Global Health Issues; A perspectives from global eradication of Wild-Polio Virus Yahaya Oloriegbe H.

SchoolofHealth;ComparativeHealthStudies

ORIGINAL ARTICLE

It is paramount to state that global action towards control of any disease should go beyond funding and knowledge contribution, rather global health actors need to take more holistic approach by encompassing diplomacy for the good of all instead of focusing on individual donor countries interest. High-income countries need to note that other activities such as diplomacy for personal interest during conflict situation deters the primary aim of health intervention. These interventions are been funded using tax payer money, as such tax-payers need to seek justification for the way their money are been channelled. Nonetheless, global health is important for every individual worldwide but the sole purpose of global public good should always be the goal of global health intervention. Introduction

The World Health organisation-WHO declared wild Polio virus prevalence as an “international public health concern” in 2014 (Global Polio eradication initiative GPEI, 2014). Apart from the fact that the virus is close to been eradicated globally, achieving this stride has always been a global challenge for the past decades (GPEI, 2010). However, with series of global effort; one of which is the creation of an institution – the global polio eradication initiative GPEI, It is safe to assume that this has contributed to the reduction of the polio virus by almost 99% (Independent monitoring board of GPEI, 2014). The remaining 1% lingers in three countries; Afghanistan, Pakistan and Nigeria in Southeast Asia and Sub-Saharan Africa respectively (GPEI, 2010). The prevalence of the polio virus has been attributed to the mutating biological characteristics of the wild Polio virus. Furthermore, analysis has shown that causation factors of polio virus goes beyond its biological characteristics, rather series of associated social factor may have also contributed to the prevalence of the virus. Thus, this essay will explore the biological and social factors associated with the prevalence of Polio from a global health perspective while also understanding efforts that is been put in place to eradicate the diseases that has lingered for several decades. In other to get a clear understanding of the complexity surrounding the resurgence of polio globally, it is paramount that this issue is explored from a global health perspective. Therefore, the next paragraphs will explore the scopes and perspectives of global health. To further understand the scopes of global health, a series of the global health issues will be explored. Focus will then be drawn towards eradication of Polio virus as a global health issue. What is global health and what are the global health issues? To understand the term “global health” seems to be a

major debate both in the academic and practice field. According to Rowson et al. (2012), global health was described as a field that owes its origin and scope to the trend in which the global society addresses health issue. However, it can be argued that Rowson et al. has not really been able to distinct their view of the term “global health” from that of public health activities. Rowson et al. definition of global health imitates the scope of public health activities where individual countries prevent cross border infectious diseases by developing policies to protect their social and economic interest. Interestingly, Kickbush (1993) argued that global health goes beyond individual countries interest. He would further go to argue that global health encompasses the interrelatedness of globalisation on individual countries health and how this globalisation affects the distribution of health across different countries. Nonetheless, there is a concession in the academic field reported by Beaglehole and Bonita (2010) that Koplan et al. definition of global health seems appropriate to describe the scope and activities of global health. Koplan et al. (2008) defined global health as ‘an area for study, research, and practice that places a priority on improving health and achieving health equity for all people worldwide’. Beaglehole and Bonita would however depict Koplan and Kickbush definition to be “too wordy, uninspiring, broadly focused and has no clear goal. Instead, Beaglehole and Bonita (2010) defined global health to be a “collaborative trans-national research and action for promoting health for all”. From the analysis above, it can be suggested that defining the activities, scope and meaning of global health represent one of the issues in global health itself. More so, defining what the global health issues are, represents an additional global health concern. For example, the US department of health (2014) identified disabilities, global health security, health diplomacy, LGBT, global water supply, non-communicable diseases, maternal and child health as the global health issues. Whereas the World health organisation, considering burden of disease as

