‘Eliminating polio was a singular achievement for India’: Thomas Abraham - The Hindu
‘Eliminating polio was a singular achievement for India’: Thomas Abraham - The Hindu |
| ‘Eliminating polio was a singular achievement for India’: Thomas Abraham - The Hindu Posted: 29 Feb 2020 02:30 AM PST Thomas Abraham's Polio: The Odyssey of Eradication, shortlisted for The Hindu Prize for Non-Fiction, is a gripping exploration of the complexities that lie in the way of the worldwide project to banish polio. And is it a goal within reach or is it an example of public health efforts having gone off track? An excerpt from an interview: Given that health has been a relatively new area for you, how did you get interested in the subject and in polio? Was your experience in Hong Kong a catalyst? I had no experience, or even great interest, in health, until SARS (Severe Acute Respiratory Syndrome) erupted in early 2003. I was at the time living in Hong Kong and was approached by a publisher to write a book about it. This was what got me interested in health and disease, and how human beings respond to threats to their health. At a deeper level, SARS as well as the coronavirus now demonstrate the power that microbes have over our lives. The relationship between man and microbe is fundamental to our  physical as well as social and cultural evolution. This is what I explore in this book on polio, where I look at the effort to drive the virus that causes polio into extinction in much the same way that humans have driven so many other living beings into extinction. Viruses of course have existed on earth a lot longer than humans have (and will probably continue to exist after we disappear) so whether we can drive the polio virus to extinction and stamp out polio is still an open question. The year 2019 was a setback for polio elimination, especially in Pakistan. Did the extent to which a major health campaign to get rid of a crippling disease became a hostage of geopolitics surprise you? The polio eradication campaign has faced setbacks for several years now, not just in 2019. Its last big success was the elimination of polio from India in 2011. Since then, polio caused by the wild, or natural polio virus has remained entrenched in Pakistan and Afghanistan, but more worryingly, cases of vaccine derived polio have surfaced in many countries that were previously thought to be polio-free. The polio campaign does not like to talk about vaccine derived polio, for fear that people will lose confidence in the vaccine. But this is a growing issue the polio campaign faces. Regarding geopolitics, a fascinating story that I was able to explore in this book is how polio eradication became a victim in the U.S. hunt for Osama bin Laden in Pakistan. Polio eradication in Pakistan has always been enmeshed with the rise of the Taliban in Pakistan, and the larger triangular conflict between the Taliban, the Pakistan government and the U.S. This is not particularly surprising. Pakistan is located in a geostrategically important space, and health cannot really be insulated from the larger political environment. Would you agree that the polio eradication programme has been struggling? What is the spark needed? The polio programme has been struggling, and largely because those who are managing it and running it often tend to think in very fixed ways and are reluctant to change. I think one of the biggest mistakes made was to not to move much sooner towards an inactivated polio vaccine rather than the current oral live polio vaccine. The oral polio vaccine is much cheaper, easier to administer, and in most parts of the world, extremely effective. But it has the disadvantage of requiring multiple doses, as well as the side effect of creating vaccine derived polio viruses. The inactivated vaccine does not have these problems, but is more expensive and requires trained personnel to administer. Had the polio campaign raised the funds for a vaccine switch five years or so ago, and made polio vaccination part of other childhood vaccinations, many problems might have been avoided. While India's polio campaign has been a public health triumph, there are grey areas about what has not been achieved, especially in other areas of public health. What are your views on the human response to disease? Eliminating polio was a singular achievement for India, particularly given that two States with the poorest performing governments in the country, Uttar Pradesh and Bihar, had the bulk of polio cases. The elimination of polio in India showed what the country is capable of achieving in the area of health if the political will exists. Unfortunately the same political push does not exist to achieve so many other health problems that cause much more death and disability than polio, ranging from eliminating