Health workers say the world has a unique chance to wipe polio off the face of the planet. It could be the biggest public health victory since the eradication of smallpox.
Hopset Mohamm ad wasn’t surprised to see polio vaccinators at her doorstep in a village near the Nigerian capital, Abuja, in May 2013. They had come around before and she was prepared to send them away, again.
“I have five children,” she said proudly in her native Hausa language. “None of them has been immunized but they have not become sick.”
The last time polio vaccinators were in the neighbourhood, Mohammad told her husband the vaccine drops didn’t seem to be hurting other children. But her husband refused, saying they may not harm children right away, but 20 years from now they could suffer the consequences.
Because polio tends to attack children under 5, the health workers were most interested in Hopset Mohammad’s youngest child. Standing outside her door, the health workers listened to her explanation. Some were surprised. Normally, when parents refuse vaccinations it is because they’ve been told it will hurt the children immediately.
Frustrated by her refusal, Rilwanu Mohammed, the executive secretary of the regional health-care board and one of the vaccinators, asked Hopset Mohammad for her husband’s phone number. He called from his cell-phone and argued his case. Other vaccinators examined the fingers of small children passing by. Children who had been vaccinated in the past week all had a fingernail striped with a magic marker.
“The man actually has never [had] a vaccination,” Rilwanu Mohammed says. “We need to immunize the child because he is at risk.” He added that, while this risk is small compared to more common deadly diseases such as dysentery, malaria and measles, polio is entirely preventable and it can spread like wildfire. Even one new case could lead to an outbreak in the region.
What is polio?
A highly contagious viral infection that tends to attack the young, pregnant women and those with weak immune systems. The virus usually enters the environment in the faeces of an infected person, spreading via contaminated water or food.
The final push
While most people accept the vaccine, the encounter on Hopset Mohammad’s doorstep is a good example of the challenges health workers around the world face as they make the final push to eradicate polio.
To achieve group immunity levels in places susceptible to this deadly and crippling disease, polio vaccines must be delivered to at least 90 per cent of children in communities that often have poor sanitation and limited access to health care — and where negative attitudes about medicine and vaccines are sometimes deeply rooted.
This type of direct communication is critical to reaching what health officials sometimes refer to as the ‘fifth child’ — the last 20 per cent of children in remote regions or in areas that are hard to access due to poor infrastructure, civil unrest or conflict.
Polio is now considered endemic in only three countries — Afghanistan, Nigeria and Pakistan — and the cases are generally isolated to specific areas where insecurity and armed violence make universal coverage extremely difficult or dangerous.
In Nigeria, for example, fighting in the north-east has rendered many communities off-limits to nearly all health initiatives. The states of Borno and Yobe, two of three states currently under a state of emergency, now account for 69 per cent of Nigeria’s cases of wild polio, the strain of polio found in nature as opposed to the one derived from the virus used to produce polio vaccine.
At the same time, there is an active campaign in Nigeria against many vaccines, polio in particular, on the part of some prominent community leaders and clerics who claim, among other arguments, that polio vaccination is part of a foreign conspiracy to sterilize young women.
In Nigeria and Pakistan, health workers have increasingly come under direct attack. In February, nine local health workers in the northern Nigerian city of Kano were shot and killed as they prepared to vaccinate against polio. Meanwhile, in Pakistan, some 20 people have been killed in separate attacks
on polio vaccination teams since July 2012.
The polio paradox
Despite these tragic setbacks, there are reasons for optimism. Since the Global Polio Eradication Initiative (GPEI) was launched in 1988, the number of polio cases has decreased by more than 99 per cent. At the time of the launch, there were an estimated 350,000 cases globally. In 2012, only 223 cases were reported.
During that same period, the number of polio-endemic countries shrunk from 125 to three. No cases have been reported in the Western hemisphere in two decades and Europe was declared polio free in 2002.
In areas of conflict, the Movement’s neutrality and impartiality are key assets. The Afghanistan Red Crescent, for example, routinely vaccinates in war-torn communities. The ICRC also plays a role in facilitating access for health workers.
But eradication has remained elusive. Key deadlines and milestones have come and gone; political will has waxed and waned. Some wondered why focus on eradicating a disease with a relatively small caseload compared to other big killers such as HIV, tuberculosis, malaria and dengue fever?
But it was during the frustrating period between 2000 and 2010 (when the number of polio cases had flat-lined at an average of about 1,000 cases per year) that the global polio eradication partners learned critical lessons about this disease, says Bruce Aylward, assistant director general for polio, emergencies and country collaboration at the World Health Organization (WHO).
