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A winning shot for Moradabad

As India records a year without any new case of the wild polio virus,Uma Vishnu travels to Moradabad,once branded the world’s polio capital,to tell the story of a turnaround

Written by Uma Vishnu |
January 29, 2012 3:47:58 am

On a wall on Station Road,among posters of Khoonkar Darinde and The Dirty Picture,Amitabh Bachchan looks out of a row of yellow-and-red posters and says,“Do boond har baar.” Here in Moradabad,the town in western Uttar Pradesh that till recently exported,besides its intricate brassware,strains of the deadly polio virus,the posters have been around for long. The writing on the wall was clear: this was the hotbed of polio in India and if the virus that crippled more than 1,600 children in the country till as recently as 2002 was to be eliminated,the fight had to begin here.

On January 13,as India recorded a year without any new case of the indigenous wild polio virus,in Moradabad,an army of polio workers and doctors silently cheered a milestone of their own. It was in September 2009,over two years ago,that the district recorded its last polio case,a stunning turnaround for the place that had been branded the world’s ‘polio capital’.

The last case recorded in the country was on January 13,2011,when 18-month-old Rukhsar Khatoon in Howrah,West Bengal,was detected with polio. Now,if the pending lab tests of stool and sewage samples do not show traces of the poliomyelitis virus,India will drop out of the acronym ‘PAIN’,which stands for Pakistan,Afghanistan,India and Nigeria,among the last few holdouts of the polio virus in the world. If that happens,India will officially not be held responsible for the transmission of the wild polio virus. But to be declared “polio free”,India will have to keep up this performance for two more years,and ensure all samples stored in laboratories are free of the virus.

In 1988,when 192 member countries of the World Health Organization passed the Global Polio Eradication Initiative,India posed the biggest challenge. The virus was paralysing nearly 1,000 children a day,nearly half of them in India.

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In India,the battle seemed lost even before it began,with the challenges seemingly insurmountable—a vast population,a majority of them poor,illiterate,hungry and suspicious. How do you tell them that queuing up with their children at a polio booth won’t solve their problems,won’t get them their ration cards,won’t ensure a life of dignity,but will help their children stand on their feet? That didn’t sound convincing and so,even after India started its mass immunisation campaign in 1995,most people stayed away. Till as recently as 2009,India recorded 741 cases,74 in Moradabad.

But the government showed a rare initiative to take on the public health challenge. In 1997,it set up the National Polio Surveillance Project with WHO. There were other global partners—UNICEF took the lead in social mobilisation and Rotary International provided funds and did the advocacy—and all of them had clearly defined roles.

Who’s surveillance officers were to provide the technical inputs,check the vials and vaccines,plan the operations,prepare microplans that map every house and every child in each of these houses,train vaccinators,deploy an army of volunteers,compile exhaustive data and conduct extensive surveillance to make sure no child has been left out or no case of Acute Flaccid Paralysis goes unreported. In the process,they developed markings to identify houses where children had had their vaccines (P) and where they hadn’t (XL when children were not home when the vaccinators visited,XS when they couldn’t be vaccinated because they were sick,and so on). UNICEF was to do the social mobilisation,a key element of the anti-polio programme given the resistance to the vaccine in the northern plains of the country. Besides social mobilisation and fundraising,Rotary did the advocacy and roped in celebrities to lend their voice to the cause. The government,meanwhile,deployed an army of vaccinators and supervisors and arranged for the vaccines.

“The success that you see in the polio programme today is entirely because of this team effort among the different partner agencies,more so in Moradabad. It wouldn’t have happened otherwise. Look at the scale of the programme. Which other government programme reaches the doorstep of the people,” asks Amar Singh,District Immunisation Officer for the government of Uttar Pradesh in Moradabad.

But through all this,the doubts persisted. Why was the government pushing for polio eradication when there were other pressing problems and health issues? Among the largely poor and illiterate Muslim population of Moradabad,there were other fears. Was it a ploy by the government to bring down their numbers? Would the polio drops then cause their children to be impotent? Fears that got the community angry,vulnerable and insecure,to react by boycotting the pulse polio drive.

They did everything they could to block the vaccinators—hid children when the teams came for rounds,threatened them,let the dogs loose,sometimes simply argued with all the vehemence they could muster.

***

11 a.m. Karula Colony,Moradabad Urban. Kamar Jahan accompanies her team of three polio workers on a ‘house-to-house activity’ to see if there are children who have been left out of the immunisation drive the previous Sunday. Kamar is a Community Mobilisation Coordinator or a CMC deployed by UNICEF to bring reluctant mothers round.

Karula Colony is a picture of urban rot. The lanes are dingy,narrow and crowded. But the colony throbs with life—kirana shops with garlands of shampoo satchets and mounds of rusks,butcher shops where men and women crowd around,children running barefoot and cottage foundries where men covered with toxic silver dust mould aluminium ladles and brassware.

Till recently,the dark,stagnant drains on either side of the alleys,throbbed with life of another kind—invisible,deadly polio viruses that maimed and killed infants just as they took their first baby steps into the galis. That made Karula Colony one of the focal points in the fight against polio and its residents reacted with anger at this intrusion into their lives.

“It used to be tough earlier. Mujhe dekhte hi gaali dete the. Jamil bhai ne to tamancha bhi nikala tha (They would swear at me and Jamil bhai even aimed his pistol at me). Once Maroof bhai held his butcher’s knife against the supervisor’s throat. I used to come home from rounds and cry. All that has changed. Now Maroof bhai is friendly,ab murga khilate hain (treats us to chicken). I know everyone here,they are like family. But we had to speak to them several times before they were convinced that the polio drops wouldn’t do their children any harm,” says 25-year-old Kamar,now shrill and confident. She juggles her studies—a BA in English from Hindu College in Moradabad—with her polio work. She earns Rs 1,500 a month.

