From Development Communication specialist Wendy Quarry. Image: Young Fulani girl at a polio and sanitation meeting (September 2012; credit: Chris Morry)

Communication professor and writer, Silvio Waisbord [1] got it right ten years ago when he noted that the rift between those who see communication as behavioral change and those who support a more participatory approach has still not healed. I thought about this during a recent review of Polio Communication in Nigeria. Here a 'top-down' full-scale behavioral change approach is in full swing despite an apparent need to adopt longer-term, participatory and more 'bottom-up' approaches to reach 'missed' or non-compliant households. When asked to write about my impressions of this review, my first thought was the difficulty the polio machine might face in pausing long enough to build in a new approach. The train has so clearly left the station and is gaining momentum based on the hope that its power alone would solve the problem. Perhaps in other countries, but not Nigeria. Here the reasons for non-compliance are complex within an equally complex environment. This is in direct contrast to Canada decades ago where I had my first brush with the disease.

When my mother contracted polio in the 1940's she was paralyzed from the neck down. After a year or so and extensive rehabilitation in a special school in the United States she regained the use of almost all her limbs save for the left leg. This happened in a privileged neighbourhood in Toronto where we all grew up with dread that we too would catch the disease during the summer months. We did not swim in public wading pools, did not go to movies or visit the exhibition (crowds) and never, ever drank from outdoor water fountains. The fear of polio (coupled with the fear of a nuclear attack) was the sole negative backdrop to an otherwise ideal childhood and all of that was before Jonas Salk.

We got over the fear of polio entirely as a result of the Salk vaccine (the nuclear fear a whole other issue). The advent of the vaccine generated relentless media campaigns and public education programs meant to convince every Canadian parent about the necessity of immunization and the polio vaccine. That wasn't difficult. Parents across the country were genuinely terrified of the disease and, even if some were wary, in Canada the public media had the ability to sway opinion. Or so we thought back then. My father was a publisher dependent on advertising and he never hesitated to teach us his conviction of its value. On car trips through the States we would sit in the backseat while he would encourage us to yell out slogans as we passed them on the highway, "In Philadephia nearly everybody reads the Bulletin," and "We all love Burmashave."

Not surprisingly I became interested in communication and ended up a communication specialist in various ramifications for different organizations. At one point when I was working for a regional water and sanitation program in Bangladesh, I listened to a male health communicator harangue a group of women all gathered together in a large tent. It was all about hand washing and the need for sanitation. I wasn't sure exactly why but I knew that something did not feel right. [2] Now I realize that the context was completely out of kilter and instead of listening to women discuss their own concerns and objectives around sanitation, they were subjected to a male lecturer acting like an old fashioned school master. This could only be counterproductive.

This moment catapulted me out of what might have been a career in health communication into what I thought of as the more participatory camp. I wouldn't have been able to explain it to myself back then but I knew that waging campaigns to tell people what to do was not going to be my forte. I always understood its value but it was not what I wanted to do.

This reaction was instinctive and not at all based on the academic know-how already well ahead in capturing these basic differences in approach through theory and practice. [3] Little did I know that I had entered the turf war that Waisbord talks about and had firmly put up my flag in the participatory camp rather than the diffusion one over on the other side. I know that it isn’t necessary for me to go into this when talking to people involved in polio communication but I have to bring it up here since the issue of the two camps and the need to blend them is germane to my reaction to the polio communication work that I recently reviewed in Nigeria. [4]

I don't pretend to know very much about polio communication and I ask you to bear this in mind when you read my next comments and observations. I have experienced only two polio review missions - one in Pakistan and this one in Nigeria and in Pakistan security kept me from barely getting out the door. Nigeria was much better.

We arrived in Abuja one week before the polio ERC [5] committee was set to arrive. The ERC would bring in all the Generals from North America (Gates, CDC [the Centers for Disease Control and Prevention] and UNICEF [the United Nations Children's Fund]) and Europe (WHO [World Health Organization]) and our review was meant to feed into this larger, more political event. I was amazed once I got a glimpse of the very large machine that powers the global polio eradication program and equally impressed at the complicated and far - reaching infrastructure for the same thing in Nigeria.

We were only partially prepared on the details when we arrived but well prepped and accepting of the idea that the quest to eradicate polio was not so much about long term participatory approaches to behavioral change as it was about literally waging a war on the disease. Winning was more important than 'building relationships'. The government of Nigeria with a great deal of help from the donor agencies was verbally on board with winning this war, and I had read Dr. Susan Goldstein's excellent piece on her recent polio review in Pakistan aptly called "the End Game", and understood that the communication I would be reviewing would be anything but participatory. There was an emergency here and missed children had to be inoculated – no time for these longer-term approaches.

But here's the thing, the whole time I was there, during all the discussions both before and after our four-day field trip, I never ever heard the word communication. Oh I heard a lot about data and the need to get it right; I heard about targets and missed children and plans and numbers. But I never really heard a discussion about the quality of the communication, the whys and the wherefores. Nor how we might reach people so that we might understand their concerns.

