Polio tales

107BlockPlanICU

India Communication Update is produced monthly by the United Nations Children’s Fund (UNICEF) India in consultation with partners and is circulated by email as a PDF document. This particular edition highlights the strategic vision of the 107 Block Plan, which is a holistic and multi-pronged approach to address the challenges in the 107 blocks of India’s two polio-endemic states (Uttar Pradesh (UP) and Bihar), as well as how the communication effort is supporting implementation in the field. The strategy is motivated by commitments such as that expressed by the Government of India, which – as the Deputy Commissioner (Immunization) states here – is committed to the Global Polio Eradication Initiative (GPEI) and to ensuring that India is polio-free.

As detailed here, the 107 Block Plan is focused on ensuring maximum oral polio vaccine (OPV) vaccination coverage during each polio immunisation activity. Children and young people play a critical role in community mobilisation.

In one interview that is included in this resource – that with the Project Manager, World Health Organization (WHO)/National Polio Surveillance Project (NPSP) – the 107 block strategy aims at focusing all efforts to ensure high-quality oral polio vaccine (OPV) campaigns in the high-risk blocks and at the same time rapidly improving routine immunisation (RI) and prevention and control of diarrhoea through sanitation, availability of clean water, and hygienic practices. NPSP is supporting the local authorities in implementing the strategy, in part by offering management trainings and technical briefings on RI and 107 block plan strategies for surveillance medical officers (SMOs) to enhance their skills.

Another interview, with the Chairman of Rotary International’s India Polio Plus Committee, notes that task forces have been established in both states to initiate the plan; also Rotary has proactively put together two additional task forces to cover West Bengal and Punjab in the wake of emerging polio threats and cases in these states. Rotary has appointed 47 Rotary Polio Block Coordinators in 66 blocks of UP and has assigned 2 Rotarians per block in the 36 blocks in Bihar. These personnel, having recently received training, are providing support for OPV and RI, diarrhoea management, and converting resistant families. Other strategies Rotary is pursing include: building political will and momentum (by, for example, visiting a Rotary-supported health camp in Kusumpur slum, Delhi) and keeping up the morale of the health worker in the field by providing motivating incentives like utility kits and recognition for service in the form of Rotary “Appreciation Certificates”.

Also described here is a new system developed by UNICEF and the CORE Group for communication monitoring, which has been initiated and fast-tracked first for the high-risk blocks of UP. The one-page communication profiles are generated and posted online after each supplementary immunisation activity (SIA) and are reviewed together with polio case data and operational data in order to relate communication issues to epidemiological and other health challenges that may impact the eradication effort.

Contents of the resource include:

• Polio Eradication: A Priority on the Government’s Public Health Agenda
• The Battleground for Eradication: Finishing Polio in the 66 Highest Risk Blocks of UP
• Rotary Builds Support and Political Momentum in Polio High Risk Blocks: Interview with Deepak Kapur, Chairman Rotary International’s India Polio Plus Committee
• India Unites to End Polio Now: Partnering with the Private Sector to Expand Polio Messaging and Outreach
• UNICEF’s Communication Strategy to Promote Healthy, Polio-free Children: Interview with Karin Hulshof, Representative UNICEF India
• Mobilising Nomads for OPV in Ghaziabad
• Targeted Risk Reduction Strategies: The Key to Polio Eradication in India – An interview with Dr. Hamid Jafari, Project Manager, WHO-NPSP
• Progress in Convergent Activities under the 41 High Risk Block Plan in Bihar
• Washing Hands to Prevent Polio Transmission in Uttar Pradesh
• Sharpening Communication Interventions with Data: Monitoring community engagement in the 107 Blocks

Amitabh Bachchan, Oct 24, 2010

Dr Margaret Chan
Director-General of the World Health Organization

Mr Secretary-General, distinguished panellists, ladies and gentlemen,

I welcome the opportunity to speak at this event. The title is apt. Polio eradication is unfinished business. Persistence in moving towards the eradication goal, and changes made along the way, hold lessons for the wider MDG agenda.

Polio eradication demands that we deliver the most basic of health services, two drops of vaccine, to every last child. Scaling up to reach everyone in need is the core of the polio initiative, and the core of the MDG approach for reducing human misery.

For the health-related MDGs, this means scaling up the delivery of commodities, but also strengthening basic health services and infrastructures along the way. Polio has done both.

From the polio experience, I see three key lessons. They concern innovation in partnerships, innovation in strategies, and innovation in technologies. These lessons can help rid the world of this virus, once and for all. They can also help us reach the MDGs.

Ladies and Gentlemen,

One of the most important lessons offered by the Global Polio Eradication Initiative is the strength that comes from partnerships.

This entire initiative began because of the vision of Rotary International, one of the oldest civil society organizations in the world. Its more than one million members have been tireless partners in the polio eradication effort, volunteering to immunize children, advocating with political and community leaders, and mobilizing nearly 1 billion dollars.

In the past year, the International Federation of the Red Cross and Red Crescent Societies has massively scaled up its support for polio eradication. This support has enabled the eradication initiative to reach and mobilize the most remote communities in west Africa, and independently monitor the recent 19-country synchronized immunization campaigns.

Let me be very clear: the UN cannot achieve polio eradication without this kind of support from civil society organizations. You are on the ground, on the spot, in touch with grassroots and the leaders at the top.

And let me give you a clear challenge: we need your support going forward, particularly in helping us reach every child in Angola, in Chad, and in eastern Democratic Republic of the Congo.

Reaching the MDGs means reaching everyone in need, also in difficult and dangerous conflict zones where health needs are often greatest. Again, partnership with NGOs active in these areas has been critical.

Through organizations like the International Committee of the Red Cross and other NGOs, the initiative has negotiated Days of Tranquillity by working with all sides of the conflict, from international military forces, to peacekeeping operations, to armed militias. Such negotiations help guarantee safe passage for vaccination teams and secure access to children.

Reaching the MDGs requires courage as well as commitment. Polio eradication has taught us that even children living in the world’s most dangerous places can be reached.

We know, and our vaccination teams know, that every time we hold an immunization campaign in these areas we are risking lives. But we also know that we are saving lives.

Ladies and gentlemen,

As a second lesson, polio shows the importance of having flexible strategies that are constantly refined, as we are seeing this week with the MDGs.

To attain the MDGs, we need strategies that deliver interventions to hard-to-reach populations, strategies that build political and grassroots support, and strategies that enhance accountability. Sometimes, we need strategies that carve basic infrastructures out of virtually nothing.

For polio, efforts to reach migrant populations have elevated micro-planning to an art form. Every child under five, in every home, in every street, city, town, and village has a name. Even children in highly mobile populations are being tracked.

Every child that needs to be reached to attain the MDGs has already been reached by polio teams. The lesson: it can be done.

For example, in the vast, flooded Kosi River Area of Bihar State in India, our vaccination teams can travel for up to seven hours to reach the last child in the furthest village. They travel by boats and motorcycles, and wade through mud. That’s determination, and that’s a strategic plus.

This year, Mr Bill Gates went to meet that last child, travelling to this remotest region to see for himself just how difficult it is to reach, but also to see how effectively these campaigns are being conducted.

Needless to say, Mr Gates didn’t wade through mud for the final miles. He took his helicopter. In his view, as stated to the press, the Indian polio programme is unmatched by any health programme in the world. Why? Because it reaches every child in one of the most populous, fastest-growing countries on earth. Because it can be done.

In the final pockets of polio transmission, highly localized challenges have demanded distinct area-specific approaches. Together with partners, the polio eradication initiative has mobilized massive, on-the-ground technical assistance and infrastructure in these most at-risk areas.

UNICEF has ensured the timely procurement and delivery of more than 2 billion doses of oral polio vaccine to these far corners of the world.

To deliver this vaccine, the polio initiative has built a functioning cold chain, transportation, and communication system. This is a key infrastructure which greatly assists in strengthening local health systems and other immunization services. This is how scaling up the delivery of commodities can build infrastructure.

Polio has also developed an independent monitoring system to evaluate the reach and effectiveness of immunization activities and help identify areas of weakness.