Those lessons have led to significant reductions in the last few years that have reinvigorated the global polio eradication effort. “We are at a watershed moment,” he says. “The level of political will and donor support is unprecedented.”
helped me, I would
my schooling. I
would forget this
begs for money
pushing himself on
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Several key developments have helped turn the tables since 2009: improved ‘intelligence’ and tracking of the disease’s spread; the creation of an independent monitoring board that has held WHO and governments accountable; the increasing commitment of the Bill & Melinda Gates Foundation; the declaration of polio as a global health emergency by the World Health Assembly; and important breakthroughs with oral polio vaccines.
Meanwhile, eradication efforts on the ground have also inspired hope. One case in point is Afghanistan. With the help of the Afghanistan Red Crescent, the country has reduced polio cases dramatically through mobile and permanent health clinics, and by organizing national immunization days.
India is another example. “The world became aware of the phenomenal effort in India with hundreds of thousands of vaccinators going door-to-door,” Aylward says. “And then [in 2011], India stopped transmission of polio. And that was a game changer. There was a sense that this can really be done… because a lot of people thought India would never get there.”
Since then, momentum has only grown. In April, world leaders and donors gathered at a Global Vaccine Summit in Abu Dhabi endorsed a new, US $ 5.5 billion, six-year plan to eradicate polio by 2018. Donors have already pledged to finance three-quarters of the plan with the Bill & Melinda Gates Foundation promising US $ 1.8 billion. Gates joined others, including the IFRC, in calling for additional donors to commit the remaining US $ 1.5 billion needed. Michael Bloomberg, media mogul and mayor of New York, has since pledged US $ 100 million to the cause.
Though the global polio eradication programme is not fully funded, polio eradication is an achievable goal, according to Carol Pandak, director of Rotary International’s PolioPlus programme, a long-time leader in the polio eradication effort. But money
alone won’t finish the job, she says.
“If military operations are taking place in certain areas, it makes it difficult to conduct immunization campaigns,” she says. “I think there are also issues of geography: really remote rural communities that have rarely, if ever, been accessed with any sort of health intervention.”
Polio eradication requires persistence. Frustrated by the refusal of a mother to allow her child to be vaccinated, Rilwanu Mohammed, the executive secretary of a regional health board in Nigeria, calls the child’s father to plead his case for vaccination. Photo: ©Heather Murdock/IFRC
And in today’s mobile world, polio travels. Within weeks of the Vaccine Summit, two new outbreaks in Kenya and Somalia hit in areas that had been free from polio but where immunization levels were low. The IFRC allocated US $ 147,000 from its Disaster Relief Emergency Fund to the Kenya Red Cross Society to support emergency polio vaccinations in five districts (including the Dadaab refugee camps). More than 1,000 volunteers fanned out in teams of 20, going from house to house, visiting churches, mosques and community centres, getting the message out and pre-registering children.
This rapid response, says Siddharth Chatterjee, IFRC’s chief diplomat and head of strategic partnerships, shows how the Movement’s community-based volunteer network can reach out quickly to hard-to-access communities. Chatterjee says the drive to eradicate polio can also help the IFRC and National Societies build up community-based first aid and improve health-care systems for the most vulnerable people.
“By being part of this effort,” he says, “we also have the chance to enhance the value of community health systems and increase the uptake of vaccines for other diseases, thus contributing to better health, improved livelihoods and basic human development among the most vulnerable.”
‘Forget this begging’
Just as global philanthropists, health organizations and humanitarians make their call for new funding, young polio victims on the streets of Abuja, Nigeria were also calling for donations, but on a much smaller scale.
Umar Mahmoud, 20, pushes himself through the crowded market on a home-made skateboard, using pink flip-flops to protect his hands from the rough street while asking strangers for spare change. His legs, useless since he was a small child, were folded underneath him. Like many polio victims, he said begging was the only job he could find. “If somebody helped me, I would continue with my schooling, I would forget this begging.”
While some polio victims are given help at orthopaedic centres (some run by the ICRC in places such as Afghanistan, Pakistan and South Sudan), such services are far from universal. For many, polio is a life sentence of poverty, begging and hardship.
‘Why is polio so
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sense of indignation
… the community
needs need to be
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While the price tag for eradication is high, many point to cases such as Mahmoud’s to suggest that not eradicating polio is much more costly in the long run. In 2010, the journal Vaccine reported that eradication would net an economic benefit of between US $ 40 billion and US $ 50 billion to 2035, while averting 8 million cases of polio paralysis. “And once we get to zero cases,” argues Aylward, “it becomes a permanent benefit.”
In his Abuja office, Javier Barrera, head of the IFRC’s Nigeria delegation, says humanitarian organizations are galvanized right now in part because a polio-free world — once a far-fetched dream — may actually be within reach. “There is a sense of accomplishment dawning upon us,” he says. “It could be one of those milestones in humanitarian history.”
To realize this dream, however, more efforts need to be made to convince people to accept polio vaccinations. The most common reason some communities reject vaccinators, according to Barrera, is because they distrust health workers that provide a vaccination for a rare disease but offer no help for common ailments.
