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‘Shoe leather’ public health efforts and polio’s re-emergence

AAsk most Americans to name a polio victim and they will say President Franklin Delano Roosevelt. Ask I the name of a polio victim and I would offer two: my father’s older sister and his younger brother.

My father’s sister was a medical student in India when she died of polio in 1950. She contracted it from their younger brother, my uncle, who was five years old at the time and became permanently paralyzed in his right leg. I remember the first time I met my uncle at our family home in Chennai, India and asked him what happened to his leg. I couldn’t imagine facing such a challenge, and was relieved to learn that I wouldn’t have to because I was vaccinated against polio as a baby.

Americans, and those in many other countries, have been tricked into thinking that polio is a disease of the past, thanks to more than half a century of concerted global health action to vaccinate children. Within the last few decades, the public health community has seen a path toward global eradication of polio, most notably with the World Health Organization eradicating wild poliovirus in Africa in 2020. This would have followed smallpox, which was declared globally eradicated in 1980. This has not happened, largely due to the consequences of global under-vaccination caused by a combination of mistrust, poor implementation, lack of access in conflict zones, insufficient funding, loss of global momentum, and work suspended as as a result of the Covid19 pandemic.

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So I wasn’t entirely surprised when a man was diagnosed with polio in Rockland County, NY in July 2022, nor by the subsequent discovery of poliovirus in wastewater samples in New York City and other places in the state. This is in addition to a surge in polio which has been found in waste water samples across London. The US is now one of about 30 countries where circulating poliovirus strains have been identified.

This “new” infection, breaking out in the midst of the Covid-19 pandemic and the monkeypox, has fueled understandable fear and anxiety. A quick response by public health workers at the New York City and state health departments, with support from the Centers for Disease Control and Prevention, helped ensure that polio remained what we were all taught it was: a disease of the past.

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The emergence of Covid-19 and the response to it was the first real impression of public health that many people had. This is because so much public health activity is routine and happens behind the scenes, and its success is measured by prevention: stopping disease in its tracks or preventing it altogether, which is often invisible to the public. The efforts in New York City and State to contain polio are a clear example of such everyday public health work, and they provide a guide for other communities and states that may be faced with a resurgence of polio. The response requires working directly with communities with low polio vaccination rates as well as with paediatricians, parents, schools and community leaders to educate, inform and raise awareness, and to make a call to action to protect children without hesitation get vaccinated against the virus. .

Public health, like politics, is often local. That’s why we led community and provider roundtables, distributed culturally respectful education and messages in multiple languages, and worked to ensure that health care providers had adequate supplies of polio vaccine. We regularly conduct messaging and awareness campaigns in schools, community centers and other gathering places, and meet face-to-face with faith-based leaders and other respected and influential community members and organizations. We get the message out via local media, including announcements in neighborhood newspapers and local access television.

All of this is routine, public health work. that can be replicated in every city, state or county in the country, and should be part of the goal when talking about strengthening the US public health infrastructure in the wake of the Covid-19 emergency.

The work must certainly be tailored to the constituencies served, especially when they are as diverse and sometimes as opinionated as New Yorkers. Still, my colleagues and I were encouraged by how the communities most at risk responded to this outreach and acted on recommendations. In just two months, there was a 20% increase in polio vaccines administered to children up to 5 years old, compared to the same time last year, in New York City ZIP codes with the lowest vaccination rates for that age group. There was also a 9% increase in polio vaccines administered citywide. Similar increases in vaccination rates, and the associated reductions in population-wide polio risk, are occurring in other parts of the state, and can be achieved wherever public health workers are supported to do the largely unsung work at the root of the profession: community engagement on the ground , education and delivery of key preventive services, informed by precise data collection and analysis.

But there is much more that public health professionals and agencies everywhere can and should do, including fighting back against the misinformation that has led to the persistent decline in vaccinations across the spectrum of vaccine-preventable diseases. This must be one of public health’s main goals moving forward, but it cannot do it alone. State and federal regulators must hold social media companies accountable for spreading anti-science and anti-vaccination messages without warning, context or qualification.

As polio re-emerges from the shadows, global citizens and public health officials alike must recognize the factors that have made polio eradication such a challenge. And when we talk about reimagining or reinvesting in public health infrastructure, we need to build the foundation of a strong workforce and support for grassroots engagement that is the backbone of prevention. We must also honor the memory of past polio victims, such as my aunt and uncle; meeting the needs of those in the present, such as the person tragically paralyzed in New York state; and celebrate the everyday heroes who make up our nation’s and the world’s extraordinary public health workforce by giving them the attention and investment they need to succeed.

Ashwin Vasan is a primary care physician and epidemiologist, the 44th commissioner of the New York City Department of Health and Mental Hygiene, and an assistant professor of population and family health and medicine at Columbia University.

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