The initiative has worked extensively with local civil society organizations, mainstream and traditional media, religious and traditional leaders, and the communities themselves. This builds grassroots support, another lesson for the MDG agenda.

To ensure buy-in from politicians and communities, the initiative has systematically advocated with leaders at national and sub-national levels and developed accountability mechanisms, such as the Abuja commitments in northern Nigeria. Doing so relied on strong support from partners like Rotary International, the Bill and Melinda Gates Foundation, the UN Foundation, and the Organization of the Islamic Conference.

As we have learned, the engagement of traditional leadership is critical. Take the state of Kano in northern Nigeria. Five years ago, this state suspended all polio immunization campaigns for two years. Even 18 months ago, Kano was the global epicentre of type 1 polio.

But thanks to the leadership of officials like Dr Muhammad Pate, who is with us today, this state has experienced an extraordinary turnaround through effective dialogue with communities and engagement with traditional leaders.

Twice in the past year, the Emir of Kano has launched two immunization campaigns by standing in front of the state’s media, vaccinating his grandson, and calling on Kano’s citizens to do the same.

As a final lesson, the eradication initiative shows the importance of technical innovation. We now have a full toolbox of vaccines, having developed and fast-tracked the introduction of monovalent and bivalent oral polio vaccines. This innovation has allowed the programme to tailor solutions to problems.

With excellent support from the US CDC, the programme has built sensitive surveillance systems globally, which are the world’s first defence against outbreaks. The programme has also established an accredited laboratory network, staffed with trained lab technicians.

Real-time scientific procedures were developed to rapidly identify polio cases and genetically track each virus. This tells us, for example, that Angola’s outbreak came not from Nigeria, but all the way from northern India.

Ladies and gentlemen,

I have a final lesson that is also being discussed this week: the need for financial sustainability.

Polio is unfinished business but it is also good business. Polio eradication will save the world billions of dollars each year. The economics are sound. They have been studied and published. Yet even this close to the final goal, the lack of funding is the greatest risk facing this historic effort.

We have few opportunities in our lives to deliver a historic goal such as polio eradication. I therefore call on donors to capitalize on this historic opportunity, and help fund the full implementation of the new polio eradication strategic plan for 2010-2012.

The strategy is already having an impact. In Nigeria, case numbers have fallen by a striking 99%. The Horn of Africa is again polio-free. West Africa has not had a case since the first of May. In India, cases are down by 87%. But we must not let down our guard.

Nigeria and India are still recording cases, and outbreaks are still occurring. This is precisely the time when we need to be more vigilant and more aggressive in our actions to finish the job.

Polio also tells us something about the rewards of steadfast commitment to ambitious goals. When eradication is achieved, we will have delivered a perpetual gift: no child will ever again suffer life-long paralysis from polio.

Equally important, this enormous effort will have established partnerships, infrastructure, and new knowledge that can help other programmes reach everyone in need, everywhere.

Thank you.

As CEO of the Bill & Melinda Gates Foundation, my job is to make sure we are using our resources—our endowment, the expertise of our staff, and the voices of our leaders—to the utmost, so that we can have the maximum possible impact on people’s lives. And the next five years offer a historic opportunity to have an impact on the health and welfare of people in the developing world. Even in the face of very tough economic times across the globe, I am optimistic when I think about all that we can accomplish together with our partners.

I think in terms of the next five years because 2015 will be a landmark year. In 2000, the United Nations took the historic step of setting specific targets in eight areas of global health and development. It called them the Millennium Development Goals (MDGs), and it gave the world 15 years—until 2015—to meet them.

The MDGs set the clearest health and development agenda the world has ever had, and the decade since they were ratified has seen more progress than any other 10-year period in history. Just two weeks from now, the UN will convene a special session to discuss how governments, foundations, and NGOs can work together to speed up that progress.

In the next five years, we also have the chance to introduce vaccines for rotavirus and pneumococcal disease into the developing world. Vaccines are a miracle (not to mention an extremely high-return investment), because with just a few doses, they protect a child for a lifetime. In five years, we could be immunizing hundreds of millions of infants against two diseases that currently take the lives of 2 million children every year.

And in five years, we will be even closer to the complete and total eradication of poliovirus from the earth.

Almost everybody has heard of polio, but many people don’t know it still exists. Most people aren’t aware of the enormous and longstanding global effort to eradicate the disease, and very few understand the critical juncture we’re at right now.

It’s worth taking a moment to reflect on what eradication means. If vaccines are miraculous because they protect a child for a lifetime, then eradication is the ultimate miracle. Eradicating a disease protects all children, forever.

It’s enough to measure the impact in terms of lives saved and suffering averted. But the moral case is augmented by an economic one that’s almost as powerful. Yes, it’s going to be expensive to travel the last mile toward eradication. But it will be exponentially more expensive if we don’t reach the end of the road, because we’d have to keep on treating thousands of children paralyzed each year indefinitely.

According to a recent cost-effectiveness study, investments in polio vaccination in the United States have prevented 1 million cases of polio and saved more than $180 billion. In the countries where polio is still a threat, that savings could go a long way toward addressing some of the other health problems with which poor people continue to struggle.

Since 1988, when the world set the goal of eliminating the disease forever, the number of polio cases has gone down by 99 percent. Just two decades ago, the disease was circulating in 125 countries; now, there are only four countries that have never stopped transmission of the disease.

But eliminating polio from the last handful of countries is a lot harder than eliminating it from the first handful. It takes a massive effort to eradicate a disease, which is why it’s happened only once before, when smallpox was eradicated in 1980.

The difficulty involved in ferreting out every last poliovirus is staggering. It takes an effort of such consistent intensity that it’s simply not sustainable over a period of years and years.

We have a narrow window of opportunity. It is impossible to keep the virus at its current levels indefinitely. Either we eradicate polio—preventing suffering, saving billions of dollars, and demonstrating what is possible with a global effort—or we fail and start to backslide. If we fail the number of cases will start to go back up, and the virus will spread back over borders into countries where it has been eliminated. We are seeing this play out in Tajikistan, part of a region declared polio-free in 2002, where 454 cases of polio have been confirmed this year.

The stakes are so high, and we have come so far, which is why I am so surprised that the world is short of the funding it needs to finish the job. Right now, there is not enough money past next summer to carry out all of the immunization activities to keep the world on track to eradicate polio. It’s shocking, but funding from the G8 countries has actually gone down in the last several years.

It’s very clear: This is make-or-break time for polio eradication. That’s why polio is one of my top priorities as CEO.

When we invest in polio eradication, we know exactly what we’re getting for our money. The eradication campaign is extremely well organized and has a long record of success.

The Global Polio Eradication Initiative (GPEI) is a model partnership. The U.S. Centers for Disease Control and Prevention (CDC), Rotary International, UNICEF, and the World Health Organization (WHO) have been working to support polio-affected countries for more than 20 years.

Each partner plays a particular role, doing what they do best to make an extraordinarily effective whole. Rotary is a powerful fundraiser and advocate. CDC provides technical expertise. UNICEF purchases oral polio vaccine and supports grassroots mobilization, and WHO leads surveillance, operations, and the complicated logistics on the ground.

One of the main things we’re adding to the effort, along with our own financial commitment, is our voice. We have a platform from which we can help generate attention. Hopefully, that attention will in turn help generate the funding and political commitment needed to finish the job.

Bill, Melinda, and I make regular site visits to India, one of the four remaining countries where the disease is endemic—and we will continue to do so, to see the progress on the ground and meet with key leaders. In recent years, Bill has also traveled extensively to Nigeria, another endemic country.

The progress happening in both those countries makes me optimistic. In Nigeria between January 1 and August 24, 2010, there were just six cases of polio, compared to 368 during the same period last year. India has reported the lowest number of cases in a decade; so far this year only 30 cases have been registered, against last year’s 236 at this point.

The most exciting thing about all the work we’re doing together with our partners around the world and in the United States is the tangible difference we can make in the lives of millions and millions of people: newborns in India, high school students in Los Angeles, small farmers in Ethiopia, homeless families in my hometown of Seattle, to name just a few.

