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Precious Window of Opportunity Is Closing. Can a Bunch of Glad-Handing
Rotarians Really Save the World From Polio Before the Chance Is Lost
Forever?
By Susan Emerling
Susan
Emerling is a Los Angeles-based freelance writer.
Every Tuesday
at noon, the Rotary Club of Simi Valley holds its weekly meeting in
a hotel ballroom. The 60 or so members--local businessmen and businesswomen,
civic leaders and retirees--collect their name tags and backslap their
way through the buffet line. Then, against a backdrop of Rotary banners
from around the world, the club president rings a bell and the group
rises for the pledge of allegiance and a sing-along of "God Bless
America."
Then it's on to weekly reminders of birthdays, anniversaries and bawdy
jokes about this year's Rotary theme: "Sewing the seeds of love."
("After 25 years of marriage, my wife and I almost have sex every
night. We almost had it on Monday, we almost had it on Tuesday . . .
.") Next is the weekly bad-tie contest and the collection of "happy
bucks," which triggers a round of good-humored banter as club members
donate a few dollars to charity in the name of something that makes
them happy. Someone kicks in a dollar to celebrate the purchase of her
first home. Her realtor kicks in two, one to celebrate the sale and
another to apologize for missing the new owner's painting party. A third
member throws in a dollar to tease a trustee of the local community
college whom "radical right-wing Republicans" want to see
ousted. An insurance salesman, one of the few Democrats present, throws
in a buck because he's happy that someone in the group finally called
them "radical right-wing Republicans."
Before the day's speaker takes the podium, in a moment that passes without
fanfare, a member announces that the Rotary Club of Los Olivos is raffling
a cruise to Tahiti to support Rotary's campaign to rid the planet of
polio. Heads nod and the club moves on to the next order of business.
Left unsaid is any hint of a story that, despite the corny bonhomie
of the day's proceedings, is as dramatic as it is astounding in its
scope, ambition and logistics.
Beginning with their first fund-raising campaign in 1985, Rotarians
all over the world have been washing cars, racing rubber duckies, and
holding golf tournaments, flea markets and rodeos to raise money for
the fight to finish off polio. They have auctioned 60-year-old bottles
of scotch and a '57 Chevy, ocean cruises and a BMW. One Rotary club--today
there are more than 30,000 clubs (375 of them in Southern California),
with 1.2 million members in 163 countries--built and raffled a luxury
home. Itzhak Perlman, the violin virtuoso and a childhood polio victim,
played a benefit concert in Cleveland. A 7-year-old girl in India roller-skated
1,250 miles in 41 days. A man who contracted polio in Santa Monica in
1948 and spent part of his childhood in an iron lung joined Rotary and
donated more than $10,000. Many Rotarians have written the polio-eradication
program into their wills, and one Chicago member gave $1 million.
By focusing on its goal for nearly 20 years, Rotary International--the
merry-making civic organization characterized by Larry King as a bunch
of guys in brown suits who sell each other insurance over lunch--has
been the primary catalyst in driving one of humanity's most insidious
diseases to the brink of extinction. With an extraordinary single-mindedness,
the club with a reputation as local do-gooders has battled a stealthy
and stubborn virus and problem-solved its way through staggering logistical
challenges, a brief lapse of will and reminders that the world, at times,
seems to be working against Rotary's noble goal.
One week from today, 530 of Rotary's newly elected district governors,
their spouses and Rotary's board of trustees will arrive in Anaheim
from 158 countries. Among other things, they will fire themselves up
to raise another $80 million to finish the job Rotary began nearly two
decades ago. Along with its partners--the World Health Organization
(WHO), UNICEF and the national Centers for Disease Control and Prevention
(CDC)--Rotary hopes to celebrate victory on its 100th anniversary in
2005. If that happens, polio will be only the second disease in history
to be eradicated.
Rotary began its seemingly quixotic quest in the heady days after the
defeat of smallpox, which made other global health challenges seem less
daunting. It also was a time when the world seemed capable of working
together toward a noble goal. Who could have imagined that today's headlines
would be filled with news of anthrax bioterrorism and threats of smallpox
as a weapon of war? The world today is a far different place than it
was 20 years ago, and Rotary's remarkable efforts to make it a better
place have taken on a delicate poignancy. Its success or failure will
either affirm humanity's best impulses or its worst, and say much about
our stewardship of the planet.
