An independent monitoring board convened by the worldwide polio-eradication initiative has delivered a report on the global effort that is striking for its brutally frank and even frustrated tone.

Among its findings, just in its first few pages: “Case numbers are rising”; “unwelcome surprises continue”; “as many milestones are being missed as are being met”; and “the (eradication) Programme is not on track for its end-2012 goal, or for any time soon after unless fundamental problems are tackled.”

Possibly the biggest problem, the board concludes, is a get-it-done optimism so ingrained in the 23-year effort that it cannot acknowledge when things are not working:

We have observed that the Programme:

Is not wholly open to critical voices, perceiving them as too negative – despite the fact that they may be reporting important information from which the Programme could benefit.

Tends to believe that observed dysfunctions are confined to the particular geography in which they occur, rather than being indicative of broader systemic problems.

Displays nervousness in openly discussing difficult or negative items.

If some of this sounds familiar, that is because the board hit similar notes in its last report in July, in which it declared that the international effort “is not on track to interrupt polio transmission as it planned to do by the end of 2012.” I get the sense, reading the latest, that the board does not believe it was heard.

As before, the board — which comprises eight very senior public-health experts, including a former director of the US Centers for Disease Control and Prevention — assesses what is going on in countries where the disease either has never been beaten, or has surged back across borders and become re-established. This time, though, they have added an assessment of problems across the entire campaign that could keep the effort — to make polio the second human disease eradicated after smallpox — from succeeding.

They review problems in three of the four endemic countries (Nigeria, Afghanistan and Pakistan) and praise progress in the last, India, which strikingly has had no polio cases for almost a year. Then they turn to the countries where polio has been re-imported, including three especially problematic ones — Angola, Chad and the Democratic Republic of the Congo — where the disease was once fought to a halt, but then was reimported, and now has become so entrenched that it is as if transmission there had never been stopped. Of the seven countries, they point out, five have had more cases so far this year than in all of 2010. Out of the five, the board reserves its greatest worry for Pakistan, about which it says: “Pakistan’s progress now lags far behind every other country in the world. Without urgent and fundamental change, it is a safe bet that it will be the last country on earth to host polio.”

Beyond the country worries, though, the assessment identifies problems that extend throughout the worldwide effort. The board is strikingly candid in asking pointed questions about them.

How can it be that individuals known to be tired and ineffective are allowed to remain in key leadership positions?

How can it be that front-line positions in some countries remain so underrewarded that they are not attractive to the kind of workforce that the GPEI needs?

How can it be that some people are not held accountable for poor performance?

How can it be that some vaccinators are not paid the money that they are promised?

How can it be that some team leaders are not capable of quality assuring the work they are supervising?

Questions such as this could be dismissed as the sort of internal challenging that can arise in any vast bureaucracy, but the monitoring board are not the only group that are asking these questions. In July, the Financial Times ran a tough editorial (now behind a paywall) in which it told the global effort to “radically step up their commitment or have the courage to abandon the goal.” Last week, the Economist examined the faliure of polio campaigns in Pakistan, the country responsible for re-seeding polio to China, and summed up the situation as: “Pakistan flounders.”

The eradication effort is a joint project of the World Health Organization, UNICEF, the Gates Foundation, and Rotary International, whose millions of businessperson members are the campaign’s relentless ground troops. (Despite the report’s bluntness, Dr. Robert Scott, chairman of Rotary’s contribution to the effort, wrote me Friday that “The success we’ve experienced over the past two decades — more than a 99 percent reduction in polio — is grounds for reasoned optimism, and we have never experienced any significant membership fatigue regarding polio eradication… The reasoned optimism of Rotarians is very different than pie-in-the-sky, Pollyanna-type optimism, which is why we take the message of the IMB report very seriously.”) The effort’s first deadline for interrupting transmission everywhere in the world was 2000, which was then postponed to 2002, 2005 and now the end of 2012.

The monitoring board is clearly skeptical that deadline will be met. It ends its analysis by saying:

Fifteen months remain. We continue to genuinely believe that this is long enough — that success could still be attained. But this will not happen through more of the same, nor will it happen by sharpening performance here and there. It will only happen if the Programme seizes on the most fundamental problems that this report identifies and deals with them as real organizational, national and global priorities. Some of the problems identified in this report run so deep that nobody should believe that ‘more time’ is the solution to them. The focus needs to be on solving the problems themselves. More time may be a requirement, but is not the answer in itself.

It concludes by underlining why the effort remains worthwhile: “To fail now would unleash widespread suffering and death on the world’s most vulnerable children.”

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