malnutrition to controlling diseases like malaria, dengue and chikungunya. The government poured resources and political and administrative muscle into polio elimination because India's inability to eliminate polio when so many other countries had was becoming a global embarrassment. Unfortunately, there is no similar international pressure to achieve other health targets. In global health campaigns such as these, it may not be an exaggeration to say that donor funding plays a major role. Is there a danger then of picking only the low hanging fruit with the pressure of timelines and targets? Would this impact the next public health challenge? Donor funding does play a major role in global health campaigns, but many of the existing global campaigns, particularly those required to achieve the sustainable development goals, are long-standing, deep-rooted problems. The health-related sustainable development goals include issues such as reducing the number of women who die in childbirth, the number of children who die in infancy, ending epidemics of diseases like malaria and so on. None of these is difficult to achieve; they do not require any sophisticated technology. All they require is for the government to invest more in our healthcare system, and also give to health the same importance that is placed on issues such as defence and foreign affairs.  |
| Posted: 29 Feb 2020 02:59 AM PST  On 12 December 2019, Bastaj Bibi, a Lady Health Worker (LHW)1 was killed in the Bakkhel area of Bannu in the Khyber Pakhtunkhwa (KP) province in Pakistan while she was on polio vaccination duty. Her rickshaw was attacked and the rickshaw driver also lost his life.2 This unfortunate incident received little international media coverage, though it occurred during a three-day intensive polio vaccination campaign, which commenced on 9 December 2019, following the discovery of a large number of polio cases in Pakistan, a record high since 2017. Incidentally, according to the same report, KP province was the worst affected with 68 cases, in all of which 28 cases occurred in Bannu and 19 cases in the nearby Lakki Marwat region.3 It might be recalled that a nationwide anti-polio vaccination drive launched on 22 April 2019 had to be suspended when gunmen opened fire on female health workers on vaccination rounds, killing Nasreen Bibi (aged 35) and wounding Rashida Afzal (aged 24) in the south-western town of Chaman's remote village of Sultan Zai, which lies in the north-west of Balochistan's provincial town Quetta.4 Two weeks earlier, in two separate incidents, policemen chaperoning polio teams were killed in Buner and Bannu, whilst another male polio worker working with the United Nations (UN) and advocating for vaccination in Ghazi Beg area of Malumzai tehsil in Mohmand tribal district (KP province) was murdered.5 Around the same time, 25,000 children were rushed to hospitals in north-western Pakistan, with social media-fuelled rumours that polio drops were making children ill.6 In 2019, the resurgence of attacks on polio workers followed an acceleration in vaccination rounds, taking the overall tally of polio workers killed in Pakistan since 2012 to 95, of which at least half were women.7 However, the Pakistani government loathes to acknowledge that the killings were directly related to the workers' partaking in the polio campaign, as in the case of a particularly gruesome attack on Salma Farooqi, a 30-year-old LHW, who was abducted from her home, tortured and killed in 2014.8 Women workers, in general, have borne the brunt of anti-polio violence. In 2012–13, nine women were gunned down in Kano in northern Nigeria, and six others in a series of targeted attacks in various parts of Karachi and Peshawar in Pakistan. The murders of UN aid workers following the killings of polio workers lead to a worldwide outrage, but more importantly, the withdrawal of UN workers from Pakistan (Roberts 2013). The Pakistani polio campaign is afoot only due to local (mainly women) frontline workers. GPEI and Pakistan Launched in 1988, the Global Polio Eradication Initiative (GPEI)9 is concentrating all its energy on eradicating the wild polio virus (WPV) 1. WPV 2 and WPV 3, the two other immunologically distinct strains of WPV have been eradicated, and WPV 1 remains endemic only in Pakistan and Afghanistan. The last strongholds of polio also remain in the conflict-ridden regions of Pakistan. KP province (and Federally Administered Tribal Areas [FATA] before it was merged into KP in 2018) exhibits considerable hostility to vaccination, and so does the politically fragile Balochistan. The violence directed at polio workers in urban Karachi can also be traced to the settlements of internal refugees arriving from these conflict zones. This violent opposition (although direct responsibility