Today, on Remembrance Day, while the nation remembers the fallen, battles continue to rage throughout the world. Alongside wars, the scourge of disease is claiming victory over the weak and dispossessed. Less than two weeks ago, the WHO reported 10 cases of wild poliovirus isolated from 22 children with acute flaccid paralysis in Syria. Most were under the age of two, and un-immunised or under-immunised.
A week earlier, a large-scale supplementary immunisation activity (SIA) had been launched to vaccinate 1.6 million children against polio, measles, mumps, and rubella. But will it be enough?
Three main issues come to mind. First is the impact of the Syrian outbreak on global polio eradication. Vaccination against infectious disease is one of public health’s greatest achievements. Only smallpox and rinderpest (cattle plague) have been eradicated globally, but the world’s sustained efforts to remove polio have borne fruit. For example, this year India celebrated having no reported cases of polio for two years—remarkable for a country formerly crippled, quite literally, by the disease. We no longer see wards lined with iron lungs. Only in Pakistan, Nigeria, and Afghanistan does polio remain officially endemic. In April 2013, the sense of an ending was so strong that a Scientific Declaration on Polio Eradication was launched. Therefore, this new outbreak and the uncertainty of its trajectory present a significant and frustrating setback.
Of course, not all is rosy in the polio narrative. It is not a coincidence that those countries where it remains endemic, and those with a surge in cases, such as Somalia, have been mired in conflict. The second issue in this story relates to the impact of armed conflict on health.
Many wars are fought in the name of justice (jus ad bellum). Usually, however, both sides think their cause is just; one side happens to win, then writes the rest of history, making itself feel better by tidying up certain uncomfortable truths. These include slaughter, physical injury, destruction of housing, sanitation and food supplies, fragmentation of communities, and large-scale movements of people fleeing it all. Whether or not a “just war” exists, through these processes war affects health, at which point the rules on how to conduct warfare justly (jus in bello) come into play.
There is no specific international legal requirement to cease hostilities for vaccination, but a case can be made under various human rights frameworks, through international organisations such as the UN and WHO, and within the emerging entity known as customary international humanitarian law. Indeed, regarding children as “zones of peace” has become an important concept in humanitarian relief programmes. For example, during the civil war in El Salvador in the 1980s, government and rebel forces agreed to three “days of tranquillity” each year until the end of the war, during which hundreds of thousands of children were immunised against major infectious diseases. Similar arrangements were made during Operation Lifeline Sudan. The international community—including health professionals—must campaign for these rights to be upheld, regardless of the nebulous and nefarious politics of war.
But how does this affect us in the West? Perhaps we can focus on our own problems? Not so, because of the third issue, the increasing globalisation of disease.
A couple of days ago I received an email from Public Health England telling me about “a suspected outbreak of polio” in Syria, along with recommendations for what to do if I suspect it in someone recently arrived from the area. Here’s the thing: diseases do not respect borders. Polio, like the most fickle of mercenaries, gravitates to wherever it reaps the greatest reward, finding the best combination of virulence and pathogenicity with which to inflict the greatest bad for the greatest number. Polio moves with people, and our involvement in defying its will is paramount.
As health professionals, no matter where we live we can educate the public about the benefits of vaccination, we can speak out against spurious research, and we can support efforts to eradicate diseases that continue to inflict suffering on the most vulnerable. Doing so isn’t just about altruism. As others have argued more eloquently than me, the world is increasingly reliant on international and transnational networks to communicate incipient disease and halt epidemics. For the sake of Syria and beyond, in the domain of health it is time to understand that “global” is not a million miles away from home.
For more information visit the Global Polio Eradication Initiative.
Suchita Shah is a family doctor based in Oxford. She has a background in public health and international relations.