A Clear-Eyed Look at Polio

Over the past 25 years, international eradication efforts have wiped out 99 percent of the cases of the deadly virus. So why is the last 1 percent now all of the story?

Things have been going really well for polio eradication -- in fact, so well that the world hit an all-time low in 2012: Cases were down more than 99 percent since 1988. Still, it seems like the bad news about polio outbreaks and the difficulties in providing vaccines dominates the headlines. On May 5, the World Health Organization declared an international health emergency to further contain the virus -- targeting Pakistan, Syria, and Cameroon as countries where the virus has spread.

But the thing is, fighting polio has never been easy.

Over the past 25 years, a global effort to eradicate polio has immunized more than 2.5 billion children, and cases worldwide declined from 350,000 cases in 1988 to just over 400 in 2013. This success was driven by the Global Polio Eradication Initiative and governments around the world that have, since 1988, supported the goal of reaching all the world's children -- no matter where they live -- with the polio vaccine. The Bill & Melinda Gates Foundation, where I lead the global development team, has been a major funder of this initiative since 2009.

However, despite this incredible achievement, the obstacles faced on the last mile to success have now seemingly become 100 percent of the whole polio story.

By early 2011, polio was only coming from three countries where transmission of the disease had never been stopped: Afghanistan, Pakistan, and Nigeria. By the end of 2012, the world had the lowest number of polio cases ever. Governments and donors around the world stepped up to support a new eradication plan, pledging $4 billion over six years and cheering the goal of a polio-free world by the end of 2018. So, in 2013, when India was well on its way to officially eliminating polio, with no new cases since January 2011, optimism was high and momentum was strong.

But the ticker-tape parade wasn't scheduled just yet. Beginning in December 2012, a new and alarming set of challenges emerged: deplorable acts of violence against health workers delivering the polio vaccine, a Taliban-imposed ban on polio vaccination campaigns in Pakistan's Waziristan region, and escalating violence by Boko Haram in northeast Nigeria.

Since then, more than 50 polio vaccinators and security personnel in Pakistan and northern Nigeria have been murdered; in Pakistan, 400,000 children living in North and South Waziristan and the Federally Administered Tribal Areas have been denied access to the polio vaccine. Pakistan has seen the erosion of two years of dramatic progress against polio, and the resulting spike in cases has led to the introduction of wild poliovirus in Syria, Iraq, and other countries in the Middle East. Adding to the challenges was an outbreak of 200 polio cases in previously polio-free countries in the Horn of Africa and a separate spread of the disease to Cameroon and Equatorial Guinea.

Altogether, these tragic events amounted to serious challenges -- but they weren't a defeat. Over the past few months, the media has managed to ignore the other part of this story: Polio eradication efforts have always been beset by numerous challenges, among them the need to vaccinate millions of children living in conflict zones, geographically remote areas, and communities that lack basic health-care infrastructure. Due to successful efforts to address these challenges on every continent, only two reservoirs of the poliovirus remain today. This means that all wild poliovirus strains that exist in the world today originated either from the border areas between Afghanistan and Pakistan or from northeast Nigeria.

Despite the tragedies in recent months in the final polio reservoirs, local authorities in these last reservoirs are showing renewed determination to ensure greater protection for vaccination workers and to reach more children with vaccines.

Since January of this year, provincial governments, in close coordination with the federal government of Pakistan, have provided hundreds of thousands of children with the polio vaccine coupled with other health services, including lifesaving vaccines, clean water, and soap. These health services were delivered for the first time in and around Peshawar, Pakistan, through the "Justice for Health" program, rolled out by the local government's ruling party, Pakistan Tehreek-e-Insaf. With thousands of police deployed to protect the vaccination teams, the effort has proceeded without incident. Other provincial governments also working with the federal government have launched similar campaigns in Karachi, and local polio vaccination teams are setting up at key transit points along the border of North and South Waziristan. Global and local Islamic leaders and scholars have issued fatwas to endorse the value of vaccination and to urge parents to protect their children from polio. Under the leadership of the grand imam of the Grand Mosque of Mecca, Islamic scholars recently joined the eradication effort with a pro-polio vaccination "Jeddah Declaration" and six-month action plan to address challenges in the remaining polio-endemic parts of the Islamic world.