is seldom claimed after attacks) to serve in these troubled areas is broadly perceived as a major challenge in the global polio eradication campaign. Meanwhile, the steps taken to ensure the safety of vaccinators, "such as conducting SIAs (supplementary immunisation activities) without notice, reducing or suspending house-to-house visits in some locales, conducting campaigns in one day, and cordoning areas to create a security zone" or even "cancellation of post-SIA surveys" have compromised the quality and efficiency of vaccination activities (Alexander et al 2014). Some leading global health scholars (Abimbola et al 2013) tend to explain away the attacks directed at the high-profile polio campaign mainly as a shock tactic to gain international attention.10 However, this argument does not help one understand the rage and general mistrust directed against vaccination teams in this region, more particularly, the persistent, targeted attacks on frontline women workers. There is a broad agreement that the Central Intelligence Agency's (CIA) covert 2010 hepatitis-B campaign wherein a local Pakistani doctor Shakil Afridi was deployed to gather DNA samples as a prelude to the assassination of Osama bin Laden damaged the credibility of all future international health work in the region (Robbins 2012).11 Foreign-driven vaccination drives, already a source of acute unease and nervousness, became unfortunate legatees of this vaccination ruse. Mary Guinan, a distinguished American woman doctor, in her memoirs, rues the rejection of polio vaccination in Pakistan and Nigeria as a result of historic misuse of immunisation programmes even as she recounts her own implication in a similar covert campaign in Pakistan way back in 1980 (Guinan 2016).12 US Public Health Workers and CIA Guinan reminisces that in April 1980, the United States (US) State Department had sought help from the Centers for Disease Control and Prevention (CDC) for their health outreach work. Guinan was enjoined to travel to Pakistan and collect information about health conditions in refugee camps in Pakistan. Another woman doctor from the CDC, Mary Serdula, was recruited into this mission. Guinan was under considerable pressure from the highest echelons of the CDC to accede to this assignment despite her reservations. In fact, both female doctors were initially clueless about their roles. In late May/early June 1980, the CDC provided them a special instrument to measure the height and the weight of children and briefed them about the information they had to collect through a questionnaire administered to women in the camps. In June/July 1980, both women doctors flew into Islamabad, from where they headed to Peshawar. They visited Pathan tribal camps on the Pakistan–Afghanistan border accompanied by a large posse of state department officials. At one point, they learnt that their medical team actually comprised of CIA agents. Both Guinan and Serdula squirmed at this information, but continued their investigations and dutifully submitted their report on "refugee health conditions," although the actual purpose of this expedition was obviously only espionage. The presence of women doctors provided the CIA access into areas that would otherwise be out of bounds for an all-male team. Guinan admits that she had no experience of working with refugees, though the state department ostensibly picked her because of her previous experience of working with infectious diseases in an international context (Guinan 2016). Guinan's first overseas assignment was as a consultant epidemiologist in Uttar Pradesh during India's smallpox eradication campaign (SEP) in 1975. That international health workers were never above suspicion in any country is confirmed by my own survey of memoirs of participants in the Indian SEP. Another female doctor, Cornelia E Davis (then not associated with the CDC), who arrived in India in a similar role, a little after Guinan, discloses that she was asked to report to the local police station as she moved between districts during her surveillance work. Davis admits that she was bewildered to discover that the local police thana in a non-descript town had received prior information about her arrival in the area well in advance (Davis 2018). In politically sensitive parts in north-eastern India, Soviet rather than American epidemiologists were given permission for smallpox work. In the Cold War context, India always tried to balance off its American and Soviet epidemiologists in the field (Guinan 2016: 20), something that the World Health Organization (WHO) bureaucracy was mindful of even when putting together teams of high-profile international epidemiologists. Meanwhile, it must be remembered that Guinan's reminiscences date to a particularly tumultuous period in Cold