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TED2011

Bruce Aylward: How we'll stop polio for good

March 3, 2011

Polio is almost completely eradicated. But as Bruce Aylward says: Almost isn't good enough with a disease this terrifying. Aylward lays out the plan to continue the scientific miracle that ended polio in most of the world -- and to snuff it out everywhere, forever.

Bruce Aylward - Epidemiologist
As the Assistant Director-General of the World Health Organization’s Polio and Emergencies Cluster, Bruce Aylward works to ensure that polio stays under control and that the world is prepared to respond to health crises. Full bio

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Double-click the English subtitles below to play the video.
I want to share with you
00:15
over the next 18 minutes
00:17
a pretty incredible idea.
00:19
Actually, it's a really big idea.
00:21
But to get us started,
00:23
I want to ask if everyone
00:25
could just close your eyes for two seconds
00:27
and try and think of a technology or a bit of science
00:29
that you think has changed the world.
00:32
Now I bet, in this audience,
00:38
you're thinking of some really incredible technology,
00:40
some stuff that I haven't even heard of,
00:42
I'm absolutely sure.
00:44
But I'm also sure, pretty sure,
00:46
that absolutely nobody is thinking of this.
00:49
This is a polio vaccine.
00:53
And it's a great thing actually
00:56
that nobody's had to think about it here today
00:58
because it means that we can take this for granted.
01:00
This is a great technology.
01:02
We can take it completely for granted.
01:04
But it wasn't always that way.
01:06
Even here in California,
01:09
if we were to go back just a few years,
01:12
it was a very different story.
01:14
People were terrified of this disease.
01:16
They were terrified of polio, and it would cause public panic.
01:18
And it was because of scenes like this.
01:21
In this scene,
01:24
people are living in an iron lung.
01:26
These are people who were perfectly healthy two or three days before,
01:28
and then two days later,
01:31
they can no longer breathe,
01:33
and this polio virus has paralyzed
01:35
not only their arms and their legs,
01:37
but also their breathing muscles.
01:39
And they were going to spend the rest of their lives, usually,
01:41
in this iron lung to breathe for them.
01:44
This disease was terrifying.
01:46
There was no cure,
01:48
and there was no vaccine.
01:50
The disease was so terrifying
01:52
that the president of the United States
01:54
launched an extraordinary national effort
01:56
to find a way to stop it.
01:59
Twenty years later, they succeeded
02:02
and developed the polio vaccine.
02:05
It was hailed as a scientific miracle
02:07
in the late 1950s.
02:09
Finally, a vaccine that could stop this awful disease,
02:11
and here in the United States
02:14
it had an incredible impact.
02:16
As you can see, the virus stopped,
02:18
and it stopped very, very fast.
02:20
But this wasn't the case
02:23
everywhere in the world.
02:26
And it happened so fast in the United States, however,
02:28
that even just last month Jon Stewart said this:
02:31
(Video) Jon Stewart: Where is polio still active?
02:34
Because I thought that had been eradicated
02:36
in the way that smallpox had been eradicated.
02:39
Bruce Aylward: Oops. Jon, polio's almost been eradicated.
02:41
But the reality is
02:45
that polio still exists today.
02:47
We made this map for Jon to try to show him exactly where polio still exists.
02:49
This is the picture.
02:52
There's not very much left in the world.
02:54
But the reason there's not very much left
02:57
is because there's been an extraordinary public/private partnership
02:59
working behind the scenes, almost unknown,
03:02
I'm sure to most of you here today.
03:05
It's been working for 20 years
03:07
to try and eradicate this disease,
03:09
and it's got it down to these few cases
03:11
that you can see here on this graphic.
03:13
But just last year,
03:16
we had an incredible shock
03:18
and realized that almost just isn't good enough
03:20
with a virus like polio.
03:23
And this is the reason:
03:26
in two countries
03:28
that hadn't had this disease for more than probably a decade,
03:30
on opposite sides of the globe,
03:33
there was suddenly terrible polio outbreaks.
03:35
Hundreds of people were paralyzed.
03:38
