In these days of electioneering when pessimism and criticism is order of the day, it is worth recalling success stories of the Indian Government in collaboration with other agencies in the health sector. There have been two significant achievements after the Green Revolution, by the country since independence, which somehow, although acknowledged are not highlighted tremendously, especially because such achievements are handful. There is perhaps no book or detailed paper on them which can give the common man the way and manner in which they were achieved. Both are in the field of health and before their eradication were widespread throughout the length and breadth of the country.

BACKGROUND :

The two worthy achievements are the total eradication of small pox and polio from India. While India is already declared small pox free it is on way to be declared polio free also in the near future. Both these were achieved by the active support of concerned government departments and agencies ably supported by private and many global agencies and institutions also. Today no child's face will be disfigured by small pox or legs and arms afflicted by polio that is if they survived the attacks. Both would frequently appear in form of epidemics and affect hundreds and thousands of small babies and scar or maim them for life.

Small pox was so widespread and a dreaded disease that in Hinduism a Goddess named Shitla Mata was indeed worshiped to save one's children from it. There were temples devoted to this goddess. One of the main reason both these dreaded diseases could not be controlled was because Ayurveda the medicine existing from ancient times does not recognise the existence of germs and viruses and thus could not formulate a strategy for their control / eradication. It was only when modern science understood that these were caused by viruses against which no antibiotics can work that vaccines were invented and formulated. It was only then that these could be controlled by vaccinating the small children  and helping them to neutralize the virus if it attacked them. Fortunately the vaccines gave life long immunity.

SMALLPOX:

Smallpox is caused by two virus variants, Variola  major and Variola minor. As per Wikipedia it is supposed to have emerged in humans in 10,000 BC and one of its most famous victims is the mummified body of Egyptian king Ramses V having rashes. 

Smallpox localises itself in the small blood vessels of the skin, mouth and throat. The mortality rate for V.major, its severest and most common form, was around 30% and it would leave scars especially on the face of 60 - 65% survivors. The mortality rate for V.minor which was less common and mildly severe form, about 1%. Smallpox also resulted in blinding nearly 30% of those affected. It was transmitted by inhalation of the variola virus from the exhaled oral, nasal or mucosa of infected persons. Thus its spread was contagious, relatively fast and widespread.

Smallpox infects only humans and animals are not infected or nor do they transmit it.

It is estimated that 300 - 500 million people lost their lives to small pox in the 20th century. In 1967 as per WHO estimated that 15 million people contracted smallpox and two million died during the year. Such devastating was its effect on the human race.

Mention of smallpox is found in ancient Indian writings dating back to 1500 BC. It is believed to have come to India through Egyptian traders. It has gone to Japan from China in the sixth century. It spread through out the world in due course of time, killing around 400,000 persons annually in Europe in the eighteenth century.

POLIO:

Poliomyelitis commonly known as polio is an infectious disease caused by the poliovirus. It is a contagious disease transmitted through the oral-fecal route, from person to person. Although polio existed for thousands of years , the polio virus was  identified in 1908 by Karl Landsteiner. Widespread polio attacks were not common before the 19th century, but took a virulent form in the 20th century, killing and crippling thousands especially in their childhood itself. The presence of thousands of paralyzed children all over the world was to provide a great push to find a vaccine for combating it.

Three strains of poiliovirus have been identified and named PV1, PV2 and PV3. It is PV1 which is very common and causes paralysis. Its peak transmission occurs in summer and autumn. Today PV1 is highly localized in Afghanistan, Pakistan, Nigeria, Niger and Chad. PV2 is eradicated but PV3 is existing in only Nigeria and Pakistan.

In about one percent of affected persons paralysis of some limb occurs and this lasts life long. Most common form affects the legs creating asymmetric paralysis. The polio  causing virus was detected in 1908. The crippling disease became a dreaded childhood disease in all parts of the world in the 20th century affecting especially the young.

The persons either affected by the virus or immunized develop lifelong immunity to further attacks as is the case with small pox also.

SMALLPOX & POLIO IN HISTORY:

Smallpox was the scourge of India from ancient times till a few years back. It would strike in form of epidemics and affect thousands, killing or scarring them for life. There was no treatment available. The ancient Ayurveda was also helpless. It was seen as the wrath of Goddess Shitlamata and she was worshiped to save oneself. Only divine intervention could save oneself. There is evidence of existence of smallpox in India in 1500 BC and in China in 1122 BC.

