Political Committment Issues, Polio, and the Measles Initiative

For the most part, political commitment is a counterintuitive term; the majority of government-backed or state-supported endeavors appear to be fraught with inconsistency and lack of funding. In the health sector, the consequences of this manifest in either failure or incomplete results, which typically high-light the stratified populations of people who receive different forms of intervention and health care due to socioeconomic factors.

                In this way, the Measles Initiative is unique; despite its large-scale character, it was able to bypass the shortcomings of public services and inadequate infrastructure in certain countries. This is due to the MI’s complex coordination and planning, especially in regard to awareness campaigns. Learning from previous failures in the 1970s, the kick start of the Measles Initiative in 2001 made strategic outreach a core focus in its roll-out. The visibility of the endeavor-which was achieved by aggressive campaigning and case-based surveillance- made it impossible to ignore. By beginning initial efforts in stable governments and regions, it was able to achieve a reputation of success that would later make it impossible for insecure governments to ignore.

                This is interesting for many reasons; in global health, there seems to be a theme of grand-scale intervention that inevitably leads to failure. Superficially, it appears that lack of funding, cooperation, and technical deficiencies are the villains responsible for wreaking havoc on theoretically sound plans of intervention. For instance, the Polio Eradication Initiative has been successful across the Americas and Europe, yet the disease remains endemic in countries such as Pakistan. Many health officials point to Pakistan’s crumpled infrastructure as a scapegoat, but perhaps it is more helpful to search for reasons as to why the public health systems in certain governments are so dysfunctional. Clearly, lack of funding reflects a lack of support, but what are the reasons behind governmental resistance, and why do certain campaigns win over the hearts of dictators while others do not?

                The book Chasing Polio in Pakistan by Svea Closser begs this very question, and surmises that the Polio Eradication Initiative is failing in Pakistan due to issues of political commitment. Pakistan fails to comply with WHO and UN requests not only because it feels that the PEI is an extension of Western imperialism, but also because it simply does not regard Polio as a top-priority issue. In Pakistan’s agenda, health problems are already of low-importance, and so they are largely shuffled to the bottom of the government’s to-do list. Assuming that this is correct, what then makes an issue a priority?

In many western nations, priority is divided amongst different sectors and government levels. Political commitment is not necessarily a government promise- it is merely associated with a larger force, but implemented by a division of the system that is entirely dedicated to that cause or mission. Thus, the relation of the PEI and the MI is found in each one’s varying levels of political commitment and strategic approach. The PEI began as a top-down measure; the WHO and UN delivered demands, and countries with the capabilities and resources followed dutifully. This is also the case for the MI, but success has been somewhat more attainable due to the Initiative’s early emphasis on reaching out to strong nations in positions to carry out large health interventions. Health endeavors are inherently political, and like anything else in politics, the reputation of a health program is the ultimate determinate of whether or not it will succeed. By starting with wealthy and capable countries, MI was able to convince the most skeptical of leaders and governments that eradication was possible, whereas the PEI went straight to the most affected countries, which were the least-equipped to deal with the issue.

                Ultimately, failure of public health interventions is in its most literal sense a result of inadequate funding, support, and commitment. Symbolically, however, failure is due to an oversight in recognition on the part of these health initiatives. The PEI did not take into account the political environment of the countries where Polio is endemic; the MI-while not perfect- did notice the correlation between measles and political instability. This acknowledgement allowed MI to strategically plan its roll-out, and success has been much more prevalent as a result.

The Measles (& Rubella) Initiative

In recent years, the field of global health has moved away from disease-specific approaches, like the Measles initiative, as health system approaches are favored.  At the same time, U.S. measles cases are on the rise even in our 92Y neighborhood where a health system is long established and fairly accessible.  Weak health systems prevent measles from being eradicated, so health system strengthening is a crucial long-term goal.  But without organizations with targeted short-term goals, regression in public health outcomes is possible, as evidenced by the reappearance of measles in the U.S.

In a Google search for the Measles Initiative’s website, I was surprised to discover that since the Global Health Delivery’s 2011 Case Study on the Measles Initiative, the organization broadened its name, and mission, to the Measles & Rubella Initiative.  The organization partners with countries to immunize and monitor outbreaks through planning, monitoring, and implementing campaigns.  In its 13-year mission, the M&R Initiative reduced measles deaths by 74% from 2000-2007 and by 78% from 2000-2012.  There are still 122,000 measles deaths annually, and the disease accounts for 4% of all child mortalities.

There is still a gap between today’s 78% reduction and the proposed 90% reduction, or even eradication hoped for by 2010.  There are many challenges associated with eliminating Measles: there is no cure, it is highly contagious, and immunity often requires two vaccinations.  The slow progress achieved by the M&R Initiative is not insignificant in light of these challenges.  The widening of the organization to encompass Rubella appears to be an effort to maintain its crucial role in mitigating these specific diseases, while addressing the larger health care issue of ensuring regular vaccination. 

Cure-alls are a myth

The global response to control the HIV/AIDS epidemic put global health on the map. The global science community, especially in wealthier countries with major research capabilities, tackled the virus head on and new antiretroviral medications were patented by the 1990s and 2000s. The world could rest easy knowing that AIDS cocktails could be distributed to the masses to control the HIV/AIDS epidemic at $10,000-15,000 per patient per year.

