A History of the World Since 9/11

by Dominic Streatfeild

  ‘On the one hand,’ he told the crowd, ‘the United States is bombing us for no reason.’ He turned to the medical team. ‘On the other hand, here you are – coming here, disguised as health workers to spread vulgarity’

  Ghani winced. It was going to be a long day. Worse, despite his assurance of the day before, he had left home that morning in an official government car.

  One of the ironies of human progress is its propensity to create its own obstacles. The emergence of poliomyelitis in the West is a case in point. A hundred and fifty years ago, advances in public health programmes, specifically proper sanitation and clean drinking water, decimated poliovirus reservoirs in industrialized nations. While this might have been expected to improve the health of their populations, when it came to polio the exact opposite happened: as exposure to the virus dropped, natural immunity levels dropped with it, rendering the First World not less but more susceptible to infection.

  Further human progress – a revolution in global travel – allowed the virus to spread internationally. By the late 1880s, polio was causing serious problems in Europe. In the early part of the twentieth century, the United States was struck by wave after wave of outbreaks. In 1916, New York City succumbed: 17,000 people were paralysed and 9,000 died.

  The result was panic. Cinemas and music halls were shut. People stopped shaking hands to avoid contamination. Parades were cancelled, swimming pools closed and insecticides hosed over the city’s streets in an effort to wipe out the infection. Nothing worked. By the 1950s 20,000 Americans were being paralysed by polio each year and images of wasted-limbed children in callipers and adults entombed in iron lungs had seared themselves into the public consciousness: other pathogens may have killed more people, faster and more efficiently, but the suffering inflicted by this disease, together with the fact that its victims were mainly children, earned poliomyelitis a reputation as the most dreaded childhood affliction of the twentieth century.

  Such was the level of public fear surrounding polio that, when the Salk vaccine was declared effective in April 1955, 54,000 physicians attended live broadcasts in movie theatres around the country, and department stores set up loudspeakers so shoppers could hear the announcement in real-time. The result was an outbreak of spontaneous celebration. In the streets, motorists honked their horns; criminal trials were suspended; flags were flown and church bells pealed nationwide. Factories observed a moment’s silence. In schools, parents and teachers wept openly. Shopkeepers wrote thank you, dr salk on their windows.

  Within two years of the announcement of an effective vaccine, cases of polio were down by more than 80 per cent. The number of new infections dropped consistently until 1979 when, for the first time ever, the sum total of children paralysed in the United States by polio was zero. Pre-emption worked. Here, it seemed, was a disease that could be beaten.

  American enthusiasm for polio vaccination was infectious. In 1985, South America’s health ministers launched a project to remove the virus from the rest of the continent, too. Three years later, ministers from 166 countries at the World Health Assembly voted unanimously to launch a global programme to wipe the disease from the face of the earth. It was time to ensure the safety of all children from polio forever. The virus’ demise, it was declared, would be a fitting gift ‘from the twentieth to the twenty-first century’. A date for complete eradication was set: the year 2000.

  There was a precedent. In 1959, a similar motion had been passed regarding smallpox. At the time, the virus was killing two million people a year, scarring and blinding millions more. Within twenty years, through a globally comprehensive vaccination and surveillance programme, the virus and the disease were gone.

  Saving millions of lives more than justified the smallpox effort, but America’s motives were not entirely altruistic. Since the Second World War, the White House had seen fighting infectious diseases as part of its duty to protect its own citizens. The problem was, when it came to smallpox, vaccination at home had not provided a permanent solution. Viruses did not respect international borders. In an increasingly globalized world, where people could move from country to country in a matter of hours, any smallpox virus anywhere was a potential threat. If protection from the disease was to be anything other than a stopgap, the virus had to be hunted down and killed worldwide.