When I travel on behalf of the foundation, whether it’s to slums and villages in poor countries or to high schools and community colleges in the United States, I am always moved by people’s eternal hope for a better life. At the foundation, we share their ambition and their optimism.

I look forward to the day when I can write a letter talking about how the world eradicated polio.

Jeff Raikes
CEO, Bill & Melinda Gates Foundation

Abstract

In 1988, the World Health Assembly (WHA) passed a resolution calling upon the world community to eradicate polio by the year 2000.¹ Together with Rotary International, the United Nations Children’s Fund (UNICEF), and the U.S. Centers for Disease Control and Prevention (CDC), the World Health Organization (WHO) launched the Global Polio Eradication Initiative (GPEI) in 1988. Since then, millions of health workers and volunteers have been mobilized to provide the Oral Polio Vaccine (OPV) to billions of children, and the incidence of polio paralysis has been reduced by 99% around the globe. In spite of this enormous effort, eradication has remained elusive, and GPEI deadlines have come and gone twice. This article seeks to draw lessons from the advocacy work that kept the money flowing in the face of increasing needs and a constantly receding horizon.

As of November 2009, the official projection for certifying the world polio-free is 2013, 25 years after the 1988 resolution and 13 years after the original target date, with no certainty that even 2013 is attainable. One informant involved with the GPEI suggested that no one was prepared for the prolonged eradication effort and the spiraling costs that made resource mobilization such a challenge. In 1988, the cost estimates to secure eradication by 2000 totaled U.S.$1 billion (Bart, Foulds, & Patriarca, 1996; Informant-9, 2009), and the U.S.$100 million annual cost figure for polio eradication remained static through the mid-1990s (Cochi, Hull, & Ward, 1995). Numerous unforeseen factors drove up costs. Volunteer vaccinators were replaced by those receiving per diems. Vaccine refusal, increasing vaccine prices, armed conflicts, political instability, health system decentralization, deterioration of health care delivery, and related declines in routine immunization challenged eradication planners and drove up costs (Fields, 2009). The GPEI projections for 2013 now suggest total expenditures of U.S.$7.2 billion over the life of the effort.

In hindsight, it is clear that the GPEI until late in the initiative underestimated the costs of eradication, the funds needed from donors, and the centrality of resource mobilization to the success of eradication. Funding shortfalls at critical junctures (1999-2005) had a negative impact on the GPEI efforts, underscoring the conclusion that advocacy for resource mobilization is as central to operational feasibility as are science and technical solutions.

The advocacy messages used by the GPEI tended to be overly optimistic and glossed over criticisms of eradication or countered criticism with arguments that have grown harder to sustain. The program’s need for increasing levels of funding seems to have encouraged overly optimistic statements about the achievability of deadlines even in the face of contrary evidence. In addition, the publicity surrounding the resource mobilization campaign directed toward the Group of Seven/Group of Eight (G7/G8) and smaller Western countries inadvertently may have played into perceptions that polio eradication was a Western-driven and not a truly global priority. This plays out as a fairly pervasive belief in endemic countries that priority should be given to other diseases such as malaria and measles, which have higher perceived mortality, morbidity, and cost implications.

It is important to recognize at the outset that decisions were made in the context of the knowledge available at the time. None of the findings or questions raised in this study is intended to take away from the commitment, the dedication, and the many substantive accomplishments of those who have led the effort to eradicate polio and who have mobilized the resources required to do so. While it can be said that a lack of sufficient resources has plagued the program and may have contributed to missed deadlines, it also has been, according to informants, a remarkable achievement of unprecedented resource mobilization for global health.

Research Methodology

Sources for this study have included numerous publications and unpublished reports of the GPEI partners and working groups, partner internal documents, hundreds of print media articles in donor and polio-infected countries, secondary sources, and interviews with key polio eradication stakeholders. Most interviewees asked to speak on the condition of anonymity. The WHO/GPEI in Geneva declined a request for an interview.

Setting and Missing the 2000 Goal

In setting the goal of polio eradication by the year 2000 with certification 3 years after the last case, the WHA was buoyed by the important strides made by the Pan American Health Organization (PAHO) toward achieving polio eradication in the Americas. In 1985, under the leadership of Brazilian epidemiologist Ciro de Quadros, the PAHO launched an initiative to eradicate polio from the Western Hemisphere by the year 1990 (Fujimura, 2005). The striking success of mass immunization of children in Brazil and Cuba, using National Immunization Days (NIDs), showed the feasibility of eradication and established technical methods that could be applied to the global effort.

The global movement to eradicate polio also came on the heels of the successful, comparatively inexpensive, and relatively short-lived (under 10 years) smallpox eradication campaign. Smallpox eradication succeeded in large measure because there were a number of highly favorable characteristics that facilitated eradication, including a very heat-stable vaccine that protected with a single dose. No other disease came close to matching these advantages (Henderson, 1998). The idea of ridding the world of a second disease generated impassioned advocacy, as evidenced by the testimony of Rotary International polio eradication advocate Herbert Pigman before a subcommittee of the U.S. Senate Appropriations Committee in 1998: “Humankind is on the threshold of victory against Polio, and we must not miss this window of opportunity. Poliomyelitis will be the second major disease in history to be eradicated, but not the last” (Pigman, 1998).

The setting of the year 2000 goal was rich in symbolic value. The 1988 WHA Resolution indicates that the date “represents both a fitting challenge…and an appropriate gift, together with the eradication of smallpox, from the twentieth to the twenty-first century.” The architects of the 1988 resolution also believed that achieving eradication by a specified date would help assure that the GPEI would be spared the fatigue that inevitably would result if the eradication campaign were to extend over a longer period of time (Quadros, 2009)—one of the lessons learned from the failure of the costly effort to eradicate malaria that began in 1955 and was called off in 1970 (Prothero, 2003; Scholtens, Kaiser, & Langmuir, 1972).

A former United Nations (UN) agency official involved in the GPEI believes that the goal setting for polio eradication was likely a miscalculation:

Our technical communities wanted to serve up the silver bullet and make promises to get near-time resources without thinking about the long-term consequences of losing credibility on missing dates. The issue is, with 20-20 hindsight, did you really need a polio eradication goal to make long-term sustainable progress on polio elimination and possibly even eradication? (Informant-5, 2009)

The failure to attain successive target dates has tested the GPEI’s credibility among diverse audiences, including donors, and, according to informants, discouraged many around the globe who had rallied to the goal of achieving eradication by 2000. Despite the missed target dates, the GPEI continued to attract substantial amounts of funding, possibly because the size of past investments and early public statements of support seemed to incline major donors to continue to pursue eradication. One donor country official discounted the influence of GPEI global advocacy efforts on donors:

To some extent our decision on funding is a product of the fact that we’re in so deep already; the sense is that we can’t tell the public we spent billions, and we didn’t do what we set out to do. For me, that’s a much more powerful motivation than any sort of advocacy I’ve seen from GPEI. (Informant-2, 2009)

The Slow Start: From Country Level to Global Advocacy

Two early implementation decisions delayed the design of GPEI’s resource mobilization strategy, and the delay led to future setbacks in the eradication effort, including the failure to meet the 2000 goal. First, based on experiences in the Western Hemisphere, the 1989 Plan of Action sought to secure “high-level national commitment to the program and to ensure that personnel and resources are made available” (G8 Research Group, 2006). The Plan of Action was intended for polio-endemic countries, which was valid and necessary. By the second half of the 1990s, however, the GPEI partners realized they had underestimated the resource requirements and overestimated the capacity of lower-income countries to cover eradication costs, and so they gave greater emphasis to mobilizing resources from donors.

Second, in expanding polio eradication beyond the Western Hemisphere, the GPEI first focused on regions with stronger health infrastructures and only later turned to the more challenging areas, including sub-Saharan African (Informant-7, 2009). The following factors created an environment for rapid success in the first regions: political commitment to high-quality polio campaigns, effective routine immunization systems, trust in government-provided health services, and the capacity to find innovative solutions required to eliminate pockets of transmission (backed by substantial technical assistance from the GPEI). Countries in more challenging regions proved more difficult due to their weaker health infrastructures, fewer human and financial resources (e.g., to reach all underserved, minority, or nomadic areas), limited ability to address local conflicts or counter rumors about vaccine safety, or all of these conditions (Letor, 1998; WHO, Regional Office for Europe, 2001).

