 by July 18—a figure all the more alarming compared to this point last year, when there had been just 21 cases.

“It’s a scary number,” says Aziz Memon, Pakistani chairman of Rotary International’s polio eradication campaign. “Children in North Waziristan have been trapped for three and a half years without a drop of polio vaccine, and that’s what’s causing this.”

The folks at Rotary know what they’re talking about. Since launching their polio eradication effort in 1985, they have been responsible for the vaccination of 2 billion children in 122 countries. Along with the World Health Organization, UNICEF, The Gates Foundation and others, they have helped slash the global infection rate from 350,000 cases per year in 1988 to 416 in 2013.

That’s indisputably good news, but polio is an exceedingly sneaky virus, with 200 symptom-free carriers for every one case of the disease. That fact, combined with the anti-vaccine forces in Pakistan, not to mention the porous borders cause by war and unrest in the overall region, has caused the disease to leak out from the three endemic countries, with stray cases turning up in Equatorial Guinea, Iraq, Cameroon, Syria, Ethiopia, Somalia and Kenya. In a handful of other countries, the virus has been detected in sewage, but it has not led to any cases of the disease—yet.

It’s Pakistan though that’s considered ground zero, and Rotary has announced that it’s now deploying some very simple weapons in what has always been a village-to-village, door-to-door battle. To improve surveillance and tracking—a maddeningly difficult job in a country in which so many people live off the communications grid—Rotary has distributed hundreds of cell phones to midwives who circulate through communities, canvassing residents to find out who has received the vaccine and who has been overlooked. Information on the unvaccinated kids—the “missing children” in the fieldworkers argot—is entered into the phones and uploaded to a central spreadsheet, allowing later vaccinators to target their efforts more precisely.

“The midwives also track pregnant mothers,” says Memon. “And when their children are born they can continue to maintain complete health records, not just for polio but for other vaccines and basic health care as well.”

Rotary has also worked with The Coca-Cola Company to build what’s known as a reverse osmosis water plant—essentially a sophisticated filtration facility—in the town of Malin, within the city of Karachi. Polio is a disease spread almost entirely by human waste, and once it leeches into the water system it can spread nearly anywhere. The Malir plant, which was constructed near a school to give polio-age kids the first access to the newly filtered water, is a relatively modest one, with just 20,000 gal. (76,000 liters) of clean water on hand at any one moment, and cost only $40,000 to build. But as a pilot project it represents a very good start. “We can’t build a massive plant like the government can,” says Memon. “This is a small plant for a small community.”

One thing, paradoxically, that’s working in the vaccinators’ favor is the increased number of displaced people in Pakistan. A recent push by the Pakistani military to flush the Taliban from its safe havens has broken the vaccination blockade, and already 350,000 children have received at least one dose of the polio vaccine. But 1.5 million refugees are scattered around the country. Rotary has dispatched field workers to refugee camps and transit points to identify the children and few adults who need the polio vaccine and administer it on the spot.

“The government did not have any idea about what the numbers of displaced people would be,” says Memon. In the refugee camps, he adds, there are at least 40,000 pregnant women, whose babies will have to be vaccinated shortly after birth.

The diabolical thing about polio—and indeed any disease science hopes to eradicate—is that even one case is too many. As long as any wild poliovirus is out there, everyone needs to be protected. It is only when the last scrap of virus has been found and snuffed, that the protective push can stop. That has happened once before in medical history—with smallpox. In the case of polio, it’s tantalizingly close to happening again.

TIME Infectious Disease

Polio Virus Discovered in Brazilian Sewage

Poliovirus, Tem
Poliovirus. Transmission Electron Micrograph Of Poliovirus Type 1. BSIP/UIG/Getty Images

Found in Campinas in São Paulo state, host to the Portuguese and Nigerian soccer teams during the FIFA World Cup

The polio virus has been found in sewage samples collected in March from Viracopos International Airport, in Campinas, the World Health Organization reported on Monday. No human case has been discovered.

Campinas, which is part of São Paulo state, is the team base camp for both the Portuguese and Nigerian soccer teams during the FIFA World Cup tournament.

The strain, wild poliovirus type 1, is a close match to one recently isolated in Equatorial Guinea.

The WHO said that the “virus has been detected in the sewage only” and that “no case of paralytic polio has been reported.”

Brazil has been free from polio since 1989. The disease, which can be prevented by vaccination, attacks the nervous system and can result in rapid paralysis. It is most dangerous to young children.

The Brazilian Health Ministry commented: “This detection does not mean any change in the epidemiological situation of Brazil or a threat to the elimination of the disease.”

Health authorities in Brazil are reported to be looking for any un-immunized persons as well as potential cases of paralytic polio. Immunization in São Paulo state is higher than 95% with the last national vaccination in June 2013.

This is not Campinas’ first health scare. In May, AFP reported that the city was battling an outbreak of dengue fever which killed three people.

 

Your browser, Internet Explorer 8 or below, is out of date. It has known security flaws and may not display all features of this and other websites.

Learn how to update your browser