Author: Peter K.A. da Costa, Ph.D., July 7 2017 - is a member of the Horn of Africa Polio Technical Advisory Group (TAG) and has been a technical advisor on polio communication in Central Africa as well as Nigeria. He has worked as a development expert in and on Africa as well as on global issues and initiatives for more than two decades and, among many other things, serves as Senior Adviser to the Africa Progress Panel, chaired by former UN Secretary-General Kofi Annan. He holds a Ph.D. in Development Studies and is based in Nairobi, Kenya.
The Global Polio Eradication Initiative (GPEI) represents a major achievement in consensus on how to eradicate one of the most debilitating conditions known to humankind. The political will it signifies is matched by the dedication of a collective of agencies, driven by hundreds of thousands of committed foot-soldiers around the world. Its strategy, objectives, goals and targets are eminently achievable.
For me, the recognition of the critical importance of communication and social mobilization as an integral part of the polio 'End Game' strategy is one of the abiding achievements of the GPEI that will inform efforts to prevent and respond to disease outbreaks for years to come. And from where I sit as a member of the Horn of Africa Technical Advisory Group (TAG), having also participated in TAGs in Central Africa and Nigeria, there is a lot of progress to celebrate.
For example, we've seen an array of creative risk communication innovations developed in response to the outbreaks in recent years. These have included:
- increased capacity to understand the dynamics around mobile populations;
- recognition of the need to increase cross-border surveillance and prevention efforts;
- improved preparedness, as manifested by the mainstreaming of national Polio Outbreak Simulation Exercises (POSEs);
- improved micro-planning involving clan and community leaders;
- harnessing of community dialogues to overcome resistance;
- rolling out of interpersonal communication training for health educators;
- creative partnerships (such as with the Islamic Affairs Supreme Council (IASC) in response to the Ethiopia Somali Region outbreak 2013-2015), as well as with media, especially radio journalists and broadcast networks with community reach;
- enhanced understanding of behaviour and knowledge barriers and more diligent focus on how to overcome non-compliance;
- improved collection, analysis and use of data for action, communication and social mobilization; and
- combination of Routine Immunization (RI) and Supplementary Immunization activities (SIAs) such as Immunisation Plus Days (IPDs - Nigeria) to achieve improved immunity.
Innovations such as these provide a strong basis for hope that the GPEI can successfully get to the end of the Last Mile.
Now to my deepest fears.
The frustrating thing about polio is that, despite the best efforts of the community around GPEI, new cases can pop up when we least expect them. And there are factors beyond the control of any single agency, country or actor that provide a basis for wild poliovirus (WPV) and its variants to spring surprises.
Key among these factors is governance, manifested by the occurrence of internal and cross-border conflicts leading to breakdown in health and sanitation services, shortages of clean water and medical supplies, and mass movement of displaced communities within and across countries.
Nigeria's announcement in August 2016 that it had discovered new cases of WPV was a huge setback, considering the two polio-free years leading up to the new discovery. Barely a year before the outbreak, in September 2015, the World Health Organization (WHO) had removed Nigeria from the list of polio-endemic countries, and the country was on track to be declared polio free on 24 July 2017. This was an incredible achievement, given that in 2012 Nigeria accounted for more than half of the world’s polio cases.
In the Lake Chad Basin countries as well as in the Horn and Eastern Africa, the Nigeria outbreak has had a huge ripple effect. It has provided a sobering reality check, reminding us that however strong prevention efforts are, and however advanced techniques of surveillance, outbreaks can occur at any time.
In Nigeria, a strong case could be made correlating the Boko Haram insurgency in the northernmost states with the new cases discovered. And as we know from Central Africa and most recently Yemen, conflict and the absence of peace and security create the environment in which polio, as well as other communicable diseases, will spread - as public health systems break down and internally displaced people are forced to go on the move in search of safety and shelter.
Yemen, previously declared polio free in 2009, is in the midst of a devastating conflict that has seen more than 2 million people displaced and health and sanitation infrastructure destroyed on a massive scale. The conflict has led to a deadly outbreak of cholera, which has claimed more than 1,700 lives, with more than 300,000 cases detected. The numbers are rising daily. In February 2017, the authorities, supported by the United Nations Children’s Fund (UNICEF), WHO and humanitarian agencies, launched a massive immunization campaign to prevent importation of WPV. The campaign demonstrated that even in the toughest of circumstances, polio prevention can be mobilized at scale, and with considerable innovation. However, it's a race against time, and the fear is that it won’t be long before WPV cases begin to escalate.
