|Image: Gates Foundation, flickr|
In the second decade of the 21st century, the ancient scourge of polio is endemic in only four countries; three of them are in our region. But in the global campaign to eradicate the disease, it looks as though India will be the next domino to fall. The last indigenous case of wild poliovirus in India was reported on 13 January 2011, and if another year goes by – that is, if we get to 13 January 2012 – without an additional case, the number of polio-endemic countries will officially be down to three. Further, the lessons that have been learned in tackling polio in India will be helpful in beating the disease in Afghanistan and Pakistan.
Passed from one child’s belly to another’s through faeces-contaminated water, polio either kills children or leaves them paralysed. Until the late 1990s, when polio eradication began in India, there were 150,000 cases a year. By 2003, transmission was occurring largely in two areas, western Uttar Pradesh and Bihar’s Kosi River basin. Several factors made these last endemic regions of India extremely difficult to crack, not least because the virus unfailingly seeks out the poorest and most vulnerable children to attack. In Uttar Pradesh and Bihar, 500,000 children are born every month, and each child must be reached with polio vaccine before the virus reaches them.
Making this already complicated task more difficult, rumours have circulated, especially in the Muslim community, that polio vaccination is a plot to sterilise children, or that the vaccine contains ingredients that are haraam under Islamic law. Further, high rates of diarrhoea – due to poor hygiene and sanitation, poor nutrition, and mothers not exclusively breastfeeding for six months (and not using their first milk or colostrum) – mean that the oral polio vaccine has less opportunity to be absorbed in the gut, making it less effective. In India alone, 638 million people still practice open defecation leaving children constantly exposed to germs and bacteria. Finally, in most of the world three doses of oral polio vaccine are enough to protect a child against polio, but in UP and Bihar multiple vaccination rounds have been required to build immunity.
|Image: Gates Foundation, flickr|
Casting the net
In 2002, the UN’s children’s agency, UNICEF, for whom both of these authors work, launched a campaign for polio eradication in India, creating a vast set of contacts called the Social Mobilization Network (commonly known as SMNet). Behind the low-tech equipment of thick paper ledgers and chalk marks on the walls and doors of homes is a cutting-edge 21st-century data-driven communications operation, which has become a model for beating the disease elsewhere.
The Indian SMNet focuses on 107 blocks identified as being at highest risk of polio. That risk might be due to previous transmission of the virus in the area, high rates of resistance to vaccination, or more subtle indicators such as a high rate of self-declared ‘childless’ households (often an indicator of hidden resistance). With the huge scale of the population, just one percent in India still represents a huge number of people. If only a fraction of children are missed, that is enough to leave a significant number of the population dangerously exposed. On the ground there is an army of more than 8000 workers, mostly women, known as Community Mobilisation Coordinators (CMCs). Each CMC is responsible for between 150 and 500 homes; this allows coordinators to know individual families by name, hopefully ensuring that every child under five in her neighbourhood receives the vaccine each time it is offered.
Most of the CMCs are highly motivated young women, and over half are university graduates. One is Hena Mehar, who lives in Moradabad (UP), a 27-year-old who has worked with SMNet for five years while completing her master’s degree in Urdu. During a vaccination drive in September, Mehar was up early to discuss last-minute details with a respected local figure who would inaugurate the vaccination booth, and at the mosque that would be broadcasting reminders about the immunization. She had already placed posters around the neighbourhood, and called on every family to let them know it was vaccination time again. She also already knew that, on vaccination day, 25 children under five would be staying as guests within the 450 households she covers, and that they too would need to be vaccinated. And she knew that of the seven newborns in her community, five were at home and two were still in hospital.
The need for each of these bits of information is laid out in detailed micro-plans contained in each CMC’s field book. The process of converting resistant families continues between vaccination rounds, year-round. As Dr Hamid Jafari, head of the World Health Organization’s National Polio Surveillance Project in India, says: ‘The micro-planning has to be of exquisite quality.’ The detailed statistical reporting the CMCs provide, and the targeted advocacy they are able to deliver inside homes where it is most needed, has allowed governments to develop a health-related communications system of unprecedented size and sophistication.
Because the polio virus is a moving target, however, the strategy needs to continue to evolve. In 2008, the increasing importance of covering migrant populations became clear. Nineteen million people take the train every day in India, while Uttar Pradesh and Bihar have the highest rates of seasonal migration for work. So, the SMNet now tracks migrant workers to and from brick kilns and construction sites outside the targeted states, from Punjab to Delhi, from Gujarat to Maharashtra. In addition, during each vaccination round, more than five million children are vaccinated at train stations and on trains. During this process, a virtual net is drawn around the whole state of Bihar, with the National Cadet Corps (similar to the Boy Scouts) vaccinating children at key transit points. Supported by Nepali-speaking volunteers, vaccinators also arrange themselves at 81 points along the Indo-Nepal border. Since September, teams have also been situated at the two land-crossing points on the India-Pakistan border.
