Reflections on Polio Lessons from Conflict-Affected Environments [A Brief History of the GPEI in Conflict-Affected Environments]

A Brief History of the GPEI in Conflict-Affected Environments

The GPEI's history of working successfully in conflict zones goes back to its earliest days. As lessons have accumulated, they have coalesced into a kind of evolving toolbox of strategic and operational approaches based on a growing body of experience. As the map in Figure 1 shows, for the period 1990 to 1999, poliovirus circulation was successfully stopped in a number of countries that had ongoing conflicts, such as Cambodia, Colombia, El Salvador, Peru, the Philippines, and Sri Lanka (Tangermann et al. 2000). In 2000, the GPEI was still working in a number of countries with major conflicts, such as Angola, the DRC, Liberia, Sierra Leone, Somalia, what is now South Sudan, Afghanistan, and Tajikistan.³ Several of those conflict-affected countries have become polio-free (Liberia, Sierra Leone, and Tajikistan—though the first two remain at high risk for reintroduction). However, the world has seen increasing instability in regions where the poliovirus still circulates, and nearly all of the remaining endemic and outbreak countries, and many of the high-risk countries, are affected by conflict to degrees serious enough to have an impact on the operations of the GPEI.⁴

Polio eradication is driven by the need for very high levels of immunity accomplished through routine immunization and supplemented with large-scale and necessarily high-quality campaigns designed to reach every child possible. Nearly all children need to be vaccinated multiple times in order to achieve the "herd immunity"⁵ needed to interrupt WPV transmission. Reaching such levels of coverage means there can be no groups of missed or inaccessible children large enough to sustain circulation⁶, vaccines need to be safely transported and stored for distribution, confidence in knowledge as to whether and where the virus is circulating has to be high, and communities have to be willing to accept the vaccine each time it is offered. All of this is obviously more difficult to achieve in the midst of conflict. By the 1990s, the GPEI had recognized the importance of negotiation, health infrastructure, surveillance, and community-level trust as foundational strategies for ensuring each of these potential gaps was filled.

Negotiation to establish ceasefires or "days of tranquillity" was essential if large-scale immunization campaigns were to access children in areas where ongoing conflict would otherwise make it impossible.^7,8 Where health infrastructure such as health centers and cold chains was inadequate or had been destroyed, it had to be replaced or at least supplemented to ensure full vaccine availability and distribution through routine immunization supplemented by campaigns.⁹ Disease surveillance systems had to be reviewed and brought up to acceptable standards to ensure polio cases were dependably identified. Building trust with very marginalized, vulnerable, often suspicious, and war-damaged communities was essential to having them accept the vaccine and vaccinators, as well as for developing alternative strategies to identify hard-to-reach groups. Approaches to building community trust during the 1990s often focused on such things as combining polio campaigns with other similar health services that could be delivered concomitantly, such as vitamin A supplements.

The 1990s ended with the GPEI missing its first eradication deadline and, though most remained optimistic that the new deadline of 2005 was attainable, it was clear that conflict would remain a common feature of many of the countries where poliovirus still circulated. The past decade had proven that succeeding in conflict-affected environments was possible, but it had also demonstrated that eradication would take longer, cost more, and be vulnerable to setback. Of course, 2005 came and went, and while conflict was not the only factor that led to missing this and subsequent deadlines, it was and remains one of the most important.

Each new conflict has slowed progress and challenged those working on the front lines to continue the task of polio eradication under dangerous and sometimes deadly circumstances.¹⁰ The years following 2000 saw the GPEI continuing to operate in conflicts that disrupted health delivery systems, undermined surveillance, displaced personnel, interrupted vaccine supply, destroyed cold chain systems, cut off financial resources, threatened neighboring countries with large movements of displaced people, and reduced demand for immunization, as basic survival became the major priority for many families. While new challenges continue to emerge, lessons from the 1990s remained relevant and formed a basic foundation that has been enhanced and built on over time.

Writings on polio lessons from conflict-affected areas in the 2000s are sparse, but a brief from the United States Institute of Peace titled Defying Expectations: Polio Vaccination Programs Amid Political and Armed Conflict captures challenges and successful approaches to negotiating with such disparate antigovernment forces as Sendero Luminoso (Shining Path) in Peru, multiple rebel groups in the DRC, and the Taliban in Afghanistan and a page on the GPEI website, entitled Reaching the Hard to Reach: Ending Polio in Conflict Zones (GPEI 2017), broadly captures lessons from the response to 2013's polio outbreaks in Central Africa, the Horn of Africa, and the Middle East. These sources build on the already-established foundations of negotiation and community trust mentioned above, but expand on both and add some new ideas. Negotiating access through respected interlocutors and maintaining neutrality continue to be critical when control of territory is contested or in the hands of different factions in conflict. In relation to building community acceptance and trust, knowing the concerns and priorities of the communities that the polio program needs to access is viewed as an essential first step but it is also essential to reach transparent agreement on logistical details so there are no unexpected incidents as vaccination campaigns are implemented. Practical suggestions for building trust include recruiting local vaccinators and engaging trusted local leaders from within conflict-affected areas to advocate for, and participate in, polio immunization campaigns.

