Questions for Consideration During this Lecture

ADITI RAO: Hello, everyone. My name is Aditi Rao. I’m a research associate at the Johns Hopkins Bloomberg School of Public Health. Welcome to the lecture on eradication and the challenge of reaching the last 1%. We know polio has existed for thousands of years, causing illness and, in some cases, permanent disability and death. However, today, we stand at the very brink of eradication due to the dedicated efforts of very many organizations across the globe since 1988. The road to eradication has been longer and harder than anyone expected, and tackling the last 1% of polio cases remains a challenge today.

The final pockets of disease remain among hard-to-reach populations, including those residing in environmentally and geographically challenging areas, socially excluded and vulnerable populations, and those in high-risk, conflict-ridden areas. Each of these groups continue to receive inequitable access to resources and health services. Addressing these challenges and finding new ways to reach children in high-risk, hard-to-reach areas is essential to achieve eradication and importantly to achieve health equity and social justice. Proponents of disease eradication have argued that it provides the ultimate in health equity and social justice, bringing identical and universal benefits to every person globally.

But reaching the world’s hardest to reach with an education program may distort systems, even as it delivers an intervention to populations who do not often receive quality health services, often diverting limited resources from integrated programs for a focused, vertical effort. This lecture draws on the polio eradication experience to explore how and why political, social, and technological forces function differently in the last 1% of eradication programs and to consider the consequences for the least developed and poorest communities. As we attempt to unpack this very interesting and complex challenge, I’d like each of us to consider some key questions. What are the underlying factors which have led the last 1% of children with polio cases to be consistently underserved?

And how did eradication activities confront and address these forces? What are long-term effects of eradication programs in communities as well as health systems’ performance and equity? And, finally, can tools developed for eradication be transformed for health systems strengthening, or are new approaches required? To begin with, let’s look at an example. This map is of Pakistan and Afghanistan from October 2019. Pakistan and Afghanistan are the only countries in the world where the Global Polio Eradication Initiative has failed to ever eliminate polio. The two countries are often taken as one epidemiological block. The red dots on the map indicate polio cases, and the blue dots are places where environmental samples tested positive for polio.

For a moment, think about what this map tells us about how polio’s distributed in these two countries, particularly in areas along the border. As we move through the lecture, Pakistan and Afghanistan will be our key examples.