There are valid reasons for delaying programs in difficult operational environments, including the need to establish baseline information and build surveillance and laboratory capacity (Informant-7, 2009). There is also merit in looking for quick wins to build momentum. Since the most difficult areas also may be those where social and political challenges are more likely to threaten implementation, and waiting may only make the threats worse and costs higher, however, decision-making on where and when to start a program should consider political as well as health factors. An argument can be made that the longer a public health initiative requiring mass social mobilization takes, the more likely the effort will encounter unexpected social and political developments, both in endemic countries and globally.

The decision to first start in the “easiest” environments meant that the credibility of the main advocacy message about the achievability of eradication by 2000 was not tested in the more difficult operational environments until quite late in the game, and it also contributed to the relatively late recognition of resource underestimation. By the mid-1990s program managers recognized that earlier resource projections fell far short because they failed to appreciate the difficulty of the effort required to carry out large-scale eradication campaigns, especially in countries with poorly developed systems to support routine immunization (Informant-9, 2009). The long-term challenge of resource mobilization came to pose a threat to the entire eradication effort in the period 1999-2003, as eradication costs skyrocketed and funding shortfalls emerged (Lahariya, 2007).

The limited resources used for polio eradication from 1988 through 1995, as well as the burgeoning costs after 1995 as the GPEI encountered difficulties and as assistance to resource-poor countries increased (WHO, 2009).  Annual expenditure, 1988-2008; financial resource requirements, contributions, funding gap, 2009-2013.

Rotary Takes the Lead in Responding to Growing Resource Demands

In the 1980s, Rotary International had adopted polio eradication as a global humanitarian cause that could be achieved by the time of the organization’s centennial in 2005. A far-flung international volunteer organization of business and professional leaders that in 2009 consisted of more than 32,000 service clubs and 1.5 million members in 166 countries, Rotary’s prominent and successful role in the mobilization of human and financial resources for polio eradication is unique in the global public health arena (Anonymous, 2005; Pigman, 2005; Rotary International Foundation, n.d.).

From the beginning, Rotary saw its commitment as complementing the work of UNICEF, WHO, and other major players. With concurrence of its partners, it made the decision in 1995 to increase its advocacy efforts in response to the anticipated gap caused by growing resource demands. The organization budgeted U.S.$3 million over 5 years to launch two major advocacy initiatives: the PolioPlus Partners Program and the Ad Hock Task Force on International Advocacy. PolioPlus sought to involve Rotarians in target countries in social mobilization, assistance to polio laboratories, and support to polio medical officers/epidemiologists. Most relevant for this study, the Ad HocTask Force on International Advocacy’s aim was to convince donor governments to increase their financial support for polio eradication. Rotary reported that this advocacy campaign resulted in increased contributions of more than U.S.$135 million. Rotary also was instrumental in securing the involvement of private sector partners—for instance, Coca Cola support in several African to “Kick Polio Out of Africa” (Rotary International Foundation, 1997).

Also in 1995, Rotary took the lead in articulating a strategy of media outreach to influence government leaders in donor countries and their constituencies (Rotary International Foundation, 1996). Prior to this, there had been little or no media coverage of GPEI within donor or potential donor countries. A survey of leading U.S. newspapers including the New York Times, Washington Post, and Boston Globe revealed that only one article was published on global polio eradication in the period 1990 through 1995. Once Rotary (and, later, other GPEI partners) began to engage the media, polio eradication enjoyed more frequent coverage in these major U.S. newspapers as well as in newspapers in other donor countries. In the United States, this helped create the enabling environment and momentum that contributed to Rotary’s success in securing U.S. government funding to launch, for instance, USAID’s GPEI in 1996.

Accelerating Polio Eradication Activities and the Growing Challenge of Resource Mobilization

In 1998, GPEI’s Technical Consultative Group expressed its “deep concern that the resources needed to complete the eradication task had not yet been identified” and said looming shortfalls constituted “the single greatest obstacle to global eradication” (Global Technical Consultative Group, 1998). In a race to meet the 2000 target, the GPEI had adopted a new strategy, and additional resources were desperately needed to carry out expanded and accelerated activities, including increased rounds of NIDs and a house-to-house vaccine delivery strategy designed to enable vaccination teams to find and immunize more children (WHO, 2001a).

The polio partners responded by intensifying their global advocacy effort. A new GPEI management team took charge in 1998 at WHO headquarters with a mandate to revitalize the eradication effort and mobilize additional resources. Canadian physician and epidemiologist Bruce Aylward led the team; he soon gained a reputation for being a tireless and passionate champion of global polio eradication.

At this time, GPEI also named WHO and UNICEF as the lead partners in donor advocacy and announced its intention to launch a “global communication campaign” aimed at donor governments, health ministries and political leaders in polio-endemic countries, private companies, development banks such as the World Bank, UN agencies, and the general public. The new resource mobilization campaign defined five core messages:

• Polio eradication is within reach.
• With peace, political commitment, and extra resources, we can meet the target.
• It will be a phenomenal achievement—both in terms of data and human interest.
• Eradication will bring health, economic, and peace dividends, in the form of access, partnership, savings, and truces.
• It is a platform for preventive health services.

UNICEF sponsored a meeting of polio partners that focused on social mobilization and donor advocacy, and the WHO published its first guide for polio advocacy, Advocacy: A Practical Guide With Polio Eradication as a Case Study, which detailed appropriate messages targeting key global, national, and local stakeholders (WHO, 1999a).

By 1999, GPEI found new partners in the Bill and Melinda Gates Foundation and the UN Foundation. Beyond the monetary resources these two foundations brought to the table, their commitments engendered confidence with other donors that polio eradication was attainable (Informant-2, 2009).

A U.S.$1 million gift from the UN Foundation enabled the WHO to hire, for the first time, a full-time advocacy officer in 2001 (WHO/GPEI, 2001). The new hire was tasked with developing and implementing a plan to sustain the political commitment to eradication, keeping high-level UN officials and Heads of States involved, and identifying polio advocacy opportunities for senior WHO and UNICEF executives (WHO/GPEI, 2002b). An informant close to GPEI/Geneva said that WHO advocacy on behalf of GPEI became more successful with the creation of this position (Informant-1, 2009), raising the question of how the polio eradication initiative might have evolved differently if WHO had earlier demonstrated greater commitment to global advocacy. The UN Foundation also set aside U.S.$5 million to enable Rotary to solicit funds from new, non-Rotarian private sector donors—an approach that reportedly was not very successful (Informant-5, 2009). The Gates Foundation has been active in advocating for financial commitments from donors and encouraging countries to increase their own funding toward eradicating polio. The Gates Foundation continued as a major donor to GPEI, providing its first contribution ($50 million) in 1999, and through 2008 it had committed a total of $400 million (Bill and Melinda Gates Foundation, n.d.).

Core Advocacy Arguments: Health System Strengthening

From the outset, the GPEI used its potential to foster health system strengthening to help justify the expenditure on polio eradication. In the PAHO-led eradication effort in the Americas, systems strengthening had been a core component and had proved essential to promoting a sense of national ownership of polio eradication (Quadros, 2009). As a result, the 1988 WHA global polio eradication resolution emphasized that “efforts to eradicate poliomyelitis serve to strengthen other immunization and health services.”