The idea came to Australian Clem Renouf in 1979. Then president of Rotary
International, Renouf was returning to Rotary headquarters in Evanston,
Ill., from the Philippines, where the organization had just participated
in its first polio project. Rotary had dipped into its new Health, Hunger
and Humanity fund for $760,000 to purchase enough polio vaccine to immunize
the country's 6 million children. Typical for Rotary, this was a local
project initiated by a Filipino Rotary club addressing a need in its
community. On the plane home Renouf read about how WHO had just eradicated
smallpox at a cost of $100 million.
When Renouf got off the plane he called John Sever, a pediatric epidemiologist
and one of the many medical doctors who join Rotary to expand their
social circle. Renouf had a question: What disease could Rotary tackle
for a similar amount of money and expect similar success? Sever got
back to him a month later, recommending polio.
The idea was particularly appealing because of polio's potentially devastating
physical, psychological and economic impact. It strikes the most vulnerable,
usually children under the age of 5, and can leave them permanently
crippled and unable to breathe without assistance. The fear of polio
once gripped the United States, causing panic among parents and children.
But the U.S. saw its last new polio case in 1979, and the disease was
disappearing from the industrialized world in the post-vaccine era.
Still, it remained a devastating problem in the developing world, where
vaccinations were spotty and sanitation was often poor. Ironically,
people become more susceptible to polio as sanitation improves, because
they do not build up a natural resistance to the virus. That can set
the stage for increasingly devastating epidemics, including the one
in 1952 that struck 58,000 Americans and filled hospital wards with
terrified children who relied on iron lungs to keep them breathing.
It was in the wake of this epidemic that doctors Jonas Salk and Albert
Sabin, working separately, developed their revolutionary vaccines in
the mid-1950s.
Although immunization quickly became routine in the United States and
other industrialized nations, in 1979 "only about 60% of the world's
children were getting any kind of routine immunization," recalls
Sever. Under Renouf, Rotary went to the health ministries of some of
the poorest countries in the world and offered funds to purchase the
polio vaccine. It was Rotary's first top-down directive for a worldwide,
club-wide project.
"Some people thought it was heresy," says Bill Sergeant of
Oak Ridge, Tenn., a high-energy octogenarian with 55 years of 100% Rotary
attendance. For the last nine years he has been the linchpin of Rotary's
polio efforts. "Past presidents were horrified at the idea of all
of Rotary working on one project, but Renouf saw Rotary doing something
more significant than painting the water tank every year."
For the next four years, under four successive presidents (all elected
offices in Rotary are single-year terms), Rotary purchased enough oral
polio vaccine for various ministries of health so that officials in
Haiti, Bolivia, Morocco, Sierra Leone and Cambodia could inoculate the
children in their countries. Then, in 1985, Sabin spoke at Rotary's
annual convention in Kansas City, Mo. Rather than congratulate Rotary
on its good work, however, Sabin told the assembled crowd that buying
a couple of years' worth of polio vaccine for a handful of countries
was nice, but so what? Despite Rotary's efforts, there would be 400,000
polio cases worldwide each year, Sabin estimated. By the time Rotarians
celebrated their 100th anniversary in 2005, an additional 8 million
of the world's children could be permanently paralyzed.
Sabin gave the traditionally conservative club a lesson from Cuba. In
1963, with tensions still high between Cuba and the U.S., Fidel Castro
rapidly eliminated polio by administering Sabin's oral vaccine to every
child under 5 in the country on the same day through a nationwide network
of "community committees for the defense of the revolution."
The strategy essentially left the virus nowhere to go since every potential
host had been immunized. Until 1980, everyone assumed it only could
be done on an island under communism. But that year Brazil adapted the
Cuban method to vaccinate 20 million children. The Pan American Health
Organization (PAHO) took the technique to the rest of South America
and Central America, brokering cease-fires in civil wars, finding remote
villages with aerial photography, and using "well-organized armies
of community volunteers" to administer inoculations.
Sabin issued a challenge to Rotary. Would it do something much more
difficult than just pay for vaccines? Would it use its network of volunteers
to get the vaccine into the mouths of every child in every affected
country on the planet?
