I remember vividly the first time I went to India, not because it can be a shock to the system for the uninitiated or because it was different to anywhere else I had ever worked (it was), but because I joined the polio eradication programme in WHO Geneva the day before 9/11. The events of that day, and our inability to deal with their implications in any sustained fashion, have significantly hampered our capacity to fully eradicate the virus to this day.
I had arrived at WHO Geneva from Somalia, where I had led the team as head of the UNICEF zonal office in the centre and south of the country. We used a unique approach to the polio programme, where WHO and UNICEF teams were combined and worked properly as one UN, and managed to stop the wild polio virus. Somalia had been the last place on earth to eradicate smallpox, so we were rightly proud of our efforts in stopping polio transmission before Nigeria, India, Pakistan and Afghanistan, the four big endemic countries. Post 9/11 the story may have been different.
I was on loan from UNICEF, full of my African field bravado and UNICEF know-it-all attitude, excited for what lay ahead. I joined the famed Country Support Team, full of highly experienced medical doctors, scientists, logisticians and surveillance specialists, and was asked to be the focal point for India. This surprised me as I had no experience in South Asia and was expecting to go to Africa. I soon realized the scale of the challenge; India at the time accounted for some 60 percent of global polio cases, and with a population of more than a billion, the National Immunisation Days were by far the largest vaccination campaigns in history.
So, off I went to Delhi, and then on to the districts in the state of Uttar Pradesh. UP was, and still is, the most populous state in India, home to some 180 million people. And that is where I realized that I knew nothing. I had to completely reset my expectations and learn everything from scratch. I know all the arguments against a vertical disease eradication programme and agree with some, but at that time, heading off to the ‘hot 4’ districts of UP and conducting round after round of polio campaigns, the urgent need for stopping transmission was obvious. There is nothing else that compares to an eradication programme in our work for UNICEF. It was an experience that changed my life.
The first campaign that I was part of, was in the district of Moradabad, which at the time had the highest rate of transmission in the world, with several hundred polio cases per month. The disease was out of control and so was the programme; we were missing thousands of children under 5, the medical officers working for the Government were not committed, the birth rate was so high it seemed like we would simply never be able to keep up. After my first campaign, I went back to Delhi in shock and told my boss that it couldn’t be done, it was impossible, there were too many children, the microplans were poor, health workers were not fully engaged, we should go back to routine immunization. He looked at me and replied, ‘keep going mate’, and sent me back again.
For the next four years, I went back repeatedly, and the programme began to change. The most important aspect was the massive shift in commitment from the Government of India. With technical support from CDC and WHO they became the biggest manufacturer of vaccines in the world (thank goodness). Critically, they instructed their District Magistrates to engage, bringing in all arms of Government. WHO and UNICEF and Rotary also got their acts together, creating the best polio surveillance programme in the world (the truly great NPSP), developing a network (the SM Net) of volunteers responsible for educating, registering newborns, living and working with families in hard to reach areas and bringing them for vaccination. To this day, the SM Net remains the largest social mobilization network UNICEF has ever developed.
But the key to polio eradication and control of vaccine preventable diseases is, of course, vaccination. And this changed out of all recognition from the first campaign I witnessed to the last. With excellent surveillance and genetic sequencing, we were soon able to pinpoint the communities where the virus was being sustained. The first major initiative was the ‘underserved’ strategy, focusing on the poorest Muslim communities as well as some of the low caste Hindus that were simply left out altogether, whose dwellings did not exist on any map. We also realized that more boys were being paralysed than girls, a sure sign that parents were scared to vaccinate their sons and were hiding them, and adjusted our strategies accordingly.
Then we had a large outbreak in a group of families working in the brick kilns; these were small informal settlements that might contain up to 100 children, not registered at school, inhabited by people who were not even from the state. We developed the brick kiln strategy, mapping every informal settlement in UP and sending special teams to vaccinate the children, many of whom came from Bihar, the next-door state, at the time the least developed state in India. Slowly the number of cases went down in UP, but as they did, they went up in other states of India. We realized that nomadic families, migrants moving from Bihar to other parts of India, were carrying the virus with them or bringing it back to their homes. A big outbreak in Mumbai led to the railway strategy, mapping of every train and station in India and sending vaccination teams to wait for the trains or to travel on them. I went to the main train terminus in Mumbai, where a staggering 3 million people arrive per day, and tried to board a train with a vaccination team. It proved worthless, because we could not move on the train and so could not vaccinate anyone. But slowly these outbreaks were brought under control.
As expected, the final frontier was Bihar, and it proved to be one of the biggest challenges. The poorest state, with the highest birth rate in India, the most informal settlements, a large number of citizens considered low caste, with no land and limited access to services. Many of the 90 million inhabitants lived in the flood plains of the Kosi River. It was called the ‘Sorrow of India’, because of the flooding and erosion the river created every year. When the river floods, millions of people would move from their homes to higher land, in informal and very crowded settlements on the banks of the river, where many disease outbreaks occurred, including polio. We developed the Kosi River strategy, entering the flooded villages, offering help with shelter, water chlorination, with Vitamin A and other micronutrients, with deworming, and vaccinating, over and over again. Slowly the polio outbreaks stopped.