The problems with this outcome are numerous, including education, access, and focus. A family of medications has caused a number of problems that go beyond the epidemic itself and bleed into many facets of society.

One of the biggest problems lies in education and distribution knowledge about the HIV virus and what spreads it. The view that HIV is a “gay disease,” that there is a connection between the virus and the queer community continues to this day. Uganda, infamous for its legislation against homosexuality, has closed a US-funded HIV project. The government has cited that the Walter Reed Project “trains youths in homosexuality.” The demonization of certain groups in connection to spreading the disease remains a huge problem around the world, including in nations that seem to have a more “lenient” view. Is all the attention placed on developing new drugs taking away from educational initiatives so people can understand the semantics of the disease?

Intellectual property rights have caused a monopoly by pharmaceutical companies over the secret “recipes” of HIV/AIDS medications. Do private companies have the right to keep the rights to their medications? Medical treatments for HIV/AIDS are subsidized by wealthier countries, where many of these medications originate. The cost is so prohibitive for some medications that generics from countries like India are becoming more and more popular, adding up to $93 billion in trade in the United States alone.

The focus on treating HIV/AIDS is also distracting from other problems that many people in a country face. With the rise of global health, a large percent of donations go specifically to HIV/AIDS treatment. How much money goes to preventive measures, like safe sex education and prophylactics? Is money going to training medical professionals or building more infrastructure?

Medications are an integral part to treating HIV/AIDS, but I also wonder what we’re losing by focusing too heavily on the physical treatment rather than risk factors that affect the spread.

The Wider Implications of Epidemics

Obviously, the first thing that comes to mind when you hear the word "epidemic" is illness.  Hundreds of people sick, many dead, more joining them every day.  But it is also important to keep in mind the wider implications of an epidemic.

When there is an epidemic, particularly one that is proving to be virulent, people stop going out.  No one wants to come into contact with more people than is strictly necessary for survival.  Think about all the people you come into contact to on a daily basis.  A rough estimate of my number from today is 40, and that is just the people I actually saw and interacted with.  We should also consider everyone who touches the self check out unit I used, everyone who sits in the Metro North seat I sneezed on, or touches the bathroom door handle, or sits in the seat I sat in at the Red Hook Diner this morning.  That is a significant number of people and they are all now likely to find themselves waking up in three days with a sore throat and unreasonably itchy nose, all because I traveled from Bard to New York this weekend.  When you really think about how easy it would be for you to come into contact with the carrier of a deadly disease, it becomes easy to see why epidemics have a massive negative drag on economies.

Particularly for countries that depend on tourism for large segments of their economies, epidemics can be crippling.  If no one travels to your country you cannot make money from a tourism sector.  So to do the economies that feed those tourism industries suffer.  If no one is going out to fancy dinners in southern asia, there is going to be a sharp decline in the amount of fish sold from Australia.  this dip in sales then impacts the australian economy, and the effect continues to trickle down.  The interconnected nature of our globalized world means what happens in one country is not confined to its borders, whether that thing be illness or economic stress.

This potential for suffering makes countries that discover epidemics less likely to tell anyone else about them for fear of losing out on foreign economic support, and domestic spending lost to fear of contact with other people.  This is a real problem for the global health community, particularly if they want to build a robust health infrastructure with failsafes to prevent a global pandemic.  We are all going to have to trust each other more, and be willing to support those who are suffering from illness so they will feel safe warning us that the illness exists in the first place.

Americans, let's pat our backs

The SARS outbreak perpetuated and epitomized the mass panic response of humanity. It brought our attention to global health in a much more fearful, shocking, and real way. We are selfish, and thus, while we may give some matter of attention to the global AIDs pandemic and ‘care’ about the cause, we do not really very much. I suppose I am overstating, some people care, just not the majority of America. I suppose what I am saying is that while we are completely narcissistic—and may donate a few dollars with a text to the Red Cross for Haitian quake or Philippine tsunami relief—but we only buy canned food, take out cash and draw the blinds when we are really scared, and we are only scared for ourselves. I suppose I am getting a little ranty and am not saying much, but what I am attempted to do is explain the rational for our haphazard and selfish response to relief. In New York, people were upset that FEMA had messed up to badly in New Orleans, but did not really care until Sandy hit them, and wanted their power back sooner. According to the Textbook of International Health, most health emergencies take place in poor countries, but somehow, we only care about the very few that directly effect us. We’re wonderful, eh?

Where am I going with this? I believe that people need a little more motivation to help in the case of an outbreak or medical emergency. While SARS is important to notice, and yes, to fear, it was not very large, and was just the Vietnam to our Cold War—that is, hopefully we will get it right soon enough not to have a bigger problem.

Now, how do we use rational self-interest to dictate aid be given, planning measures be made, and attention paid? That is the real question. Maybe institutions such as the Red Cross should be subscription based, like the IMF; you only get a bailout, if you paid your charter. Maybe donation by wealthy countries should be mandated to pay into funds that help less wealthy ones? Neither of these would work for many reasons. But maybe they should. Either way, we should pay more attention to what needs attention, not just to ourselves.