The pol­i­tics of po­lio eradication

Financial Mirror (Cyprus) - - FRONT PAGE -

A few years ago, the global cam­paign to erad­i­cate po­lio seemed to have stalled. Af­ter decades of eradication ef­forts, the virus re­mained stub­bornly en­demic in Pak­istan, Afghanistan, and Nige­ria. Then, in 2013 and 2014, it was found to have re­turned to seven pre­vi­ously po­lio-free coun­tries in Africa and the Middle East, prompt­ing the World Health Or­gan­i­sa­tion to de­clare the dis­ease’s resur­gence a “pub­lic-health emer­gency of in­ter­na­tional con­cern.”

De­spite this re­cidi­vism, the world to­day is closer than ever to erad­i­cat­ing po­lio. In 2015, there were just 74 new cases of the dis­ease – 80% fewer than the pre­vi­ous year and the low­est an­nual to­tal ever. And all of the cases were con­cen­trated in just two coun­tries, 54 in Pak­istan and 20 in Afghanistan. More­over, it has been 18 months since the virus was last de­tected in Africa.

The rea­sons be­hind this re­mark­able turn­around are in­struc­tive, il­lus­trat­ing the chal­lenges fac­ing pub­lic-health work­ers and the best ways to over­come them.

The bar­ri­ers to po­lio eradication are no longer med­i­cal; the dis­ease does not oc­cur where vac­ci­na­tion pro­grammes op­er­ate un­hin­dered. Dur­ing the past five years, po­lio cases have oc­curred al­most ex­clu­sively in five con­flict-af­fected coun­tries: Nige­ria, Pak­istan, Afghanistan, So­ma­lia, and Syria. Be­cause i mmu­ni­sa­tion pro­grammes are led by na­tional gov­ern­ments and the WHO, which, as a spe­cialised agency of the United Na­tions, works closely with in­cum­bent regimes, it can be dif­fi­cult to carry out vac­ci­na­tions in ar­eas where mil­i­tants wage war against the state.

The fall in the num­ber of po­lio cases largely re­sulted from im­proved ac­cess to such ar­eas. In Nige­ria and Pak­istan, vac­ci­na­tion pro­grammes were able to pro­ceed af­ter troops as­serted the state’s con­trol over con­flict-af­fected ter­ri­tory.

Most po­lio cases oc­curred in north­ern and east­ern Nige­ria, where the ter­ror­ist group Boko Haram had killed and kid­napped im­mu­ni­sa­tion work­ers, dis­rupt­ing vac­ci­na­tion pro­grammes and leav­ing more than a mil­lion chil­dren un­pro­tected. Af­ter a re­gional mil­i­tary force pushed the group into sparsely pop­u­lated moun­tains and forests, im­mu­ni­sa­tion work­ers were pro­vided ac­cess to pre­vi­ously rebel-con­trolled ar­eas.

In Pak­istan, po­lio is con­cen­trated in the Fed­er­ally Ad­min­is­tered Tribal Ar­eas in the northwest of the coun­try, where the Tal­iban are strong­est. In 2012, mil­i­tant lead­ers in the re­gion banned im­mu­ni­sa­tion pro­grammes over con­cerns that they were be­ing used to gather in­tel­li­gence for drone at­tacks by the United States. Con­se­quently 1-3.5 mil­lion Pak­istani chil­dren were not vac­ci­nated.

That changed in the sum­mer of 2014, when the Pak­istan mil­i­tary brought large ar­eas of the re­gion un­der govern­ment con­trol. In the space of a sin­gle year, the num­ber of po­lio cases fell from 306 to 54.

Us­ing troops to as­sert con­trol over con­flict-af­fected ar­eas is not the only way to im­prove ac­cess for po­lio work­ers, and in some cases it may not be the most ef­fec­tive. In Afghanistan, So­ma­lia, and Syria, the govern­ment was ei­ther un­able or un­will­ing to as­sert au­thor­ity over rebel-con­trolled ter­ri­tory. In­stead, im­mu­ni­sa­tion work­ers adapted to the political re­al­ity and worked with mil­i­tants to gain ac­cess to ar­eas un­der their con­trol.

The Afghan Tal­iban have co­op­er­ated with po­lio vac­ci­na­tion pro­grammes since the 1990s. In most cases, lo­cal-level lead­ers have wel­comed im­mu­ni­sa­tion work­ers, see­ing vac­ci­na­tion pro­grammes as a form of pa­tron­age that re­in­forces their au­thor­ity. The few po­lio cases that have been de­tected have been ei­ther cross-bor­der trans­mis­sions from Pak­istan or have oc­curred in ar­eas where in­tense con­flict be­tween the Tal­iban and the Afghan govern­ment has tem­po­rar­ily dis­rupted po­lio cam­paigns.

By con­trast, in So­ma­lia, the ter­ror­ist group al-Shabaab has his­tor­i­cally for­bid­den po­lio work­ers from op­er­at­ing in ar­eas un­der their con­trol, view­ing vac­ci­na­tion cam­paigns as part of a for­eign cam­paign to i mpose a cen­tralised govern­ment. One mil­lion chil­dren were un­vac­ci­nated be­tween 2010 and 2013, when a po­lio out­break oc­curred. Since then, im­mu­ni­sa­tion cam­paigns have im­proved their ac­cess to rebel-con­trolled ar­eas by em­ploy­ing lo­cally re­cruited staff to work within their own clans and ne­go­ti­ate ac­cess with lo­cal-level mil­i­tant lead­ers.

In Syria, af­ter the start of the up­ris­ing in 2011, the govern­ment pre­vented the WHO from op­er­at­ing in ar­eas out­side its con­trol. Over three mil­lion chil­dren were not vac­ci­nated for po­lio, lead­ing to an out­break in re­bel­con­trolled re­gions in 2013. In re­sponse, an ad hoc coali­tion, in­clud­ing mod­er­ate op­po­si­tion groups, Turk­ish au­thor­i­ties, and lo­cal NGOs car­ried out a se­ries of vac­ci­na­tion cam­paigns and con­tained the out­break. The coali­tion ne­go­ti­ated ac­cess with lo­cal rebel lead­ers, al­low­ing them to choose vol­un­teer vac­ci­na­tors. Mil­i­tant groups – even the so-called Is­lamic State – per­mit­ted im­mu­ni­sa­tion cam­paigns to op­er­ate in ar­eas un­der their con­trol. The les­son is clear. Suc­cess­ful im­mu­ni­sa­tion cam­paigns must se­cure the sup­port of de facto political lead­ers – whether of an in­ter­na­tion­ally recog­nised state or of a vil­i­fied mil­i­tant or­gan­i­sa­tion. As ob­jec­tion­able as work­ing with groups like the Is­lamic State might be, it is im­por­tant to re­mem­ber that the main ob­jec­tive of ef­forts like the cam­paign to erad­i­cate po­lio is to im­prove the health of peo­ple wher­ever they may live.

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