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global health concern; listed HIV/Aids, diabetes, Tobacco use, cardiovascular diseases, disability, child health / newborn diseases and maternal health issues as the global health issue. In another description of what the global health issues are, Ronal and Jerry (2003) categorised global health into environmental global degradation such as (green house effect, biodiversity, water shortage and deforestation); Socio-economic issues (increasing poverty, financial instability, digital instability and taxation, etc.); and lastly, cross cutting issues such as (governance, food security, war and conflict amongst others). Therefore, it can be concluded that global health issues cover a wide range of topics and cannot be limited to a particular theme, as such description of global health issues depends on the position of the actor engaged with it. Thus, description of global health issues could be based on a developed country seeking to address issues that poses social and trade threat or low-middle income countries who tends to reduces burden of diseases from communicable diseases or researchers and students who identifies global health issue from a critical point of view. It is based on these premises that this essay will focus on polio as a global health issue by exploring the biosocial association with its global prevalence. Associated Biological and social factors to prevalence of Wild polio virus Polio is an entero-virus infectious disease of three strains (wild polio virus type1-3) that affects children under the age of 5years (WHO, 2014). The virus enters the human system through faecal-oral route, multiplies in the intestine and enters the blood stream, which may then invade the central nervous system, and often leads to paralysis of the lower limbs (WHO, 2000, 2014). In rare conditions, mortality may arise from the invasion of the brain stem, which causes breathing difficulty and eventually death (WHO, 2000; WHO, 2014). One in 200 Polio infections leads to irreversible paralysis with 5-10% deaths recorded in those paralysed (WHO, 2014). The virus spreads through agents such as food, water and sometimes flies when they are contaminated with faeces of infected children (GPEI, 2010). The long period of paralysis manifestation in infected children allows the silent spread of the virus in a community. Therefore, it is for this reason W.H.O. considers a confirmed single case of acute flaccid paralysis (AFP), evidence for a polio epidemic especially in a community with previous low prevalence of polio cases (GPEI, 2010). The virus however, doesn’t have a cure but can be eradicated through the use of vaccines such as oral polio vaccine, inactivated polio vaccine, monovalent OPV and bivalent OPV (GPEI, 2010; WHO, 2014). Genetic alteration of the OPV vaccine through poor handling, storage, and administration are associated to the incidence and prevalence of circulating vaccine derived polio vaccine-CVDPV (GPEI, 2010). In addition, low immunisation coverage in a community facilitates the spread of this strain of virus. For example, CVDPV constitutes the highest percentage of the remaining reported polio cases globally with more countries suffering polio outbreak from CVDPV than WPV for the first time in 2012 (WHO, 2013). Therefore, programmatic errors could be said to be an on-going challenge in the complete eradication of polio in low-middle income countries.

Nonetheless, Humans are the only susceptible host of the virus, therefore allowing for easy control of the diseases. Thus, global focus on polio intensifies day to day due to its susceptibility to eradication once and for all. According to Bruce et al., (2014) eradication of the Poliovirus represents a good example of public good for health. This is because once an infectious disease such as polio is controlled or eradicated; every person in receipt of this protection diminishes the protection enjoyed by others and therefore provides protection for every newborn entering the global community (Bruce et al, 2014). Although polio is deemed to be a high morbidity rate disease with about 1000 paralysis recorded everyday globally in 1988; moreover, its detrimental effect on global economy due to the paralytic effect on mostly children under 5 makes it a public health concern. However, the establishment of the global eradication initiative (GPEI) by the world health assembly in 1988 has led to the reduction poliovirus from 350,000 polio cases to 406 polio cases in 2012 (GPEI, 2012). As such, three countries (Nigeria, Pakistan and Afghanistan) remain endemic, constituting the last 1% of the remaining poliovirus globally (WHO, 2014). Public-private partnership activities spearheaded by national governments, WHO, Rotary international, United States centre for disease control (CDC), United Nations for children fund (UNICEF) and other partners such as the Bill and Melinda gates foundation and Gavi-alliance enhanced the process of eradicating of polio globally (WHO, 2014). Their activities since the creation of the GPEI has majorly been the facilitation of donor governments, knowledge and technical support amongst other activities. For example, Rotary international, through its ‘Polio plus’ initiative and 1.2 million volunteer worldwide has not only facilitated contribution from donor governments but also contributed about US$600million alone by itself in 2005 (). Other organisations such as the International Red Cross, Red Crescent Movement, Medicines San Frontiers, Save the Children, World Vision, CARE, and the U.S. based NGO umbrella-organization CORE have all contributed both technical strategies and funding to the eradication of polio especially in low-middle income countries. Despite the recorded success, the role of the WHO as a global health leader has been questioned in different consensus. It is being argued that the role of WHO has only been that of a figure head rather than a unilateral organization such as the Bill and Melinda gates foundation, Rotary international and Gavi-alliance whom have all taken leadership roles in not only polio-eradication but also in changing the trend of implementing vertical interventions in low-middle income countries (Cox, 1997; Ruggie 1998; Barnet and Finnemore 2004). Having said this, it is important to note that the WHO through the strategic advisory group of experts on immunisation (SAGE) provides technical leadership for the eradication of polio through agreement on strategic planning, policy development, resolution of technical concerns and priority setting (Bruce et al., 2014). Nevertheless, the threat posed by the 3 remaining endemic countries remains a global health concern. This is due to the fact that as long as a child is infected, children across the globe remains at risk of getting infected. According to WHO (2014), failure to eradicate the last 1% could led to a prevailing 200,000 new cases of

