Interview with Sir Liam Donaldson

Sir Liam reflects on his role as Chair of the International Monitoring Board (IMB) on polio eradication and his recent appointment to the Institute as Chair of health policy.

As former Chief Medical Officer to the UK Government for 12 years, Sir Liam Donaldson has been at the heart of a wide-range of global medical emergencies and public health issues. Sir Liam reflects on his role as Chair of the International Monitoring Board (IMB) on polio eradication and his recent appointment to the Institute as Chair of health policy.

The IMB report, which Sir Liam led on, said that polio eradication is under threat and this week we’ve learned that polio virus has been found in China for the first time since 1999 – why is polio so hard to get rid of?

Polio has been eradicated from almost all countries in the world. There are only four countries left that have never eradicated polio (India, Nigeria, Afghanistan and Pakistan). Others have stopped polio transmission before, only to now become re-infected. In countries with a well-developed healthcare system, stopping polio transmission was relatively straightforward. Reliably vaccinating all children was not too difficult. By definition, the countries in which polio remains are the countries in which eradication is going to be the most difficult. In Afghanistan, for example, many of the polio-affected areas are difficult to access due to fighting.

I do think – and the Independent Monitoring Board has said – that polio eradication is attainable. But this is not to the underestimate the challenge. Establishing an independent board to monitor the progress of a major global health programme is an unusual – perhaps unique – approach, and I was pleased to be invited to chair it. I hope that we are playing an important role in frankly highlighting the challenges that remain. We all look forward to the day when no more children have their lives ruined through being paralysed by polio.

What’s missing in the fight against polio?

Essentially, the tools needed to eradicate polio are not in themselves complex, and are all in place. We have good vaccines. Every affected area draws up ‘microplans’ that show where every child in the area lives, so that a vaccination team can visit them. The challenge comes in achieving this to a sufficiently high standard and at enormous scale. To stop polio transmission, vaccination teams need to reach at least 90% of children in many areas. Any less renders the campaign ineffective. Achieving this high quality in parts of the world that have many other concerns is difficult.

Why is so much focus placed on polio, but not on other diseases?

Eradication is really something very special. Only one other disease – smallpox – has previously been eradicated. The World Health Organisation and its partners started the polio eradication initiative in 1988. It is not hard to see why it caught the imagination of the many whom are involved in it and fund it. There are those who argue that it is most effective to focus on developing health systems in their entirety, rather than focusing on specific diseases like polio. In fact, this view probably predominates these days. The polio eradication effort continues because it has made such progress. The annual number of polio cases in the world is down by 99% from what it was when the GPEI started in 1988. At that time, 1000 children a day were being paralysed by polio. Now, polio affects only 1000 children a year. So in one sense, complete eradication is very close. The difficulty, though, is that this final furlong is the greatest challenge yet.

How does your role at the Institute of Global Health Innovation fit in or differ to the other roles you currently have?

I was Chief Medical Officer for England, and Chief Medical Advisor for the UK government, until May 2010. Since moving on from that role, I have taken up a portfolio of posts including, the chair the National Patient Safety Agency; and I have also been recently appointed by the World Health Organization as the Director General’s Special Envoy for Patient Safety. Holding an academic post, as Chair of Health Policy, fits very well into this mix. I can bring my practical experiences from these other posts to bear in my teaching and research work. The converse is also true.

What are the major challenges for health policy?

The underlying challenges faced by the UK at present are not unique to this country. Every developed health care system in the world faces an increasing financial burden as a result of increasing life expectancy and the availability of ever more sophisticated (and expensive) therapeutic technologies. Global economic recession has made the issue more apparent, but the underlying challenge was already present, and has been for many years. I think this provides the main pressure on governments to constantly evolve (or, in some cases, reform) their healthcare systems to achieve a sustainable solution. At the same time, the issues of quality, patient experience and patient safety are receiving wider recognition. The challenge for those involved in developing and enacting health policy is to genuinely respond to these latter issues whilst also acting to make healthcare financially sustainable.

In developed countries, health policy predominantly concentrates on healthcare systems, certainly in the public discourse. I do think this misses a tremendous opportunity. Less developed countries are making major improvements in population health by concentrating their efforts on public health interventions. Many in the developed world have a sense that we have achieved the major public health goods – clean water, sanitation, widespread vaccination – and can now concentrate on healthcare. I would argue that we still need to look for major public health interventions that can be remarkably effective. It is not so long since trains, planes, pubs and even offices were smoky environments. Fifteen years ago, few would have envisioned that we could go about our daily lives without breathing in others’ second hand cigarette smoke. When as Chief Medical Officer I first recommended smoke-free public places in England, I received a lot of opposition. Now it is difficult to imagine anything else. I think we now need to be bold, and innovative, in looking for public health solutions to tackle problems such as obesity, alcohol and the chronic diseases that dominate the health landscape around the world.