  There was also a strong financial motive. If the United States wanted to protect its citizens from smallpox, it had to vaccinate all of its children forever. This was expensive. Global eradication was a cheaper option: once the disease was gone, there would be no need to vaccinate anybody. The global eradication of smallpox cost the world $300 million, of which American voters supplied $32 million. To be sure, this was a lot of money, but within twenty years the United States had saved $17 billion in vaccination costs alone, effectively recouping its entire outlay every twenty-six days since the disease had been eradicated. To the financially minded, the project had been an incredibly astute investment.

  A similar operation for polio promised even greater benefits: the cost of vaccinating American children against the disease was more than $230 million per year. Once polio was gone, that 230 million could be put to better use. Worldwide, the saving would be even larger: approximately $1.5 billion per year.

  For all these reasons, when it came to polio it was time for the gloves to come off. In 1988, they did.

  From its inception, the WHO Global Polio Eradication Initiative (GPEI) was an epic undertaking. The only means of achieving the goal – saving 200,000 children from paralysis every year – was mind-boggling: the vaccination of every single child under the age of five on the planet. Funded by Rotary International, the US Centers for Disease Control, WHO and donations from various governments, GPEI was the largest public health project in the history of the world. The operation was rather like fighting an immense military campaign constantly, in all countries simultaneously. The challenge was immense.

  Initially, planners faced a question of accounting. How could they go about locating all 600 million children in the world under five years old? Ninety per cent of them lived in developing countries with poor infrastructures and poor healthcare facilities: chances were, their own governments didn’t know where they were.

  Admittedly, smallpox vaccinators had faced the same problem in the 1960s, but they’d had a crucial advantage: a single dose of smallpox vaccine brought lifetime immunity to the disease. Oral Polio Vaccine (OPV) didn’t. To guarantee full protection, OPV had to be administered two to four times per child. Finding and vaccinating 600 million children wasn’t enough: the WHO had to find and vaccinate them again, and again, and again. That 130 million children were born each year made the task positively Sisyphean: the target was not only moving, it was growing.

  The solution for countries in the developing world was to organize National Immunization Days (NIDs), when parents were encouraged to bring their children forward for free vaccination. The scale of the operations was colossal. During India’s first NID in December 1995, two million workers manned half a million vaccination posts; 87 million children were vaccinated. Four years later, the country successfully vaccinated 127 million children in three days: the largest health event ever organized by a single country. But that was only part of the picture. To ensure comprehensive vaccine coverage, NIDs were coordinated to take place simultaneously in neighbouring countries. In 1997, 450 million children in 80 countries – roughly two thirds of all the children on earth – were vaccinated against polio. The next January, more than 130 million were immunized in a single day. In the last ten days of May 2009, 222 million children in 22 countries were vaccinated simultaneously.

  In areas of political instability there were complications. War zones called for different tactics. Based on operations pioneered in South America, WHO staff called for ceasefires in civil wars during NIDs. The organization shortly found itself arranging not just polio vaccine but armistices. In El Salvador, insurgent guerrillas took part in the programme, themselves vaccina
ting children in remote areas; in Peru, Shining Path leaders helped to deliver vaccine and gave specific orders that no health workers were to be harmed. ‘Days of Tranquillity’ were effective in Lebanon, Afghanistan, Sri Lanka, the Democratic Republic of Congo and Somalia. Everywhere, the fighting stopped for the sake of the children. In some areas, combatants actually dug up landmines to allow vaccinators safe access to them.

  But vaccination was the easy part. The really tricky task was keeping track of polio’s global movements. Where was the disease? Where was it going? How fast? When smallpox had been eradicated, virus surveillance was relatively simple: the disease caused physical scarring, leaving a trail of evidence wherever it went. Polio was harder to pin down. In 199 out of 200 polio cases, victims experience no more than temporary flu-like symptoms: many had no idea the virus had even passed them by. Entire populations could be infected without knowing it: until a child was actually paralysed, it was unlikely a diagnosis would be made. Even when it was made, for each paralysed child there were another 200 to 3,000 carriers of the virus presenting no symptoms whatsoever. All were capable of spreading the infection.

