Infectious Diseases

With the United States likely to pull back on global health funding, the World Health Organization, under its new director-general, will need to undertake serious structural and administrative changes.

Thursday, December 1, is World AIDS Day, a fitting occasion to call attention to an HIV vaccine clinical trial that has started in South Africa. The vaccine being tested is based on one used in a Thailand trial in 2009 which had a protection rate of about 30 percent, reports the BBC. Results from the South Africa trial will be known in about four years. The study is code-named HVTN 702. It is led by Glenda Gray, a South African university research professor and the head of the country’s Medical Research Council. The study is sponsored by the U.S. National Institutes of Health. South Africa has been the world’s ground zero for HIV/AIDS. One estimate is that by 2015 seven million South Africans were HIV positive, including approximately 19 percent of the country’s adult population. The HIV/AIDS disease burden is carried disproportionately by blacks. A 2012 study found that 15 percent of black South Africans tested HIV positive, while only .3 percent of whites tested positive. There have, however, been successes. Under the current minister of health, Aaron Motsoaledi, the Zuma administration’s approach to the disease has been vigorous, with public education programs, widespread condom distribution, and male circumcision campaigns. On World AIDS Day 2014, the government broke the record for the number of people tested for HIV/AIDS. Minister Motsoaledi in 2016 said that mother-to-child transmission of HIV/AIDS was down below 2 percent. Overall mortality rates, driven by HIV/AIDS and associated diseases such as tuberculosis, is also down. Nevertheless, other statistics from the credible South African Human Sciences Research Council (HSRC) indicate that the fight is far from over, with a resurgence of new cases and much of the population still unaware how the disease is transmitted.

The public reappearance of polio in northeast Nigeria is a disappointment. Nigeria had been thought to be free of polio for two years. The recent cases of paralysis caused by polio are likely the result of ongoing, undetected transmission rather than a new introduction of the disease from elsewhere. The small numbers of paralysis probably masks the extent of the presence of the disease. Only about one in two hundred polio cases results in paralysis. Polio would appear to remain present in areas formerly under control of Boko Haram, which is opposed to vaccination and western medicine in general. The Global Polio Eradication Initiative, a consortium that includes UNICEF, government agencies, and non-governmental organizations, is responding to the newly detected outbreak with a major campaign to vaccinate 41 million children against polio in the Lake Chad basin, which comprises Nigeria, Cameroon, Chad, and Niger. UNICEF states that the Initiative has deployed 39,000 health workers in the region and has already vaccinated approximately 30 million children using oral polio vaccine. UN spokesmen identify two challenges: continued insecurity in the region and a shortage of funds. Boko Haram has not been destroyed and continues to attack soft targets. For example, Nigerian media report that a Boko Haram bombing killed at least eighteen in Maiduguri on October 11. UNICEF has also not received all of it’s necessary funding, it has received only $50.4 million of the $158 million it needs for the Lake Chad basin campaign. Victims of paralysis in the Lake Chad basin lack even the most rudimentary medical care where wheelchairs are a rare luxury. Given the horror of polio, surely the international community can cover the $108 million shortfall, a pittance compared to other government expenditures.

The appearance of two cases of polio in northern Nigeria is an unmitigated tragedy. Anybody who has traveled in the region and seen firsthand the victims of paralysis caused by polio can but weep. And now there are two more. Victims often have no wheel-chairs and, as elsewhere, health care is rudimentary if it exists at all. The tragedy is only mitigated by the courage the victims show in carrying on, and in the support they receive from their families and communities. Martins Ifijeh surveys ongoing immunization efforts and also analyzes the re-emergence of the disease in a thoughtful article in ThisDay. He notes that the effectiveness of immunization is reduced when children are malnourished, and malnourishment is endemic among the very large population of the internally displaced. He also highlights the need for the vaccine to be stored at a low temperature, hard to do in a war zone. He also cites Boko Haram hostility to immunization, which it characterizes as a “western plot.” Further, even in areas where Boko Haram no longer controls territory, security for health workers has not necessarily been re-established. So, polio is yet another cost of Boko Haram.

Sometimes, it seems like the bad news from Nigeria never stops. Tucked away in the December 23, New York Times was a brief notice that on December 22, explosions in Gombe state killed at least twenty-six and wounded seventy-nine. That carnage in northern Nigeria merited less than sixty words, so inured has the international community become. Yet, just in time for Christmas there is a good-news story from northern Nigeria. The polio vaccination campaign, more than a decade old, is working. The Globe and Mail (Toronto) reports that only six cases of polio have been recorded this year in Nigeria, a 90 percent drop from last year. There has not been a single case of wild polio virus in the past six months. The Globe and Mail quotes Tunji Funsho, chairman of the Rotary Polio Plus Committee in Nigeria as saying, “We can see light at the end of the tunnel. All the hard work that we’ve been doing is seeming to pay off now.” Indeed, this is an extraordinary achievement. When I arrived in Nigeria in 2004 northern politicians and religious leaders claimed that the polio vaccine caused HIV/AIDS and infertility. As recently as February 2013 gunmen killed nine vaccination workers. What happened? The answer appears to be the work of the Rotary and the Gates Foundations combined with the Jonathan governments strict imposition of rules in support of the polio vaccination strategy along with energized Nigerian civil goups. In addition, religious leaders have assisted the campaign. Vaccine workers also show a new sensitivity to cultural norms. For example, they vaccinate children in front of their houses, not inside. Technology helps too, supervisors use satellite devices to track the movements of vaccinators. Hence, villages overlooked can be visited. They have even been able to track and vaccinate nomadic cattle-herding families. The security situation also plays a part in the treatment strategy. In parts of northern Nigeria plagued by Boko Haram, vaccinators use hit-and-run tactics. In coordination with security forces they go into an area when it is safe, vaccinate, and then run back to safety. For anybody who has seen Nigerians paralyzed by polio getting about on skate boards (wheel chairs can be a luxury), the apparent elimination of polio is a huge achievement. Deo gratias.