“Communities say, ‘Why is polio so important when my child died of diarrhoea?’” he says. “There’s a sense of indignation… community needs must be taken into account.”
Downstairs in the office of the Nigerian Red Cross Society, health workers agree that if they had the resources to treat other health needs — like malaria, which kills hundreds of thousands of Nigerians every year — it would be easier to address polio.
Still, they say it is possible to convince people to accept vaccinations through educational campaigns. Before polio teams head into towns and villages, Nigerian Red Cross volunteers go in with bullhorns, slogans and pictures of children disfigured by polio.
“It’s not that [the villagers] are really ignorant,” says Alatta Ogba Uchenna, head of the Nigerian Red Cross’s health and care department. “It’s just that they don’t have that [particular] information.”
Given the distrust in many communities, some vaccination experts argue that the best approach is to integrate polio vaccination with expansion and improvement of wide-ranging community-based health care.
Often, polio eradication campaigns are ‘vertical’ one-time projects in which volunteers or workers go door-to-door or organize large events focusing exclusively on polio for one or two days in given village. While this has been extremely effective in some areas, the places where polio is still entrenched may require a different approach, says Terhi Heinäsmäki, health coordinator for IFRC’s Asia Pacific Zone, which includes Afghanistan and Pakistan.
• Polio mainly affects children under 5 years of age.
• One in 200 infections leads to irreversible paralysis.
• Among those paralysed, 5 to 10 per
cent die when their breathing muscles
• There are three types of wild polio virus,
referred to as types 1, 2, and 3. Type 2 has
not been seen since 1999.
Source: World Health Organization
“The vertical programmes can work in a country such as India which is not in conflict,” says Heinäsmäki. “But where there is conflict, or where we cannot get access due to security or community resistance, then I believe we need a more holistic approach.”
“What is needed first is the trust of community,” she suggests. “To get that, we need to listen to the community and take care of other ailments they are concerned about — and polio vaccination can be included in that.”
Other questions should also be considered, according to some interviewed for this story. By spending our time and resources on the expensive goal of polio eradication, rather than control, will we drain resources from more deadly diseases — undermining our impartiality and our focus on the most vulnerable people — in the name of an international public health goal? Or, on the other hand, could polio eradication efforts help improve local health systems — and their reach — so as to enhance the universality of all health services for vulnerable populations?
It may not need to be an ‘either-or’ proposition. The GPEI’s strategic plan talks about the need to boost community health through routine immunization and building lasting public health systems.
Still, WHO ’s Aylward argues that simply improving health services and routine immunization is not enough. “Eradication is about getting to kids that nobody else gets to,” he says. “And we need to put tools into the hands of communities to vaccinate
their own kids.”
“This is where the Red Cross Red Crescent is incredibly valuable,” he says, referring to the community-based nature of the Red Cross Red Crescent volunteer network.
Aylward concedes that the way some campaigns were carried out has contributed to local distrust in some areas. The fact that conspiracy theories have taken root is a failure on the part of the WHO polio programme, he says, adding that he agrees with a recent critique by the GPEI’s Independent Monitoring Board which said WHO is not doing a good enough job communicating with affected communities.
But Aylward also agrees that it’s not enough simply to reach that fifth child with polio vaccination and then walk away. “When the polio programme is over, it can’t just pack up and go home. It’s got to give birth to something else,” he says. “The legacy of polio needs to be about sustaining access to that last 20 per cent of kids.”
The last mile
At the Kaduna Nigerian Red Cross office, Bright Charles, the state disaster management coordinator, adds that conflict and natural disasters also take a toll on health initiatives. Health workers cannot wander through villages searching for children in the midst of shoot-outs, bomb blasts or floods.
“When a disaster happens, it interrupts rounds,” he says. Children, he adds, are more likely to get sick when living in unsanitary, crowded displacement camps after they had to flee the disaster. On the other hand, displaced people’s camps are often filled with individuals from remote areas and polio workers have had some luck vaccinating children while they wait out the flood or fighting.
But even in areas of northern Nigeria safe enough to give vaccinations, ideology espoused by opponents of vaccination often increases the number of families refusing the vaccine. “Sometimes they put the children in the room and lock the door,” said a volunteer named Baupme, one of the vaccinators standing outside Hopset Mohammad’s door. “We tell them, ‘I know there are children in there’.”
In the meanwhile, Rilwanu Mohammed had stopped arguing with her husband on the phone and relayed the conversation to Hopset Mohammad, who listened patiently to him and then talked to her husband on the phone.
With his permission, she relented and vaccinators huddled around the smallest boy. One woman held his mouth open while Baupme dropped in the vaccine. A single tear welled in his eyes but he quickly calmed as the taste faded and the adults handed him back to his mother.
By Heather Murdock
Heather Murdock is a freelance journalist based in Abuja, Nigeria.