Author: Sebastian Taylor, Date: July 30 2013      Having spent USD$9.46 billion dollars between 1988 and 2010, a targeted USD$1.8 billion between 2010 and 2012 (totalling USD$11.26 billion) - and with an estimated budget of USD$5.5 billion for the end-game between 2013 and 2018 - there is a lot riding on the strategy taken by the global polio programme in the remaining endemic countries to get the job done, and justify the cost to date. [Editor's note: For context, please see: Polio Eradication and Endgame Strategic Plan 2013-2018]. The cost is more than financial. Failure to eradicate would result in a resurgence of the disease worldwide, with hundreds of thousands of newly infected children, many physically disabled for life. The concept and practice of a viable global approach to public health would also be substantially damaged - at a time when new money and global cooperation for health are in the balance.

The residual problem for the global programme is, relatively speaking, small. The virus has been successfully limited to a few endemic countries (notwithstanding recent outbreaks in places like Chad and Somalia). And within these countries - primarily Pakistan and Afghanistan, and Nigeria - the susceptible population has been successfully driven down by successive campaign rounds, and some improvement in routine immunisation, to relatively confined and well-defined areas.

The killing of polio vaccinators in Pakistan and then Nigeria in late 2012 and early 2013 has raised the stakes once again in the contest between those who would protect children and those who would use the polio programme for their own political ends. In one sense, setting aside the acts of marginal radicals and getting on with the job that the vast majority of the world supports is the sensible option. It should not go unnoticed that Taliban officials, for example, have disavowed both the killings in Pakistan and the attack on Red Cross offices in Kabul [Afghanistan], stating that they are not opposed to the humanitarian principle of polio eradication as a key intervention in the life chances of the lives of those they claim to represent.

But the polio programme is obligated to respond - taking responsibility for the safety of the frontline workers whose efforts, since 1988, have made this programme the global achievement it is. The question is, what should that response be?

From a communications and public perception - as well as a simple operational - point of view, there are two predominant options. First, ramp up visible and effective delivery of polio vaccine, with emphasis on those remaining under-immunised areas and, even in the face of increased and potentially violent opposition, simply soldier on with tightly-spaced immunisation rounds until the weight of immunised population makes viral survival impossible. Second, submerge the programme in a wider programme of delivering health services and other development benefits long desired by the communities involved, obviating the objections that too much emphasis has been placed for too long on one disease at the expense of other needs, and reducing the value of attacks on polio workers as a means of giving violent radicalism a quick and easy global platform.

The advantage of ramping up is that it maintains programme momentum and limits the need for developing (and paying for) new and potentially complex programme approaches. The disadvantage is that ramping up will simply exacerbate and entrench the various types of non-cooperation we have seen to date, failing to break down that non-compliance and hence leaving behind a small cohort of under-immunised communities at a scale at which the virus can continue to survive. Ramping up is especially risky where it is likely to mean increasing the use of security agencies - at first as passive protection for vaccinators but quite conceivably more actively involved as and where antagonistic interaction between households and vaccinator teams heats up.

The advantage of submerging the programme is that it reduces the visible value of attacking polio immunisation as wider community issues are addressed. The problem is that getting government in remaining endemic countries to engage seriously in financing and operationalizing a meaningful community development agenda in areas marginalised for decades will be a slow process and one whose speed does not easily match the 2013-2018 requirement.

It is sometimes assumed that this is a zero-sum proposition - that a country programme can go either 'ramp up' (with increasing support from security agencies) or 'ramp down' (maintaining delivery of OPV [oral polio vaccine] but within a wider package of meaningful and demanded interventions). And here, then, is the point. The Polio Eradication Initiative is no longer operating in a world in which one monumental proposition, operationalized under a single monolithic strategy, makes sense. That time - and the astonishing success of eliminating polio from all but the tiniest remaining corners of the planet - has finished. The end-game is, instead, about micro-level, surgical strategies, fitted to the precise circumstances of household reticence, community objection, ideological cooption or localised manifestation of insecurity, that contextualise each small area where rates of vaccine coverage remain just too low. In each of the remaining endemic countries, we are going to need to see a more sophisticated and evidence-driven approach to strategizing vaccine delivery in residual poorly covered localities - strategies that can distinguish between social environments in which a ramping up approach is appropriate, and those in which a ramping down approach is liable to work better; and of course environments in which elements of both are required.

