Syed Latif has been giving out vaccines to children in his home country Pakistan for twenty years. Taleban militants shot him in 2012 for doing so, and afterwards, Latif was hospitalized for three months, with eleven metal rods inserted in his leg.
Commanders in the North and South Waziristan tribal districts decided that June 2012 to ban polio vaccination teams until the US ended drone strikes. Latif’s work has been dangerous since then.
Latif’s colleague, shot at the same time, was killed. So was another polio vaccinator worker on 1 July 2017 — two assault-rifle armed militants on motorcycles shot him as he returned from an outreach campaign.
Latif says he does not think of himself as a hero, and he has “never thought” of quitting. “I just want the children of my country to be healthy and protected,” said Latif in an interview. “I want to continue until we see a polio-free Pakistan.”
The goal is near, with only 32 naturally occurring cases of polio worldwide until November 2016. Of these, 28 were in Pakistan or Afghanistan. The other four were in Nigeria, where Boko Haram has hampered vaccination in the country’s north.
The World Health Organization lists 25 vaccine-preventable diseases: along with polio and malaria, the list includes cholera, typhoid fever, and diphtheria.
In the 2017 Future Health Index Report, about 59 per cent of healthcare professionals around the world said preventive care “should be their focus”. At the same time, around one-third of the general population in the 19 countries surveyed did not agree they had access to medication or treatment to prevent disease. But recent progress in vaccines, along with rapid diagnostic tests and low-tech interventions like bed nets, brings previously unimaginable progress in preventable diseases like polio and malaria within reach.
New preventive tools
Insecticide-treated nets are a low-tech, powerful fix, with more than one billion nets distributed in the last ten years. Dr. Sikolia Wanyonyi, who is working in Kenya, cautions that some recipients “will pick the free samples and use them as curtains, pieces of clothes or even resell them to get money for food. The people may not have extra money to buy the insecticide once the impregnated ones expire, so the net becomes a mere piece of cloth.”
Inexpensive rapid diagnostic tests offer a way to reduce incorrect prescribing of malarial drugs, which has helped spread resistant strains. “Test and treat” is a better front line approach than relying on unevenly trained community health workers prone to treat every African fever as malaria, a strategy Dr. Charles Masaki, a doctor in Kenya, says “has failed.”
One new rapid diagnostic test, GeneXpert developed by Dr. David Persing, can detect extremely low levels of a pathogen, along with drug-resistant variants, by testing for signature DNA sequences.
Called a nucleic acid amplification test, it works by placing a clinical specimen in a cartridge containing a series of chambers, which amplify nucleic acid and make billions of copies of the target sequence.
This test is quick—taking 90 minutes—and inexpensive, with a test cartridge costing $10 for poorer countries The machine processing the cartridge is automated, meaning GeneXpert can be operated by people with less technical training.
Eighty-eight percent of Kenyans now have mobile phones, says the country’s Communications Authority. For Dr. Nelson Muriu, director of health services in Nyeri County, Kenya, this doesn’t only revolutionize communicating with patients, including by telemedicine when they are far from clinicians. Tracking SIM cards has helped model people’s movements, and refine models of how malaria spreads—as it turns out, from the Lake Victoria region with its mosquitoes, to the bustling Nairobi hub, and from there outward. Dr. Muriu says it also opens new options for tracking and tracing medical stock between local dispensaries in uncertain security environments.
Smartphones are also connecting clinicians in remote areas to networks like Pathologists without Borders —specialists across Europe and North America who volunteer to review histological slides and biopsies from far away.
“There has been huge growth in health workers using mobile phones to identify where outbreaks are happening, and this allows better identification of disease outbreaks,” says Celina Shocken, a health care consultant, who points to an open-source disease management system called DHIS (District Health Information Software) 2.
Climate change and “Monkey Malaria”
At the same time of all this progress, war and climate change are “waging a counterassault”, says Dr. Megan Coffee, an infectious diseases doctor and technical advisor to the International Rescue Committee. For one, deadly diseases reappear where conflict or local authorities prevent vaccination—like in Waziristan or northern Nigeria.
Health bodies are sometimes able to make unlikely allies. In 2007, the World Health Organization successfully sought Mullah Omar‘s permission to vaccinate in Taleban-controlled areas of Afghanistan. The Afghan Taleban leader provided a letter for vaccination teams to show local militants.
Climate change and travel are also reintroducing diseases where they have been eliminated. Malaria-bearing mosquitos are climbing to higher altitudes in Ethiopia than before, because of climate change.
Similarly, Zimbabwe and Botswana have seen anti-malarial gains eroded in recent weeks by heavy rain—which brings flooding, and mosquitos. And just as progress is made in Senegal, Burundi has declared a malaria outbreak, with two million cases in the first three months of 2017.
Travel and climate change are unearthing new strains of diseases, too. Southeast Asia had been steadily wiping out malaria, but then a new version of the disease began showing up in forest workers.
Falciparum is the most common malaria-causing parasite, but the loggers found an equally deadly one. “There’s a crazy new ‘monkey malaria’ (Plasmodium knowlesi) in Malaysia thanks to logging and encroaching in the forest, which is as bad as falciparum “, says Dr. Coffee.
Looking ahead, “when polio is gone, there will be a huge hole in global health budgets, as so much global health work is done under the polio budget,” says Dr. Coffee. This may mean a reduction in funding for preventable diseases, or it may mean unlocking more resources for eliminating malaria.
The Bill and Melinda Gates Foundation recently embraced eradication of the malaria parasite as ‘the only sustainable approach to addressing malaria’. While this represents a scope of ambition not seen in decades—not since the World Health Organization’s Global Malaria Eradication Programme, from 1955 to 1969—it also reflects donor fatigue, too. “Donor countries cannot maintain funding of several billion dollars a year in perpetuity,” says the foundation.
As for Dr. Coffee, she says the final eradication of polio and malaria is all to play for. We will beat Polio, she says, “maybe in 15 years, but it could be a lot sooner if the conditions are right.”