Editor’s note: The following excerpt has been taken from the book, Polio: An Odyssey of Eradication written by Thomas Abraham. The book chronicles World Health Organization’s twelve-year long campaign to wipe out polio. Despite billions of dollars being pumped into the project, it was and still is a hard long fight against the resilient virus, which affects many children across the world, even today.
By Thomas Abraham
India — A Long Dirty War
India has had a history of programmes to introduce community-level village workers, none of which have worked particularly well. UNICEF and its polio partners demonstrated through meticulous planning, training and implementation how such an army of community-level workers should function.
Besides their ability to talk to local families, these women were also taught to be record keepers. They had to conduct surveys of how many children under the age of five (the target group of polio vaccination) each household had, have meetings with ‘resistant families’ until they were ‘converted’. They also had to track newborn children so they could get a quick initial dose of polio.
They were trained to use management tools such as resource maps, monthly work plans and micro plans mapping the households in the areas they worked in.
Since this network was initially set up to focus on the Muslim community, and the community workers were for the most part Muslim women, they were also trained to talk about vaccination in a religious context. They talked about the need to protect children who are a gift from Allah, to keep the mind and body free from disease, and how it was important to prevent diseases.
In addition to these community-level workers, high-profile Muslim imams were also drafted into the polio campaign to use their Friday sermons to urge worshippers to get their children vaccinated. A key figure in this was the head of a prominent mosque in Lucknow in Uttar Pradesh, Khalid Rashid Firangi Mahali. Mahali helped the polio campaign find a leading Muslim scholar in every district to form a committee that would spread messages in support of polio immunisation.
This intensive campaign for polio vaccination eventually wore down the resistance of the resistors, and vaccination
rates in the Muslim community increased. While poor Muslims refused vaccination even though it was being brought to them, there were other poor non-Muslims who were not reached by polio vaccinators, or by any health service for
that matter. This was because poverty had pushed them to the outer fringes of society, beyond the reach of the health system. Many were wretchedly poor migrant workers, making their way across the Gangetic plain to find work on construction sites and brick kilns.
There they would live in small colonies, in flimsy, makeshift shelters, with no clean water and sanitation. While the adults worked making bricks and breaking stone, the children ran around, often malnourished, underweight and
prey to every common infection. Some belonged to traditional nomadic groups, living in makeshift huts and shelters wherever they decided to stop: beside railway stations, near marketplaces or on the edges of existing slums. These nomadic families had little contact with more established local populations who tended to view them with suspicion and would look down upon them.
It is one of the great triumphs of the polio campaign that vaccinators managed to reach these families, who had been had been forgotten, ignored and looked down upon throughout the country’s history. To discover who these communities were, where they lived and how best to reach them, the WHO and UNICEF performed one of the most detailed mapping exercises that had ever been conducted of these marginal communities. UNICEF recruited a network of over 20,000 informers, such as local shopkeepers, and owners of brick kilns, or even local residents, who would provide information whenever new families of migrants arrived in the neighbourhood. Based on information from this
network of informants, around 40,000 sites where migrant populations tended to live were mapped out.
Over 20,000 migrant families who travelled as far as Mumbai in the west and West Bengal in the east were identified. Community workers were hired to contact these families, win their support and get their children immunised against polio. Once identified, the WHO included them in their micro plans, or detailed household and community maps, and vaccinators were dispatched.
Mobile teams were formed to vaccinate children of migrant workers as they travelled. Vaccinators would jump onto trains and walk down the carriages, putting drops into the mouths of children they thought would be five years or under. Teams of vaccinators would wander through railway stations and bus terminals and other transit points to vaccinate children.
Other vaccination teams would be stationed on the busy land border between India and Nepal to try to keep the virus from crossing borders. At one stage, eighty-one vaccination posts were set up all along the border. Perhaps the remotest and most challenging terrain on which the polio virus was pursued in India was along the floodplains of the Kosi river in northern Bihar, and its tributaries the Kamala and the Kareh.
This was an area that was inaccessible for three to five months of the year, when the river waters would overflow onto the surrounding plains. There were few bridges and roads, and the only way to reach isolated communities was by boat, by motorcycle or on foot. Once again, the WHO and UNICEF, backed by the district administration began to map and enumerate communities that no one had paid any attention to before.
Since travel was difficult, shelters were set up where vaccinators and supervisors could spend up to ten days at a time. No other health programme in India had put in such a meticulously planned and executed campaign to reach the often invisible children in the poorest of the country’s poor families. By the end of 2009, surveys indicated that the polio campaign had succeeded in reaching 97 per cent of children even in remote field huts in the Kosi river basin.
In Uttar Pradesh, 96 per cent of children in migrant populations had been reached during immunisation campaigns.
With these high levels of vaccination, the poliovirus was getting fewer and fewer opportunities to replicate, and it was only a matter of time before it would disappear from India. ‘We weren’t going to give up, and we knew at some point as we were getting more and more children vaccinated, and missing fewer and fewer children, there would be a tipping point when we would succeed,’ observed Hamid Jafari, the WHO’s head of the polio campaign in India during this period. But before the last case of polio in India was recorded in early 2011, the polio campaign would have to survive two explosions—one epidemiological, and the other political.
(The following excerpt has been published with permission from Context (Westland Books). Written by Thomas Abraham, the hardcover of Polio: The Odyssey of Eradication, costs Rs 699.00)