For an organization of small businessmen (Rotary did not admit women
until 1989) committed to "service above self," Sabin's image
of 8 million children crippled by Rotary's inactivity was haunting.
So Rotary leadership did what Rotary does best--they networked. With
the help of the late James Grant, executive director of UNICEF, they
calculated that for each of the next five years, from 1985 to 1990,
there would be 100 million newborns in the developing world. Each would
require six doses of the vaccine at four cents per dose. In the fall
of 1985, at the 40th anniversary celebration of the United Nations,
Rotary announced that it would raise $120 million to vaccinate the world's
children against polio--a goal that wouldn't necessarily eradicate the
disease but would significantly control its spread.
"It was a staggering amount of money," says Sergeant. Polio,
however, was a perfect target for the aging leadership of Rotary. In
1985, the average Rotarian was 55 years old. Most had lived through
the terror of polio summers and had grown up with a president, Franklin
D. Roosevelt, who was crippled by the disease. There were Rotarians
in wheelchairs who had been in iron lungs. They had accompanied their
children to the Salk vaccine trials.
Rotary spent a year educating its members for its "PolioPlus"
campaign. The leadership set target fund-raising goals for each club
and Rotary volunteers gave speeches over buffet breakfasts and lunches.
Cyrus Johnson, a 31-year member of the Rotary Club of Westlake Village,
gave hundreds of these speeches. A veritable demon with a photocopying
machine, the retired Air Force lieutenant colonel-turned-life insurance
salesman delivered the facts about polio and asked his friends and neighbors,
"What would you pay to have your grandchildren live in a polio-free
world?"
The campaign ended in 1988 at Rotary's convention in Philadelphia. There
was a roll call of the 44 multinational committees. A representative
for each stood and announced what its clubs had raised. By the 43rd
committee, the membership began to realize that its $120-million goal
was within reach. When the 44th chairman, representing the United States,
Bermuda, the Bahamas and Puerto Rico, stepped forward and announced
donations of more than $119 million, the place cut loose. There were
balloons, marching bands and a room full of grown men sobbing as the
membership celebrated what the inner circle had known for months. Not
only had Rotary reached its goal, but it had raised nearly $219 million
in cash and pledges. In the next months the number would grow to $247
million. Today Rotary's fund-raising total to combat polio stands at
more than $500 million.
Rotarians weren't the only ones startled by the results. The World Health
Assembly (WHA)--the governing body of WHO--had been shifting its priorities
away from disease eradication in favor of other containment strategies.
"Rotary called everyone's bluff on a global scale," says Bruce
Aylward, a 40-year-old Canadian physician and epidemiologist who has
coordinated WHO's Global Polio Eradication Initiative since 1998. "WHA
was focused on building broad horizontal health systems. Rotary said,
'Great, but that could take forever. We have vaccines, we know how to
tackle polio.' HIV was taking off at that time, but they said, 'You
don't stop doing something because another disease comes along.' "
With so much money available, WHA changed course, inviting Rotary International--with
its newfound wealth and network of volunteers--to form a first-ever
public-private partnership with WHO, UNICEF and the CDC. Together, they
optimistically projected, the alliance could expand Rotary's original
goal from control to worldwide eradication of polio by 2000, five years
before Rotary's target year. If Rotary's leaders had known then what
they know now, Sergeant doubts that they ever would have accepted the
challenge.
"It is a massive step from control to eradication," agrees
Aylward. For one thing, the job requires a rare combination of what
he calls "technical and biological feasibility." Polio met
the technical criteria in 1955, when children across the United States
lined up for shots of Salk's inactive polio vaccine. Six years later,
Sabin's oral polio vaccine, administered by two drops in the mouth,
made it possible to inoculate on a very large scale with unskilled labor.
Although highly contagious, polio can only spread through human-to-human
transmission. So there are no mosquitoes to kill and no animals to round
up. All you have to do is get two drops of the vaccine into the mouth
of every child in every country where the poliovirus is on the loose.
Eradicating a human disease had been tried at least five times before
efforts were made to eliminate polio. Smallpox is the only success story.