The progress has been especially dramatic in Nigeria. In 2012, it was the only polio-endemic country with an increase in cases. Significant progress was made in 2013, and so far this year, only two cases of wild poliovirus have been reported. The latest anti-polio campaigns in northern Nigeria have reached historic rates of vaccination coverage. Vaccinators have gained access to thousands of settlements where children had never before been reached, and vaccination teams are increasingly welcomed as they combine the polio vaccine with other routine childhood immunizations.

Afghanistan has nearly eliminated polio, with four cases reported so far this year. Of the four, only one case is endemic to Afghanistan -- the other three cases were the result of the virus originating in and being transmitted from Pakistan.

The confirmation of a polio case in a previously polio-free country is always discouraging, but not unanticipated. In the last year, the response to outbreaks has been far-reaching. In Syria, for example, where the civil conflict has created tremendous humanitarian challenges, response teams are working with local nongovernmental organizations to vaccinate even the hardest-to-reach children, and the number of new polio cases appears to have declined, with no new cases since January of this year. Governments of neighboring countries have also quickly mobilized, and more than 20 million children and adults in Syria and neighboring countries have been vaccinated. In Somalia, vaccination teams are concentrating on locations with highly mobile populations, and new cases have steadily diminished. The Horn of Africa has only seen one case of polio to date in 2014. And, in response to outbreaks in Cameroon and Equatorial Guinea, mass vaccination campaigns and surveillance efforts are under way in those countries and in neighboring Gabon and Congo (Brazzaville).

A month ago, I attended a ceremony celebrating India's success in stopping polio and the polio-free certification of 11 countries in Southeast Asia, home to 1.8 billion people. This achievement cannot be overstated, given that India was long regarded as the hardest place on Earth to end polio due to the country's population density, high rates of migration, poor sanitation, high birthrates, and low rates of childhood immunization.

At a global level, of the two types of wild poliovirus left in the world, we've only seen one type in the past 16 months, signaling the shrinking genetic diversity of a disease that has thrived for millennia.

As the global polio eradication program has proved time and again, the world can overcome new obstacles as they arise. Setbacks are inevitable in the ambitious effort to rid the world of any infectious human disease -- a feat that has been achieved only once before, with smallpox. But these challenges should all be viewed in context: In spite of the newest obstacles, a world free of polio is still on the horizon.



Grading Egypt's Roadmap Toward Democracy

Is president-in-waiting Abdel Fattah al-Sisi living up to his word?

In Washington last week, the White House openly decried the sharply negative trajectory of Egyptian politics. The mass death sentences leveled against hundreds of Egyptians, the imprisonment of journalists and activists, and the tightening restrictions of freedom of expression and assembly, the White House said, are cause not merely for "deep" but also "growing concerns."

Visiting Egyptian Foreign Minister Nabil Fahmy seemed to be representing a completely different country when he boasted of Egypt's difficult but steady progress toward democracy since last summer's overthrow of President Mohamed Morsi. "The Egyptian people revolted twice for a democratic system," he told an assembled Washington audience. "That is their objective. That is where they're going. But the process will have to go through a transition."

Which way is Egypt's politics heading? The Egyptian regime's main justification for its determined optimism has been its checklist. Then-Defense Minister Abdel Fattah al-Sisi set out a clear road map on July 3, this argument goes, and he prepares to assume the presidency only after the country has faithfully followed the steps outlined last year. To focus on this negative development or that -- as Western diplomats and foreign journalists seem wont to do -- ignores this progress. Having lived up to their word, Egyptians should be greeted not with ostracism and criticism but with accolades for managing a democratic transition under very difficult circumstances.

So let's dust off the July 3 road map and use it as a yardstick for measuring what is happening in Egypt. A look at both the fine print and the general spirit reveals that parts of the road map have been fulfilled. But important parts have been forgotten, ignored, or violated. And that points to the deeply flawed nature of the Egyptian "transition" -- if the country is transitioning to anything, it is not to a democracy in anything other than the most technical sense of the term.

