[This article is from the Boston Globe]

Polio's path

By bus and by boat, crippling virus spreads, despite vaccine drive

NIAMEY, Niger -- Nine hours late, the bus inched loudly out of the terminal in first gear. The ugly metal box, fitted with poorly padded benches and welded atop a truck chassis, set off for a two-day trip across the southern fringes of the Sahara to the Mali frontier town of Gao.

It carried 47 passengers from all over West Africa -- Cameroon, Nigeria, Niger, the Ivory Coast, Burkina Faso, and Benin -- part of the vast daily flow of people traveling across borders in this region.

The trip was nothing out of the ordinary. But, to a group of health professionals who are working to erase the disease of polio from the world, such travelers pose a great threat: They are potential carriers of the virus and could reach areas where children have not been immunized against the crippling disease.

Other travelers along that route this year brought polio back to Mali after a four-year hiatus. They unintentionally left seven preschoolers unable to walk or use their arms.

All over West Africa, this fight for the health of children is a race between these two opposing forces. On one side are hundreds of thousands of volunteers who, in the past two months, in two synchronized campaigns, have vaccinated more than 80 million children under the age of 5 in more than 20 countries in West and Central Africa. They have reached some of the most remote areas in the world to put two drops of the vaccine into the mouths of every young child they could find.

On the other side is the natural flow of millions of travelers who don't think about polio when they buy $11 bus tickets to take them to Gao, board a ferry or drive a truck to a neighboring country.

The outcome will help determine history: whether polio becomes just the second disease ever to be eradicated -- smallpox is the only success so far -- or whether it continues to cripple and kill children.

Sitting near the back of the Gao bus, 25-year-old Zeinab Shehu squeezed on one bench with her three young daughters. She was elated despite the heat and the long hours on the road. They were traveling to the ancient Mali city of Djenne, famous for its mud-brick mosque, and where Shehu's parents lived. Shehu had been gone eight years; the grandparents had never seen their grandchildren.

But, like others on the bus, Shehu knew almost nothing about polio, and the campaign to eradicate it. She has been living in the northern Nigeria state of Jigawa, next to polio's epicenter, the state of Kano. Her children have never been immunized against the crippling disease.

''No one came to vaccinate," she said. ''I had never heard of polio vaccinations."

Shehu said she would try to get her children -- Binla, 5; Falinal, 3; and Batour, 8 months -- immunized in Mali, but she said she may not have time. She intended to leave her three girls with her parents in Mali so they could get an education; in Jigawa, she said, her husband's family had discouraged her from sending them to school.

The strategy of the health workers has been to concentrate their efforts on vaccinating as many children as possible all at once over an area larger than the continental United States -- and, they hope, snare some travelers in the process.

The Great Crippler

Polio, called the ''Great Crippler" when it caused widespread panic in the United States and Europe during the first half of the 20th century, passes only through contaminated feces, often spread by water, surviving for a full two months outside the body. It enters a person through the mouth or nose, multiplies in the intestine, and destroys nerve cells responsible for muscle movement.

Paralysis of limbs, though, occurs in less than 1 percent of the cases -- virtually all of them young children. The other 99 percent-plus become unknowing carriers, showing no symptoms absent an initial fever, but for nearly five weeks after infection are highly contagious through their feces. Adults and older children are often carriers but rarely are paralyzed by the disease.

The introduction of two vaccines in the mid-20th century swiftly led to eradication of polio in wealthier countries and eventually inspired the global eradication movement because one of the vaccines, delivered orally, was so simple to give. In 1988, when the campaign started, polio was transmitted in 125 countries, with an estimated 350,000 cases. At the end of last year, the virus resided in just six countries, accounting for 784 cases.

The idea is for near-blanket immunization coverage so that the carriers of poliomyelitis can carry the disease nowhere, and polio will die out. When health workers confirm a case of polio, they immunize all children in the surrounding area, hoping to stop its spread.