The GPEI used systems strengthening arguments in their advocacy to assuage concerns that polio eradication would divert funds from other public health investments, including routine immunization (Bart et al., 1996). The WHO pointed out that general immunization coverage had been stagnating or declining in many countries since 1990 and that polio eradication offered many opportunities to turn this around through improved surveillance, stronger cold chains, and better trained health staff:

The excitement generated by polio eradication and the consequent achievements have heightened visibility of immunization and increased political support for immunization programmes. Heightened political support often translates into an increase in the national budget for immunization. (WHO, 1998, p. 7)

In 2000, a WHO-commissioned report, Meeting on the Impact of Targeted Programmes on Health Systems: A Case Study of the Polio Eradication Initiative, refuted the argument that the initiative was undermining basic services but also called into question GPEI’s health systems strengthening assertions:

Polio eradication does not automatically have a positive health systems impact, nor grave disruption or diversion. Commonly the studies found mixed positive and negative effects, with no firm conclusion in either direction. (WHO, 2000)

The report also found that GPEI had “missed opportunities” to help strengthen the health care systems in targeted countries (WHO, 2000). Bruce Aylward seems to have been aware of the problematic nature of the health strengthening argument. In 2003, he cautioned that “proponents of future worldwide health goals should recognize the challenge of measuring such indirect [health and system strengthening] benefits, be modest in arguing their worth, and ensure there are agreed indicators and the capacity and mechanisms for their monitoring” (Aylward, Acharya, England, Agocs, & Linkins, 2003). After 2000, GPEI added to its advocacy messaging the extra health benefits of integrating the administration of vitamin A into polio NIDs. According to the WHO, the joint polio-vitamin A approach proved “to be a cost-effective strategy for reaching millions of children suffering from vitamin A deficiency, … , helping to avert an estimated 240,000 deaths” (WHO, 2001b).

Even after the evidence supporting the systems strengthening argument had been challenged, the argument remained central in GPEI’s advocacy. It made the case that “instead of competing with the primary health care services, the eradication program fosters the development of primary health care through a focused approach and the strengthening of managerial and other capacities of the primary health care system.” In time, the emphasis on the broader capacity of the GPEI-supported surveillance system seems to have emerged as the core systems strengthening argument. According to the WHO GPEI 2008 annual report, “of the 999 WHO immunization staff in the AFR [African Region], for example, 914 (91%) are funded by the polio programme, with the vast majority spending a considerable proportion of their time on work related to immunization, surveillance and outbreak response” (WHO/GPEI, 2008, p. 9). While it is undeniable that polio-funded staff spends time on related activities, the exact contribution to system strengthening remains undefined and unmeasured.

Core Advocacy Arguments: Cost Benefit

The cost benefits of polio eradication also emerged as a central tenet in GPEI’s advocacy toolkit. Eradication advocates persuasively argued that the public health strategy of disease eradication offered considerable advantages over disease control, noting that the benefits of eradication would be permanent and would accrue long after the finite costs of eradication ceased, while the costs of controlling the same disease must be maintained indefinitely (Bart et al., 1996). For high-income countries that already had eradicated polio, GPEI cited the savings to be attained through the cessation of routine polio immunizations as a resource-mobilization strategy. In 1996, USAID projected that eradication costs of U.S.$100 million per year worldwide would be a sound investment when compared with the then-current costs of U.S.$230 million per year for vaccinating U.S. children alone (USAID, 1996).

The cost-benefit advantage of eradication was a persuasive argument because eradication expenditures were temporary while control costs accrue ad infinitum. As long as eradication continued to be perceived as a feasible goal, it had to be conceded that it would be cost-effective over time (Hoel, 2007; Thompson & Duintjer Tebbens, 2007).

Rotary used the cost-benefit analysis of smallpox eradication to make the case with the U.S. Congress that polio eradication was a wise investment (Pigman, 1998). The point of the message was that it was not only developing countries that would reap the benefits, but the developed countries would benefit greatly because they would no longer have to keep vaccinating their populations once eradication occurred. Rotary may have inadvertently contributed to an impression, however, that eradication was being pursued globally because it was financially advantageous to developed countries. Such arguments fed perspectives in developing countries that polio eradication reflected a Western-driven agenda rather than the priorities of developing countries, where mortality and morbidity rates indicated that priority should be given to other diseases such as malaria and measles (Informant-1, 2009; Knippenberg, 1996; Renne, 2006).

More Obstacles on the Home Stretch

As the 2000 target for eradication approached, advocates began using slogans such as “the home stretch” and “final push” to motivate existing and untapped donors to fill recurrent funding gaps. The GPEI faced numerous problems, such as inadequate surveillance (including the absence of cross-border surveillance systems), low routine immunization coverage, and poor-quality NIDs, and difficulty reaching children (especially in conflict zones; UNICEF, 2000). In conflict-ridden countries, the costs of immunizing a child during NIDs could be two to three times higher than elsewhere. Furthermore, weak health infrastructures in many countries necessitated that staff be trained, cold chains be refurbished, transportation be improved, and program communication be strengthened–further driving up eradication costs (WHO, 1999b). Ironically, the policy of rapid acceleration was working, and the resulting increase in demand for vaccine had created additional challenges when OPV manufacturing capacity proved insufficient. According to GPEI, however, lack of funding compromised the quality of polio surveillance (especially in Africa), reduced the speed and quality of emergency outbreak response, and hindered the implementation of activities in key reservoir areas (WHO, 2000).

All of these factors put increasing pressure on the GPEI to secure sufficient funding to meet growing demand and to address a widening array of often-costly obstacles. Then, in late 2002, a number of partners did not provide expected year-end resources, resulting in an acute funding gap for 2003. This led to a revised strategic approach and a significant scaling back of activities and staff (WHO, 2003).

The Funding Gap Poses a Threat

With the acceleration of the eradication effort and skyrocketing resource demands, the GPEI adopted a “funding gap” argument in its advocacy to donors and potential donors. In 2001 UNICEF Director Carol Bellamy noted, “A $400 million funding gap posed a great threat to the program,” although she expressed confidence that the new 2005 target date for certifying the world polio-free was still within reach (UN News Center, 2001). In 2002, the Technical Consultative Group (TCG) stressed that the funding gap “constitutes the greatest threat” to polio eradication and that “closing the funding gap should be the highest priority of the partnership.” For 2002-2005, the TCG projected a U.S.$1 billion requirement with a U.S.$275 million shortfall (WHO/GPEI, 2002a). For its part, USAID challenged the accuracy of these projections, arguing that resource requirements were actually much higher (Ogden, 2001). The GPEI partners also began to face the possibility that the failure to reach goals, the requests for more funding, and competing international health priorities might undermine support for eradication.

In response, GPEI’s advocacy experts advised, “When approaching national leaders and possible donors, polio messages need to be integrated with other public health issues to minimize the fatigue factor and avoid overloading leaders with too many issues-for-action” (UNICEF, 2002). Press coverage in the eight U.K. and U.S. media houses analyzed as part of this study frequently repeated GPEI’s core funding gap message. Indeed, their reportage read much like expanded WHO press releases.

This favorable, unquestioning coverage would change, however, after the missed 2005 target, when dissident voices began to emerge from within the international health community. D. A. Henderson, who headed WHO’s smallpox eradication effort, said that “the siren song of eradication” had led public health authorities to declare goals he considered more “evangelical” than attainable. Dr. Julian Lob-Levyt, Executive Secretary of the Global Alliance for Vaccines and Immunisation (GAVI), contended that increased mobility of people and chaos in places like Sudan and Somalia make eradication harder today. “We are not talking about eradication the way we used to,” he said (McNeil & Dugger, 2006). In response, leading GPEI spokespersons assumed a more defensive posture as to the feasibility of eradication.

One result of the funding gap argument was that the focus was directed to donors’ failure to provide the resources required for success rather than to the need to respond to programmatic and technical weaknesses and social and political factors in endemic countries.

In packaging its funding gap messages, the GPEI highlighted commitments from international donors but rarely mentioned the contributions in money or in-kind made by countries carrying out polio eradication activities. One question for future programs is to what extent the lack of reference in WHO/GPEI publications to contributions by “host” countries may have fed into local perceptions that polio eradication reflected a Western-driven agenda (Renne, 2006). In the age of the Internet, material targeting one audience is available to virtually all, and publications prepared by WHO Geneva targeting international donors are accessible to diverse audiences. A clearer indication of the contribution made by affected countries may have helped foster the perception of GPEI as a truly global initiative and may have contributed to strengthening the sense of national ownership of the eradication initiative. This sense of national ownership over the polio eradication initiative was a factor in its success in the Americas (Quadros, 2009).