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polio yearly. Thus, it is important to note that limiting the causative factor of polio prevalence to its biological characteristics pose a great risk to the eradication of the virus. Analysis has shown that social factors play a major pact in the resurgence of the poliovirus. According to global polio eradication initiative (2014), conflicts, political instability, hard-to-reach areas and poor health infrastructure pose threat to the eradication of the poliovirus. Other co-founding factors such as the economy status of a country also plays a role in the lingering poliovirus globally. Research and knowledge patency by high-income countries can be explained to be one of the major factors affecting the eradication of polio. This is because; countries especially the low-middle income countries find it difficult sustaining immunisation programs due to its related high cost of vaccines purchase (Sidsel et al., 2013). This suggests that knowledge and research ownership by developed countries creates barriers for low-middle income countries to produce and utilize these necessary vaccines. Nevertheless, the establishment of the GAVI-alliance, which encompasses a public-private partnership between developed nations and international financial firms, research institutes, vaccine manufacturers and NGOs, through whom funding and technical knowledge where facilitated for the production and purchase of vaccines at lower cost for low-middle income countries (GAVI-alliance, 2013). It can be argued that on the positive side, GAVI has brought about increased attention and adequate resources to promoting immunisation, but the power exerted by global actors based primarily but not exclusively on their financial resources, exacerbates the asymmetric relationship between strong and weak actors, thus threatening the already limited autonomy-especially the low-middle income countries (Sidsel et al., 2013). As such, vertical program is imposed on low-middle countries by donor countries, which endangers the eradication of diseases as homogeneous “one size fits all” solution disallow development of programs based on country/community needs, therefore reducing the effectiveness of these interventions. Most donor countries support to low-middle countries as regards disease control including polio eradication includes technical and financial contribution with less emphasis on good governance, this is despite the agreed conditions that stipulate this. For example, the term of reference (TOR) between GAVI and receiving countries highlights ensuring accountability at all level of government. Corruption in the health sector and the governments in low-middle countries prevent the required downstream approach in eradicating polio globally. For example, field experience of the author revealed that funding allocated for the training of health workers at local government levels are cut and diverted without getting to the intended recipient (health worker), therefore little amount of budgeted fees are paid to the staff and as such, the workers are less motivated to give optimal performance. Further experience has shown that health workers prioritise vertical programs such as polio eradication over other routine health services as the huge sum of donation from donor countries and organisations encourages health workers to affiliate more to vertical programs in other to meet their financial need. As a result of this, health workers in this category view the eradication of the poliovirus globally to mean an end

to their source of livelihood. This phenomena thinking weakens the health system through the neglect of other areas of the health system. The eradication of polio from India gives the consensus amongst stakeholders that polio eradication globally can be a reality. Eradicating polio from India was thought impossible at some point due to the demographic characteristics of the nation; a large population, high social-economical disparities, difficult geographical terrain and poor governance amongst others were some of the threat to polio eradication in India. However, Initiatives such as advocacy through the use mega Bollywood faces for polio eradication, intense supplemental immunisation, and government accountability amongst other strategies contributed to the eradication of Polio in India (GPEI, 2014). Global health actors (WHO, 2014; GPEI, 2014) have suggested that eradicating the last 1% in the three endemic countries depends largely on how they can emulate lessons from the India success story. This author however argues that eradicating polio in the remaining three countries goes beyond science and other programmatic approaches used in India, rather a more holistic view into how global diplomacy through political activities affects the eradication needs to be explored. An analysis of the three endemic countries shows that they are all affected by civil unrest and political instability. Resurgence of poliovirus has been recorded in the past where these conflicts took place. For example, in Nigeria, the activity of the terrorist group ‘Boko Haram’ hinders health workers from reaching children in the northern part of Nigeria. Result of this threat is a reduction in the immunisation coverage rate, which inherently facilitates the spread of poliovirus not only within the affected states but also to other neighbouring communities. Therefore, it is paramount to state that global action towards eradication of any disease should go beyond funding and knowledge contribution, rather global health actors need to take more holistic approach by encompassing diplomacy for the good of all instead of focusing on individual donor countries interest. As such, countries like Syria, Palestine, Russia amongst others where diplomacy war amongst high-income countries sustains continuous conflict in this war zone, facilitates resurgence of not only polio virus but other communicable diseases due to a weak government and eventually the health system. In conclusion, the development of the polio-end game strategic plan 2013-2018 which aims to eradicate polio by 2018 is a unique plan, in that for the first time, all strains of the polio virus are targeted simultaneously encouraging concurrent eradication of both wild polio virus and vaccine derived polio virus (GPEI, 2014). However, as argued initially, the success of this plan will depend not only on the continuous global support of the eradication but largely on how challenges surrounding polio eradication can be approached holistically. Therefore, assumptions such as the “one size fits all” solutions, concentration on vertical programs, prioritising high income countries vested interest in global-policy development should be reviewed towards ensuring global public good for health. Most importantly, high-income countries need to note that other activities including global diplomacy in conflict situation and other situation deters the effect of any intervention which they invest tax payer money on, as such it is paramount for tax-payers to

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