Author Chris Morry, from his Field Notes series for the Polio Network on December 11 2013: It has been very busy since we left Afghanistan for Nigeria. So busy in fact that it was 24 hours before I learned of Nelson Mandela's death. His passing is a moment for reflection not only on the impact of a single person who came to represent the best elements of one of the most powerful social justice movements of our time but also on what brings us together to create large scale societal change. Warren Feek recently posted a blog containing his reflections on the man, the movement and the dangers of thinking that major social transformations can be accomplished by technocratic management or policy makers alone. Immersed as I have been for the past few weeks in the polio programme, it is useful to be reminded of this, and it led me to reflect on the nature of 'demand' in the GPEI and the sources of its power for change.
Certainly, the eradication of a disease that has been killing and disabling children for thousands of years is no small feat, nor is it the kind of thing that can be accomplished without the mobilization of states and communities, money and time, courage and dedication. In this sense, it has some of the attributes of a social movement, a great global effort to remove forever, the burden on humanity of a single disease. But it is also (and needs to be) an intensely technocratic endeavour driven by epidemiology and supported by well-planned large-scale communication programmes. It is about government policies and commitment, the development of vaccine technologies, global diplomacy and statecraft, advocacy for the mobilization of resources, the deployment and management of thousands of staff, and the utilization of media together with social mobilization outreach to encourage parents to immunize each child under five as often as possible.
Marshalling all of these resources towards a single goal gives the polio programme its purpose and single-minded vision - a great humanitarian global effort and huge technical enterprise with a sharp focus and clear objectives. However, these attributes also push it away from the context of the lives and aspirations of the very people it seeks to benefit. Communities rightfully ask why so much polio immunization and so little attention to other important development aspirations? Why have their priorities not been better reflected in the development and implementation of such large global initiatives?
At one level, the answer to such questions is fairly simple. Disease eradication has to be single minded. It needs to be based in science, central management and coordinated global planning. At another, this answer leads to a dilemma at the heart of the programme. To succeed, parents and caregivers in rural villages and urban centres of different religious and cultural beliefs and across the entire socio-economic spectrum have to embrace, or at least accept and participate in, the global goal, even when it features not at all in the most pressing needs they would describe as important to them.
It is for these reasons that the GPEI finds itself struggling in the 'end game', and the reasons pose a tremendous challenge for the programme. Demand in many places is low, leaving the programme vulnerable to: politicization and bans such as in Pakistan; lack of government commitment at local levels leading to poor coverage; and disinterest or antipathy among caregivers resulting in children being missed. Creating demand for a single antigen amongst people who have other and more immediate needs (water, food, employment, to name a few), who receive few other government services and who have little reason to feel connected to global priorities, no matter how humanitarian in nature, is not an easy task.
The difficulties this creates for the programme are reflected in the long-standing shift from national immunization days, in which people brought their children to booths or health centres to be immunized, to the present and much more resource intensive practise of going door-to-door to take the vaccine to the children. The GPEI has evolved to meet these challenges by introducing a range of initiatives to help bolster demand, such as: creating large social mobilization networks to conduct local outreach activities; using the polio programme to deliver other health information about breast feeding, nutrition, hand washing and the importance of routine immunization; holding health camps where polio vaccine is given with other and much needed services; and delivering polio vaccine with other immunization campaigns, such as measles, or with a 'plus' such as vitamin A. But, at their heart, these initiatives ensure that more children receive polio vaccine by adding value and linking polio with other services more than they build demand for polio immunization itself.
GPEI’s place is in the realm of health system improvement, driven by government and global agencies, much more than in the realm of community-based demand or leadership. In this sense, building demand for polio vaccine is not the point. The extent to which demand (relevant to increased immunity against polio) can be created lies more in the realm of integrating polio immunization with other services - services that more genuinely reflect community priorities. This has been recognised, but, in a context where services are few and people’s development aspirations are often ignored and out of reach, integrating polio with other services raises its own set of questions.
Reflecting on the great social changes Nelson Mandela came to embody and how they were based in and led by the communities most affected, it is clear the GPEI is radically different in its nature and the source of its energy and power to change. It is an endeavour of policy, of systems and invention, of media and enticement much more than it is a product or manifestation of community aspiration, priority or demand. Worth doing? An emphatic yes! A major contribution to the health of present and future generations? Again yes! But there is a great difference between change that wells up from people in their communities, demanding change based on their experiences and aspirations from often reluctant governments and powerful elites, and those changes which are devised and led by governments and large global public bodies. Polio clearly falls into the latter, and its approach to demand building largely reflects this. But it also comes up hard against the reality that many of the services with which it would integrate are not supplied (routine immunization for one), and many of the development aspirations and priorities of the communities it seeks to immunize are denied them. Perhaps there is a need for a social movement after all...
The Communication Initiative