Ending wild polio in Africa: A Q&A with Michael Galway and Violaine Mitchell

This week, and four years after the last case was discovered in Nigeria, the Africa Regional Certification Commission officially certified the WHO Africa Region (AFR) free of wild polio (WPV). We spoke with Michael Galway and Violaine Mitchell, both of whom have worked intensively in Nigeria and other countries in Africa as part of the foundation’s polio eradication initiative, about this announcement and what it means for the global battle against polio.

Let’s start with this week’s WPV certification announcement. What does this mean exactly?

MICHAEL GALWAY: This is a major milestone for Africa, and a huge accomplishment for the families and the governments of that region. VIO MITCHELL: With this certification, five of the six WHO regions around the world, encompassing 90% of the world’s population, are now officially free of wild polio—only one region, which includes Pakistan and Afghanistan, remains.

MICHAEL GALWAY: It was a long road to get here, but this is a strong signal that we are on the right path to making this a world free of polio.

When was the last WPV certification before this?

VIO MITCHELL: In March 2014, in the WHO Southeast Asia Region encompassing 11 nations, including India, Indonesia, and Bangladesh.

How did Africa and Nigeria make this final push to eliminate WPV completely?

MICHAEL GALWAY: The primary tools to fight polio are vaccination through campaigns, surveillance to make sure we’re not missing any virus, and routine immunization to build up immunity in the population. That’s the straight story, but actually it’s much more complex. You must have great government engagement, superb operations, outstanding management, and communities ready to accept the vaccine. Everything can go wrong in each one of those stages, and invariably they did, both in Africa and in every other region. So this final push was not done overnight. It took more than a decade of almost constant effort in specific locations in Africa, particularly Nigeria because it’s so big, populous, and complex.

You mentioned this was a long road. When did the polio eradication campaign in Africa begin in earnest?

VIO MITCHELL: This effort goes back several decades at least. In the 1980s, WPV was still everywhere—in more than 125 countries and paralyzing 350,000 people every year. After a big push by Rotary International—who have helped lead this fight from the beginning—to encourage polio vaccinations, the World Health Assembly passed a resolution to eradicate polio worldwide, and the Global Polio Eradication Initiative (GPEI) was formed in 1988. Eight years later, Nelson Mandela launched the Kick Polio Out of Africa campaign, which helped jumpstart efforts to vaccinate every child in Africa.

MICHAEL GALWAY: But the polio work was terribly complicated in the early 2000s after a decision in northern Nigeria to halt vaccinations over “safety concerns” that were fabricated and politically motivated, on the pretext of completely false rumors and misinformation that the real goal of the program was forced sterilization. That resulted in the rapid accumulation of a huge cohort of unimmunized children, allowing the virus an opportunity to circulate—which it did—it exploded out of Nigeria to the rest of the world, even reaching as far as Indonesia. That was a major setback that took years to recover from.

When did the foundation get involved in this campaign, and in what capacities?

VIO MITCHELL: In the 2000s, we were involved primarily as a donor, making significant investments to the GPEI and polio eradication.

MICHAEL GALWAY: What really boosted our engagement was Bill’s trip to Nigeria in February 2009. That’s when Bill’s involvement grew to help turn the tide for the polio program in both Nigeria and Africa writ large, and when we at the foundation really began to focus more intensely on helping to make Africa polio-free. From there, it was a complex set of interventions, including Bill’s engagement with governments, the foundation’s technical engagement with other partners to improve the quality of vaccination campaigns, and then some real innovation to try to make sure that families and communities were comfortable and ready to accept the vaccine.

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Who were the key public and private partners you worked with on these interventions?

MICHAEL GALWAY: By far the most important group or constituency in Nigeria were the traditional leaders: For example, the Sultan of Sokoto, the Emir of Argungu, and the Shehu of Borno. These leaders have tremendous credibility with the Hausa-speaking and Kanuri people of Northern Nigeria. They helped the polio program rebound from the setback due to the early-2000s rumors and gave it a degree of credibility and trust. Families could say, “If my Emir has told me it is ok to immunize, I will allow my child to be immunized.”

VIO MITCHELL: Building that confidence and trust, particularly with traditional leaders in Borno, was absolutely critical, and it could only be built up over time.

Ahmed Iya of the Dangote Foundation (left) and Michael Galway (second from left) and Vio Mitchell (far right), meet with the Emir of Argungu, Samalia Muhammed Mera, and his daughters in 2018. Mera is the co-chair of a group of northern Nigerian emirs, responsible for raising support for polio immunization among the country’s traditional leaders. Iya, Galway, and Mitchell have visited with the Emir at his home on many occasions—including hours after the birth of his older daughter, pictured. — Ahmed Iya of the Dangote Foundation (left) and Michael Galway (second from left) and Vio Mitchell (far right), meet with the Emir of Argungu, Samalia Muhammed Mera, and his daughters in 2018. Mera is the co-chair of a group of northern Nigerian emirs, responsible for raising support for polio immunization among the country's traditional leaders. Iya, Galway, and Mitchell have visited with the Emir at his home on many occasions—including hours after the birth of his older daughter, pictured.

MICHAEL GALWAY: The second major partner was Aliko Dangote, Africa’s richest man, who hails from Kano state in northern Nigeria. He brought to the fight against polio tremendous credibility in the government, the private sector, and with traditional communities in the North. His partnership and close friendship with Bill brought a strong combination of voices to say that immunization is important, primary health care is important, and fighting polio is proof of concept that we can all work together to achieve great things.