It's also clear that mobilizing the needed resources is becoming more and more difficult. The global health community has spent more than US$14 billion over the past three decades towards eradicating polio. So the question of fatigue arises as everyone is looking towards the 'Polio End Game'.
We are seeing a growing scarcity in resources as funding for the GPEI dwindle, and UNICEF, WHO and other actors who have been critical in bringing the virus under control are faced with the prospect of transitioning away from a focus on polio to other communicable diseases. The networks assembled and put in place in countries such as Somalia - immunizers, social mobilizers, communication for development (C4D) specialists and others – have been nothing short of phenomenal. And yet the scale-down in funding now means that country teams are struggling to keep these networks and capacities in play.
In the meantime, and even as teams improve country preparedness, surveillance and response capability, challenges persist. This is the paradox of polio - you’re only as good as your preparedness for the future, not for the present or the past. Being polio free today means there's even less room for complacency - you need to step up your efforts and ensure you are polio free tomorrow, the year after that. And the year after that.
And even then, there are no guarantees. There are many moving parts, and the response relies on many different actors - government health systems at national and decentralised levels; international agencies at global, regional and in-country levels; research institutions; and community immunizers and social mobilizers, etc. And all elements of the eradication effort need to work together in synergy.
A number of challenges keep me awake at night:
- It is necessary to ensure polio communication assets remain in place during and after transition. How can these networks and capacities be kept in play as resourcing dwindles? How can the wider outbreak response draw on these assets and ensure they continue to be adequately resourced to prevent future outbreaks? How can an integrated capacity to respond to communicable diseases (CDs) and curtail epidemic outbreaks be maintained and built upon?
- The perception of risk from polio has diminished as the response has become more successful. The fewer the cases, the less of a sense of urgency people have. This also affects the ability of GPEI to mobilize resources for the 'End Game' strategy. It challenges strategic communication experts and practitioners to find new ways of keeping polio high on the agenda;
- Repeated rounds of vaccination, seen as a tried and tested strategy for reducing the risk of re-infection and spread, also account, to an extent, for community resistance. Over-vaccination leaves open the prospect of vaccine-derived poliovirus (VDPV) spread, with some areas reporting increases in cVDPVs (circulating VDPVs);
- As the 16th Horn of Africa TAG noted, the detection of the latest cVDPV2 cases in Nigeria in October 2016 has fuelled concerns that the virus will be re-imported from the Lake Chad area into to the Horn and Eastern Africa;
- There is continued concern over missed children, especially in mobile and other hard-to-reach populations, and understanding reasons for non-compliance/ caregiver refusal/ community resistance;
- In Nigeria in 2011, we saw missed children numbers from community resistance rising in the high-risk states, and this has been exacerbated by the outbreak of the Boko Haram insurgency in Northern states. We've also seen a lack of awareness of the benefits of vaccination as a contributory factor to non-compliance. Issues of trust, or the lack of it, are critical. If caregivers consider the vaccines unsafe or likely to cause other problems, or if they do not trust the vaccinators, they are more likely to keep their children away;
- Lack of RI in conflict-affected regions and countries (in Nigeria, this has been the case in Northern states) also poses a perennial challenge;
- There continues to be sub-optimal surveillance, especially in conflict-affected countries/ regions;
- Viewing polio in isolation from other communicable diseases - for instance, insisting on round after round of polio vaccination while other diseases such as cholera and meningitis are not addressed to the same levels of intensity or in a joined-up way - will have negative consequences going forward; and
- Polio is sometimes tackled separately from wider development challenges such as shortage of clean water, poverty and vulnerability, all of which diminish the extent to which it is prioritized by communities.
All in all, I'm more hopeful than fearful. But the hope is contingent on: intensified vigilance and mobilization by government health systems; continued proactive support from UNICEF, WHO and the humanitarian system; and a more joined-up approach - both to addressing polio in relation to other communicable diseases and to preventing and managing conflicts to minimize transmission and re-importation risks.
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