War history. In 1979, the US–Pakistan relations had reached a nadir. Pakistan along with Iran had opted out of CENTO (the Central Treaty Organization), a quarter-century long US-sponsored alliance system. The US was growing increasingly uneasy because of reports in the Western media of Pakistan's clandestine nuclear weapons programme, which had been actively pursued by Prime Minister Zulfikar Ali Bhutto and continued by his successor, the military dictator Muhammad Zia-ul-Haq. On 22 November 1979, the American Embassy in Islamabad was torched by a mob, leading to deaths of two Americans and two Pakistanis. In Lahore, another mob attacked the US Information Center and set it on fire. There were demonstrations of anti-American violence in Rawalpindi and Karachi. Though contemporary reports relayed that mob violence was triggered by rumours that the US and Israel had participated in an attack on the holy mosque at Mecca followed by a broadcast by Ayatollah Khomeini blaming the Americans, subsequent analyses indicated that the broadcast came two hours after the start of the attack on the American Embassy (Richter and Gustafson 1980: 195). There was an obvious build-up of anti-American feeling after the suspension of food aid earlier in April, among other things, that may have fuelled the anger of Pakistanis. However, the Soviet military invasion of Afghanistan in December 1979 forced both the US and Pakistan to reassess their position and policies, and the US–Pakistan relations were on the mend, most famously evidenced through the "Carter Doctrine" restoring military and food aid to Pakistan. The Soviet military build-up had led to the burgeoning numbers of Afghan refugees arriving into Pakistan. There were 80,000 refugees by mid 1979, and by the end of the year, more than 4,00,000 (counting only those who had registered) were residing in refugee camps, fed by Pakistan and by donations from world relief organisations. Most of them with ever-swelling numbers of women and children were camping in the area of the Khyber Pass close to the Afghan border in the North–West Frontier Province, now known as the KP province. The CIA had used women doctors to infiltrate and spy on these very refugee camps as recalled by Guinan. And, it is precisely in KP and FATA areas that female vaccinators have been violently attacked. Female Frontline Health Workers Reviews of polio immunisation delivery in Afghanistan and Nigeria convinced GPEI of the importance of deploying female frontline workers (FLW) who could access households and vaccinate children in communities practising strict gender segregation (WHO 2019a: 8). Similarly, female "social mobilisers" were deemed useful to improve "attitudes" towards polio vaccination. In Pakistan, a female community volunteers (FCV) initiative, reinitiated in areas of "super high-risk Union Councils" in 2014, showed how an increase in FLWs' participation brought better results for polio eradication. The FCV strategy, which involved women going house to house administering polio vaccine in addition to regular health camps, resulted in community acceptance and improved coverage in hitherto underserved Sindh and Balochistan (WHO 2019: 8–9). What these euphemistically phrased acronyms hide is the fact that these volunteers are "day wage labourers" hired solely for polio work. The women are "paid workers" roped in during vaccination drives. But, a significant workload of polio vaccination is in fact handled by LHWs, many of whom receive an extra allowance for "polio work," which means that this work is privileged over their other routine duties. Even though the stipend is only ₹ 500 ($3) a day, the fact that the campaign manages to recruit women workers is only indicative of their general impoverished status. However, reading over the official policy documents of GPEI, one is struck by the marginal attention paid to violence in these documents. The 2018 GPEI Technical Brief: Gender (WHO 2018: 14) at least mentions the "safety risks" and vulnerability for women on the front line, although startlingly dissociating these attacks from polio, advocating women to keep a "low profile" as they move within communities that "trust" them. Subsequent documents, however, are totally silent on the issue. Meanwhile, dead workers are usually anointed as "heroes."13 The anthropologist Svea Closser offers a scathing critique of the "moral economy of heroism" with which the GPEI (and I add even the Pakistani state) cloaks the lethal targeting of polio workers. Thus, being killed while delivering polio vaccine is not seen as an unacceptable occupational hazard, it only proves the "deep morality of the ground-level staff" (Closser 2015: 25). Women were first aggressively recruited in India between 2007 and 2013 for polio work and the numbers