I think I understand and accept the blunt fact that when you are waging a war - and this is a war with troops (vaccinators), reserves (Stoppers), officers in the field, higher ranking officials in Abuja and Generals mainly residing in Europe or North America calling the shots. When you are waging a war like this, I admit it is hard to stop long enough to try to search out and actually listen to the missing.

As war correspondents we did our best under fairly tight circumstances. After a full day briefing in Abuja we divided into four groups of about 3-4 each and travelled to four different northern States. My group of three (1 woman and 2 men) was responsible for assessing the role of religious and traditional leaders within the campaign so focused on Sokoto, an 8-10 hour drive from the capital. Once in Sokoto we were well looked after both by government officials and by those representing the religious and traditional leaders. Our trips 'to the field' felt like one of those World Bank missions I used to travel on in South America with 5-6 SUVs [sport utility vehicles], clouds of dust and zooming in for quick stops on bewildered villagers. Except it was the rainy season in Sokoto so we couldn’t zoom very well. In fact the armoured vehicle belonging to one of our team got well and truly mired in the mud.

Once again we listened to a great deal of talk about data and numbers and accompanied large crowds of local politicians, traditional leaders and health personnel to a variety of villages in 'non-compliant' communities. But we didn’t really get a chance to see how things were done in reality and no one actually discussed communication.

It was frustrating. We wanted to do our job and learn about the various communication approaches but found the timing to be wrong. Apparently communication is something that only happens during set 'polio' rounds when teams of vaccinators converge on communities and seek to vaccinate children (or find missed children). As far as we could tell, this wasn't about helping parents learn about the value of long-term immunization, it was all about giving the shots. And it works - by and large - it works, at least for the short term. It seems to me that if your main goal is to vaccinate children against polio you can do that and be successful in maybe 90% of the cases. But when your goal is to eradicate a disease where every child counts and where 5-10% of them are missing, you figure that most of those children are missing for a reason. Why is that, you need to know?

As 'the' woman on the team, I had the chance to leave the mass meetings with politicians and other leaders in the villages and walk off to visit mothers in individual households accompanied by two other women willing to translate. In each village we were able to meet 3-4 mothers who had refused vaccination for their children. Altogether we met with about 10 households in various communities, rural and urban. Reasons for non-compliance were compelling. For some, their husbands had flatly refused to allow them to vaccinate their children fearing it was a western plot to render them infertile (they never actually said that but this is what we had heard). Some (unlike the Canadian parents in the 1950s) simply didn't fear polio. Dysentery and malaria were far more prevalent and much more of a worry. In others there was outright anger. The women of the household said that they had been promised roads; clean water supply and help against malaria but none of this had materialized. "Why then, they asked should they do what the government wants and vaccinate their children against polio when the government doesn't do anything for them as promised?" No one appeared to be listening. It was a protest of sorts and no amount of new IEC [information, education, and communication] materials or radio songs appears to make a difference to these families.

If Nigeria truly hopes to eradicate polio (and we believe they do) then a whole new approach must be taken with the non-compliant. Time to lay down the gloves, stop the bullying and prepare to really listen to the various concerns. Yes it will take time but time may be necessary if the country wants to go beyond winning battles and finally win the war.

Polio is not, I understand, as straightforward as smallpox. With smallpox, one scratch of the vaccine and the child is immune. Polio requires 3 shots to be effective so the 'swooping down and catch them as you can approach' just doesn't work unless you repeat it three times and that isn’t always feasible. Compliant parents understand this and are willing to do what is needed. But it's just not good enough to count on corralling missing households into immunizing their child (as the top Traditional and Religious leaders have pledged to do) without taking the time to really help those families understand the need for a longer-term immunization schedule or to really listen to their concerns. You can't do that by coercion and, useful as they are, flipcharts on immunization cannot replace a government's willingness to listen.

Given that it is difficult to change gears once a full-scale campaign approach to communication is underway, the vast number of people engaged in polio communication in Nigeria cannot be shifted overnight. By all means I would say, continue with the carefully orchestrated polio campaigns - blanket the airwaves and train the vaccinators. Don't stop with what for the 90 odd percent appears to be working. But at the same time, recognize and act on the need to develop another cadre, a special force within the ranks that is trained in a more listening approach to communication. We have learned the hard way that this kind of training is better done separately since its premise is less about prescribing and more about listening. Nor can it be done in a two to three days workshop. It requires a mentoring approach where the trainer accompanies the communicator on his/her rounds and learns together the best way to approach the missing. This approach to communication may take longer but there is a fighting chance that combining the two approaches will pay off in the long run. It did in India, at least for now but it must be continued if India hopes to eradicate the disease entirely. In Canada there are signs that parents no longer afraid of polio are not getting their children vaccinated. Public health authorities are aware of a possible comeback. In 2012, they say, this is simply not acceptable.

[1] Waisbord, 2003
[2] Health Communication, Can it change behavior?
[3] Morris, Nancy. "A Comparative Analysis of the Diffusion and Participatory Models in Development Communication"
[4] USAID [the United States Agency for International Development] contracted the Communication Initiative to put together small teams of communication specialists (including people from the Communication Initiative) to review the polio communication work in various high risk countries where the government of the country with UNICEF/WHO/Gates and CDC support, is working to eradicate polio.
[5] Expert Review Committee on Polio Eradication