Smallpox is believed was brought into India by Egyptian traders in the first millennium and entered into China also around the same time. It is believed to have  traveled to Japan from China in 6th century AD. The Arab armies carried the virus into south Europe in the 7th and 8th century AD and whole of Europe was covered by the sixteenth century. It was carried into the Americas by the Spanish conquers in the sixteenth century killing thousands of natives. Subsequently smallpox had spread itself throughout the world.

It equally attacked the high and mighty and the low and poor alike. The well preserved mummy of Pharaoh King Ramses V who died in 1157 BC has smallpox lesions on his face. Both George Washington and Abraham Lincoln survived the smallpox attacks and went on the become Presidents of USA. In India the 8th Guru of the Sikhs Guru Har Krishan was a victim of smallpox. The first Sikh King Ranjit Singh had lost his one eye to smallpox in his childhood.

The only saving grace was that those who survived its attack got lifelong immunity from it.

Polio is also a disease existing from pre-historic times. One of the earliest evidence is provided by an Egyptian relief of the period 1403 - 1365 BC showing a person with a shrunken leg affected by polio. However it is interesting to note that the paralysis causing disease remained endemic till the late 19th century and thereafter became virulent. But although it did not come as epidemics it paralysed and killed throughout human history. Localized polio epidemics began to appear in Europe and America from mid 1800 on  wards with larger groups getting affected every year. By the early 1900's regular polio epidemics were occurring worldwide. 

It was the English physician Michael Underwood who in 1789 described polio as the debility of lower extremities. The disease rarely affect children 2 before six months of age but most affected were those between six months and four years of age. The regular exposure to poor sanitation resulted in constant exposure to polio virus and this helped built immunity in the population. However as sanitation improved immunity levels went down and the disease struck young children with increased frequency. In due course of time the survivors formed the largest disabled group and this was to spur the need to treat the disease effectively.

  DEVELOPMENT OF VACCINES:

Once the viruses responsible for both smallpox and polio were identified, it became inevitable that a cure be also found quickly. The death rate was high and those who survived were either scarred or paralysed for life. Both the diseases would come as epidemics and strike and kill or maim thousands irrespective of their status or affluence. It was clear that vaccines needed to be developed.

The smallpox vaccine was the first to be developed. Historically there are references of inoculation being practiced in India in 1000 BC, but this is disputed as the techniques are not described in any of the ancient texts. In China it is believed to have been practiced, as there is a reference to it by an author in 1549, where dried and powdered smallpox swabs would be inhaled by the healthy. This gave them an immunity against smallpox. This process was also known as virolation and was also practiced in Turkey, Africa and Persia. The wife of the British ambassador in Turkey is widely believed to have brought this practice into UK in 1721 after she practiced it on her own two small children who developed immunity to the disease. Similarly in America also it was observed that slaves from Africa were immune because they were virolated at an early age.

Thus it became clear that a vaccine was the best hope for combating the smallpox. Edward Jenner in UK had observed that those who worked with cattle got affected by a mild disease known as cowpox. They never got affected by smallpox. It was also known to many that cowpox gave immunity against smallpox. Jenner tested this by inoculating cowpox lesions from affected persons on a few patients and found it to be true. When these patients were inoculated with smallpox they did not develop it and thus successfully resisted it. He wrote to the Royal Society in 1797 about his findings and soon the news traveled all over Europe and America. The cowpox lesion became the vaccine for smallpox prevention. Its inoculation gave lifelong immunity and soon small children started receiving it in UK and the continent and America.

In fact the term vaccination is derived from the Latin vacca for cow. It was not till late 1940's that a method of freeze drying of the smalllpox vaccine was found by Leslie Collier who also added a peptone, a form of soluble protein, in the process which helped in protecting the virus from heat and thus it could be transported safely over long distances. This was a critical input in makjng available the vaccine throughout he world over a period of time.

The first polio vaccine was developed in 1952 by Jonas Salk at the Pittsburgh University in USA. After exhaustive testing it was licensed for public use in 1955. Soon mass immunization programs were launched on children in USA and the number of polio victims considerably fell to only 161 cases in 1961. The vaccine was effective against all three types of polio virus PV1, PV2 and PV3. The Salk vaccine is also known as inactivated polio virus (IPV). A higher potency IPV was licensed for use in USA in 1987. It is given in form of a dose of drops, the first one within 1-2 months age followed by a second dose at 4 months of age. A third dose is given between 6-18 months age depending on the vaccine formulation.

Oral polio vaccines (OPV) were developed by many groups including by Albert Sabin, Hilary Koprowski and H.R. Cox. After large scale trials especially in Russia during the 1950's and early 1960's, OPV developed by Sabin was released for worldwide use. One dose of OPV results in immunity against all the three types of polio virus in  nearly 50% of recipients. Whereas by the recommended third dose immunity is produced in more than 95% of recipients.