The Polio Advocacy Group and the G8

Faced with an officially acknowledged U.S.$275 million shortfall and questions about the attainability of the 2005 eradication goal, in 2002 the GPEI created a structure known as the Polio Advocacy Group (PAG). This interagency group was mandated to coordinate international advocacy and resource mobilization activities across the polio eradication partnership. Consisting of external relations, resource mobilization, and communications experts from WHO, UNICEF, the UN Foundation, and Rotary, the PAG set its sights on the G8 summits and declarations as a mechanism to further lobby donor governments to fill the funding gaps (UNICEF, 2002).

At the 2002 G8 Summit in Kananaskis, Canada, the G8 nations committed to provide sufficient resources to eliminate polio by 2005. Thereafter, the PAG began to focus attention on appeals and personal visits to translate the G8’s commitment to the GPEI into firmer monetary pledges. From 2003 to 2005, the G8 nations pledged successively higher dollar amounts to meet the GPEI’s requirements and committed its member states to the overall goal of global polio eradication (G8 Research Group, 2006; WHO, 2003). Between 2006 to 2008, that is, after GPEI missed its 2005 target date for eradication, however, G8 funding decreased by approximately 40%. Contribution from the United States remained steady, while all other G8 countries decreased their contributions (GPEI, 2007a). As a result, to implement the intensified eradication activities in 2007, traditional development partner financing had to be supplemented substantially by host country domestic funding, most notably from the Government of India, as well as a U.S.$ 104 million reprogramming of International Finance Facility for Immunization funds previously earmarked for a posteradication-era vaccine stockpile. Rotary International and the Bill and Melinda Gates Foundation also sought to fill the gap. In November 2007, they announced a partnership designed to inject U.S.$ 200 million into the GPEI over the next 4 years. The Gates Foundation awarded the Rotary Foundation one of its largest-ever challenge grants of U.S.$100 million, to be expended in 2008, with Rotary matching dollar-for-dollar over the next 3 years (GPEI, 2007b).

Outreach to Organization of Islamic Conference

By 2003, only seven countries were polio endemic. Only 784 cases of polio paralysis were reported worldwide for the entire year, an impressive accomplishment considering that in 1988 the caseload was more than a thousand people a day in 125 countries. In addition, three WHO regions had been certified polio-free: the Americas in 1994, the Western Pacific in 2000, and Europe in 2002.

But events in Nigeria and India derailed progress. Rumors that OPV deliberately had been laced with harmful substances such as antifertility agents (estradiol hormone), HIV, and cancerous agents posed challenges in many countries (UNICEF, 2002), but in predominately Muslim areas of Nigeria and India the impact of these rumors was particularly damaging.

In response, the GPEI began in 2003 to reach out to the Organization of the Islamic Conference (OIC) for political and financial support. The setbacks in majority-Muslim areas of Nigeria and India led many to argue that the previous success of other OIC members in eradicating polio could be used as positive examples of the benefits of polio immunization (Aylward, 2007).

The OIC passed a resolution in October 2003 urging an all-out effort to eradicate polio from the countries of the OIC still afflicted by it. The WHO worked to encourage religious leaders to publicly support polio eradication. Ambassadors from OIC countries were briefed in order to build political support (Kaufmann, 2008). This messaging was successful in the sense that it helped to soften Islamic opposition to vaccination in Nigeria (Soares, 2004).

Soon thereafter, Malaysia and the United Arab Emirates each made U.S.$1 million contributions to the eradication program. The GPEI advocates were disappointed, however, that the resource-rich Persian Gulf countries donated less than U.S.$3 million, falling short of the U.S.$250 million requested of them (Rosenstein, 2006).

Advocacy to the OIC took on new life in 2009. In July of that year, following U.S. President Barack Obama’s June speech in Cairo, Egypt, the United States and the OIC announced the formation of a partnership to eradicate polio within the framework of the GPEI (Bernama, 2009). OIC Secretary General Ekmeleddin Ihsanoglu echoed the themes of the Obama speech in Cairo:

Fighting Malaria and Polio has recently become an important priority for our organization. We are working hard for reconciliation between Islam and the West because we believe that today’s human civilization is one civilization with a multitude of tributaries and branches. (OIC, 2009)

In September 2009, on the eve of the fortieth anniversary of the OIC, Saudi Arabia pledged U.S.$30 million to support polio eradication (PRWeb, 2009).

The Stakes Are High: It’s Now or Never

As target dates were missed, heartening slogans such as “We are in the home stretch” were replaced by messages emphasizing the dire consequences of failing to achieve eradication: “The stakes are high; it is now or never.” Such messages suggested that the investment already made in polio eradication would be in vain and that progress in reversing the human toll of polio would be lost unless donors continued to invest in eradication. Jim Lacy, Chairman of the Rotary Foundation, said, “With so much at stake, we must not come this close and not finish successfully” (Altman, 2004). Bruce Aylward asserted:

This $3 billion investment in polio eradication since 1988 is really in jeopardy…. There is no such thing as a polio “control program.”…If you don’t get it finished now, you are not going to have 5,000 cases in five years—you are going to have 250,000 again. It will happen if we don’t finish it now. (Brown, 2003)

While GPEI continued to argue for eradication, some members of the international health community began to ask again if polio eradication was realistic and suggested the need to redefine success. They asserted that certain factors militated against successful eradication:

• changes in the global political landscape since the 1988 WHA resolution, which created social and political settings unfavorable to a vaccination campaign and sufficient levels of routine vaccination;
• the reality that the wild virus was known to survive even saturated vaccination campaigns such as those in northern India;
• the reversion of vaccine-derived virus to a wild form; and
• evidence that the virus can circulate undetected longer than previously known.

Konstantin Chumakov, Associate Director for Research, U.S. Food and Drug Administration, noted that there seemed to be no inclination among GPEI leadership to reassess whether an eradication campaign still made sense. They “press on as if nothing had happened, as if it were 1988.” Chumakov called them “captives of their own advertising.…Every year is the final one. This can’t continue forever.” He added that the program should be proud of what it has achieved, and the world should “declare victory now” (Roberts, 2006). Others called for a shift in the global strategy from “eradication” to “effective control” (Arita, Nakane, & Fenner, 2006).

A study on the economics of eradication released in 2007 suggested the following:

Focusing on the large costs for poliomyelitis eradication, without assessing the even larger potential benefits of eradication and the enormous long-term costs of effective control, might inappropriately affect commitments to the goal of eradication, and thus debate should include careful consideration of the options. (Thompson & Duintjer Tebbens, 2007)

The authors found that even more short-term eradication expenditures were necessary. They suggested that the intensity of immunization had to be increased to achieve eradication, and that even small decreases in intensity could lead to large outbreaks. Their findings implied the need to pay even higher short-run costs, even though this likely would further exacerbate concerns about continued investment in interventions that were perceived to be expensive in relationship to the outcomes. They concluded that a wavering commitment would lead to greater cumulative costs, many more cases, and a failure to eradicate (Thompson & Duintjer Tebbens, 2007).

The Final Push, Once Again

The study by Thompson and Duintjer Tebbens set the parameters for discussion of yet another “intensified effort” launched in 2008 to achieve eradication. In announcing the “new intensified eradication” effort, the WHO/GPEI opted this time, however, not to set a new target date for eradication. The 2008 GPEI strategy did, nonetheless, project resource requirements to achieve certification in 2012; in 2009, the projection was extended to 2013 (WHO, 2008, 2009). The truth of the matter is that international health experts are unable to predict the end of polio; newly projected eradication certification dates have come to reflect best-case scenarios for eradication under current approaches. The technical and scientific basis of eradication is undergoing constant review, and new approaches are being adopted. Operationally, the wild polio virus persists in very difficult regions of four especially challenging countries: Afghanistan, India, Nigeria, and Pakistan. With gaps in routine immunization and the export of virus from the endemic countries by 2008, the polio virus was found in 18 countries. The need to contain outbreaks in formerly polio-free countries is driving up costs. These dynamic factors make forecasting very difficult.