  Poliovirus moved among the people like fish swam in the sea. It emerged, took a few lives, took a few limbs, then vanished. The weakest, the most vulnerable, the most backward, impoverished people in the poorest nations on earth were targeted. Once infected, the virus’ victims themselves became reservoirs, machines for producing more virus. Each infected person shed between 10 and 100 million virus particles per day – any one of which was capable of claiming another victim.

  Despite the extraordinary levels of international co-operation the GPEI fostered, the WHO was careful with its rhetoric. The organization might well have launched a war on polio, but it wasn’t coming out and saying so in quite those terms. It was also rather more circumspect about its ultimate goals. It was quite possible, officials admitted, that the effort might not work. The main thing was that the initiative was used to spread global health advances, rather than focusing simply on one disease. To this end, vaccinators also acted as monitors of infections such as ebola, Marburg disease, yellow fever and cholera. They distributed mosquito nets to young mothers in malarial zones and encouraged parents to vaccinate children against other diseases. They handed out free Vitamin A supplements: a single act that saved the eyesight of millions in the Third World.

  Health officials were also reticent when it came to speculating about the future. A common question to senior eradicators was which disease would be next after polio was gone: measles, perhaps? GPEI staff were reluctant to answer. The job was not yet finished.

  ‘It is critical,’ US Surgeon-General David Satcher explained in September 1998, ‘that the global public health community focus on finishing polio eradication before embarking on a more difficult and expensive measles-eradication initiative.’

  The message was clear: one war at a time. A global campaign such as the one against polio could be fought effectively – and possibly even won – but only if it was done thoughtfully methodically and without distraction.

  There were lessons to be learned here, if anyone at the White House was listening.

  Abdul Ghani knew all about polio. Pakistan was one of the world’s leading reservoirs of wild poliovirus, with tens of thousands of cases each year. His home, the North-West Frontier Province, was itself the reservoirs’ main reservoir; the young doctor had no shortage of crippled children to attend to. In the 1970s and 1980s, with eradication years away, no one paid the disease much attention. Besides, there were other things to think about.

  To strangers, Ghani came across as a quiet, scrupulously polite, diligent individual. Aside from his love of cricket, about which he could become passionate, there was little that appeared to excite him. Like many Pakistanis in the area, he was struggling to better himself. Born in Laki Marwat in southern NWFP to a poor farming family, he and his brother had worked hard at school to get ahead. The brother ended up managing a sugar mill in Charsada, funnelling his wages to Ghani, supporting him through medical school. The process of self-betterment never stopped. After qualifying as a doctor in the early 1980s, his first posting was as a junior Medical Officer at the Rural Health Centre in the village of Manki Sharif, Nowshera. It was here that a fortuitous encounter bore fruit.

  In 1985, Ghani treated a local man over a period of months. The treatment was successful, the two became friends and the patient offered to introduce the doctor to his sister, an accomplished poet. Since the man was the Pir (spiritual and political leader) of Manki Sharif, this was an opportunity. In Pashtun society, where women are seldom allowed to venture outside the family home, marrying off a sister is a tricky business. More so in this case, since the sister of the Pir could not marry just anybody: a marriageable male of suitable social standing had to be found.

  Ghani – a Pashtun, a qualified medical man, and one who had proved himself a competent and thoughtful physician to the family – appeared to fit the bill. The two were married, and children arrived soon afterwards: in 1988 Amir Hamza, the following year Rabia Ghani, the next Ali Raza.

  Accelerated into the fast stream of conservative Pashtun society, Ghani’s rise was now rapid. The family took hiking holidays in the Swat Valley, day trips shopping in Peshawar and mingled with the most influential figures in Nowshera society. There was, however, a cost: as a member of the Fir’s family, he was expected to conduct himself appropriately. All the unsuitable friends he had made on the way up were to be discarded. The family had a reputation to uphold.