Hundreds of people died --
03:40
children as well as adults.
03:43
And in both cases,
03:45
we were able to use genetic sequencing to look at the polio viruses,
03:47
and we could tell these viruses were not from these countries.
03:50
They had come from thousands of miles away.
03:53
And in one case, it originated on another continent.
03:56
And not only that, but when they came into these countries,
03:59
then they got on commercial jetliners probably
04:02
and they traveled even farther
04:05
to other places like Russia,
04:07
where, for the first time in over a decade last year,
04:09
children were crippled and paralyzed
04:12
by a disease that they had not seen for years.
04:15
Now all of these outbreaks that I just showed you,
04:19
these are under control now,
04:22
and it looks like they'll probably stop very, very quickly.
04:24
But the message was very clear.
04:27
Polio is still
04:30
a devastating, explosive disease.
04:32
It's just happening in another part of the world.
04:35
And our big idea
04:39
is that the scientific miracle of this decade
04:42
should be the complete eradication
04:46
of poliomyelitis.
04:48
So I want to tell you a little bit
04:50
about what this partnership, the Polio Partnership,
04:52
is trying to do.
04:54
We're not trying to control polio.
04:56
We're not trying to get it down to just a few cases,
04:58
because this disease is like a root fire;
05:01
it can explode again if you don't snuff it out completely.
05:03
So what we're looking for
05:06
is a permanent solution.
05:08
We want a world in which every child, just like you guys,
05:10
can take for granted
05:13
a polio-free world.
05:15
So we're looking for a permanent solution,
05:17
and this is where we get lucky.
05:19
This is one of the very few viruses in the world
05:21
where there are big enough cracks in its armor
05:24
that we can try to do something truly extraordinary.
05:26
This virus can only survive in people.
05:29
It can't live for a very long time in people.
05:32
It doesn't survive in the environment hardly at all.
05:34
And we've got pretty good vaccines, as I've just showed you.
05:37
So we are trying
05:40
to wipe out this virus completely.
05:42
What the polio eradication program is trying to do
05:45
is to kill the virus itself
05:48
that causes polio
05:50
everywhere on Earth.
05:52
Now we don't have a great track record
05:54
when it comes to doing something like this,
05:56
to eradicating diseases.
05:58
It's been tried six times in the last century,
06:00
and it's been successful exactly once.
06:03
And this is because disease eradication,
06:07
it's still the venture capital of public health.
06:10
The risks are massive,
06:13
but the pay-off --
06:15
economic, humanitarian, motivational --
06:18
it's absolutely huge.
06:20
One congressman here in the United States
06:22
thinks that the entire investment
06:25
that the U.S. put into smallpox eradication
06:28
pays itself off every 26 days --
06:30
in foregone treatment costs
06:33
and vaccination costs.
06:35
And if we can finish polio eradication,
06:37
the poorest countries in the world
06:40
are going to save over 50 billion dollars
06:42
in the next 25 years alone.
06:46
So those are the kind of stakes that we're after.
06:49
But smallpox eradication was hard;
06:52
it was very, very hard.
06:54
And polio eradication, in many ways, is even tougher,
06:56
and there's a few reasons for that.
06:59
The first is that,
07:02
when we started trying to eradicate polio
07:04
about 20 years ago,
07:06
more than twice as many countries were infected
07:08
than had been when we started off with smallpox.
07:10
And there were more than 10 times as many people
07:13
living in these countries.
07:15
So it was a massive effort.
07:17
The second challenge we had was --
07:19
in contrast to the smallpox vaccine,
07:21
which was very stable, and a single dose protected you for life --
07:23
the polio vaccine is incredibly fragile.
07:26
It deteriorates so quickly in the tropics
07:29
that we've had to put this special vaccine monitor
07:32
on every single vial
07:34
so that it will change very quickly
07:36
when it's exposed to too much heat,
07:38
and we can tell that it's not a good vaccine to use on a child --
07:40
it's not potent; it's not going to protect them.
07:43
Even then, kids need many doses of the vaccine.
07:45
But the third challenge we have --
