The Final Push for Polio Eradication: Addressing the Challenge of Violence in Afghanistan, Pakistan, and Nigeria

"Polio eradication will only be achieved with stronger health systems and bottom-up community engagement, which is likely to require more time and more investment than is currently available in Pakistan, Nigeria, and Afghanistan because of their political fragility."

As researchers working in the remaining 3 polio-endemic countries, which all have large Muslim populations, the authors of this piece acknowledge that increasing militancy, political unrest, lack of trust, and deteriorating security conditions are common denominators that threaten polio eradication efforts. However, in this paper, they stress that the root causes of the failure of polio eradication differ markedly among these countries and are deeply embedded in country-specific contexts. Thus, they argue here that the battle to eradicate polio will only be won with policies that are informed by a detailed understanding of these contexts - as follows (in sum):

1. Afghanistan: Global Polio Eradication Initiative (GPEI) programme managers have been able to implement polio immunisation in politically unstable places through local people who relate to the Taliban, which "is now working to build trust among the general population and have allowed local people to engage in social welfare campaigns, including the GPEI." According to the authors, this situation is fragile because "Taliban-like or pro-Al Qaeda forces entering Afghanistan from other parts of the world, particularly central Asian states, might hinder the GPEI by using interference with polio eradication as part of their strategy for countering the Western alliance in Afghanistan."
2. Nigeria: "There are many health issues in northern Nigeria that the people rightly consider as priority issues, but the government - which they do not trust - seems to concentrate on polio eradication. This situation breeds suspicions and leads people to refuse the polio vaccine to prevent a disease that is less threatening and less visible than other problems."
3. Pakistan: "Targeting the polio campaign is one way that terrorist groups can attract attention, not least because of the large-scale advertisement campaigns run by government authorities to sensitise local communities to polio vaccination."

In these varied contexts, the authors recommend:

• Making polio eradication part of routine immunisation (RI) - "The solution is to strengthen the routine health system, including door-to-door general vaccination coverage, rather than highlighting polio as 'the only' health problem..."
• Ensuring that locals see polio eradication as a social problem and take ownership - "We suggest that communication and implementation strategies that place polio eradication side-by-side with other health and development challenges faced by local communities should be introduced....In addition, local media should be encouraged to take ownership of polio eradication and highlight what has been achieved under the GPEI in each country, instead of concentrating on the negative consequences."
• Continuing immunisation but without all the fanfare - "Because it will be difficult for government agencies to maintain neutrality and keep a low profile if security is provided for health workers via military personnel, we believe that efforts should be made to depoliticise polio activities. Support for this approach comes from rural areas in Afghanistan, which have been the most insecure places for government employees to work but where negotiations with and empowerment of local communities has facilitated the national polio eradication initiative..."
• Working directly with community members and leaders - "Although people will initially listen to their leaders, as the leaders receive more funds people will increasingly see them as agents of the government, which they do not trust. This problem might be mitigated by focusing on community members and leaders of smaller community units, such as village health committees, in addition to engaging provincial, traditional, and religious leaders."
• Building trust by keeping a low profile on international deadlines - "We believe that giving the GPEI a lower international profile could weaken the 'Western' link, and help to build trust both in polio immunisation and in national governments. Trust is essential if communities are to accept the vaccines and is needed to ensure the commitment of local leaders to polio eradication. Trust on its own will not stop the attacks on polio workers, but once terrorist groups realise that polio eradication no longer has a high profile, they may turn their attention to other soft targets."

In conclusion, the authors state: "Misinformation and myths around immunisation are neither peculiar to the polio vaccine nor to Nigeria, Pakistan, and Afghanistan, but we believe that implementation of the GPEI has been greatly limited in these countries because of a lack of trust between the people and their national, West-supported governments. It takes time to build trust. Already, the support of local people has enabled children in insecure areas of these countries to be reached; but an increase in the coverage of overall health services and improved access to health services by the general population might help in building trust between governments and the people and between health workers and communities. Without the nuanced and realistic approach to policy-making and global goal-setting that we have advocated in this article, we are concerned the recent portrayal of polio by some as the new battleground between Western forces and terrorist groups may change the perception and resolution of high-risk public health problems..."