But the endgame of polio, long predicted by experts to be difficult and full of last-minute surprises, has not gone well in West Africa over the last year. While India, Pakistan, and Afghanistan have made strong gains, a movement by Muslim religious leaders in northern Nigeria to boycott the polio vaccine has given the virus new life, allowing it to move from Nigeria and Niger, and spread to 12 previously polio-free countries around Africa.

The religious leaders had charged that the polio immunization campaign was part of an American plot to make their children infertile and parents should refuse it. While they have since backed off such claims, and immunization campaigns have restarted in northern Nigeria, the damage was done.

As of late last month, health officials have confirmed 988 cases in 16 countries this year, compared to 572 cases at this time in 2003. Nigeria alone has had 699 cases so far, and could top 800 cases this year -- more than in the whole world last year.

The problems in West Africa have pushed the goal of eradication from the end of 2004 to the end of 2005. In the meantime, polio has spread into two conflict areas, the Darfur region of west Sudan and the Ivory Coast, creating greater difficulties because of poor access to children.

The great worry of those organizing the polio eradication effort is that if their efforts take much longer than the next year, donor countries and health ministers in Africa will lose interest. Organizers say they need $200 million in additional funds just for next year's work.

The Niamey-to-Gao bus route, which follows the Niger River, is one of the new polio pathways. On this road, epidemiologists say, at least seven polio carriers traveled into Mali this year and infected seven children, the first cases in Mali in more than four years. Genetic sequencing tests confirmed the cases originated from Niger. Mali had stopped vaccinating its children in 2002, part of a cost-cutting measure by those directing the eradication effort, leaving all children 2 and younger vulnerable to infection.

Traveling in close quarters

For the travelers on the Niger-to-Mali bus, though, the polio campaigns were fleeting events. As the bus passed brown fields of millet, goats standing on their hind legs to reach thorn bushes, and the wide Niger River, the passengers exchanged stories of travel.

Abdoul Qadir Cisse, 25, had just spent two wonderful months on holiday in Benin and was returning to his home in Gao. Brothers Daouda and Mohammadou Bassirou, 28 and 26, respectively, had been on the road for more than a week, starting in Cameroon, passing through northern Nigeria and Niger, and now on their way to see a friend in Mali's capital. And Diarra Mamadou, 64, had made a big circuit of his own, starting from the Ivory Coast, passing through Mali into Niger to see his ailing father, and now was retracing his steps.

For three hours, the bus rode smoothly on paved roads, but then it rolled onto rutted dirt and sand, which rattled the windows so fiercely that it stopped conversation. At a police checkpoint at 10 p.m., the bus stopped and its passengers walked into pitch darkness, laid out straw mats in the sand, and turned on their backs to watch shooting stars arc across the sky.

At 4:30 a.m., the bus left, minus one passenger; he could not be found and the driver wouldn't wait. Two hours later, the bus arrived at the border, and passengers produced their ID cards, passports and vaccination cards for Niger and Mali authorities. At both border posts, they required vaccinations for yellow fever and meningitis.

No one asked about polio. ''It's just for kids," said a Mali guard. ''And most kids don't have [vaccination] cards anyway."

In all, including Shehu's girls, six children under the age of 5 from Niger also rode the bus; just one had been vaccinated for polio, and she had received the oral drops only once. Three doses, properly spaced, are necessary to give a child lifetime immunity.

The bus advanced slowly on the sand trail. The sun grew hot, and trouble festered on the bus. One woman moaned in pain -- from the onset of a malaria attack, she said, and a fellow passenger gave her traditional medicine, small pieces of tree bark fished from a plastic bag. A second woman argued passionately with a bus employee about leaving the passenger behind; the unfortunate man could be stuck for days. Then the bus itself became stuck in deep sand. Men pushed for 30 minutes, and it finally plowed through.