07:48
and probably even bigger one, the biggest challenge --
07:50
is that, in contrast to smallpox where you could always see your enemy --
07:53
every single person almost who was infected with smallpox
07:56
had this telltale rash.
07:59
So you could get around the disease;
08:01
you could vaccinate around the disease and cut it off.
08:03
With polio it's almost completely different.
08:06
The vast majority of people who are infected with the polio virus
08:09
show absolutely no sign of the disease.
08:12
So you can't see the enemy most of the time,
08:15
and as a result,
08:18
we've needed a very different approach to eradicate polio
08:20
than what was done with smallpox.
08:23
We've had to create
08:25
one of the largest social movements in history.
08:27
There's over 10 million people,
08:30
probably 20 million people,
08:32
largely volunteers,
08:34
who have been working over the last 20 years
08:36
in what has now been called
08:38
the largest internationally-coordinated operation in peacetime.
08:40
These people, these 20 million people,
08:44
vaccinate over 500 million children
08:47
every single year,
08:50
multiple times
08:52
at the peak of our operation.
08:54
Now giving the polio vaccine is simple.
08:57
It's just two drops, like that.
08:59
But reaching 500 million people
09:01
is much, much tougher.
09:03
And these vaccinators, these volunteers,
09:05
they have got to dive headlong
09:08
into some of the toughest, densest
09:10
urban slums in the world.
09:12
They've got to trek under sweltering suns
09:14
to some of the most remote, difficult to reach places in the world.
09:17
And they also have to dodge bullets,
09:21
because we have got to operate
09:23
during shaky cease-fires and truces
09:25
to try and vaccinate children,
09:27
even in areas affected by conflict.
09:29
One reporter
09:32
who was watching our program in Somalia about five years ago --
09:34
a place which has eradicated polio,
09:37
not once, but twice, because they got reinfected.
09:39
He was sitting outside of the road,
09:41
watching one of these polio campaigns unfold,
09:43
and a few months later he wrote:
09:45
"This is foreign aid at its most heroic."
09:47
And these heroes, they come from every walk of life,
09:51
all sorts of backgrounds.
09:53
But one of the most extraordinary is Rotary International.
09:55
This is a group
09:58
whose million-strong army of volunteers
10:00
have been working to eradicate polio
10:02
for over 20 years.
10:04
They're right at the center of the whole thing.
10:06
Now it took years to build up the infrastructure
10:09
for polio eradication --
10:11
more than 15 years, much longer than it should have --
10:13
but once it was built, the results were striking.
10:16
Within a couple of years,
10:19
every country that started polio eradication
10:21
rapidly eradicated all three of their polio viruses,
10:23
with the exception of four countries that you see here.
10:27
And in each of those, it was only part of the country.
10:30
And then, by 1999,
10:34
one of the three polio viruses
10:36
that we were trying to eradicate
10:38
had been completely eradicated worldwide --
10:40
proof of concept.
10:43
And then today,
10:45
there's been a 99 percent reduction --
10:48
greater than 99 percent reduction --
10:50
in the number of children
10:52
who are being paralyzed by this awful disease.
10:54
When we started, over 20 years ago,
10:57
1,000 children were being paralyzed
10:59
every single day by this virus.
11:01
Last year, it was 1,000.
11:04
And at the same time,
11:07
the polio eradication program
11:09
has been working to help with a lot of other areas.
11:11
It's been working to help control pandemic flu,
11:13
SARS for example.
11:16
It's also tried to save children by doing other things --
11:18
giving vitamin A drops, giving measles shots,
11:21
giving bed nets against malaria even
11:24
during some of these campaigns.
11:26
But the most exciting thing
11:28
that the polio eradication program has been doing
11:30
has been to force us,
11:32
the international community,
11:34
to reach every single child, every single community,
11:36
the most vulnerable people in the world,
11:39
with the most basic of health services,
11:42
irrespective of geography, poverty,
11:44
culture and even conflict.
11:48
So things were looking very exciting,
11:50
and then about five years ago,
