Books

POLIO: The Odyssey of Eradication by Thomas Abraham. C. Hurst & Co, London, 2018.

IT is not often that books are written on one particular disease, more so by a non-medical person. Though, by its title, this book would be of interest to those interested in child immunization, Abraham’s book makes for delightful reading even for persons with a cursory interest in global health policies. Not delving too much into the technical aspects of polio vaccination, he sets out the politics, the concerns, the events, and the compulsions that led to the struggle for polio eradication as a global priority, one that has been sustained for three decades.

Polio is a viral infection that afflicts children and paralyzes them for life. Vaccines thus protect them from such a debilitating situation. Since the polio virus replicates only in humans, a good vaccine can make eradication possible. Thus, the discovery of the injectable vaccine, closely followed by one that could be administered orally, stirred the ambition that eradication of polio was an achievable goal. The oral administration of the vaccine opened up immense possibilities – it was easy to administer with little training and infrastructure support and so eminently scalable even in poorly endowed countries.

With the backing of President Truman, a polio survivor, it was only a matter of time before efforts to eradicate the disease began. Launched in 1988 it was ‘one of the most ambitious enterprises in the history of public health’. That was the year when there were over 350,000 polio cases each year in 125 countries. By circa 2000, these reduced to 2880 in 20 countries. The book traces the debates, arguments, deliberations and the considerations that went into adopting the oral vaccine developed by Sabine over the injectable developed by Salk.

At the time of the launch there were two dominant points of view between the key players – the WHO and UNICEF. The then Director General of WHO, Dr Mahler, was uncomfortable with adopting a campaign mode for the eradication of a disease. He and others like Carl Taylor, felt that countries should be encouraged to simultaneously focus on the eradication of the causal factors such as contaminated water and insanitary conditions and building health systems that could address more pressing issues, arguing: ‘Should poor countries, with many health problems that could be controlled, divert their limited resources for a global goal that has a low priority for their own children?’, a question that kept reverberating time and again in several countries during the long journey. On the other hand, there were those committed to using a technological solution to eradicate the disease on the premise that, ‘if you can eradicate you should eradicate, no ifs and buts.’ The book enunciates these debates and how WHO finally fell into line.

The book is divided into three parts. The first part deals with the virus, the vaccine and the crippled President who gave heft to the idea of global eradication. The second part deals with the Road to Eradication, covering the inter-agency debates and its adoption by the global community as a global priority; while the third part is about the Long Endgame. In this section, Abraham takes up a more detailed examination of the bewildering and frustrating journey in India and Pakistan that required administering every child under five with the vaccine, nearly a dozen times every year.

After spending close to $15 billion and battling the disease for three decades, polio is still not eradicated and worse, there is an emergence of vaccine derived polio cases. But then as Abraham says, ‘The original decision by the World Health Assembly to eradicate polio was, as we have seen, taken almost on a whim, with no consideration of how much it would cost and the difficulties that might lie ahead.’ In 2001, the WHO declared that in future, before launching such single disease campaigns, the technical, managerial and resource aspects should be examined carefully – in other words, as observed by Abraham, ‘The polio eradication partners were unlikely to have embarked on the project had they known how long, difficult and costly it was going to turn out to be.’ An estimate in 2008 showed that to protect children from the 14 vaccine preventable diseases would require USD 35 for 72 of the world’s poorest countries spread over nine years that made Abraham rue, ‘If the money spent by the polio eradication campaign had gone into broader vaccine programmes (including polio vaccination), perhaps the world’s children would be better off today’ – a question that will always haunt the program critics and proponents alike.

The book offers a wide canvas of the politics and compulsions that accompanied this programme. Disappointed with the elusive eradication despite massive efforts as never witnessed before, that even went to the extent of threatening the arrest of those refusing to get vaccinated in Pakistan and Nigeria, Abraham concludes with a strong indictment: ‘If there is a lesson from this for future global programmes, it is that their task would be far easier if they were more responsive to the needs of the people that they were supposed to service rather than the well meaning donors funding their projects.’

Abraham does not venture into the role commercial considerations might have weighed into continuing this programme or the arguments on whether it is at all possible and advisable to eradicate diseases that could rob future generations of the natural immunity they enjoy today. But then he does confess that this book is not the last word on the topic. That it has lessons to be learnt with some humility by those with the arrogance of knowledge and power is the message that comes out clearly.

K. Sujatha Rao

Former Union Secretary, Ministry of Health & Family Welfare, GOI

 

HEALERS OR PREDATORS? edited by Samiran Nundy, Keshav Desiraju and Sanjay Nagral. Oxford University Press, Delhi, 2018.