Children are most vulnerable to polio when they also face other health threats, thus requiring CMCs to focus on broader health issues as well. ‘CMCs visit houses and see the child has diarrhoea,’ says Dr Roma Solomon, of the SMNet partner CORE. ‘You can’t just give polio drops, so the CMC comes with oral rehydration solution.’ In this context, SMNet added a new strategy in 2010 to tackle the underlying factors contributing to polio transmission. Now CMCs supplement their polio messages with information about routine immunisation, exclusive breastfeeding until six months of age, diarrhoea treatment and hand-washing. Pregnant women are tracked and targeted for tetanus vaccinations; new mothers receive information on breastfeeding, especially the importance of colostrum to the baby’s immune system. In this way, by 2011 the polio-eradication effort in India was running several strategies simultaneously.
The dangers, meanwhile, remain ever-present. Polio’s most virulent form, known as type 1, only paralyses one in every 200 children it infects. The other 199 carry the virus without realising it. India’s most recent polio case, in January 2011, occurred in West Bengal and was linked (through examination of the virus’s DNA) to a sample taken five months earlier, more than 1300 kilometres away in Delhi sewage. To ‘clean up’ after a single infection takes months and adds unnecessary cost to the eradication effort. When the West Bengal case was identified, a swift emergency response swung into action. More than four million children were immunised within 10 days, and a network comprising more than 1500 ‘mobilisers’ was established, ensuring vulnerable areas were protected from a fresh outbreak.
Today, every state in India is preparing an emergency plan, which hopefully would be quickly implemented if another case were to emerge. A massive publicity campaign, using posters, broadcast media, microphone announcements and other tools, would subsequently support a large-scale emergency vaccination programme.
In India, the SMNet places particular priority on reaching those children that are hardest to reach. During the latest vaccination round, in November, 75 million children under five were vaccinated, most of them on a single day.
The situation is quite different in Pakistan and Afghanistan. Both of these countries have seen polio cases rise this year, a clear indication that immunisation efforts there are failing to reach all children. In Pakistan, polio cases are concentrated in Khyber Pakhtunkhwah, Balochistan and Sindh. Security issues coincide with poor campaign quality, poverty and high rates of migration, especially into Afghanistan. Persistent resistance to vaccination in some communities, alongside rumours and misinformation, also remain as obstacles. The catastrophic flooding of the last two years has disrupted vaccination programmes and created unsanitary conditions in which the poliovirus can spread. This year, poliovirus from Pakistan spread to China, which had been polio-free since 1999.
A new focus of the polio-eradication strategy in Pakistan includes a massive intensification of its own social-mobilisation network. High-risk groups are being intensively targeted. The number of mobilisers is increasing and, for the first time, the network’s structure will extend to the level of the union council, the smallest unit of local administration, to allow for the required level of detailed micro-planning. The model does not mirror India’s – it is tailored specifically for Pakistan – but it does draw on the lessons that have been learned across the border.
Afghanistan, meanwhile, had made strong progress against polio in recent years, including protecting itself from a crossborder infection during an unexpected outbreak in Tajikistan in 2010. During this past summer’s peak transmission season, however, cases doubled over the previous year’s number. Infections are currently concentrated in the south, where challenges include security threats and a population that moves across the porous frontier with Pakistan. Today, the Afghan network of social mobilisers is expanding significantly. In addition, high-risk areas are being identified, more community workers are being hired and an organisational structure is being introduced that is based on India’s experience but designed specifically for Afghanistan’s challenges.
Back in India, the SMNet is also taking on a new life of its own. Critically, it is showing great potential to combat other critical threats to poor children, delivering results that its designers never anticipated. In Uttar Pradesh, for instance, dry latrines have long been abolished by law but have continued to exist, contaminating the environment and dehumanising those forced to empty them. In Badaun – the UP district with the highest number of polio cases ever recorded – the SMNet surveyed more than 100,000 dry latrines. Researchers then gave this data to the municipality, leading to 48,000 having now been converted into flush toilets. A similar process is taking place in Moradabad.