"Polio makes smallpox [eradication] look small," says Steve
Cochi, director of the Global Immunization Division of the CDC, which
handles the technical arm of the eradication campaign. For starters,
smallpox was present in only 31 countries. In 1985, when Rotary began
its PolioPlus campaign, polio was present in 125 countries on five continents.
"They were supposed to eradicate smallpox in five years,"
says William Foege, a former CDC director and one of the chief architects
of smallpox eradication. "They ended up doing it in three years
and five months and under budget." The reason, he says, was a shift
in strategy from mass inoculation to "surveillance and containment,"
which vaccinates a ring around an outbreak to cut off transmission,
much the way a moat cuts off access to a castle. With no new hosts,
the virus dies out. When there are no outbreaks for three years and
all lab stocks are contained, a disease is said to be eradicated.
Although less frequently fatal than smallpox, polio is harder to diagnose
and thus harder to know when you have an outbreak. With smallpox, the
telltale pox erupts over a victim's face and body. To find an outbreak,
all you have to do is train people to report the pox.
Polio, on the other hand, can spread widely even before the first infected
child wakes up in pain, struggling to breathe and unable to move his
or her limbs. By the time that first child's symptoms show up, hundreds
more could be infected.
"Surveillance and containment" is a pipe dream for polio.
Just to find an outbreak, a health-care worker must be dispatched to
collect not one but two stool samples from every child who wakes up
with a case of acute flaccid paralysis to diagnose whether the cause
is polio. Samples must be collected within 14 days of infection and
analyzed within 72 hours.
Otto Austel, a soft-spoken retired doctor from Simi Valley and a 26-year
Rotarian, spent three months in Angola and another three months in Egypt
as a Rotary volunteer looking for polio. "A report will come in,
but there's no address for where the child lives. Often it's in the
slums or refugee camps. If you find the child, lots of luck getting
a stool sample. An old white man like me is the boogeyman. You leave
a cooler with ice with the family, and you never know if you get a stool
sample from this kid or some other kid. Then you come back for a second
stool specimen. Twenty-four hours have passed. You wait for the second
sample. Then you have to get to a plane to get it flown to a lab that
could be in another country. It could be 110 degrees and you're traveling
with ice. If it gets to the lab and the ice is melted, they won't even
test it."
Even with a diagnosis, the only reliable way to cut off transmission
is to vaccinate every child under 5 in a polio-endemic country on the
same day so that the virus has no place to go. In the argot of polio,
you "pulse" the population on a series of "national immunization
days" that are scheduled 30 days apart to extend the window of
immunity beyond the virus' four- to six-week gestation period. This
is followed by a series of localized "mop-up campaigns." Then
you go back year after year until the last case of polio vanishes from
a country, then a region, then the world.
The numbers for this kind of intervention can be staggering. Last year,
10 million people immunized 575 million children, requiring a kind of
coordinated participation that Aylward calls the "third big factor"
in disease eradication. "You have to have the societal and political
will to launch and sustain the effort."
For example, the smallpox vaccine was available for 170 years before
societal will caught up. With polio it was 30 years before an attempt
at global eradication. A mere six years into that process--despite the
money, the generational fit, the armies of volunteers and the easy-to-administer
vaccine--the Rotary initiative nearly stalled in the labyrinthine corridors
of mammoth, geographically dispersed bureaucracies.
"In 1994, we lost our momentum," says Sergeant, who at the
time was on the Rotary Foundation board of trustees. That's when the
other trustees sent Sergeant a letter congratulating him on becoming
the first International PolioPlus Chairman, although he'd already turned
down the appointment on the grounds that he didn't feel qualified. Sergeant,
a man who describes himself as having "spent his life managing
things that I didn't know a whole lot about," discovered that the
problem was managerial and not technical. He locked onto the project
and he has never let go. He has chaired the committee for nine years,
working as a full-time volunteer out of a small office in Oak Ridge,
Tenn. Last year, the 83-year-old Sergeant boarded a plane 110 times.
WHO, UNICEF and the CDC credit Sergeant and Rotary not only with professionalizing
the campaign, but also with supplying its heart and soul. "The
level of cooperation is unprecedented," says Jean-Marie Okwo-Bele,
a physician from the Democratic Republic of the Congo and UNICEF's chief
of immunization. "There is progress and accountability by all partners.