INDIAN ERADICATION CAMPAIGN :

Even after the vaccines became available the incidence of both diseases continued unabated in India and many Asian countries. It was to be expected that the Western nations because of their funding abilities and better delivery mechanisms would be the first to eradicate these from their counties. Indeed that is what happened. Polio was eradicated in USA by early 1960's and smallpox was eradicated from Europe and America by late 1950's. It was possible due to mass production of the vaccines, their preservation techniques and mass immunization of the population in a planned manner.

It is to be noted that the fact that smallpox occurs only in humans and there are no carriers were to play a very important role in its eradication not only in India but in the whole world. 

In India the Indian National Smallpox Eradication Program (NSEP) was launched for smallpox eradication. In 1963 India had the dubious distinction of harbouring 80% of all known cases of smallpox and 75% of deaths due to it, in the world. Although the first lot of smallpox vaccine was despatched to India by Jenner himself in 1802 for use in Bombay, the disease continued in its endemic form year after year. The British rulers had made smallpox vaccination compulsory in many parts of the country.

The 11th Assembly of the World Health Organisation in 1958 proposed the establishing of national programmes for smallpox eradication. In 1959 a proposal was for undertaking a national programme for total eradication was recommended by the Indian Council of Medical Research. Accordingly in 19660-61 pilot projects were set up in all states to work out the various parameters to launch a national effort.

Enumerators were to record the population details and create awareness about eradication by vaccination. this was followed by vaccination teams visit and actual vaccination of the population. This coverage and records were to be kept ongoing for twenty years. The pilot project was run for one year and problems were identified and reworked. The NSEP was launched in 1962 with the target of covering 80% of the population through mass vaccination cycles. Between 1962-67 mass vaccination campaign were launched under NSEP. Between 1968-72 surveillance teams were formed to detect any outbreak of smallpox and taking of focused attention for its containment. Between 1973-75 intensive campaign was launched to detect any smallpox case because the number of cases had fallen significantly.  Any case found had to be contained within the area itself. Four states namely W Bengal,MP, UP and Bihar were identified needing special attention. Every house was visited. 

Success came in 1975. The last case of smallpox in India was reported in May 1975. India was finally free of smallpox which had killed, blinded and scarred for centuries.  In fact soon the world also became smallpox free.(The last case in world was reported in 1975 from Bangladesh of two year old Rahima Banu).

The Pulse Polio Immunization Programme (PPIP) was launched in December 1995 for eradication of polio from the country. It was also a part of the global initiative. A National Polio Surveillance Unit was established in 1997 in Delhi. It involved the vaccinating of all children below five years of age against polio virus.

Some of the highlights of the programme were that not a single child should  miss the immunization and maintaining  a high level of surveillance and India should be polio free by 2005. In order to preserve the vaccines freezer rooms, refrigerators, cold rooms and cold boxes were created. The efforts were undertaken in all seriousness but still the 2005 target was missed. Awareness about the polio vaccine cycles were heavily advertised and leading actors like Amitabh Bachchan and Aamir khan were roped in. The programme was run like a movement with enthusiastic participation by mothers bringing their children for vaccination. Polio drops were many times given by famous personalities and electronic media highlighted it extensively. All in all it was the considerable awareness that created a bond throughput the nation that polio has to be eradicated. 

The last cases of polio in India were reported from West Bengal and Gujarat on 13 January, 2011. India had finally also got rid of the crippling diseaes of polio which for centuries killed or maimed thousands every year. On 12 February, 2012 the WHO struck off India from the list of polio stricken countries. India has to wait for further two years since to be declared polio free completely.

CONCLUSION :

The most gratiying features of both the prorammes was the unity of purpose between the Central and State governments and WHO right from the planning stage of the campaign to their finish. At all levels team work was of a very high order. All members were full of dedication and enthusiasm. Almost all the medical personnel were roped in  performed beyond and over their normal duty.

Special tribute must go to the grass root workers whose hard work and integrity was the base on which the eradication programmes were based. Lakhs of personnel were involved and we salute their commitment in eradicating the two dreaded and deadly diseases from India hopefully for ever.

India and Indians have done it and demonstrated that they can achieve wonders if they work unitedly and make not only the country but the world a better place to live in.

(A word of caution however is for polio. The Islamic countries of Afghanistan and Pakistan and Nigeria are still not free of polio, because fundamentalists are preventing the giving of polio vaccine drops to children under some religious pretext. Thus the world is not completely polio free. India has to be careful as two countries are our neighbours.)