VIO MITCHELL: The Rotarians and their network—who, as I said, have been there since the beginning—were extremely active in visits, fundraising, and advocacy both at the federal and state level in Nigeria. And the governments themselves were of course decisive in this effort.

MICHAEL GALWAY: Yes. The Abuja commitments, signed by the governors of Nigeria and overseen by the president in 2010, were another turning point. Those commitments pushed elected leaders to hold themselves, their programs, and program managers accountable for specific actions they pledged to do. For ten years now, governors have reported on a quarterly basis to say what areas are making progress and which aren’t—not in a punitive way, but so we all can figure out what we need to do to help improve success. With that framework for accountability, you really saw strong forward movement in terms of the quality of the programs.

Did the work of eliminating WPV in Africa change after 2016 once there were no more recorded cases, or was it more of the same approach that got Nigeria to zero cases?

MICHAEL GALWAY: You have to have a lot of assurance for three-to-four years following the last case that (a) you haven’t missed any children and (b) you have maintained high levels of immunity in case the virus is circulating. So, in essence the work didn’t really change from 2016 to today. It involved maintaining a very intense immunization schedule and putting a lot of investment into strengthening routine immunization.

That said, the polio program did have an unsolved problem in Borno State in Northeast Nigeria, which was significantly impacted by the Boko Haram insurgency. More than half of the children there, maybe 70-75%, could not be reached because they were living in areas controlled by Boko Haram. So the program didn’t know what was happening in those communities. Then, after a two-year period from 2014-16 with no reported case in Nigeria, news came of children with paralysis from those areas in Borno. So from 2016 to 2020, the polio program really worked to find our way back to those communities with a complex number of interventions, including further engagement with traditional leaders and building more trust in those communities.

While wild polio is now officially gone from Africa, there are still forms of polio that are paralyzing children in the region. What’s the plan to get rid of these other forms of polio?

MICHAEL GALWAY: Right. In several countries in Africa—as well as Asia, such as the Philippines—we still must contend with what are known as circulating vaccine-derived polio viruses, or cVDPVs. cVDPVs tend to emerge in places with weak routine immunization systems and low overall immunity against polio. After the weakened virus in the oral polio vaccine is secreted by children into the environment, it can potentially continue to circulate, evolve over time, and eventually paralyze children who have not developed sufficient immunity.

This is definitely a problem, but we also have solutions. To stop cVDPVs like we have stopped wild polio, good polio outbreak immunization campaigns are critical. We have also been supporting efforts for several years now to develop a new oral polio vaccine that will further reduce the risk of the vaccine virus to evolve and create this problem. We hope to see it introduced as part of outbreak response by the end of the year.

Similarly, what are the plan and prospects for ending wild polio in Pakistan and Afghanistan?

MICHAEL GALWAY: As in Nigeria, the foundation is deeply involved in both countries, working with the government and partners to really think about how the program can innovate, improve the quality of polio campaigns, and hold people accountable for progress. It’s a very complex environment in which to immunize kids in terms of rumors, misinformation, insecurity and violence. Nonetheless, the tools remain the same. The polio program must vaccinate all eligible children—especially the new birth cohort—have good surveillance, and build trust in communities to encourage routine immunizations. If these pieces can come together, Pakistan and Afghanistan will get the job done too. Because the proof of concept is already there—Africa is showing it today.

Obviously, the world is now contending with COVID-19 on top of everything else. How does the virus complicate the fight against polio?

VIO MITCHELL: One of the tragedies of COVID-19 is that people are now afraid to go to a health facility to get basic vaccinations. With polio, we depend on a growing immunity and routine immunization. In places like Nigeria, routine immunization has really been challenged.

MICHAEL GALWAY: In March, the polio program made a very difficult decision to suspend all of its preventive polio campaigns as well as its response to polio outbreaks, for fear of contributing to the spread of COVID-19 and to ensure it is protecting families and health workers. Polio vaccination campaigns have since restarted in Angola, Burkina Faso, Pakistan, Afghanistan, and the Philippines. So far, it’s been a positive experience: The polio program was able to immunize safely with good protective gear for health workers and with buy-in at the community level. The program is now slowly starting to create that same opportunity in other countries in combination with other vaccination and public health efforts, such as measles immunizations.

VIO MITCHELL: COVID-19’s impact on vaccinations has long-term consequences for the future. In some places, we will be able to do catch-up campaigns, but we’re going to have to think differently. It also means that women aren’t receiving antenatal care, families aren’t receiving primary health care—there’s a long litany of things here that we need to overcome. Some countries are really getting quite proactive about restarting central health services, but it’s going to take time.

Finally, do you have any personal reflections on this WPV milestone, given all your work over the years to combat wild polio in Africa?

MICHAEL GALWAY: I feel very lucky that I’ve had the fortune of working on this problem for the last 20 years, and to be in a position to help make a difference in the world. It’s just been a marvelous experience. I developed friendships in India, Nigeria, and across Africa that will stand me my whole lifetime. I remember when I was turbaned and given a traditional title from the Shehu of Borno for my work in Borno State. To be recognized as a part of the community was one of the highest honors of my life. I also feel really blessed that I have been able to make a difference in the lives of children across a whole region who I will never meet and never know. How many people get to say that’s what they did in their job? I feel very lucky.

VIO MITCHELL: There were lots of very hard days, but actually seeing the impossible become possible feels pretty remarkable. I remember visiting communities where there was no primary health care access to speak of—no vaccines, no clinic, nothing. But over the years, when you build confidence and trust with people, and build success against polio, you start to see routine immunizations and more primary health care put in place. Seeing that difference happen and working with my friends and colleagues to make it happen, has been enormously exciting and rewarding.