Everyone is moving together."
One of the first things to emerge under Sergeant's leadership was that
WHO anticipated a $1-billion shortfall. The cases were dropping, but
the outbreaks were getting harder to reach and costs were rising. Despite
good intentions, Rotary did not think it could raise another $100 million
annually from its membership for the next decade. So the nonpartisan
Rotary International went into the business of public advocacy.
"Rotary is a powerful constituency of small and big businesses,"
says Aylward. "This is very important to politicians." Between
1996 and 2001, in conjunction with its partners, Rotary kicked loose
more than $1.8 billion for polio eradication from governments and foundations
around the world. The U.S. expanded its budget from $9.8 million in
1995 to $130 million in 2001. Particularly influential were Clare Short,
a member of the British parliament whose mother had had polio; Canada's
former finance minister, Paul Martin, who'd had polio, as did his father;
and Eveline Herfkens, minister for Development Cooperation of the Netherlands,
where polio had been reintroduced by immigrants after 14 years without
transmission. Ted Turner's newly formed United Nations Foundation donated
$25 million. This was followed by $50 million from the Bill & Melinda
Gates Foundation.
As governments took over the purchase of vaccines (manufacturers also
have donated large quantities), Rotary shifted its focus to filling
the logistical gaps that keep the delivery system functioning. Rotarians
donated airplanes to fly the vaccine into remote land mine-studded regions
of Angola. They purchased T-shirts, fed volunteers, supplied megaphones,
produced public-service campaigns and gave candy to children and parents
to reward them for what often are long trips to inoculation centers.
They donated ice and Styrofoam boxes with independent power supplies
to chill the vaccine during long hikes in warm temperatures to remote
villages. They got telephone companies to send hourly bulletins to cell
phones and pagers to remind people to vaccinate their children. "Their
enthusiasm was so infectious, it was like a communicable disease,"
says UNICEF's Maritel Costales, who worked with Rotary in her native
Philippines.
After years of responding to what Sergeant called "bridal registries
of national needs," Rotarians from all over the industrialized
world began to go see for themselves what they were paying for. "It
was one of the great experiences of my life," says Anil Garg, an
Indian immigrant and a member of the Rotary Club of Simi Valley, who
organized 36 people to go to India for a national immunization day in
2001. "There were 2.6 million volunteers, 100,000 of them Rotarians
who immunized close to 140 million children in two days. There were
650,000 booths for people to get vaccinated."
Garg's volunteers took vacation days and covered their own expenses
in order to wave banners and walk in parades alongside Indian movie
stars and politicians to mobilize parents to bring their children in
for immunization. They put drops in children's mouths through the windows
of trains and buses that stopped momentarily at a station. They stood
in market stalls, storefronts and public buildings. Even in a population
of 1 billion, not one child could afford to be left out, so they trudged
through garbage dumps and slums, hiked to remote villages, anyplace
where they might come in contact with children.
Not everything went smoothly. As rumors spread in the impoverished Muslim
minority of the predominantly Hindu country that the drops would sterilize
their children, they found children being hidden in dung heaps and locked
behind closed doors. "If you're illiterate, any word on the street
becomes your bible," says Garg.
Persistence is paying off. "In 1999, the total number of reported
cases in India was 2,800. In 2000, it came down to 285 because of these
national immunization days," says Garg. In 2001, there were only
480 cases of polio in the world, a decrease of 99.9% from when Sabin
spoke at Rotary's convention in 1985. But the final stretch will be
as tough, if not tougher, than any other part of the campaign.
Detractors point to the exorbitant cost-benefit ratio to wipe out the
last few cases. "You have to look at this as more than a one- or
five-year return on investment," says Foege. "This is a chance
to do something that only has to be done once in history." That's
because there isn't any such thing as nearly eradicating polio.
"Either you do or you don't," says Aylward. "If we stop
now, in five years we don't go back to 1,000 cases a year. We're back
to 1,000 cases per day. The only reason we can eradicate polio is that
people in the industrial world lived through the terror of polio summers.
In 10 years, there will be a new leadership who didn't know polio. It
didn't touch their family."
