Reflections on Polio Lessons from Conflict-Affected Environments [Lessons: Strategies and Activities]

Lessons: Strategies and Activities

It has been said in many a United Nations (UN) security briefing that security objectives have shifted over the past decade or so from "how to leave," to "how to stay," to "how to stay and effectively deliver programs." This shift in focus has resulted in a number of changes, such as more nuanced security risk assessments and greater collaboration between those responsible for security and those implementing programs. Staff safety remains the priority, but security analysis has become a more integral part of GPEI program planning to provide detailed, geographically specific, and localized knowledge of risk levels that can be applied to plans for fieldwork. The polio program has used these security analyses to determine with greater accuracy where and when staff can and cannot go and, wherever possible, updates them regularly to develop a dynamic picture of field risks. This information enhances the ability to quickly move vaccination resources into areas as risk levels permit. New technologies such as satellite imagery also help with such things as identifying where populations are, approximating how many people are in an area, understanding the extent to which people are moving, and detecting new settlements such as informal refugee camps or populations of internally displaced persons (IDPs).

Of course, having a better understanding of risk levels and where people are will not help if there is no access. The capacity to negotiate ceasefires in areas of active combat or access for vaccine delivery or surveillance into areas not controlled by government was as important to Nnadi, Etasano et al., as it was to the other researchers—as is neutrality, so that all sides perceive the negotiation to have no agenda other than the health of children and the eradication of polio. This can be a complex and difficult thing to do, given the variety of actors and the changing and kinetic environment in which they operate. The addition of professional security risk assessment helps reduce the danger and uncertainty, but it is no substitute for negotiating acceptable terms for safe and effective access.

These negotiations are complex. Matters such as control and decision-making among those denying access are not always clear. Decisions and agreements made with senior leadership in a conflict can sometimes be blocked by local leadership and vice versa. Access may be allowed in one area but denied in an adjoining area, creating the need for new and different negotiations. A polio campaign's standard operating procedures are not always acceptable to groups in the midst of conflict and can be viewed with suspicion.

Eradication levels of coverage require deep engagement—not only with communities but with each household in the community. In the best-case scenario, teams of well-supervised, mostly female vaccinators go to the door of every household and enter those households to identify and vaccinate each child. Vaccinators mark the left little or pinky finger of the child to indicate they have been vaccinated. Careful records are kept of each household to document information such as how many children under 5 years of age live there; whether they are visiting or permanent; if they are absent and, if so, where and for how long; and whether caregivers are refusing and, if so, for what reason. Chalk markings are written on the door of each house indicating numbers of children and whether any have been missed. If any are missed, follow-up visits are organized. If refusal is an issue, local influencers go to the house to try to convince caregivers to allow their children to be immunized. Following the campaign, monitors go through communities checking to see that these records are accurate and that coverage rates match campaign records. Special surveys are done based on methods of lot quality assurance sampling and market surveys are conducted to identify children who have not had their pinky fingernail marked by vaccinator teams after vaccination, adding multiple layers of cross-checking. All of this means that a properly run polio campaign requires a lot of community engagement, information gathering, and monitoring (including supervision with zero tolerance for falsification of information). This can be difficult to accept for communities and groups who are suspicious of outsiders, possibly facing attacks from the air and ground, and worried about informers and intelligence gathering.

Negotiations need to begin with trying to get access under conditions that give the best chance of high levels of coverage. However, when this is not possible, compromises that may impact on performance sometimes need to be made. This can involve allowing frontline workers to be selected and supervised locally, male vaccinators to be used instead of female,¹² and local monitors who may not be as independent as they could be. Other possible compromises include setting aside recordkeeping for missed children, not marking houses, and replacing house-to-house campaigns with approaches that require caregivers to bring or carry their children to fixed sites. In some cases, compromise can go as far as simply supplying vaccines to those in control of an area and letting them do the vaccination without any outside supervision or monitoring.

Each of these compromises can impact quality and reduce overall campaign coverage. None should be taken lightly, but the realities of negotiation during a conflict will sometimes make them necessary in order to keep an immunity gap from growing more than it would without any vaccination. However, when compromises are made to multiple components of eradication strategies and approaches, coverage suffers, and the virus has more opportunity to continue to circulate. When negotiations require significant compromise, they are usually considered temporary measures to build trust so that more effective operations can resume after further negotiation. Of course, "temporary" can be a relative term, especially in the context of a prolonged conflict. It is important to be as rigorous in the design and implementation of temporary measures as in any vaccine delivery strategy and to keep transparent lines of communication open that continue to identify and address reasons for missed children.