SICKNESS is doubly dangerous: first due to the disease, second due to its treatment. Believers already know that one should be paranoid before entering a healthcare institution and fortunate to exit unscathed. The non-believers must read the systematic account by the insiders, who have spent a lifetime witnessing pervasive corruption in healthcare. Fifty one contributors, led by three editors: Keshav Desiraju, former Health Secretary and academic consultant surgeons, Samiran Nundy and Sanjay Nagral, have displayed concern and courage to present this book.

The editors define corruption as ‘misusing conferred authority for personal gain’, which serves as the underlying theme. They let the authors narrate their thoughts, with evidence and angst, in 657 pages of this hardcover book. The result is a well designed, readable book of dispassionate, non-accusatory analysis of the rot that ails healthcare. The rot is deep and wide; it infects all individuals and systems: practitioners, hospitals, laboratories, pharma companies, research scholars, medical colleges, public health workers and policy echelons. No institution is immune; the scale of the predatory behaviour is staggering and the impact on its prey – the gullible public – is devastating.

The book triumphs in maintaining an academic tone; the authors succeed in denying the reader a titillating expose. The book begins with a thought provoking section, which analyses the genesis of corruption; the authors delve deep into ‘structural basis’, ‘socio logic’, ‘commodification’ and influence of ‘globalization’ and ‘neoliberalism’ on enabling corruption. The book ends with stories of redemption from individuals and institutions, who are keeping ‘the beacon of hope’ alive with deep moral courage.

The bulk of the book handles the subject of corruption and its impact with convincing empirical evidence, such as, an estimated 2.5 million practitioners have no formal training or 3458 patients died in India during clinical trials between 2005 and 2008. The stories stretch from ‘petty to grand’, from doctors seeking gifts from pharma companies to institutional scandals like the Vyapam scam in the state of Madhya Pradesh, where 1000 students got admission to medical schools illegally, culminating in 200 registered criminal cases and 2500 arrests. Or the recalcitrant, pernicious Medical Council of India granting accreditation to undeserving medical schools. Or the criminal felony of an unlicensed pharma company in the state of Maharashtra, which killed 14 innocent patients who had swallowed adulterated medicines manufactured by the company. Subsequent legal investigation revealed the hospital staff, drug licensing officers, politicians and even ministers were wilful beneficiaries of the scam.

But it is the anecdotes of personal experience of the authors, which make the book rich in emotional content. Any attempt to select the most repulsive story will fail; the stories provoke anger, disgust, depression, cynicism in equal measure. You may want to shield your sanity by disbelief, but the book pummels you with straight punches, chapter after chapter, till it knocks you out. And if you belong to the medical fraternity, you are likely to feel diminished in the company of a predator in a white coat who could be lurking in the next patient examination room.

Avarice in healthcare is not an Indian monopoly; the fraud is universal; no country seems immune. Separate chapters describe the affairs in Bangladesh, Pakistan, Sri Lanka, UK and Australia. The authors show how market medicine disrupts the relationship between the doctor and patient; profit displaces trust, criminal greed overcomes morality, or it is the ‘triumph of avarice over public duties and professional behaviour’, as Amartya Sen articulates in his foreword.

In this dismal picture, do we have any hope of redemption? Yes! Individuals and institutions with courage and fortitude, such as the authors of this book, are willing to stick their necks out to fight the monster. The book is both descriptive and prescriptive. Amartya Sen sets the tone for solutions in his foreword by identifying three corrective measures: ‘improve primary care’, avoid ‘hasty and premature reliance on private health care’ and encourage ‘informed public dialogue’.

Other authors offer solutions derived from their work experience. The solutions range from benign (teach ethics) to radical (nationalize private medical colleges); reformative (strengthen public health) to punitive (detect and punish culprits). The solutions address all stakeholders: community, education system, institutions, regulators and policy makers.

I would have loved to read more on four aspects. (i) Many chapters conclude by recommending solutions specific to the expertise of the author. Counted, scattered and some overlapping, they amount to over forty recommendations. A chapter on aggregated recommendations to control corruption would have been welcome. (ii) Knowing that the West does influence the Indian medical industrial psyche, it would be informative to know the state of fraud and its mitigation in advanced healthcare systems. (iii) Some countries have extensively used IT systems to detect corruption. The role of IT systems in reducing corruption by audits, analytics and quality measurements needs detailed expansion. (iv) An analysis of payment mechanisms to the service provider, abetted and enabled by a healthcare financing structure, could increase the understanding of, perhaps, the keystone of corruption.

The book is pertinent, incisive and disturbing. For their honesty, the editors and authors deserve our gratitude. The exercise of showing a mirror to their fraternity must have been painful. Surely, they will win no friends, but these stories had to be told, for which we readers should be thankful. The book should act as a starting point for public discourse. A natural consequence of this book could be a ‘call to action’ by the leaders to make healthcare immune to corruption. It will be tragic if this book were to merely adorn a bookshelf.

Shiban Ganju

Founder, Save a Mother Foundation, Delhi