11:52
this virus, this ancient virus, started to fight back.
11:54
The first problem we ran into
11:57
was that, in these last four countries, the strongholds of this virus,
12:00
we just couldn't seem to get the virus rooted out.
12:03
And then to make the matters even worse,
12:07
the virus started to spread out of these four places,
12:09
especially northern India and northern Nigeria,
12:12
into much of Africa, Asia, and even into Europe,
12:15
causing horrific outbreaks
12:18
in places that had not seen this disease for decades.
12:20
And then,
12:24
in one of the most important, tenacious
12:26
and toughest reservoirs of the polio virus in the world,
12:29
we found that our vaccine was working
12:32
half as well as it should have.
12:35
In conditions like this,
12:37
the vaccine just couldn't get the grip it needed to
12:39
in the guts of these children
12:41
and protect them the way that it needed to.
12:43
Now at that time,
12:45
there was a great, as you can imagine,
12:47
frustration -- let's call it frustration --
12:49
it started to grow very, very quickly.
12:51
And all of a sudden, some very important voices
12:53
in the world of public health
12:55
started to say, "Hang on.
12:57
We should abandon this idea of eradication.
12:59
Let's settle for control -- that's good enough."
13:02
Now as seductive as the idea of control sounds,
13:05
it's a false premise.
13:09
The brutal truth is,
13:11
if we don't have the will or the skill,
13:13
or even the money that we need
13:15
to reach children, the most vulnerable children in the world,
13:18
with something as simple
13:21
as an oral polio vaccine,
13:23
then pretty soon,
13:26
more than 200,000 children
13:28
are again going to be paralyzed by this disease
13:30
every single year.
13:32
There's absolutely no question.
13:34
These are children like Umar.
13:36
Umar is seven years old,
13:39
and he's from northern Nigeria.
13:42
He lives in a family home there
13:44
with his eight brothers and sisters.
13:46
Umar also has polio.
13:48
Umar was paralyzed for life.
13:51
His right leg was paralyzed
13:53
in 2004.
13:55
This leg, his right leg,
13:57
now takes an awful beating
14:00
because he has to half-crawl,
14:02
because it's faster to move that way
14:04
to keep up with his friends, keep up with his brothers and sisters,
14:06
than to get up on his crutches and walk.
14:08
But Umar is a fantastic student. He's an incredible kid.
14:11
As you probably can't see the detail here,
14:14
but this is his report card,
14:16
and you'll see, he's got perfect scores.
14:18
He got 100 percent in all the important things,
14:20
like nursery rhymes, for example there.
14:22
But you know I'd love to be able to tell you
14:25
that Umar is a typical kid with polio these days,
14:28
but it's not true.
14:30
Umar is an exceptional kid
14:32
in exceptional circumstances.
14:34
The reality of polio today
14:36
is something very different.
14:38
Polio strikes the poorest communities in the world.
14:41
It leaves their children paralyzed,
14:45
and it drags their families
14:47
deeper into poverty,
14:49
because they're desperately searching
14:51
and they're desperately spending the little bit of savings that they have,
14:53
trying in vain
14:55
to find a cure for their children.
14:57
We think children deserve better.
15:01
And so when the going got really tough
15:04
in the polio eradication program
15:07
about two years ago,
15:09
when people were saying, "We should call it off,"
15:11
the Polio Partnership
15:13
decided to buckle down once again
15:15
and try and find innovative new solutions,
15:17
new ways to get to the children
15:20
that we were missing again and again.
15:22
In northern India, we started mapping the cases
15:24
using satellite imaging like this,
15:26
so that we could guide our investments and vaccinator shelters,
15:28
so we could get to the millions of children
15:31
on the Koshi River basin
15:33
where there are no other health services.
15:35
In northern Nigeria,
15:37
the political leaders and the traditional Muslim leaders,
15:39
they got directly involved in the program
15:41
to help solve the problems of logistics
15:43
and community confidence.
15:45
And now they've even started using these devices --
15:47
speaking of cool technology --
15:50
these little devices, little GIS trackers like this,
15:52