These sources also identify speed and preparation as important, with emphasis placed on having the capacity to vaccinate when and where opportunities arise. This means being prepared to launch campaigns as soon as access becomes available or, when access is lost, being ready to quickly set up alternative vaccination opportunities. Examples of these alternatives are transit points set up around inaccessible areas to vaccinate children moving in or out, and health camps that bundle polio immunization with other basic health services to attract families to travel to vaccination points outside the inaccessible area. Another lesson focuses on building alliances with military and/or police forces, where possible, to help ensure the safety of polio staff. Such partnerships have been used successfully in several countries, including Pakistan, Nigeria, and Angola (Fekadu et al. 2016; Habib et al. 2017; Nkwogu et al. 2018). In some cases, however, this kind of partnership jeopardizes neutrality, and negotiation with those controlling an area is the only option.

To sum up, this listing of lessons on the GPEI website and the work of Rubenstein and others, while brief and in some cases focused on single issues such as working with police and military forces, underscore the importance of strategies focused on program neutrality and community trust and add ideas for accomplishing these ends, such as the local engagement of vaccinators and influencers. They incorporate the importance of having significant program capacity for opportunistic vaccination and the usefulness of forging partnerships with police or military, where possible. Interestingly, there is no mention of building health infrastructure or surveillance systems, though endemic countries have increasingly supplemented existing health infrastructure with large-scale polio social mobilization and vaccination programs,¹¹ and, in conflict-affected environments, much progress has been made in establishing robust surveillance systems.

A detailed account of the strategic and operational approaches most widely used by the GPEI in conflict-affected environments was published in the Journal of Infectious Diseases (Nnadi, Etsano et al. 2017). This article built on previous lessons but went more deeply into specific types of activities and the contexts they are most suited to—whether it be negotiating access with nonstate actors, reaching populations in areas where access is not possible, or reducing threats to workers in accessible areas that are security compromised. Each country presents a different context, but the GPEI now utilizes some combination of the strategies and activities identified by Nnadi, Etsano et al. in every conflict-affected environment in which it operates. The next section will focus largely on the strategies and tactics identified in this article.

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³ In the case of Tajikistan, while the civil war ended in 1997, a new government had just been established in 2000, with postwar recovery still in its early stages (Matveeva 2009).
⁴ As of August 2019, the GPEI lists the following countries in these high-risk categories:
Endemic: Afghanistan, Nigeria, Pakistan.
Outbreak: Angola, Benin, Cameroon, Central African Republic, China, DRC, Ethiopia, Ghana, Indonesia, Mozambique, Myanmar, Niger, Papua New Guinea, Somalia.
High risk for reintroduction: Chad, Equatorial Guinea, Guinea, Iran, Iraq, Kenya, Lao People's Democratic Republic, Liberia, Madagascar, Sierra Leone, South Sudan, Syrian Arab Republic, Ukraine. (GPEI 2019)
⁵ A simple definition of herd immunity can be found on Vaccines Today, where it is described as "a form of immunity that occurs when the vaccination of a significant portion of a population (or herd) provides a measure of protection for individuals who have not developed immunity" (Vaccines Today 2015). For a more nuanced explanation of the historical, epidemiologic, theoretical, and pragmatic public health perspectives on this concept, see Fine et al. 2011.
⁶ When conflict denies access to immunizing large numbers of children, as seen in Afghanistan today, the problem is obvious, though negotiations need to also focus on small groups and areas. See, for instance, the work of Duintjer Tebbens et al. 2019 on polio eradication certification for insight into how small subpopulations can support low-level circulation.
⁷ It is worth noting that negotiation sometimes had ancillary benefits by creating a neutral basis (the protection of children from disease) to bring otherwise opposed groups to the table and occasionally even became the first phase of more wide-ranging discussions between combatants. For example: "The planning and conducting of NIDs [national immunization days] may also open channels of communication for further negotiations between the parties on other issues of common interest. Working together on common goals encourages cooperation and helps to build the trust necessary for permanent solutions. The creation of days of tranquility was an important step on the road to such solutions in El Salvador and the Philippines" (Tangermann et al. 2000).
⁸ While there have been questions raised on the ethical issues surrounding engagement with violent antigovernment groups, the GPEI has taken the position that vaccination campaigns "operate on the belief that children who are innocent victims of war, should not be further victimized by refusing to engage with groups that could help facilitate immunization against polio and other childhood diseases" (Rubenstein 2010).
⁹ Routine immunization services are often disrupted in times of conflict or provided by nongovernmental organizations (NGOs) or other agencies, if government services have stopped. Campaigns can compensate for low routine immunization coverage, but ideally, and wherever possible, routine vaccination needs to be supported, especially when antigovernment groups are willing to allow such services to continue.
¹⁰ For instance, over 100 polio workers have been killed in Pakistan since 2012 (Press Trust of India 2017), as have workers in other countries such as Afghanistan (Radio Free Europe 2016) and Nigeria (Smith 2013).
¹¹ While these large-scale social mobilization and vaccination programs have proven effective at reducing (if not yet eradicating) polio, they have also generated considerable debate and controversy as to the degree to which they have negatively impacted on government provision of basic health services. See, for example, Closser et al. 2014.

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Editor's note: Above is an excerpt from "Reflections on Polio Lessons from Conflict-Affected Environments". The full table of contents is here.

The next section in this paper is Lessons: Strategies and Activities.
The previous section in this paper is Introduction.