In marking World Polio Day a week ago Thursday, the Global Polio Eradication Initiative noted both that wild poliovirus cases in the three countries where it was still endemic (Pakistan, Afghanistan, and Nigeria) were down 40 percent from the year before, and that the virus known as "type 3" hadn’t been detected anywhere in the world for a year. The initiative used the word “celebrate” in conjunction with the day, and talks about the “endgame strategic plan.”
In the U.S. and most other developed countries, polio vaccination is standard and new cases of polio unknown. A 2005 exhibit on the disease at the Smithsonian Institution was named "Whatever Happened to Polio?"
But the eradication initiative also talked about the dangers of complacency. Polio is on the verge of being wiped out, yes, but it pops up with alarming frequency in the epidemiological game of Wac-a-Mole. For example, the initiative identifies a dozen “importation countries” where the virus and active cases are most likely to emerge; most of these countries appear in the “wild poliovirus importation belt” that stretches from West Africa to the Horn of Africa. Places outside the belt are not immune, and polio remains one of only four diseases that require a country to notify the World Health Organization when new cases are diagnosed. (The others are any previously unknown types of flu, SARS, and smallpox.) China, for example, had an outbreak in 2011—and stomped out the problem with the efficiency you might expect from an authoritarian state.
Polio remains one of only four diseases that require a country to notify the World Health Organization when new cases are diagnosed.
In places where it’s hard to get a nice unified stomp, especially places where war and violence interrupt the niceties of civil society, polio wins a fighting chance to rebound. That’s why Somalia has been described as the “epicenter” of the Horn of Africa’s problems—it’s a violent and unstable place. And five days after World Polio Day, the World Health Organization confirmed that several cases of polio had been identified in another violent and unstable place, Syria.
For a lot of serious diseases, if you get infected you probably get sick—think smallpox—and you get noticed. But for every person who suffers from paralytic polio there are a hundred more people who get a fever or perhaps no symptoms at all. “By the time you see a case of clinically apparent paralytic polio, that means there’s at least a hundred other people who are probably infected,” explained Dr. Peter Hotez. “It’s made it that much more difficult to eliminate and eradicate. “Syria has just become a public health disaster.”
Hotez, the dean of the National School of Tropical Medicine at Baylor College of Medicine, is also the president and director of the Sabin Vaccine Institute and Texas Children's Hospital Center for Vaccine Development. (He’s also written for us several times over the years, including once raising the then-heretical notion that the U.S. could engage with Iran (!) through “vaccine diplomacy.”)
You might recognize the Sabin part of his vaccine institute’s name; it refers to Albert Sabin, who developed an oral polio vaccine in the late 1950s. That Sabin and another researcher, Jonas Salk, were almost household names for a generation after their vaccines were introduced demonstrates the fearsome hold that polio had on the public psyche and the palpable relief at its apparent defeat.
That first world terror also helps explain why the news of polio’s resurgence in Syria has garnered headlines, while the emergence of other awful diseases in the same place and for essentially the same reasons hasn’t been so publicized.
Hotez is concerned about polio, but he sees it as just one symptom of an even bigger health problem of disease and conflict in the Middle East. And he sees the disease outbreaks in the Middle East as a symptom of a peculiar form of blindness infecting pretty much the whole planet.
“If you look at what’s happening now in Syria, it’s not just polio. With the whole breakdown in infrastructure you’re seeing a rise in measles, because kids aren’t getting their vaccinations. You’re seeing a lot of problems with dengue fever, which is a mosquito-transmitted infection.” And, he continued, you’re seeing problems with “Aleppo evil,” AKA leishmaniasias, which causes terrible ulcers to appear on the skin and face. “Now there’s an estimated more than 100,000 cases of it in Syria,” Hotez recounted, “but it’s also appearing in refugees fleeing Syria and going into the neighboring nations of Turkey and Lebanon.” There is no vaccine for leishmaniasias.
Hotez sees the whole of the Middle East and North Africa at risk of outbreaks of diseases once thought safely on the run. He cites the steep rise in the number of cases of dengue fever in Egypt as an example. Given the breakdowns in infrastructure that happened because of the Arab Spring and then the follow-up coup, it’s not hard to imagine how that might create conditions for outbreaks.
He cited the Democratic Republic of Congo and the narco-trafficking states of South and Central America as other places where instability is giving tropical diseases a leg up.
Whether through refugees or airlines, these diseases spread beyond the dotted lines that may otherwise bottle up civil conflict. Dengue is also present in Saudi Arabia and Yemen. Saudi Arabia, in fact, also has identified cases of the deadly Middle Eastern Respiratory Syndrome and Rift Valley fever. “Now you throw into the mix the Hajj,” Hotez added dramatically. “You’ll have people convene at the Hajj, potentially get exposed, then return home around the world.”
Not that you could quarantine Mecca as a public health measure, any more than you could wall off Syria ... or Houston.
“We’re in the midst of a dengue pandemic,” Hotez said. “There’s more than 130 million cases in India—it’s now struck down two Bollywood stars. Now Houston is the first major city in the United States with an emergent dengue problem. ... The diseases that we’re seeing in the Middle East are cropping up over here, too.” State-of-the-art Singapore has dengue, and so does emerging superpower Brazil, which host the World Cup next year. There is, by the way, no vaccine for dengue.
Speaking from the National School of Tropical Medicine in Houston, Hotez describes the three major forces that foster neglected tropical diseases: conflict, human migration, and poverty. “We call them tropical,” he said, “but it’s a bit of a misnomer, it’s really poverty that describes them.”
To demonstrate that, he addresses the southeast Texas that surrounds him and notes the "tropical" maladies present: “Dengue, an unusual form of West Nile virus, Chagas disease. They’re not even rare diseases—they seem pretty common,” especially in areas of poverty and in communities of people of color. “There’s probably more than 10 million Americans now with neglected tropical diseases, but they’re not sitting in Brookline, Massachusetts, Bethesda, Maryland, and Westchester—they’re in the real poor parts of the country and they can’t get attention.”
Inoculable diseases that do get attention and research dollars are ones that don’t occur: anthrax, smallpox, and avian flu.
“These neglected tropical diseases now occur in places with instability,” Hotez concluded in a cautionary message for Aleppo, Houston, and points beyond, “but I think the equation works the other way, too—I think they actually cause instability as well, and they help promote unrest. They contribute to poverty and help to promote conflict.”