were scaled up in Pakistan and Nigeria in 2013 (WHO 2018: 25). Today, 99% of frontline health workers in Nigeria are women, followed by 56% in Pakistan and 34% in Afghanistan (WHO 2019b: 33). There is continuous pressure to increase these numbers as women health workers are seen as the "linchpin of on-ground polio eradication."14 In Nigeria, male–female disparities in composition of surveillance teams are being flagged, and there is an onus on including more women in surveillance teams.15 In any case, both the policy and public-facing documents of GPEI feature mostly women workers making them the face of the ongoing GPEI campaign.16 Conclusions The push towards greater involvement of women in GPEI is only increasing their vulnerability. However, one sees little acknowledgement of risks or concrete discussion about mitigation. Unveiling a new gender strategy without adequately addressing the violence faced by frontline workers (mainly women) as they go about doing their work is perplexing to say the least, especially if one remembers that UN workers who are paid infinitesimally higher salaries are immediately withdrawn after a single bout of violence. This piece does not seek to reinforce the dominant perception in Western media that pockets of vaccination refusal by Islamic militants are the primary reason for the ongoing polio transmission. In fact, systemic drawbacks in the campaign have been routinely pointed out—the most glaring being an "under-financed" "public infrastructure" delivering a "well-funded campaign," among others (Nishtar 2010: 159). At another level, lack of public trust and violence, after all, do not seem to be unrelated. There is enough evidence that spying under the cover of health work has been a long-standing strategy with the CIA. Hence, vaccination teams, particularly those comprised of women, are resisted not least because LHWs are seen to be delivering a broad range of "Western" services, including contraception (Khan 2011). Public memory of fake campaigns going back over several years may have generally eroded people's trust in all international health services, especially when those are the only visible interventions in a decrepit public health system.17 Finally, my gripe is that workers' deaths are treated in the campaign discourse as roadblocks in the overall uptake of vaccination and eventual success of the campaign. Sadly, there are enough poor women (and men) in Pakistan who will continue propping up this costly programme, as a handful of rich and powerful men set their eyes only upon "reaching the last mile."18 Notes 1 The Government of Pakistan created the Lady Health Worker (LHW) cadre through the Prime Minister's Programme for Family Planning and Primary Care in 1994. The aim was to provide essential primary health services in the community, both in rural areas and urban slums. LHWs are community based and work from their homes (called health houses) within an area of 200 houses. The programme which received little external funding initially 2 https://menafn.com/1099397619/Pakistan-Female-polio-worker-among-two-shot-dead-in-Bannu. 3 The figures for 2019 were 140 polio cases in all with 92 cases in KP, followed by 28 in Sindh and 12 in Balochistan (https://www.endpolio.com.pk/polioin-pakistan/polio-cases-in-provinces). 4 I have scoured through media reports on these incidents to identify the victims by their names. More often than not, one only gathers the numbers of the dead from these reports. See note for a typical headline and drift of coverage (Janjua 2019). 5 https://www.dawn.com/news/1474905. 6 https://www.dw.com/en/pakistan-suspends-polio-vaccine-drive-after-health-worker-attacks/a-48510718. 7 This tally of numbers has been maintained by media sources (https://www.nytimes.com/2019/25/4/world/asia/polio-vaccine-pakistan.html). 9 GPEI, Global Polio Eradication Initiative the private–public partnership between national governments and the World Health Organization (WHO), the United States Centres for Disease Control and Prevention (CDC), the United 10 In the same article, the authors Abimbola et al do concede the detrimental impact of the fake vaccination campaign. 11 On 20 May 2014, the Obama administration formally declared an end to its use of vaccine campaigns as a ruse for spy operations, after considerable pressure from the US public health community. 12 Mary Guinan (2016) is a physician–scientist and winner of the American Medical Women's Association's 2014 Elizabeth Blackwell medal. She joined the CDC in 1974 where she first worked in the Epidemic Intelligence Service (EIS), which investigated global disease outbreaks. She served on CDC's AIDS Task Force and was the first woman to serve as the CDC's Associate Director for Science. In 2004, she was recruited to serve as founding dean at the public health school of the University of Nevada, Las Vegas and is currently Dean Emerita at the institution. 