which they put into the vaccine carriers of their vaccinators.
15:55
And then they can track them,
15:58
and at the end of the day, they look and see,
16:00
did these guys get every single street, every single house.
16:02
This is the kind of commitment now we're seeing
16:04
to try and reach all of the children we've been missing.
16:07
And in Afghanistan, we're trying new approaches --
16:10
access negotiators.
16:13
We're working closely with the International Committee of the Red Cross
16:15
to ensure that we can reach every child.
16:18
But as we tried these extraordinary things,
16:21
as people went to this trouble
16:24
to try and rework their tactics,
16:26
we went back to the vaccine -- it's a 50-year-old vaccine --
16:28
and we thought, surely we can make a better vaccine,
16:31
so that when they finally get to these kids,
16:34
we can have a better bang for our buck.
16:36
And this started an incredible collaboration with industry,
16:38
and within six months,
16:41
we were testing a new polio vaccine
16:43
that targeted, just two years ago,
16:45
the last two types of polio in the world.
16:47
Now June the ninth, 2009,
16:50
we got the first results from the first trial with this vaccine,
16:53
and it turned out to be a game-changer.
16:56
The new vaccine
16:58
had twice the impact on these last couple of viruses
17:00
as the old vaccine had,
17:03
and we immediately started using this.
17:05
Well, in a couple of months we had to get it out of production.
17:07
And it started rolling off the production lines
17:10
and into the mouths of children around the world.
17:12
And we didn't start with the easy places.
17:14
The first place this vaccine was used
17:16
was in southern Afghanistan,
17:18
because it's in places like that
17:20
where kids are going to benefit the most
17:22
from technologies like this.
17:24
Now here at TED, over the last couple of days,
17:26
I've seen people challenging the audience again and again
17:29
to believe in the impossible.
17:33
So this morning at about seven o'clock,
17:36
I decided that we'd try to drive Chris
17:39
and the production crew here berserk
17:41
by downloading all of our data from India again,
17:43
so that you could see something
17:47
that's just unfolding today,
17:49
which proves that the impossible is possible.
17:51
And only two years ago, people were saying that this is impossible.
17:55
Now remember, northern India is the perfect storm
17:58
when it comes to polio.
18:01
Over 500,000 children
18:03
are born in the two states that have never stopped polio --
18:05
Uttar Pradesh and Bihar --
18:08
500,000 children every single month.
18:11
Sanitation is terrible,
18:13
and our old vaccine, you remember,
18:15
worked half as well as it should have.
18:17
And yet, the impossible is happening.
18:20
Today marks exactly six months --
18:23
and for the first time in history,
18:27
not a single child has been paralyzed
18:29
in Uttar Pradesh or Bihar.
18:31
(Applause)
18:33
India's not unique.
18:44
In Umar's home country of Nigeria,
18:47
a 95 percent reduction
18:49
in the number of children paralyzed by polio last year.
18:51
And in the last six months,
18:54
we've had less places reinfected by polio
18:56
than at any other time in history.
18:58
Ladies and gentlemen, with a combination
19:02
of smart people, smart technology
19:04
and smart investments,
19:06
polio can now be eradicated anywhere.
19:08
We have major challenges, you can imagine,
19:12
to finish this job,
19:14
but as you've also seen,
19:16
it's doable,
19:18
it has great secondary benefits,
19:20
and polio eradication is a great buy.
19:22
And as long as any child anywhere
19:25
is paralyzed by this virus,
19:28
it's a stark reminder
19:30
that we are failing, as a society, to reach children
19:32
with the most basic of services.
19:35
And for that reason, polio eradication:
19:37
it's the ultimate in equity
19:39
and it's the ultimate in social justice.
19:42
The huge social movement
19:45
that's been involved in polio eradication
19:47
is ready to do way more for these children.
19:49
It's ready to reach them with bed nets, with other things.
19:51
But capitalizing on their enthusiasm,
19:54
capitalizing on their energy
19:57
means finishing the job
19:59
that they started 20 years ago.
20:01
Finishing polio is a smart thing to do,
20:04
and it's the right thing to do.
20:07