Beyond negotiating with combatants and antigovernment elements (AGEs), Nnadi, Etsano et al. also note the essential role of engaging with, and understanding the concerns of, local communities. Involving traditional and religious community leaders, providing respectful and accurate answers to questions, listening to local voices from all sides of a conflict and jointly identifying solutions, engaging local people as vaccinators and mobilizers, conducting ongoing education and training on vaccination, and building relationships with local gatekeepers who can help advocate for polio access and create an atmosphere where the vaccine and polio program are trusted, are all critical. While not simple to develop, such engagement can help build local trust and demand and create pressure on groups controlling a given area to provide access and/or improved campaign quality.¹³

Close coordination with other agencies delivering other health services is important for a number of reasons. Conflict creates complex humanitarian crises requiring the delivery of a range of emergency services, including vaccination, sanitation, food, and shelter. When people are displaced, they often move to safe havens like refugee camps. Ensuring that services are delivered in a coordinated fashion is not only common sense in terms of efficiency but may also improve the uptake of different services by increasing overall demand through bundling (Cronin et al. 2007; Warigon et al. 2016). A desperate family may be more likely to make the effort to go to a vaccination point if that point can also address a range of other (and potentially more pressing) needs.¹⁴

Conflict can sometimes continue over an extended period of time and at a level where access is severely compromised, leaving children unvaccinated for years. This can result in significant numbers of older children being un- or undervaccinated. Increasing the age for target populations to be immunized can help provide immunity to missed older cohorts,¹⁵ and using antigen combinations of oral polio vaccine and inactivated polio vaccine can help boost immunity more quickly in areas where access is fragile or temporary or where immunity gaps need to be closed urgently.

Where access is not possible, alternatives to campaigns need to be implemented. Setting up vaccination points strategically around an inaccessible area can provide immunization for children leaving or entering that area, protecting against virus being imported or exported and improving population immunity within the area. Setting up health camps that provide a wider range of highly sought services than just polio vaccination can also help motivate people to come to a vaccination point. In some cases, collaboration with military or police can also facilitate access, provide greater security to polio staff, and/or improve coverage at vaccination posts by requiring vehicles to stop at checkpoints. Collaboration of this kind in Pakistan and Nigeria has helped improve access and security (Nkwogu et al. 2018). Of course, this is not always possible when the conflict is between state and antistate actors. Transit and cross-border vaccination points are used in both conflict and nonconflict situations at strategic internal and international border crossings, railway and bus stations, or other points where people and their children are known to pass in significant numbers.

Other approaches noted by Nnadi, Etsano et al. are permanent vaccination teams wherein local people are recruited from insecure areas to vaccinate members of their own communities. As they are local, they are more likely to be trusted, and as they are permanent, they can vaccinate continuously without reference to campaign dates. They are resupplied with vaccines as needed and supervised only when it is safe to do so. Vaccination within repatriation, refugee, or IDP camps—in coordination with other agencies, also mentioned above—has proven to be useful in immunizing large numbers of children efficiently and for conducting surveillance.

In cases where the polio program itself has become a target in a conflict, creating a strategic media profile can be important. In the case of Pakistan, campaigns were intentionally not promoted with high-profile events, and polio materials were rebranded to disassociate the polio program from international donors and agencies. The focus of the new media campaigns and materials was on humanizing the vaccinators and other frontline workers and on emphasizing the local nature and ownership of the polio program. The campaign focused on vaccination being carried out by local community members to achieve an important good for their children. Vaccinators were presented as local heroes to be respected.

¹² Male vaccinators have more freedom to move around their communities, especially when those communities have conservative/patriarchal values related to male and female roles and appropriate behavior. Female vaccinators in such communities can be restricted in their ability to move about the community without a male family member accompanying them. On the other hand, conservative communities often deny males access to households unless they are related or well known to the family. This can create a serious challenge whereby males can get to the doorway but not inside and females can get inside the household but not to the doorway. Without access to households, male vaccinators cannot be sure they have vaccinated all eligible children in a household and can easily miss newborns and sleeping or sick children. Solutions have been found, but have to be identified and agreed by the community itself. For instance, in some areas female vaccinators have been allowed to move around their communities if they are accompanied by a male relative; in other cases older (postmenopausal) women are acceptable, especially those who have other work that takes them out into the community, such as midwifery. The importance of community involvement in solving such challenges cannot be underestimated.
¹³ Building such networks requires cultural understanding and often peer-to-peer discussions. Some of these complexities are captured in publications such as the toolkits found on the GPEI/UNICEF Rhizome website https://poliok.itor or in this toolkit developed by Islamic Relief Worldwide (Salek 2014).
¹⁴ This assumption needs to be taken with some caution as it is important to recognize that demand for health services does not abate when the state is unable to provide them. In areas where the state is unable to function, other providers will fill the void. They may be beneficial or harmful and often form a complex patchwork of health services. It is critical to understand this sphere of nonstate adaptation when implementing integrated or incentivized initiatives such as health camps (Hill et al. 2014; Pavignani et al. 2013).
¹⁵ Changes in cohort age need to be approached with caution, especially among populations where rumors are widespread and support for vaccination may be weak.

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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 In Summary.
The previous section in this paper is A Brief History of the GPEI in Conflict-Affected Environments.