The GPEI estimated the cost of the “new intensified eradication” effort to be U.S.$1.306 billion, and in January 2008, the GPEI estimated its funding gap at U.S.$525 million. It estimated the financial requirements of certification and the posteradication period (2010-2012) to be U.S.$492 million (WHO, 2008). To help implement the new intensified eradication campaign, three endemic countries contributed substantial amounts, according to a rare GPEI announcement about the contributions made by target country governments: India set aside up to U.S.$226 million; Nigeria U.S.$22 million; and Pakistan U.S.$20 million. A year later, when the GPEI extended the timeline of certification to 2013, it increased the size of the estimated funding gap to U.S.$915 million out of a total requirement of U.S.$2.3 billion (WHO, 2009), which is roughly double the originally projected total cost of global eradication given in the 1990s (not discounting for inflation).

Given missed deadlines, remaining obstacles, and rising costs, resource mobilization remains a daunting challenge for the GPEI, and by mid-2009 there was mounting evidence of donor fatigue and publicly expressed doubts about the achievability of eradication. One foreign assistance official from a donor country expressed the following:

Our official position is we’re supportive of GPEI and committed, and we’ve made funding commitments. When it looks like polio will be an ongoing commitment, then we will have to look at morbidity rates for different diseases and cost-effectiveness. But that calculation didn’t figure too much in the debate when talking about eradication. If it’s an on-going thing, then it is conceptualized in a different way. (Informant-5, 2009)

Renewed political commitments from the heads of state and local leaders in the four endemic countries in late 2009 and early 2010 hold promise that the will is there to overcome the remaining obstacles and could be a compelling factor in sustaining donor funding in the most difficult last mile of this marathon. The GPEI funding estimates are revised quarterly and may increase based on the plan to introduce bivalent vaccine and accelerate activities in 2010-2012.

Considerations for Future Resource Mobilization Enterprises

The experiences of the GPEI provide valuable lessons for any future eradication or other international global health programs. The GPEI has been successful both in progress toward eradication and in resourcemobilization. These recommendations should be seen not as criticisms but, rather, as recognition that the GPEI has forged new ground from which future programs can learn and grow.

1. Major public health initiatives should consider resource mobilization to be an integral component of their operations, on a par with technical and scientific aspects. Global advocacy and resource mobilization should be central to the assessment of operational feasibility. One of the first actions of any major global public health initiative should be to hire a professional global advocacy and resource mobilization staff to strengthen donor support and to secure commitments of adequate funding.
2. The constant funding gaps experienced by the GPEI suggest that when starting a new global health effort, whether eradication or another goal, program managers must be realistic and open about resource requirements. It would be useful to include a range of time and cost estimates, from evidenced-based best- to worst-case scenarios. Such estimates should incorporate potential technical, implementation, and political difficulties that may change an optimistic target date. In general, challenges need to be thought through at the onset of an eradication program and messaging done in the context of the lifetime of the effort.
3. It may be worthwhile to consider establishing a formal “devil’s advocate,” whether an individual or committee, whose function is to challenge preconceived notions and orthodoxies and avoid the perils of group think. Such a system, increasingly used by a variety of organizations, helps establish constructive accountability to ensure that the drive for success, the maintenance of enthusiasm and morale, and the demands of resource mobilization do not ignore alternative scenarios and responses.
4. From the beginning, systems to report on expenditures, needs, pledges, and contributions should be established. The in-kind and financial contributions made by “host” countries should be included in reporting. This not only would encourage other recipient countries to make contributions but also could help counter the perception of the initiative as Western donor driven.
5. Organizations such as the Global Fund to Fight Aids, Tuberculosis and Malaria have acknowledged the value of open and transparent financial reporting, allowing donors to see both how they compare with others and how their taxpayers’ funds are being spent.
6. The longer a public health initiative requiring mass social mobilization takes, the more likely that the effort will encounter unexpected social and political developments capable of hindering the effort. While recognizing the need for quick wins, work must begin in the hardest regions as “proof of concept” early on to help ensure that projections accurately reflect real-life situations.
7. To analyze the social and political landscape, which can adversely affect success, any new public health initiative should consider establishing from the outset multidisciplinary advisory bodies, at international, regional, and country level, that include not only epidemiologists and virologists, but also social scientists, communication and behavior change experts, diplomats/political experts, and regional and country experts. Two models might be the multisectoral and public/private Country Coordinating Mechanisms of the Global Fund or the Global Fund’s Technical Evaluation Reference Group (TERG). A strong team of skilled and multidisciplinary communication and behavior change experts can help lead, manage, and evaluate increasingly sophisticated outreach, geared to different audiences and purposes. This should be supported through separate line items in annual work plans and budgets.
8. As suggested by Bruce Aylward, when formulating advocacy messages and justifications, proponents of future worldwide health goals should recognize the challenge of measuring indirect benefits, be modest in arguing their worth, and ensure there are agreed indicators and the capacity and mechanisms for their monitoring. The need for agreed indications and for monitoring and evaluation cannot be overstated.

Warren Feek

In the very early part of this century, those with apparently nothing came very close to completely derailing the work of those with apparently everything. The huge tension this produced for the global polio eradication process led to a substantial rethink of their strategy in key countries. It also provided a case study for the broader international development community of why the supposedly soft processes of communication, participation, public engagement: local organisation and leadership, dialogue, debate, and cultural factors cannot be ignored, as they are vital to the success of large public health initiatives.

The articles in this issue of the Journal of Health Communication: International Perspectives tell the detailed story, and provide an informed critique, of the polio communication strategy pursued and the impact of that work. There are some threads that draw these stories together. By 2000 the global polio eradication process was making excellent progress. In the 12 years since 1988 when the Global Polio Eradication Initiative (GPEI) was established by the World Health Assembly, global cases for all forms of the virus had declined from 1,000 cases per day to 719 cases for the entire year of 2000 (GPEI, 2006). Compared with other public health issues such as HIV/AIDS, tuberculosis(TB), and malaria, this was stellar.

The progress being made was based on a strategy driven by a combination of money, technology, and scale. In the context of declining polio incidence numbers, the financial resources were massive—6.15 billion in the 20 years from 1988 to 2008 (GPEI, 2009), and counter-intuitively the expenditures have kept getting higher as the number of cases has diminished. In spite of the growing costs, however, confidence remained high.

The vaccine was proven and available at scale and the delivery systems, while uneven, were more or less thought to be adequate for the job. The technical experts—virologists, epidemiologists, doctors, and health practitioners of all stripes—were behind the campaign and would deliver. And they did! The strategy immunized well over 2 billion children and mobilized 20 million volunteers. The money was there. The science was great. The scale was enormous.

It looked like the smallpox eradication effort all over again!1 And then local people got in the way! In 2002 the remaining major areas of concern for eradicating polio were within some of the most economically impoverished and socially marginalised (a combination effect) population groups on the planet—northern Nigeria, northern India, northwest and south Pakistan, and south and east Afghanistan.2 People living in these areas often were extremely poor, with some of the worst indicators for child health and access to education, nutrition, and sanitation in the world. For some, especially those living in Afghanistan and northern Pakistan (and parts of the south), weak government services were combined with conflict. For others, there was a history of dissatisfaction with the national government, the lack of services provided, and perception that government was not representative.

The social, economic, cultural, and governmental context in which people in these parts of these countries lived was often very different from that in other parts of their own countries, as were the leadership structures they looked to for local decision making.

In 2003, from a base at the opposite end of the money, science, education, and culture spectrum from those running and implementing the polio eradication programme, the communities of northern Nigeria fomented a social movement focused on implementing a successful boycott that completely halted polio immunization in several northern Nigerian states. They did this with essentially no money and absolutely no international development funding. They did it through these processes: Local leadership exerted influence; Local customs were invoked; Local symbols with resonance were mobilised; Local decision-making fora were used; Key local “facts” were spread; Local public debate was promoted; Local neighbourhoods were organised—e.g., to resist; Private local dialogue—e.g., amongst heads of household was encouraged; Relevant local fears and worries—resonant to overall issues—were stressed; and Polio was integrally linked to the broader sociocultural and socioeconomic issues.

