Reflections on Polio Lessons from Conflict-affected Environments [Conclusion]

Conclusion

Eradication requires sustained high levels of population immunity, which can be difficult to achieve, even in areas where access and conflict are not major issues. Given the conflict-affected context in the three remaining endemic countries, those with outbreaks of circulating vaccine-derived poliovirus (cVDPV), and those at high risk of reintroduction, sustaining such levels will be much harder, even if WPV eradication seems tantalizingly close. Understanding the experience and history of the polio program's work in security and conflict-compromised areas is arguably more important at this stage than ever before. Clear, evidence-based lessons need to be drawn from previous experience and brought to bear on new challenges and evolving old ones.

Looking to the next 5 years the polio program will need to face and overcome several critical issues. "Temporary" compromises in campaign and surveillance strategies to gain access may extend over long enough periods of time that they become a kind of "new normal." Once a temporary situation becomes normalized, constant refinement of negotiated strategies and activities to reduce the numbers of missed children to eradication levels will become essential. Such refinement will require ongoing negotiation and listening to local concerns on all sides of a conflict to seek solutions that identify and continually reduce numbers of missed children. It will require different strategies in different places. Afghanistan, for instance, may need to look at vaccine delivery strategies that do not include house-to-house vaccination, door marking, or household-level data collection, and utilize different approaches to monitoring. This would mean major adaptations for the polio program, potentially combining campaigns with improved routine immunization, mobile population vaccination, and different approaches to monitoring and identification of missed children. In the context of continuing conflict, approaches to negotiation will need to draw on past experience and build new partnerships with local groups with capacity to deliver vaccines and/or engage local-level authorities in assessing and improving immunity levels over time. Negotiation in this context needs to go beyond appeals based on biomedical or global social good to engage more directly with the urgent needs of impending or existing humanitarian crisis. Nigeria, on the other hand, where antigovernment groups like Boko Haram refuse to negotiate and are against vaccination and where outbreaks of cVDPV have been persistent, will present a different set of issues (Nnadi, Damisa et al. 2017).

The very long-term nature of conflicts in countries such as Afghanistan means that communities are being forced to adapt their own long-term strategies for accessing health and other essential services. It can be easy to assume that as conflict destroys or radically weakens health infrastructure, there is a void created. The reality is often quite different. Demand for health care does not abate as those services become harder to access during a conflict. As communities and individuals continue to seek such services, the “void” left by deteriorating formal health care infrastructure can be filled by an often uncoordinated and usually poorly distributed range of new providers with varied effectiveness. Some of these may provide traditional medicine, some may be itinerant opportunists or quacks, some will be local but partially equipped or understaffed clinics operated by NGOs, religious organizations, or expatriate-funded groups, others may be operated by groups controlling the area (Hill et al. 2014). To work effectively in such environments requires a well-informed understanding of the various actors, the services they provide, and which actors can be effective partners in delivering vaccination and other health services. It also requires a strong understanding of the perceived health priorities of communities living in these areas and respectful engagement with local leaders. Communities and their leaders need to be engaged to support polio vaccination, with consideration given to the adaptations they have made to the conflict, their knowledge of local providers, and their priority health care needs.

Reaching the hardest to reach will require an ongoing focus on identifying clusters of missed children and the communities in which they live. This will mean finding ways to identify and access all children, including newborns and children who are too young to walk, those who are travelling or away from their houses, those who have been displaced or resettled due to conflict, and those living in communities where outsiders are looked upon with suspicion. It will also be necessary to work with communities to increase female involvement in vaccine delivery to support better access to the youngest children and to identify and establish close relationships with other organizations working with displaced or mobile populations or in areas controlled by AGEs.

Eradicating WPV is a necessary first step, but it is not the final one. It will be equally essential to respond to cVDPV outbreaks and to sustain high levels of immunity for years after WPV eradication, both of which will have to be done through building long-term partnerships with a broad range of organizations that can help deliver vaccines wherever and whenever they are needed. Sustained eradication will require stronger routine immunization programs, vaccine delivery and surveillance strategies that are effective and adapted to be acceptable to all sides of a conflict, and a range of tactics suitable to identifying and reaching children whether they be in insecure areas, displaced from their homes, or part of marginalized mobile groups. Facing these and other challenges of conflict-affected environments will require a combination of learning from past experience and finding solutions to new or evolving issues.

The lessons outlined above have been captured in a small number of reports, research papers, and guides for field staff. Even within this circumscribed literature, a more complex discourse can be seen emerging, as reflection on new lessons and new experiences is added to prior understanding. The polio program itself has become larger and more complex, as has its ability to develop and implement strategies specifically designed for operating in conflict-affected environments. There is a great deal of program experience—together with a large and growing database on the impact of multiple program initiatives—that suggests it is possible to systematically review the relative merits of the different tactics and strategies described above. Furthering research¹⁹ and expanding the literature on the GPEI’s experience could make an important contribution to the much richer realm of research focused on humanitarian work in conflict zones and other facets of health service delivery. More importantly, in the short to medium term, such a contribution can be a significant resource for a program operating in the midst of severe, ongoing, and complex conflicts. As the GPEI enters the final phase of stopping WPV while building the foundations for the sustained high levels of immunity required to achieve global eradication, navigating the complex environments it finds itself in requires a better understanding of past experience and further evolution of its strategies.

¹⁹ While this document has not looked at questions of research ethics in conflict-affected environments, any sustained effort to systematically and rigorously research the GPEI's experience, even if small, will need to pay attention to this relatively recent but growing field of enquiry. See, for example, Campbell 2017.

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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.

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