Report on polio eradication calls for attitude changes

The obstacles standing in the way of polio eradication now rest within the global eradication program itself and are not scientific challenges posed by the poliovirus, a bitingly candid new assessment of the program declares.

The latest report of an independent panel set up to assess the polio eradication effort questions why "tired and ineffective" managers are being left in key positions and suggests the program's perennially positive attitude may be getting in the way of getting the job done.

"We are convinced that polio can -- and must -- be eradicated. We are equally convinced that it will not be eradicated on the current trajectory. Important changes in style, commitment and accountability are essential," says the report, the third from the Independent Monitoring Board of the Global Polio Eradication Initiative.

All of the board's reports have called the long-running campaign to account with a frankness that is rare in public discussions of polio eradication efforts. Their critiques are especially surprising considering the insider status of the authors.

The eight-member panel includes one of the public health figures credited with launching the polio eradication program, a former director of the U.S. Centers for Disease Control, and Egypt's assistant minister of health. It was set up by the World Health Organization -- one of the partners in polio eradication -- at the request of its executive board and its governing council, the World Health Assembly.

The body is chaired by Sir Liam Donaldson, Britain's former chief medical officer, who suggested Thursday that the members feel they need to be blunt.

"We didn't want to pull any punches because as you'll have seen from the tone and the content, very clear things needed to be said," Donaldson remarked in an interview from London.

They include questions about why managers who are not up to the task are being allowed to stay in their jobs, even though their shortcomings are well known. Donaldson said these are people who are mainly working in country level programs.

The report also asks why some vaccinators are not being paid the salaries they have been promised, why some team leaders seem unable to assess the quality of the efforts they are overseeing, and others escape being held accountable for poor performances.

The latest report, released without fanfare earlier this week, conveys a tone of frustration, creating the impression that the monitoring board feels the messages of its two earlier reports haven't been adequately heeded.

Donaldson, who co-wrote the report with an assistant, admits that tone is deliberate. The group feels that the successes of the program show that the virus can be stopped, but only if the managerial shortcomings are addressed.

"This is now a change management program, and unless you sort out some of the dysfunctions that are caused by people and their behaviour and their levels of commitment and their levels of expertise and their leadership qualities, then you won't get there," he said.

"And I think we've felt ... we were more muted in saying those things in the two earlier reports but we're now absolutely convinced that that's where the program needs to give its greatest attention."

The report also hits hard at the Pollyanna-esque attitude that is the public face of the polio eradication initiative, saying the insistence on accentuating the positive may impede the program's ability to spot and address its problems.

The polio program isn't "wholly open" to critical voices, even if the critics are conveying information from which the program would benefit, the report says, adding the polio program "displays nervousness in openly discussing difficult or negative items."

The eradication program walks a tightrope, the report admits, trying to keep staff around the world motivated and donors convinced billions are not being spent in vain.

"It's a very delicate balance between telling the donors 'If you give money this is going to happen, it's going to succeed' and facing up to some of the hard realities and trying to overcome the difficulties," Donaldson said.

"So I think they've erred on the side of having a very, very positive narrative."

While the program faces a large funding shortfall, Donaldson said the two main supporters -- the service club Rotary International and the Bill and Melinda Gates Foundation -- are unswerving in their commitment.

That comment was echoed in a statement from Rotary, which has raised more than US$1 billion for polio eradication. The eradication program began in 1988 as a partnership among Rotary, the WHO, UNICEF and the CDC. The Gates Foundation joined the effort in recent years.

"Rotary's 1.2 million members worldwide remain steadfastly dedicated to achieving a polio-free world, a commitment that is reinforced by the fact that the incidence of polio has declined by more than 99 per cent since the launch," said Dr. Robert Scott, chair of the organization's International PolioPlus Committee.

The Independent Monitoring Board's report warns that the eradication effort risks missing the current deadline -- the end of 2012 -- for the halting of polio transmission.

Of four remaining endemic countries -- countries where transmission has never been halted -- only India looks poised to interrupt spread within that time frame, it says. The other three are Afghanistan, Pakistan and Nigeria.

In addition, 14 other countries are currently battling polio outbreaks ignited by viruses imported from endemic countries, according to the WHO. They are: Angola, Chad, Democratic Republic of Congo, China, Congo, Cote d'Ivoire, Gabon, Guinea, Kenya, Liberia, Mali, Mauritania, Nepal and Niger.

The report expresses dismay about the latest "surprise" in an effort that has been plagued by many surprise outbreaks over the years, this one being the discovery that polio is back in China. After more than a decade without cases, China announced recently that it is battling an outbreak, triggered by viruses that came into the country from Pakistan.

As for Pakistan, the report calls the situation there dire, saying the management of Pakistan's polio effort is deeply dysfunctional and the country will likely be the last on earth to halt polio.