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February 16, 2012

Quitting India

India’s success in polio eradication is an example for others to emulate

January 13, 2012 was a special day, marking the first year in which no new cases of polio were reported from India. For once, the headlines in media, in India and internationally, seemed devoid of hyperbole. It is a signal achievement because India was for decades one of the biggest centres of the disease. Along with Pakistan, Afghanistan and Nigeria, India was classified as an endemic polio nation. Collectively, these four countries were referred to as PAIN in health circles.

Photo: Rakesh Lalwani

Photo: Rakesh Lalwani

A decade ago, in 2002, the world was shocked at the violent resurgence of polio in India. Success seemed similarly in sight and the Indian health establishment reduced the number of planned immunisations. Then, laxity in the field resulted in at least 15 percent of homes not being visited. With these, India and more specifically, the state of Uttar Pradesh found itself as the global epicentre of polio.

New cases of polio rose six times over 2001, with India accounting for 83 percent of the cases reported worldwide. Worryingly, the Uttar Pradesh strain of the wild polio virus started travelling to other countries, resulting in resurgence in countries which had been declared to be polio free. In 2002, UNICEF made Uttar Pradesh its number one priority for stopping transmission of the polio virus around the world.

This history teaches us to be cautious and not let our guard down. The polio virus is extremely wily. Unlike smallpox, the only other global scourge eradicated decades ago by another global task force, one cannot visually identify a person infected with polio immediately. A child infected with polio can keep on shedding the virus in excreta, with the risk of infecting another 200-250 children before detection.

Polio strikes the poorest children, living in unsanitary conditions, with naturally low levels of immunity and poor nutrition. In India, UP and Bihar have been the hardest hit. The virus favours little boys over little girls— in UP it is poor Muslim boys, in Bihar it is the poor Hindu boys. This religious profile, if you will, has been targeted by mischief makers, who spread all sorts of rumours about how the polio vaccine is a nefarious plot to render the next generation sterile.

There are four reasons for the success of the current polio campaign. One, the global support for polio eradication was maintained at a high level, despite funding gaps initially estimated at $750 million. The Bill and Melinda Gates foundation pledged support to the cause of polio, providing much needed attention and a renewed vigour globally.

Two, the much improved bivalent oral polio vaccine was formulated, targeting both types of wild polio virus. With a 30 percent greater efficacy, it maximises the impact with hard to reach children.

I was a part of the communication team which discovered that high decibel advertising didn’t quite explain why the polio vaccine needed to be administered every time. The fact that polio vaccine needed multiple doses was at variance to what Mr Bachchan was saying – which was do boond, bas (two drops, that’s all). That caused enormous doubt and added fuel to rumours of inefficacy. The amended message, delivered through on-ground activation rather than via television, was do boond, har bar (two drops, every time). It went some distance in convincing parents that their children needed multiple doses of vaccines.

Finally, massive on-ground mobilisation of workers—by voluntary agencies, ministries of health, religious leaders and local influencers as well as the Rotary Club, a key sponsor of the Global Polio Eradication Effort.

These workers were up against a huge challenge. A destitute Muslim women health worker at CMC in Moradabad Urban, Zone II, with Worldvision recounted how families in the locality treated her: “They abuse. They throw filth from the balconies. Some of these well-to-do families drive us away as if we have come to beg for alms. But we have to go back.”

Even educated families had misgivings about the vaccination. An educated Muslim mother violently argued with our team: “It doesn’t work, is that why it has to be given again and again? I have heard that it is supposed to render our children impotent & infertile. I am not going to let my children be vaccinated. Go away, go away!”

Our team of volunteers would persist: “Like all girls in school, you must have got lice in your hair. Your mother must have gone crazy trying to get rid of the lice in your hair! Even if one girl in school had lice in her hair, wouldn’t all your mother’s effort to rid you of them come to nothing. Polio is like that, even one child has it, he could infect every other child.”

But that destitute health worker in Moradabad captured the spirit driving these workers: “Polio is a scourge. It can be prevented. It is just human folly if it cannot be eradicated now.”

When it finally arrives in January 2014, the victory over polio shall belong to these motivated people. India has set an example for others to emulate. “The evidence from India is if you do the job well, you stop polio,” David Salisbury, chair of the WHO’s European Certification Commission for Polio Eradication and Britain’s director of immunisation said. “And if it can be done in India, technically it can be done anywhere.”


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