What were the elements of the road map? Let us keep our eyes both on the letter and the spirit.

1. Suspending the constitution written under Morsi
Letter of the road map: Temporary suspension of the constitution; formation of committees of forces from across the political spectrum and experts to draft and review proposed amendments.

Spirit of the road map: To move quickly and in an expert and consensual manner to make limited changes to the 2012 constitution.

Performance: The suspension of the constitution was carried out flawlessly. But then the process ran into problems: The constitution was amended in a manner that may have violated the letter and certainly violated the spirit of the road map.

First, the committee did not just tinker with the constitution -- it systematically rewrote the entire document. Did that matter? Not for everyone -- but it did for the Salafists, who had only wanted minor changes so that they could protect their favorite parts, which seemed to promise a more robust role for Islamic law. But those clauses wound up on the cutting-room floor. The Salafi political leadership complained, but then decided to support the process -- and now even back Sisi for president -- in order to retain legal existence.

And that leads to the second and far larger problem: Only parts of the political spectrum were represented in the amendment process, contrary to the original promise. The largest party in the last parliamentary elections received no seats on the 50-member committee. The second largest party received one. The reason for this oversight? They were Islamists.

The committee also seemed biased in favor of state institutions, which got more than a voice in the process -- they often seemed to get a veto. Political forces outside the state were only allowed to color inside lines drawn by generals, bureaucrats, judges, and police.

2. An acting president
Letter: To have the chief justice of the Supreme Constitutional Court (SCC) serve as acting president until the election of a new president.

Spirit: The drafters of the road map went not to the 2012 constitution but back to the 1971 constitution to pick the official second in line for succession, the chief justice of the SCC, in order to pluck a figure who would take his caretaker role seriously.

Performance: When Adly Mansour was appointed, I described him with the phrase "pleasant smile, closed lips." That proved accurate -- to a degree. It took Mansour a few months on the job to smile in public, but he finally did. And when he has opened his lips, it has generally been to give speeches so short that a leading comedian, Bassem Youssef, has posed as a man sitting down with a big bowl of popcorn who cannot take a bite before the president has concluded.

The letter and the spirit of this clause have therefore been completely fulfilled. And Egypt also got an added bonus as well: some assurance that its transition would be written up in correct legal form, since that is the acting president's forte.

3. Temporary rules
Letter: The head of the SCC will have the power to issue constitutional declarations during the transitional period until the election of a new president.

Spirit: After President Hosni Mubarak was forced out in February 2011, Egypt's rulers kept tinkering with the rules of politics through a stream of "constitutional declarations," which were designed subtly and not-so-subtly to tilt the playing field in their favored direction. And they did a bad job in a technical sense as well, leaving all kinds of loopholes and planting all kinds of time bombs in those documents. By giving the job to an acting president -- and a constitutional court justice at that -- the interim rules would be minimal and nonpartisan.

Performance: Pretty good. Mansour used his power to issue constitutional declarations very sparingly: once to disband the Brotherhood's last outpost in government, the upper house of the parliament; the other to issue an interim framework for governing that expired when the new constitution was approved in a January 2014 plebiscite. Those amendments allowed the president to change the order of elections, so Egypt would hold the presidential elections before parliamentary elections.

But there are some blemishes here. While Mansour used "constitutional declarations" sparingly, he has also issued laws by decree that have harmed Egypt's effort at democratization. Foremost among these has been a vague law that the security forces have seized upon to shut down many public protests. And he is now considering laws against terrorism that are similarly vague enough to be abused in an authoritarian manner.

4. Interim technocratic rule
Letter: Forming a cabinet of national, strong, capable experts who enjoy all powers during the current period.

Spirit: No matter whom you blame -- the deep state, a bloody-minded Islamist movement, or the sheer enormousness of the challenges -- Egypt was adrift when Morsi was president. Its economic problems were perpetually mounting, and the country appeared impossible to govern. The idea last summer was to bring in a group of people who were highly qualified to manage affairs and make policy while fundamental political questions were decided.

Performance: Strong out of the starting gate but nowhere near the finish line. The cabinet appointed in July 2013 was perhaps Egypt's most qualified one on paper. It did have some political figures, but it was impressively long on degrees, experience, and reputations.

