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.

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.