The fight against polio through vaccination alone is no guarantee to keep the disease away in the times to come. In the absence of safe drinking water and lack of sanitation polio can well resurface, warns Swati Saxena
The successful eradication of smallpox led the way for adoption of global polio eradication target in 1988. It was endorsed by India as a member country of World Health Organisation and commitment was made to eradicate polio by 2000. For several years India had reported the largest number of cases, and its high population density made it most vulnerable to the rapid transmission of the virus. In India the OPV, or oral polio vaccine, was included in the national immunisation schedule of the Expanded Programme (this included diphtheria, pertussis, tetanus, poliomyelitis, typhoid and childhood tuberculosis; later measles was included and typhoid was dropped) in 1978-79, a decade before it became a signatory of the WHA (World Health Assembly) Resolution.
It was in 1995 that Global Polio Eradication Initiative (GPEI) was launched nationwide after consultation by the Ministry of Health and Family Welfare (MoHFW) with officials, aid donors, and non-governmental organisations and the National Polio Surveillance Project (NPSP) was launched in 1997. NPSP was a joint initiative between WHO and GoI. This promised eradication of poliomyelitis by the year 2000 and “certification” of eradication by 2005, i.e. no polio cases with virologically confirmed wild virus for three consecutive years (zero polio status). The first deadline was a failure and the second deadline of 2004 fared no better. It was at this point that tensions between India and the international community heightened. “Now more Than Ever: Stop Polio Forever” was issued from WHO headquarters in Geneva in January 2004 and a “declaration” was signed by the ministers of the six countries which were allegedly “of highest priority for stopping the transmission of poliovirus globally”
Following the second deadline failure WHO issued a new report entitled “Eradication of Poliomyelitis” which marked a major shift. It was termed a “New Global Eradication Strategic Plan for the Period of 2004 to 2008” and was supposed to reflect “the major tactical revisions introduced in 2003.” A revised time frame for global certification was set with a new goal of “ceasing oral poliomyelitis vaccination soon thereafter, and plans for sustaining the long term elements of poliomyelitis eradication work.”
On 13th of January 2012, India declared its first polio-free year (the last reported case was a two-year-old girl in West Bengal on Jan 13, 2011) and feelings of triumph were felt by the public health professionals as well as the policy makers. India was finally taken off the list of polio endemic countries after that. These efforts of the Indian Health Ministry garnered praise worldwide and was hailed as an unprecedented achievement for a nation which only few years ago had the largest number of polio cases in the world – 741.
In order to interrupt polio transmission, the Polio Eradication Initiative in India involved immunisation of every infant with three doses of Oral Polio Vaccine (OPV) through routine immunisation and to break transmission of wild poliovirus through supplemental “pulse” immunisation of all under-five children. This was done through Supplementary Immunisation Activities (SIAs) when some states or parts of states were covered. In addition, “mop ups” were conducted, as soon as possible after identification of the virus as an end-game strategy to interrupt transmission, when virus transmission was focalised and polio cases were found in specific areas. The immunisation continues even today with Pulse Polio Days and inclusion of vaccine in the Universal Immunisation Programme.
However from the beginning Polio Eradication Initiative saw little consensus over the number of cases, funding for the programme, the number of doses, the structure of the vertical initiative via vaccine versus a more holistic idea of controlling transmission through water and sanitation and most importantly whether it was more efficient and cost effective that disease should be eradicated or merely controlled.
One of the most important debates that surrounded the programme was of disease priority and upstream determinants of health. Polio is spread through faecal-oral route and is endemic in areas with high density, open defecation and compromised water supply. Thus, there was a section of policy makers and practitioners who believed that the programme should have been restructured to move away from just immunisation drives and be integrated with better sanitation and water provision.
This thinking has found resonance in public health approaches to disease integration. There has been a recent increase in attention to holistic approaches to health in the academic literature as well as recognition of the fact that concerns about health and disease should not be solely confined to the health sector or the Health Ministry. The document by WHO “Closing the gap in a generation: Health equity through action on the social determinants of health” recognises that the poor health of the poor, the social gradient within countries and the marked inequities between countries are caused by unequal distribution of income, goods and services. Such factors are responsible for the consequent unfairness in the immediate, visible circumstances of people’s lives.
People’s access to health care, schools, and education, their conditions of work and leisure, as well as that in their communities, towns or cities determine their chances of living flourishing lives. The report proposes focussing on other sectors to tackle issues surrounding health. Poor and unequal living conditions are the consequence of poor social policies and programmes, unfair economic arrangements and bad politics.