The SMNet programme has also empowered the CMCs. ‘You see them change, become more vocal,’ says Joshila Pallapati, a UNICEF staffer. CMCs only receive token pay for their commitment, but each one now has a bank account. Inspired by their experiences, some have decided to begin training as auxiliary nurses or midwives.
The polio-eradication campaign in India is one of the largest public-health campaigns in the history of medicine. Since 2010, the government has accepted the responsibility to purchase a billion does of oral polio vaccine a year – equivalent to half the global supply, making the Indian government the third-largest financial contributor to polio eradication in the world. Of course, any day could bring the dreaded news of another infected child, but every day without a new case is a victory. It is now possible to believe that, for the first time in history, 12 straight months will pass in which not a single Indian child has been attacked by polio. It is now possible to believe that India’s indigenous wild poliovirus, which has crippled children in the Subcontinent for thousands of years, will be stopped forever: It will simply no longer exist.
If polio can be eradicated from India’s vast population, it can be eradicated anywhere. It is proof positive that with the existing toolkit of vaccines, necessary government support and commitment, the insights gained from programmes such as these can help us beat the virus in Pakistan and Afghanistan too.
Polio capital of India
Driving into town in the run-up to a vaccination round, the signs are everywhere. Posters of Amitabh Bachchan are pasted across the concrete walls and pillars of the flyovers, holding up two fingers to represent the two drops of polio vaccine every child will receive. In the crowded bazaars, yellow banners are strung across the streets, showing where the vaccination booths will be. The date is scrawled in chalk on the walls. House calls and school visits have been made, until it is inconceivable that anyone remains unaware that it is vaccination time again. Behind the scenes, the ‘cold chain’ is delivering refrigerated vaccine in insulated boxes.
On the morning of the big day, known as ‘booth day’, a flurry of text messages goes around and everyone involved wishes each other luck. Muezzins make vaccination-related announcements from the mosques, and respected community figures are invited to declare the vaccination booths open. The community mobilisers decorate their booths with bright cloths and posters; the child mobilisers, called bulawatoli, fan out to collect their peers, eventually rewarded with biscuits, whistles, paper flags and cardboard sun-visors. Mobile vaccination teams from local Rotary Clubs fan out in yellow vests, vaccinating children wherever they find them. Vaccinated children have the little finger on their left hand inked black, their names marked off the CMC’s list.
What is striking about the polio effort in Muradabad, and across the swathes of North India where the battle is still being fought, is the sustained determination not to miss a thing. The CMCs proudly display their hand-drawn ‘resource maps’, showing every child’s home, every school, mosque, temple and doctor’s office where they can spread their message. They show off scrapbooks of press cuttings: one article records the 21st gathering of religious leaders in the city, to be presented with certificates for their support of the campaign. An enormous effort goes into keeping up motivation, recognising the efforts of individuals and applauding their participation; and it shows. At booth after booth, one can sense palpable pride among those who have turned up to help.
Shaqir Hussien, a 49-year-old civil servant in the transport department, takes a day’s leave every booth day. He was moved to get involved by the number of polio cases in his community. During the last round of vaccinations, he says, there were six refusals in his area. ‘There was a misconception that the vaccine affects the fertility of the child, and that some constituents were prohibited in Islam,’ he recalls. During the five follow-up days after booth day, he and the CMC will visit all homes where the vaccine has been refused and try to talk each family around.
In a crowded bazaar under a flyover near the railway tracks, the vaccination team spots a tiny baby in the arms of an older child, who turns out to be her aunt. The older child refuses to let any stranger put anything in the baby’s mouth. Yet when the team goes to the baby’s home the next day, they find her little finger already inked black – another vaccinator had already gotten there. Up and down the streets, chalk marks on doors and walls show where the teams have been. There are chalk marks on the bamboo poles of the squatters’ settlement by the tracks. Even on the first day of the follow-up campaign, it was a rare child in Muradabad who did not have a blackened little finger.
In Bihar the system is slightly different, where there is no static booth on the first day. Because the main challenge in Bihar is generally physical access, the vaccinators go door to door through all six days of the round. In Ranighat, the second-largest block in Bihar and a high-risk area, there are still large areas without roads. In the village of Madhulata, recent flooding meant the last three births before the vaccination round had taken place at home, because people were unable to travel to the Public Health Centre. But the vaccinators and CMCs still reached every house.
~ Thomas Bell
~ Daniel Toole is Regional Director of UNICEF, South Asia.
~ Sarah Crowe is Regional Chief of Communications for UNICEF, South Asia and former journalist.
~ Thomas Bell is a freelance journalist in Kathmandu.
Romila Thapar addresses invitees at the
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