  Ghani was having none of it. He wasn’t breaking friendships. ‘People would ask him why he was still friends with low-scale workers like us,’ says a former colleague, Fazli Raziq. ‘He just ignored them.’

  The doctor’s reasoning was solid. ‘I was a poor man myself he told Raziq on one occasion. ‘My father worked hard to educate me. I don’t see what social status has to do with it.’ At the risk of alienating his in-laws, Ghani openly visited subordinates at their homes. ‘Most of his friends were low-paid workers,’ says Raziq.

  This egalitarian approach spilled over into his work, too. ‘He was a very frank man,’ recalls another colleague, Nazirullah Muhmmadzai. ‘He never showed that he was our boss. He used to say that, if you wanted respect, you should respect others.’

  To those who knew him well, there was a more mischievous side to Dr Ghani. ‘He loved parties,’ says Azmatullah Jan Faiq, another colleague. ‘He never missed an opportunity to get people together.’

  Faiq should know. In 2002, when Ghani was promoted to Assistant District Health Officer for Nowshera, colleagues repeatedly suggested that he should organize a surprise party for their boss. ‘Only later,’ he says, ‘did I discover that it was Dr Ghani who had told them to pester me to throw a surprise party’

  When Faiq stepped up and organized a lunch party at an exclusive local restaurant, Ghani acted suitably surprised, but was unable to resist meddling again. ‘When it was time to pay the bill, he took me away from the table,’ recalls Faiq. ‘He said he knew that I didn’t have much money’

  Ghani winked at his subordinate. ‘Look,’ he said, ‘we’ve had a great time, and it’s all because of you. Let me cover it.’ There was, however, one condition. ‘Don’t tell anyone that I paid the bill.’ Having organized a surprise party for himself, Abdul Ghani covered the cost of the entire event.

  The Global Polio Eradication Initiative was so successful that by the late 1990s the WHO was on course to achieve its deadline of eradicating the disease by the end of the year 2000. On 23 September 1998, the US Senate Committee on Appropriations held hearings to determine funding levels for the programme, and to monitor progress. The event, according to its chairman, Senator Dale Bumpers, was ‘one of the most enlightening, gratifying hearings I have ever attended in my entire life’.

  According to expert testimony, 80 per cent of the world’s children were now receiving vaccine. Results were stunning. In a single decade since the commencement of GPEI,
global cases of polio had dropped more than 90 per cent. Over fifty nations were now entirely free of the disease. Several million children had been saved from paralysis and more than 100,000 lives had been saved outright.

  ‘This is a dramatic story of success,’ the Surgeon-General informed the Committee. ‘Hundreds of thousands of children who would have died from polio have been saved.’

  More money was required, but if it came on time even Africa would be free of polio by the end of the millennium. ‘The goal,’ Rotary International’s Polio Eradication Advocacy Task Force Chairman, Herbert Pigman, assured the panel, ‘is in sight.’

  And yet success was by no means guaranteed. As Senator Bumpers noted, fewer than 800 days remained before the 2000 deadline. The programme was at a ‘critical stage’. Anything could happen.

  Almost three years to the day after the hearing, in September 2001, anything did happen. That the 2000 goal for complete eradication had been missed was unfortunate, but by now progress was so meteoric that even 9/11 looked unable to stop it. In 1999, global cases of polio had dropped below 20,000. The next year, the figure was 3,000. A new vaccination initiative, Accelerated Immunization, ensured that vaccine was reaching more children than ever: close on 550 million each year. The entire Western Pacific region had been certified free of polio.

  With the end almost in sight, a GPEI technical advisory group released guidelines for laboratory containment of the poliovirus – a condition for certification of global eradication. By the end of 2001, the global number of new polio cases had plummeted from more than 1,000 per day to below 500 for the entire year. From 125 countries, the virus was now endemic in only ten. In 2002, Sudan, Ethiopia and Angola registered no new cases of the disease, leaving just seven countries to go. Poliomyelitis hadn’t been eradicated by the turn of the millennium, but the new goal of 2005 was within reach.