The rights and wrongs of this movement are for debate elsewhere,3 but the effect of the campaign was that polio incidence rates in Nigeria rose from 56 in 2001 to 355 in 2003, reaching a high of 1,122 in 2006. They were on a steep upward trajectory that threatened to reverse the gains of the past decade. In this world of the travel of people across and between communities and countries, northern Nigeria rapidly became a polio virus “factory” and exporter to polio-free parts of Nigeria and countries across West and central Africa and as far away as Saudi Arabia and Indonesia. If northern Nigeria was a very overt and open process, the situation in northern India was more difficult to discern and analyze—an altogether subtler tension. By 2006 there were 676 polio cases in India, the largest number since 2002. All of the gains of those 5 years seemed to have been erased.

 How many times in our own personal scenarios—family, town, city, country, ethnicity, and so on—when faced with views and opinions from outsiders about our situations, have we muttered to ourselves, “They just do not understand”? How many of us, faced with outsiders whom we do not know very well at all, or who disregard our social norms, would trust them with what is most precious to us? My guess is that your answer to those questions is, “Lots of times,” and “I wouldn’t.” How many of us are so well organized that we always note and take advantage of all possible opportunities? At a much lower threshold, how many of us have never missed an appointment? These questions highlight the inherent tensions in much of public health, tensions that emerged in northern India related to polio. At one end of our stretchy tension band is expert knowledge, in this case expert scientific knowledge most commonly in the minds and hands of outsiders. That knowledge is aligned with organization—On the basis of this scientific knowledge, we will deliver this service to this population at this time and it will be for their benefit. At the other end of our tension band is the natural suspicion, resistance, and absence of trust that comes from local populations when the outsiders who do not understand wish to play a significant role with those whom the local population hold most precious—in this case their children. Especially in the context of poverty, people live very busy and demanding lives and are not always in a position to notice and take advantage of opportunities—in this case when and where their children can receive polio vaccination—a situation heightened when the people doing the organising are “outsiders” with little local knowledge.

As the articles that follow highlight, this dynamic scenario manifested itself into actions such as children not being at home, parents being away, houses being missed, wrong numbers of children being given for households, rumours beings started, questions being raised, and opportunities being missed. Whereas the northern Nigerian tension might be characterized as largely “political,” the northern India situation could be seen as essentially “social.” In both scenarios—northern India and northern Nigeria—the “expert” global polio community seemed to be taken somewhat by surprise. How had the apparently smooth road to eradication suddenly become so rocky? How had those “without” so significantly challenged those “with”? The people with the polio expert knowledge and the skills found the very attributes they felt most important and the truths they felt unassailable challenged, overlooked, minimised, and, ironically, marginalised. Why, they asked, would communities work so hard and stridently against the best interests of their own children, exposing them to unwarranted risk? What could possibly motivate people to ignore proven science over unfounded and not verified information? Why can we not convince them that they are wrong? Of course, such questions in this context simply underline a set of flawed assumptions that often lead to trouble: assumptions that can lead to perceiving the poor as having no resources, the uneducated as having no intelligence, the underserved as not being able to prioritise their needs, and the marginalized as having no sense of power or relevant opinions. The approach to the issue was based on a very flawed perspective, because those perceived as being “without” actually had a tremendous amount. These were their communities and their people. They understood their local ways. They had allegiances to local leaders and the leaders had influence and their own dynamics to play out. They understood and were engaged in local decision-making processes. Whilst the polio leadership saw the polio issue as paramount, the local communities experienced polio in the context of other issues they faced in their daily lives and they understood the complex relationships between those issues. They were insiders, and the polio community—certainly the leadership—often were outsiders.

 Crucially, many local communities recognized that the polio effort was vitally important to those “outsiders” who lead it; they knew that its success depended on their engagement; and from that realization, they began to leverage results. So the tensions were set, and from this process we all learned a great deal—specific to polio eradication and more generally for health-related action. Most of the perceived wisdom for effective health and development action takes a very linear shape. The epidemiology is described and analyzed. Population groups are identified. From the results of that work, goals and objectives are established. The strategies related to those goals are devised and implemented—from campaigns to delivery systems. There are sophisticated tools for doing this, including social analyses and focus groups, but it remains a linear process, and it is a process predominantly run and implemented by technical experts. In this approach, people and communities come at the end of the chain. They are to be “targeted.” This largely described the polio approach in 2002. Maybe one of the main strategic lessons for effective health and development action from the polio crisis in the early part of this century is that a linear approach will get us only so far. When dealing with human beings, you cannot simply draw a straight line between where you are and where you want to go and expect to get there without some detours, unexpected obstacles, back tracking, and many discussions with those you pass on your journey. It has to be said that the linear approach succeeded in getting polio almost to its goal, but it could not take it the final mile. At the end, the tensions became too much and the GPEI had to develop a strategy that recognized the tensions, sought to understand where they had come from, and provided a road map for negotiating the final distances. This is very different to one party to the action seeking to influence another party. It is negotiation, not persuasion. No one perspective is correct, though, we hope, in the case of polio, all can agree on the final goal. For polio eradication to succeed, it will need to recognize that the final mile, the final meter, even the final few steps, will require all its resources—vaccines, experts, funders, logistics, cold chains, political will, motivation, worker morale, and, centrally, the active participation of people in their communities. While some of this can be mapped in a straight line, the most important parts will require dialogue, negotiation, trust, and legitimacy in local contexts. The straight line will need to bend to local paths. The science does matter. Epidemiology is crucial.

Strategies need to have significant data drivers. Vaccines need solid scientific foundations, but the local also matters. In a process that recognizes the inevitability of tension, people are not targets but are partners. It is inevitable that in the end-stage of polio eradication, tensions still exist. How the GPEI chooses to manage these tensions should be better informed and wiser after 20 years of experience. This is certainly to be hoped, as even a quick look at four very different examples from myriad possible tensions underlines the difficulties: Newborns Increasingly, there is recognition that it is important to vaccinate newborns, but some cultures do not allow outsiders to the family to physically see a baby in the first 40 days of their life—tension.

Priorities As countries approach zero polio cases, sustaining the intensity of activities needed to secure certification will be challenged by other diseases and conditions that cause higher morbidity and mortality. The level of resources allocated to polio eradication will compete with resources for things local people say are their priorities, for example, schools, maternal health, or TB. Tension exists about how to allocate limited resources. Decision Making If, on a specific issue, local and external perspectives differ, then there will be inevitable tensions: What is the appropriate gender mix for vaccinator teams? Is house-to-house tracking accepted or seen as outside interference? What is the role of inactivated polio vaccine (IPV)? Religion and Science We could apply this tension across all slices of global life, and it definitely has been a factor in the polio scene. For brevity’s sake, a few of the tensions that emerged from the polio eradication experience and needed managing as part of the positive way forward are shown below.

Tensions Short-term eradication expectations ↔ Long-term culture, community, social norms and values change processes

Global goal ↔ Community listening

Polio ↔ All other development issues

Global strategies ↔ Local contexts

Technical wisdom ↔ Social and cultural wisdom

Global control (This is our goal and work) ↔ Local control (This is our issue and life)

 Coherent consistent messages ↔ Responding to local dynamics

Since at least 2001, as can be seen in the writings that follow, we have, in effect, seen a working out of these tensions in order to take effective action on polio and reverse the increases from that period. It may be irony at its best, or it could be really good learning from experience, but the articles that follow show that what the local communities have taught the polio community over this time is being absorbed into their strategies. The tensions are being recognised and worked through. You will see these clearly as you work through the articles that follow. Not everything has been resolved, but the beginnings are there, and those beginnings have important long-term benefits for polio eradication. For polio eradication and beyond, these articles demonstrate the importance of early recognition of tensions and assumptions, the value of factoring them into strategies and budgets, the importance of keeping a finger on the pulse of public opinion, and the necessity of listening to, collaborating with, and understanding the perspectives of all people affected by the program.