Thursday, January 10, 2013

Lessons From India: How to Promote the Polio Vaccine in Pakistan


The polio vaccine being administered to a child in New Delhi, in this Jan. 12, 2012 file photo. Kevin Frayer/Associated Press.
India currently is observing a significant public health milestone: two full years without a new case of poliomyelitis, the paralyzing and sometimes deadly virus that has robbed so many millions of our children of productive futures.
The last reported polio case – a young girl in West Bengal – was recorded on Jan. 13, 2011. In February 2012, the World Health Organization removed India from the list of polio-endemic countries, a historic achievement given that until very recently, India was considered the epicenter of the disease and had been predicted to be the last country to stop polio.
Today, the wild polio virus circulates in only three countries: Afghanistan, Nigeria, and our neighbor, Pakistan, where the polio eradication campaign has been in the news lately, but, unfortunately, not because of the impressive 65 percent reduction in cases Pakistan has achieved since 2011. Sadly, the news out of Pakistan has focused on a recent spate of violence targeting polio vaccinators, the dedicated army of health workers and volunteers who go door-to-door to reach the most at-risk children with the oral polio vaccine. Their dedication and hard work are largely responsible for the tremendous progress in the war against polio, with only 218 cases reported worldwide so far in 2012,  a record low, down from 350,000 cases a year in the 1980s.
During December’s sub-national immunization days in Pakistan, nine frontline health workers, six of them women, were shot and killed. The media have linked the violence to lingering suspicions within some segments of the Muslim community that polio eradication is some sort of Western conspiracy to sicken or sterilize Muslim children.
Cultural misconceptions are one of many challenges we face as we close in on our goal of global eradication, along with poverty, illiteracy, malnutrition, poor sanitation, extreme population densities, inadequate infrastructure, geographical isolation — the list goes on.
Members of India’s Rotary clubs are very familiar with all of these challenges, including the problem of vaccination refusals by parents in Muslim communities. Over the last year we have been sharing our experiences with our friends in Pakistan in the hope our success can contribute to successful resolution of the issue there.
In a nutshell, our approach in India has been to reach out to the local and regional religious leaders and scholars to inform them about polio eradication and why reaching every child with the vaccine is so important. We openly discuss the misconceptions and suspicions that some people harbor – such as the notion that the vaccine contains swine or monkey cells — and explain why they are false.  Rotarians, as fellow members of the community, have an element of innate credibility that perhaps outside authorities lack at first. We can talk about “our” children, not “your” children.
The Rotary Club has a long history in Pakistan, as it does in India: the Rotary Club in Karachi was chartered in 1933, and there are presently 151 Rotary Clubs in Pakistan.
I have been involved in this issue since 1997, when I was appointed to India’s National PolioPlus Committee of Rotary International. (PolioPlus is the polio prevention program started by Rotary International in 1985, three years before the launch of the Global Polio Eradication Initiative now led by Rotary, the World Health Organization, UNICEF, the U.S. Centers for Disease Control and Prevention, and the Bill & Melinda Gates Foundation.)
At that time, Mumbai was at high risk for polio, especially in areas with large Muslim communities. I sought and was granted repeated meetings with the leading imam, who, finally convinced, went so far as to reprimand parents of children who were not immunized. At his request, we put up hundreds of pro-vaccination posters and banners around the periphery of the main shrine and mosque three days before a scheduled National Immunization Day. The posters at those religious places sent a message to his followers that if the imam approves polio immunization, they should also. Over time, community resistance declined and Mumbai became polio free.
We continued successfully along this path on a more-or-less informal basis as India made great gains against polio, recording only 66 cases in 2005. But in 2006, an alarming number of infections in western Uttar Pradesh and Bihar threatened to derail our progress. Of the 676 cases in India in 2006, 548 were in Uttar Pradesh and 59 percent of those were from the Muslim community.

Our response was to call for a meeting of the leading Muslim imams, ulemas, scholars, physicians, and educators in New Delhi in August 2006. Out of this came Rotary International’s State Level Committee of Muslim Ulemas in Uttar Pradesh. This, for us, was one of the biggest achievements in the effort to engage the Muslim community.
The state Muslim Ulema Committee thereafter played a significant role in bringing about a metamorphosis, successfully persuading hitherto resistant and unwilling sections of the community to accept the oral polio vaccine. Committee members issued appeals on behalf of polio eradication and walked with Rotarians, health workers, and vaccinators to booths and homes to ensure children received the vaccine. Several of them personally administered the vaccine drops to their own children to demonstrate to their followers that it was harmless.
The numbers soon demonstrated the effectiveness of this approach. In 2008, Muslim children accounted for 37 percent of polio infections in Uttar Pradesh, down from 70 percent the previous year. The concept was quickly expanded with the formation of district level ulema committees throughout the state. Rotarians in these regions continuously follow up to ensure that the campaign remains up to the mark. Last month, I met with a top administrator at Aligarh Muslim University to garner the support of doctors associated with the university to promote the campaign.
Ulema Committee members are now sought by the Health Ministry and other agencies to advocate not just for polio, but other health and sanitation needs in the Muslim community.  Rotary is organizing free camps to reach the community with basic health care services. With the Ulema Committee, Rotary created a partnership that will endure and yield benefits far beyond the eradication of a single disease.
This is not to say that the India experience provides the perfect template needed to address the situation in Pakistan. There are of course major differences between the two countries, the most obvious being that Islam is a minority religion in India. The respective political landscapes also are vastly different. But one common denominator is the presence of Rotary and the commitment of Pakistani Rotarians to rid their country of this terrible disease.
What we did in India shows that by working hand-in-glove with the true faith leaders of the communities at risk — by gaining their trust and support through sincere dialogue and by keeping the focus always on the well-being of the child – polio eradication is achievable even under the most challenging conditions.
Ashok Mahajan, a member of the Rotary Club of Mulund, Maharashtra, is a Trustee of The Rotary Foundation of Rotary International, a spearheading partner in the Global Polio Eradication Initiative.


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