The most sobering moment occurred when the bus stopped alongside a broken-down bus. Three women and four sad-eyed children climbed on. They had been abandoned for five days with almost no food or drink. A few passengers quickly gave the newcomers water and bread. The children gulped it down.

By the time the bus arrived in Gao, 29 hours after the trip began, the travelers had become a community of sorts. First names were known. But once porters unloaded the bags, everyone scattered, few offering farewells as they rushed away.

Hurdles remain

At the Gao Hospital the next morning, a team of health workers poured over maps and documents, planning their second polio vaccination campaign in a month. One of them was Dr. Karem Dambele, 40, based in the village of Bourem, about 60 miles north of Gao along the Niger River.

Earlier this year, a health worker reported a possible polio case in his district, in the village of Amgoudji, south of the Niger River. Dambele investigated, interviewing the family, examining their 5-year-old boy, and collecting stool samples to test for polio. The samples then traveled the length of Africa -- from Gao to Bamako, the Mali capital; to Abidjan in the Ivory Coast; to Pretoria, South Africa, where four weeks later a laboratory confirmed the boy had polio.

The response was swift in the Sahel region. Teams vaccinated children around Amgoudji and around a watering hole called Escheri, about 40 miles south, where the family, nomadic herders, lived for half the year. Dambele learned the boy probably contracted the virus from a visiting uncle from Niger, or possibly from other travelers from Niger. The virus, from contaminated feces, could have entered a stream, and found its way onto the boy's unwashed hands and into his mouth.

In October, teams in the Gao district vaccinated 126,875 children, or 96 percent of the estimated number of those under the age of 5 in the district.

The next round began Nov. 18. To avoid a repeat of the robbery in October of the health office's only four-wheel-drive vehicle, they added a layer of security -- assigning a military-escort vehicle to each team. That would also help the teams avoid getting lost or breaking down in the desert.

''If there are problems in the desert, we can only hope for the best," Dambele said. ''These vehicles are not equipped with communications systems, so they would have to walk out."

Dr. Goita Tingue, director of health for Gao, one of Dambele's peers, said he was confident with his district's plan, but he worried whether other countries would do the job properly.

''Since we can't master the movement of people, we have to get everyone here vaccinated to protect them," he said. ''It's quite possible, but only if every country does its job. We can't have one isolated part not vaccinating its children. What the religious people did in northern Nigeria is a crime. Because of their actions, children are now paralyzed."

Told of the unvaccinated children arriving from northern Nigeria on the Niger-to-Mali bus, Tingue's eyes widened. ''You see how this affects us? People here go to Nigeria. People in Nigeria come to Gao, and beyond. How do we reach all these people?"

Paths diverge again

Later that day, Shehu, the mother of the three unvaccinated children, left by bus for the ancient city of Djenne. The brothers from Cameroon boarded another bus to Bamako. Many other passengers drove in cars to villages at the edge of the desert. A passenger ferry, headed up the Niger River for Timbuktu, pulled into the Gao dock and left an hour later with more than 100 passengers. Lines of trucks carrying rusted metal and cattle passed through a gasoline station at Gao's eastern edge, headed for Niger.

The November campaign proved to be another success in Gao -- 99.8 percent of the estimated children were reached. The military escorts scared off any would-be bandits. But the eradication drive continues, just as people continue to travel.

Later this month, Mali will hold a national measles immunization campaign, which also will include polio vaccinations. And Dr. Ndoutabe Modjirom, the head of the WHO's vaccination efforts in Mali, plans to talk to border guards east of Gao about starting to give polio vaccinations to all children who pass through. He will pay them and hire someone 50 miles away -- the closest place with electricity to refrigerate the vaccine -- to deliver batches every second day.

The WHO doctor, though, still sees a flaw in his plan: ''The difficulty is that the road from Niger to Mali is not the only way people come into Mali -- many others cross in the desert or in fields. Travelers go everywhere."

John Donnelly can be reached at donnelly@globe.com. 

Copyright 2004 The New York Times Company


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