Now we're in tough times economically.
20:09
But as David Cameron of the United Kingdom
20:12
said about a month ago when he was talking about polio,
20:15
"There's never a wrong time
20:18
to do the right thing."
20:20
Finishing polio eradication
20:22
is the right thing to do.
20:24
And we are at a crossroads right now
20:26
in this great effort over the last 20 years.
20:28
We have a new vaccine,
20:30
we have new resolve,
20:32
and we have new tactics.
20:34
We have the chance
20:36
to write an entirely new polio-free chapter
20:38
in human history.
20:41
But if we blink now,
20:44
we will lose forever
20:47
the chance to eradicate an ancient disease.
20:49
Here's a great idea to spread:
20:54
End polio now.
20:57
Help us tell the story.
20:59
Help us build the momentum
21:01
so that very soon
21:03
every child, every parent
21:05
everywhere
21:07
can also take for granted
21:09
a polio-free life forever.
21:11
Thank you.
21:14
(Applause)
21:16
Bill Gates: Well Bruce, where do you think the toughest places are going to be?
21:38
Where would you say we need to be the smartest?
21:41
BA: The four places where you saw, that we've never stopped --
21:44
northern Nigeria, northern India,
21:47
the southern corner of Afghanistan
21:49
and bordering areas of Pakistan --
21:51
they're going to be the toughest.
21:53
But the interesting thing is, of those three,
21:55
India's looking real good, as you just saw in the data.
21:57
And Afghanistan, Afghanistan, we think
21:59
has probably stopped polio repeatedly.
22:01
It keeps getting reinfected.
22:03
So the tough ones: going to get the top of Nigeria finished
22:05
and getting Pakistan finished.
22:07
They're going to be the tough ones.
22:09
BG: Now what about the money?
22:11
Give us a sense of how much the campaign costs a year.
22:13
And is it easy to raise that money?
22:16
And what's it going to be like the next couple of years?
22:19
BA: It's interesting.
22:21
We spend right now about 750 million
22:23
to 800 million dollars a year.
22:25
That's what it costs to reach 500 million children.
22:28
It sounds like a lot of money; it is a lot of money.
22:30
But when you're reaching 500 million children multiple times --
22:33
20, 30 cents to reach a child --
22:36
that's not very much money.
22:38
But right now we don't have enough of that.
22:40
We have a big gap in that money. We're cutting corners,
22:42
and every time we cut corners,
22:44
more places get infected that shouldn't have, and it just slows us down.
22:46
And that great buy costs us a little bit more.
22:49
BG: Well, hopefully we'll get the word out,
22:52
and the governments will keep their generosity up.
22:55
So good luck. We're all in this with you.
22:58
Thank you. (BA: Thank you.)
23:00
(Applause)
23:02

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Bruce Aylward - Epidemiologist
As the Assistant Director-General of the World Health Organization’s Polio and Emergencies Cluster, Bruce Aylward works to ensure that polio stays under control and that the world is prepared to respond to health crises.

Why you should listen

A Canadian physician and epidemiologist who has authored some 100 peer-reviewed articles and chapters, Bruce Aylward is an expert on infectious diseases. He joined the World Health Organization in 1992 and worked in the field for seven years on national immunization programs for measles, tetanus and hepatitis in the Middle East, Africa and Asia. 

Aylward has overseen and managed the scale-up of the Global Polio Eradication Initiative since 1998, during which time the program expanded to operate in every country of the world, the annual global budget increased to $700 million a year, polio-funded staff deployed by WHO grew to over 3,500 people worldwide, and new monovalent oral poliovirus vaccines were developed for the programme. In 2014, only three countries remained polio-endemic.

He says: "It's been estimated that our investment in smallpox eradication pays off every 26 days."

Since 2011, Aylward has also led WHO’s work in preparedness, readiness and response to health emergencies. By developing global strategies, analyzing health trends and advising on policies and country collaboration, the WHO helps make sure that outbreaks — like the 2014 ebola epidemic — stay under control. 

The original video is available on TED.com
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