13 https://www.unicefusa.org/press/releases/unicef-and-who-polio-vaccinators-attacked-pakistan-are-%E2%80%9Cheroes%E2%80%9D/8190, 19 December 2012. 14 "The Linchpin of On-ground Polio Eradication: Women Health Workers and Leaders," 8 March 2019, http://polioeradication.org/news-post/the-linchpin-of-on-ground-polio-eradication-women-health-workers-and-leaders/. 15 "Applying a Gender Lens to Nigeria's Surveillance Network," 15 December 2019, http://polioeradication.org/news-post/applying-a-gender-lens-to-nigerias-surveillance-network/. 17 Public trust in Western medical interventions was dented in Kano, Nigeria when the American pharmaceutical company Pfizer conducted a clinical trial allegedly without licence, ethical approval or informed consent and several children died during a bacterial meningitis outbreak in 1996. For many years thereafter, locals resisted any health service that was delivered "free" of charge and remained suspicious of polio vaccination as well (Ghinai et al 2013: 1142). 18 For a powerful indictment of GPEI's top-down approach, see Muraskin (2017); GPEI (2019). References Abimbola, Seye, Asmat Ullah Malik and Ghulam Farooq Mansoor (2013): "The Final Push for Polio Eradication: Addressing the Challenge of Violence in Afghanistan, Pakistan, and Nigeria," PLoS Medicine, Vol 10, No 10:e1001529. Adil, Hafsa (2018): "The Plight of Pakistan's Lady Health Workers," Al Jazeera, 10 April, https://www.aljazeera.com/indepth/features/plight-pakistan-lady-health-workers-18041008 Alexander, James P Jr, Mufti Zubair, Muzaffar Khan, Nima Abid and Elias Durry (2014): "Progress and Peril: Poliomyelitis Eradication Efforts in Pakistan, 1994–2013," Journal of Infectious Diseases, Vol 210, Supplement 1, 1 November, pp S152–S161. Closser, Svea (2015): "Pakistan's Lady Health Worker Labour Movement and the Moral Economy of Heroism," Annals of Anthropological Practice, Vol 39, No 1, pp 16–28. Davis, E Cornelia (2018): Searching for Sitala Mata: Eradicating Smallpox in India, Laredo: Konjit Publications. Ghinai, I, C Willott, I Dadari and H Larson (2013): "Listening to the Rumours: What the Northern Nigeria Polio Vaccine Boycott Can Tell Us Ten Years On," Global Public Health, Vol 8, No 10, pp 1138–50. GPEI (2019): "Global Leaders Pledge US$ 2.6 Billion to Eradicate Polio at the Reaching the Last Mile Forum," Global Polio Eradication Initiative, 19 November, http://polioeradication.org/news-post/global-leaders-pledge-us2-6-billion-to-eradicate-polio-at-the-reaching-the-last-mile-forum-in-abu-dhabi/. Guinan, Mary (2016): Adventures of a Female Medical Detective, Maryland: John Hopkins University Press. Janjua, Haroon (2019): "Polio Vaccinator Is Shot and Killed in Pakistan," New York Times, 25 April, https://www.nytimes.com/2019/25/4/world/asia/polio-vaccine-pakistan.html. Khan, Ayesha (2011): "Lady Health Workers and Social Change in Pakistan," Economic & Political Weekly, Vol 46, No 30, pp 28–31. Muraskin, William (2017): "The Power of Individuals and the Dependency of Nations in Global Eradication and Immunisation Campaigns," The Politics of Vaccination A Global History, Christine Holmberg, Stuart Blume and Paul Greenough (eds), Manchester: Manchester University Press, pp 321–36. Nishtar, Sania (2010): "Pakistan, Politics and Polio," Bulletin of World Health Organization, Vol 88, No 2, pp 159–60. Robbins, Anthony (2012): "The CIA's Vaccination Ruse," Journal of Public Health Policy, Vol 33, No 4, pp 387–89. Roberts, Leslie (2013): "Killings Force Rethinking of Pakistan's Anti-Polio Drive," Science New Series, Vol 339, No 6117, 18 January, pp 259–60. Richter, William L and W Eric Gustafson (1980): "Pakistan 1979: Back to Square One," Asian Survey, Vol 20, No 2, pp 188–96. WHO (2018): GPEI Technical Brief: Gender, http://polioeradication.org/wp-content/uploads/2018/03/GPEI-Gender-Technical-Brief-2018-ver-3.0.pdf. — (2019a): GPEI Polio Endgame Strategy 2019-2023 Eradication, Integration, Certification and Containment, WHO/POLIO/19.04, http://polioeradication.org/wp-content/uploads/2019/06/english-polio-endgame-strategy.pdf. — (2019b): GPEI Gender Equality Strategy 2019-2023, p 8, WHO/POLIO/19.04 http://polioeradication.org/wp-content/uploads/2019/11/GPEI_Gender_Strategy_EN_web.pdf. — (undated): "Pakistan's Lady Health Worker Programme," Global Health Workforce Alliance, https://www.who.int/workforcealliance/knowledge/resources/casestudy_pakistan/en.  |
| You are subscribed to email updates from "polio vaccine in india" - Google News. To stop receiving these emails, you may unsubscribe now. | Email delivery powered by Google |
| Google, 1600 Amphitheatre Parkway, Mountain View, CA 94043, United States | |
Comments
Post a Comment