Eventually India managed to do what was once unthinkable; India stopped the transmission of wild poliovirus, thanks to the unwavering commitment of the Government and the millions of vaccinators, social mobilisers and volunteers, the real heroes of the story. Hundreds of thousands of children who would otherwise be irreversibly paralysed are free to live their lives and develop to their full potential without the fear of contracting this terrible disease. I had long gone by then, back to the field with UNICEF.
I was on loan from UNICEF, full of my African field bravado and UNICEF know-it-all attitude, excited for what lay ahead. I joined the famed Country Support Team, full of highly experienced medical doctors, scientists, logisticians and surveillance specialists, and was asked to be the focal point for India. This surprised me as I had no experience in South Asia and was expecting to go to Africa. I soon realized the scale of the challenge; India at the time accounted for some 60 percent of global polio cases, and with a population of more than a billion, the National Immunisation Days were by far the largest vaccination campaigns in history.
So, off I went to Delhi, and then on to the districts in the state of Uttar Pradesh. UP was, and still is, the most populous state in India, home to some 180 million people. And that is where I realized that I knew nothing. I had to completely reset my expectations and learn everything from scratch. I know all the arguments against a vertical disease eradication programme and agree with some, but at that time, heading off to the ‘hot 4’ districts of UP and conducting round after round of polio campaigns, the urgent need for stopping transmission was obvious. There is nothing else that compares to an eradication programme in our work for UNICEF. It was an experience that changed my life.
The first campaign that I was part of, was in the district of Moradabad, which at the time had the highest rate of transmission in the world, with several hundred polio cases per month. The disease was out of control and so was the programme; we were missing thousands of children under 5, the medical officers working for the Government were not committed, the birth rate was so high it seemed like we would simply never be able to keep up. After my first campaign, I went back to Delhi in shock and told my boss that it couldn’t be done, it was impossible, there were too many children, the microplans were poor, health workers were not fully engaged, we should go back to routine immunization. He looked at me and replied, ‘keep going mate’, and sent me back again.
For the next four years, I went back repeatedly, and the programme began to change. The most important aspect was the massive shift in commitment from the Government of India. With technical support from CDC and WHO they became the biggest manufacturer of vaccines in the world (thank goodness). Critically, they instructed their District Magistrates to engage, bringing in all arms of Government. WHO and UNICEF and Rotary also got their acts together, creating the best polio surveillance programme in the world (the truly great NPSP), developing a network (the SM Net) of volunteers responsible for educating, registering newborns, living and working with families in hard to reach areas and bringing them for vaccination. To this day, the SM Net remains the largest social mobilization network UNICEF has ever developed.
But the key to polio eradication and control of vaccine preventable diseases is, of course, vaccination. And this changed out of all recognition from the first campaign I witnessed to the last. With excellent surveillance and genetic sequencing, we were soon able to pinpoint the communities where the virus was being sustained. The first major initiative was the ‘underserved’ strategy, focusing on the poorest Muslim communities as well as some of the low caste Hindus that were simply left out altogether, whose dwellings did not exist on any map. We also realized that more boys were being paralysed than girls, a sure sign that parents were scared to vaccinate their sons and were hiding them, and adjusted our strategies accordingly.
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| Polio eradication in India (photo by GPEI) |
Then we had a large outbreak in a group of families working in the brick kilns; these were small informal settlements that might contain up to 100 children, not registered at school, inhabited by people who were not even from the state. We developed the brick kiln strategy, mapping every informal settlement in UP and sending special teams to vaccinate the children, many of whom came from Bihar, the next-door state, at the time the least developed state in India. Slowly the number of cases went down in UP, but as they did, they went up in other states of India. We realized that nomadic families, migrants moving from Bihar to other parts of India, were carrying the virus with them or bringing it back to their homes. A big outbreak in Mumbai led to the railway strategy, mapping of every train and station in India and sending vaccination teams to wait for the trains or to travel on them. I went to the main train terminus in Mumbai, where a staggering 3 million people arrive per day, and tried to board a train with a vaccination team. It proved worthless, because we could not move on the train and so could not vaccinate anyone. But slowly these outbreaks were brought under control.
As expected, the final frontier was Bihar, and it proved to be one of the biggest challenges. The poorest state, with the highest birth rate in India, the most informal settlements, a large number of citizens considered low caste, with no land and limited access to services. Many of the 90 million inhabitants lived in the flood plains of the Kosi River. It was called the ‘Sorrow of India’, because of the flooding and erosion the river created every year. When the river floods, millions of people would move from their homes to higher land, in informal and very crowded settlements on the banks of the river, where many disease outbreaks occurred, including polio. We developed the Kosi River strategy, entering the flooded villages, offering help with shelter, water chlorination, with Vitamin A and other micronutrients, with deworming, and vaccinating, over and over again. Slowly the polio outbreaks stopped.
Eventually India managed to do what was once unthinkable; India stopped the transmission of wild poliovirus, thanks to the unwavering commitment of the Government and the millions of vaccinators, social mobilisers and volunteers, the real heroes of the story. Hundreds of thousands of children who would otherwise be irreversibly paralysed are free to live their lives and develop to their full potential without the fear of contracting this terrible disease. I had long gone by then, back to the field with UNICEF.
But India changed everything in the Global Polio Eradication Initiative, because the impossible became possible; it forged the way, so that the disease could then be eradicated from the entire African continent, too. We still have two countries to go, Afghanistan and Pakistan; they are nearly there, but the current security situation is uncertain. But eradication in India means anything is possible, because stopping Polio there was the greatest challenge of all.
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