A report on polio immunisation - and resistance to immunisation - in the US [United States] in 1962 notes, interestingly, that richer areas evinced fewer problems of vaccination, whilst poorer areas had higher rates of under-immunisation. It concluded that, in order to reach poorer households, the key approach should be to expand vaccine delivery in public areas (in other words, ramping up), increasing the cost of avoidance to a point where parents simply conceded and had their children vaccinated. Of course, it should be remembered that the approach to vaccination in Miami Dade [Florida, US] was based primarily on out-of-house vaccination, while strategy in the GPEI [Global Polio Eradication Initiative] in endemic countries since at least 2000 has been to go door-to-door. Moreover, there is little evidence that residents of Miami in the 1960s had ideological objections to polio, either as households in their own right, or as households living in fear of wider political or insurgent groups.

But the US study offers a useful insight. In Nigeria, Pakistan and Afghanistan, households - especially those living in remote, rural or marginalised conditions, and especially women who exist in a state of more or less permanent purdah - can live their lives with very little or infrequent contact with the outside world through the kinds of public spaces the Miami Dade project used to leverage compliance. Instead, in the case of these households, ramping up the programme's visibility is likely to have little impact. This is especially the case where ramping up implies a more forceful approach to engagement with communities and, ultimately, with individual non-compliant households (as we saw, for example, with the smallpox programme's end-game in both Nigeria and India).

Pakistan offers useful lessons for a more nuanced approach to what we hope is the polio end-game. In his book A Hard Country, Anatol Lieven notes, as anthropologists, political scientists and colonialists have for upwards of a century, how the modern Pakistani state is, in reality, a patchwork of overlapping kinship, tribal, ethnic and geographical identities, networked together through economic and political relationships. What makes sense now to one of the myriad groups, may make little sense to another, and may make progressively less or more sense to the same group as prevailing conditions change. Hence, engagement with a humanitarian endeavour such as polio eradication may make more sense to Pashtun communities as perceived Western aggression in Afghanistan recedes over the next two or so years, while those external events are unlikely to change perceptions of the programme amongst rural labourers in southern Punjab.

The net effect of these observations is that the sporadic, diverse and highly localised forms of remaining under-immunisation (and the range of reasons for non-compliance in households) require not one single end-game strategy (be that programmatic diversification or security-enhanced vaccine delivery). Rather, the objective conditions on the ground suggest the need for multiple strategies, fitted to the evidence of what causes a locality's problem with the programme. In some cases, increasing programmatic opportunities to encounter and vaccinate unimmunised children in 'out-of-house' environments such as markets and transit points will be the best fit. In others, creating a gravitational pull on uncertain households through the local provision of other, genuinely needed goods and services may be more effective in gaining access to families and adding polio immunisation into other more highly valued interventions.

In some instances, a show of force may be helpful in persuading communities that antagonism towards humanitarian vaccinators is unacceptable. But in many cases, the use of security services as protection or back-up needs to be very carefully modulated, to avoid appearing to substantiate anti-polio claims of Western imperialism and an assault on democratic rights. In almost all conceivable instances, gaining the support of local community leaders will remain an important goal. However, identifying leaders who genuinely represent the range of local constituencies targeted by the programme has not always been done well, or on the basis of evidence. Equally, understanding how local leaders influence households (through processes of religious observance, access to local entitlements such as food distribution or economic opportunities such as employment, or through straight patronage relations) should shape in much more nuanced fashion how leaders are engaged and their positive influence secured.

In each locality experiencing problems with residual under-immunised children, a composite strategy should be formed using elements of the above, shaped by detailed evidence of what causes under-immunisation in that locality. And behind these micro-strategies two elephantine programme factors will continue to require considerable strengthening.

On one hand, high-level political support. In Pakistan, for example, the establishment of the Prime Minister's polio unit was seen as a major advance in the commitment of the federal administration (and uncertainty about its function and future under the decentralisation programme of the 18th Amendment is cause for a degree of concern). Yet, even prime ministerial endorsement failed to translate into effective negotiation (either directly or with the support of international partners involved on the Afghan side of the border) to maximise secure access for vaccinators across FATA [Federally Administered Tribal Areas] and KP [Khyber Pakhtunkhwa]. On the other hand, better quality service delivery. Recent assessments of programme performance in northern Nigeria suggest that institutional commitment at LGA [local government authority] and even at state level remains variable and in some cases worryingly weak. Stronger and more persuasive communications - including clear policy directive, financial management and transparency, local political engagement, and training to vaccinators - are needed from the FCT [Federal Capital Territory (of Nigeria)] down to the community.

The overarching message is this: the time for monolithic, massively-applied strategies (based on population-level ideas of national commitment and national programming) is over, and has been for some time. This has not always been recognised as speedily or as convincingly as one might hope in the operational programme. What happens next must be a series of locale-specific micro-strategies, tailored by use of good data whose meaning is commonly agreed across all programme partners, backstopped by continuing improvement in the quality of the ambient larger-scale supplementary and routine immunisation processes.