But as it turned out, it was also short on authority, direction, and coherence. Security questions were left to Egypt's scheming security apparatus, which seemed more concerned with vengeance than political reconstruction. Economic plans were designed -- but then postponed. Foreign leaders tried to go straight to Sisi, seeing him as the current and future leader. Decisions seemed to be made -- or shelved -- in the shadows.

As a result, the country remained adrift and some of the most able figures in the cabinet left. When Sisi steps into the presidency, he will find an in-box similar to the one that greeted the cabinet last July when it took office -- and not unlike the one that greeted Morsi in June 2012.

5. Parliamentary elections
Letter: The SCC was to expedite its review of the election law for parliament passed by the Brotherhood-dominated upper house, and then the country was to move toward parliamentary elections.

Spirit: Egypt had been without a parliament since June 2012; it would get one quickly.

Performance: The letter of the road map remains completely unfulfilled -- the law was never submitted to the SCC. Instead, Mansour is having some lawyers work on a new law. And that means the spirit has been violated as well -- it is likely to be several months more before a parliament is finally seated. By this foot dragging, Egypt's interregnum was prolonged greatly.

One benefit of the procedure is that Egypt may get its first parliamentary election law since the 1970s to be found constitutional by the SCC. Mansour, after all, is pulling double duty as the SCC's chief justice and the figure overseeing the drafting of the law. He will have to recuse himself if the SCC reviews the law that he helped draft, but he is likely to have a bit of insight of how they will react to the law as it is being prepared.

6. Media reform
Letter: Putting together a code of ethics that ensures media freedom and achieves professional standards, credibility, and objectivity that prioritize the nation's high interests.

Spirit: Have the media reform themselves.

Performance: The letter has been forgotten. And the spirit? Pockets of professionalism aside, Egyptian media seem to specialize in pouring gasoline on any flame and yelling fire in crowded theaters. Enthusiasm is their strong suit, ethics are not.

Nor has the media been left to reform itself. Security forces and the public prosecution have lent a helping hand -- or to switch metaphors slightly, an iron fist -- by jailing journalists, Egyptians and foreigners alike, who poke their noses in the wrong places.

7. Youth integration
Letter: Taking executive measures to empower and engage the youth in the state institutions, to be a decision-making partner as aides to ministers, governors, and in different executive posts.

Spirit: Getting Egypt's gerontocracy to add a few seats to the table.

Performance: There has been some grudging compliance with the letter of the road map, but tokenism aside, Egypt is still ruled by older men (and a few older women). There is some indication that Egypt's new rulers sense they have a problem -- there was much handwringing over low youth turnout in the constitutional referendum earlier this year. But Egypt's rulers have still fallen back on head-bashing when faced with rebellious youth movements: One such prominent group, the April 6 Movement, recently found itself banned and its leaders imprisoned.

8. National reconciliation
Letter: Forming a supreme committee for national reconciliation of personalities who enjoy credibility and acceptance by all national elites and represent different movements.

Spirit: Can't we all just get along?

Performance: No, we can't. What else can be said in a country where "reconciliation" has become a dirty word? There was a grudging effort to allow some mediation efforts last summer. But since that time, would-be mediators have been more likely to be attacked than welcomed. There has simply been no attempt to comply with the letter or the spirit of this pledge.

With over 1,000 death sentences, thousands of violent deaths, and well over 10,000 people jailed since the overthrow of Morsi, the claim that Egypt is in the midst of a democratic transition has convinced few outside observers. But even according to its own checklist, Egypt's record is uneven. The shortcomings are not all technical and legalistic -- some, such as the fate of the reconciliation pledge, have been fundamental. And the process has taken much longer than was suggested in July 2013, allowing it to be more carefully managed by the country's new leaders.

The existence of two different visions of Egypt -- one sliding into despotism, the other dutifully following its people to a democratic future -- is deeply problematic for the country's leadership. As a result, defenders of the new order have come to equate statements of concern about the political climate in the country to hostility to Egypt. Once again, regime, state, and society are being blended in political debates -- and there is no better sign of the way that the hopes of 2011 have been dashed.