With them goes that precious political and social will. This is something
that Okwo-Bele sees as intolerable. "So many public health things
have failed," he says. "In 1994, there were 32 countries in
Africa with polio. At last count there were two. In Africa, to have
tangible results is not common and so important. If we don't finish,
it will be a big loss that could jeopardize everything else."
Aylward agrees: "If we couldn't do this with the oral polio vaccine,
what can we do?"
There is always the spark of recidivism to keep the dream alive. In
2002, the number of polio cases worldwide jumped to 1,351, with epidemics
in Nigeria and India threatening Rotary's dream of global eradication
by 2005. In Nigeria the political commitment is strong, but neighboring
countries with low vaccine coverage offer an escape route for the virus.
In India resources are strained because it has been combating the disease
on a massive scale for years. Egypt has suffered a breakdown in monitoring.
"This is when you need great leaders within and outside the health
system to turn around some very tired people," says Aylward.
On the positive side, epidemics don't just devastate--they also inoculate.
Although the number of cases in India is up, the outbreaks are localized
in the state of Uttar Pradesh and are all caused by the same virus strain.
If this winter's national immunization days go well, India may be polio-free
by the end of 2003. The Type 2 poliovirus, one of three known types,
has not been seen since 1999, and only 10 countries remain polio endemic,
the lowest number ever. Pakistan has had a 20% drop in cases. Afghanistan--despite
American bombings and restricted access to Kandahar and Tora Bora--is
expected to stop transmission by the middle of this year. So are Angola,
Niger and Somalia, despite vicious civil conflicts that can be extremely
dangerous for vaccinators.
It doesn't matter, says Aylward. "We'll get them the vaccine. They
can administer it themselves. If we can eradicate polio in [the Democratic
Republic of the] Congo, it shows we can do it in regions in conflict.
If we can do it in Bangladesh, it shows we can do it in the poorest
countries. The strategies work."
"This is the biggest thing in public health ever," says Cochi.
It's not just big in terms of the scope, but also in terms of its legacy.
In the last 17 years, a worldwide network of 148 laboratories has been
accredited to do the genetic sequencing of the poliovirus because it
was impossible to eradicate without them. "We can build on the
polio effort to do measles, yellow fever, bacterial meningitis and other
infectious disease work," says Cochi.
The "plus" part of the "PolioPlus" campaign also
is working. Vitamin A is administered along with the oral polio vaccine
to decrease the susceptibility to measles and HIV. Cochi says that could
reduce infant and child mortality rates by as much as 25%. The Styrofoam
boxes have been segmented into different temperature zones to carry
measles, tetanus and other vaccines for routine immunizations. Vaccine
vial monitors, invented to identify whether the heat-sensitive oral
polio vaccine has been exposed to high temperatures, have been added
to the measles vaccine packaging.
"From now on all public-private partnerships will measure themselves
against Rotary International in polio," says Aylward. "WHO,
UNICEF, CDC, none could have done what Rotary has been able to do in
terms of consistency of vision and leadership. They're different animals.
Rotary doesn't answer to anyone except its own membership. They couldn't
have done it without us. We couldn't have done it without them."
"This is visionary leadership for a community-based organization,"
says Patty Stonesifer, co-chair and president of the Bill & Melinda
Gates Foundation, which awarded Rotary the $1-million Gates Award for
Global Health in May 2002. "I was born in 1956. I never had a peer
threatened by polio. Here we are 50 years later. I'm visiting India
[and] watching a boy dragging himself around. There are low-cost vaccines
and we didn't get them there. If after 20 years of searching for an
HIV vaccine, we took another 50 years to roll it out, the cost to humanity
would be unthinkable."
In the meantime, Rotary has gone back to its membership to raise another
$80 million of a projected $275-million shortfall. This new campaign
will allow the current membership--most were not around for the first
campaign--to participate financially in what will be Rotary's greatest
achievement.
Cyrus Johnson, now 79, is ready to answer the call. You'll find him
at the door of a hotel ballroom in Westlake Village, greeting his Rotary
club as they handshake their way into the room for their Wednesday lunch.
He'll have on his Rotary tie and his ruby- and diamond-studded Rotary
pins. His blue eyes will sparkle as he hugs the women, and he'll dance
an excited jig when one of the men teases him about calling at 7 on
a Sunday morning to see if he'd decided what he plans to do to rid the
world of polio.
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