What is needed is a broader definition of public health since health encompasses not just a healthy body but also a healthy environment. Health is a function of social, economic and cultural forces. Thus, addressing any health concern cannot be solely confined to the disease and dosage but factors like its transmission, water, usage of toilets, nutritional status of the family or the community and exposure to pollutants and toxins must be taken into account. Thus for polio, emphasis on vaccination, while the modes of transmission (water and toilets) remained unchecked was problematic.
It must be noted that in India majority have no access to toilets and open defecation is rampant. A look at the NFHS-3 data demonstrates that majority of households (55 percent) and a similar majority of the population (56 percent) in India have no toilet facilities. UNICEF estimates that around 600 million are defecating in the open, which is almost half the population and almost 44 percent of the mothers dispose their children’s faeces in the open (http://unicef.in/Story/1125/Water--Environment-and-Sanitation). The proportion of households without any toilet facility is much greater in rural areas (74 percent) than in urban areas (17 percent). This discrepancy persists with improved toilet facilities (including toilet facilities with a flush or a pour flush that is connected to a sewer system, septic tank or pit latrine, a ventilated improved pit (VIP) latrine, a biogas latrine, a pit latrine with slab, and a twin pit, composting toilet.)
More than 97 million in India lack access to safe drinking water (http://www.swissrefoundation.org/what_we_do/global_programmes/capacity_building/182366551.html ) and there remains a considerable gap between water infrastructure created and service available at the household level. NFHS-3 data demonstrates that this basic right remains elusive. Only half the households in India reported having drinking water on their premises, 37 percent of households do not have water on their premises and it takes them around 30 minutes for a round trip to fetch drinking water and for the remaining 12 percent one round-trip takes more than half an hour. Urban households are more likely to have a source of drinking water on their premises (71 percent) than are rural households (42 percent). A majority, (66 percent) do not treat their water.
Practice of hand washing remains also dismal. According to Public Health Association, only 53 percent of the population wash hands with soap after defecation, 38 percent wash hands with soap before eating and only 30 percent wash hands with soap before preparing food. NHFS-4 data is on the way and it will be interesting to see what changes it shows in terms of these indicators.
Thus, while we may have successfully eradicated polio for now and led to its disappearance from the environment, without addressing the extremely poor water and sanitation infrastructure there remains constant danger of virus resurfacing. Even if one person becomes infected, the virus discharged from the guts of infected children or adults by means of faeces and untreated human waste would continue to circulate in the open sewers, lanes and rivers, becoming a source of transmission for the others.
The question of sanitation goes beyond just polio eradication. It can help in controlling a large number of other diseases like enteric fever, cholera, diarrhoea, hepatitis-A, malaria, Japanese Encephalitis etc. The definition of sanitation also goes beyond environmental sanitation to include personal hygiene, home sanitation, safe water, garbage disposal, excreta disposal and waste water disposal.
Polio Eradication Initiative could have benefitted from trying to achieve a better integration of vaccination with improvements in water and sanitation and achieved a bi-directional relationship with these services. There have been efforts made in this regard to programmes like National Rural Health Mission (as initially conceptualised) which have sought convergence with departments of Water and Sanitation, Women and Child Development, Panchayati Raj etc. The revamped National Health Mission hopes to continue this trend. The earlier Nirmal Bharat Abhiyan and now Swachh Bharat Abhiyan have continued to underline the importance of sanitation and toilet construction. More intensive efforts are needed in the direction of behaviour change, communication, awareness and information especially when toilets constructed are often used for storage purposes (mostly for dung cakes used as fuel) and communal toilets are in non-working conditions.
The most important lesson that can be drawn from PEI is in the way we think about diseases and health. There needs to be a paradigm shift in policy pertaining to infectious diseases - from seeing ‘solutions’ in terms of just technology to realising that ‘solutions’ can only come through grass root engagement with basic but vital upstream determinants like water and sanitation. At the same time immunisation coverage needs to be improved. Evidence has shown that even vaccines are not very effective when child’s immune system is compromised through poor nutrition or the child is battling constant bouts of diarrhoea.
In other words there needs to be dismantling of the myth that the diseases can be eradicated through technology alone. There is a great need to fund and prioritise basic infrastructure. Building toilets and ensuring clean drinking water to every household form the foundation upon which the health, dignity and the future of the nation stands.
– The writer is a scholar with a doctorate in Public Health Policy from University of London