Moradabad and other high-risk districts hold 8-10 such immunisation rounds a year,each lasting six days,when every child who is five or below is identified and vaccinated. In Moradabad alone,1,830 vaccinator teams and 649 supervisors visit more than 8.52 lakh houses to vaccinate 8.61 lakh children during each immunisation round. Apart from the houses,teams have identified nomads and migrants in slums,brick kilns and at construction sites. This giant machinery works itself into a frenzy almost every month.

A key part of social mobilisation strategy was to involve the elders and the priests of the community.

Mohammad Nasir Saqlain,a 24-year-old maulana of Khateeb Lal Masjid in Moradabad,says he was initially suspicious,but not any more. “It’s about yakeen (trust). Earlier,we thought this was American propaganda,why was the government forcing us to do this,polio hi kyon? Then,we got to know that this was a global programme and wasn’t just in India. Also,some of the kids who were vaccinated had grown up fine. I was convinced.”

It took a lot of convincing. On polio Sundays,after the call to prayers,loudspeakers in mosques would exhort people to take their children to the booths. On Friday,after the namaaz,the imam would talk to people about the benefits of being polio-free.

Israr Ali alias Pervez bhai,who owns a shop in Karula Colony,is among the ‘converts’. He used to vehemently oppose polio drops for his three children,but now his youngest child gets polio drops and his shop serves as the site for routine immunisation sessions. “Now I tell my customers that if they don’t take their children to the booth,I won’t give them credit,” says Ali,a genial 42-year-old with flowing henna-dyed beard.

“We involved children too. We formed bulawa tolis where some of the older kids were given whistles and caps and they would happily go around,their shrill whistles alerting people to the rounds,” says Dr Nirmal Singh,Communication Development Officer for UNICEF.

***

But there were setbacks too. In 2002,Moradabad recorded 79 cases of the wild polio virus,contributing to the all-India tally of 1,600,the second-highest since the polio campaign was launched. Every such setback took the technical experts back to their drawing boards.

There are three strains of the wild polio virus—P1,P2 and P3,of which P2 was eradicated in 1999—and the oral vaccine was initially designed to target all three. When P1 cases recorded a surge,a monovalent oral polio vaccine to target P1 was introduced in April 2005,but that saw P3 cases shooting up. The agencies got into a huddle again and in January 2010,a bivalent vaccine was introduced that targeted both P1 and P3. That proved the winning shot. That year,merely 42 cases of the wild polio virus were recorded and Moradabad had none. The following year,2011,India had one case and since then,none.

But as Hamid Jafari,Manager,National Polio Surveillance Project,says,from here on,“complacency” could be the biggest enemy in the fight against polio. “If we lower our guard and think that the job is done,that will be a real hazard for the programme,” he says,warning that there is still a risk of the virus coming back. What India has done now is to stop the transmission of the indigenous wild polio virus; the risk of ‘importation’,or the virus coming in from outside,remains.

Sudhir Gupta,an advocate in Moradabad and a key member of Rotary International’s India National Polio Plus Society Rotary,says,“From here on,we have to move cautiously—cheenti ki chaal se—and do the basics right.”

***

Someone else is waiting with bated breath for India to be declared polio-free—neighbours Sri Lanka and Bangladesh. They are among the 11 countries who are part of WHO’s South East Asia Grouping. The last case in Sri Lanka was reported in 1993 and in Bangladesh in 2006,but they won’t be declared polio-free till all member countries in the region earn that tag. India was that big laggard,but may no longer be so.

‘Time to celebrate,but we are not out of the woods yet’

Dr Hamid Jafari is Project Manager of WHO’s National Polio Surveillance Project that provides technical inputs to the Government of India in the polio eradication programme. In an interview,he says the success of the polio programme shows that “if it can be done in India,it can be done anywhere else”.

No wild polio cases for a year. Is it a time for celebration or caution?

It’s a time for both. Given that India has historically suffered the greatest burden of polio,and that conditions here are favourable for the transmission of wild polio virus,this achievement affirms that strategies work when applied rigorously and if it can be done in India,it can be done anywhere else in the world. But we are not out of the woods yet. There is a real risk that the virus can resurge. There can still be importations of the wild polio virus. Until two years ago,India exported the virus to several countries,including Tajikistan in 2010. Indian strains are still circulating in Africa. The same traffic that took the virus out of the country can bring it back. So we need to be vigilant. Apart from maintaining sensitive and speedy surveillance,we need to maintain immunity of children through intense pulse polio campaigns and routine immunisation and must reach out to high-risk population groups. Also,all states need to maintain a high level of alertness and ensure their high risk populations are covered through routine immunisation along with pulse polio vaccination. So this one-year mark provides a solid platform to complete the task of polio eradication in India.

Given the scale of the challenge in India,did you see this coming five years ago?

The size and complexity of the programme in India always made precise predictions difficult. This programme has gone on for long and along the way,there have been constant refinements in the vaccines used,in surveillance techniques and operational innovations. For instance,the trivalent vaccine that was in use in all parts of India was found not as effective in parts of UP and Bihar. Therefore,monovalent vaccines were introduced in 2005 and in January 2010,the bivalent vaccine against Type 1 and Type 3 was introduced. That proved successful. Then there were special strategies developed to reach newborns,to identify and map migrant populations,to reach children in remote field huts in the Kosi flood plains in Bihar. We always had a roadmap,but when you are trying to get rid of polio infection from the last person among 1.2 billion people,it’s difficult to predict with precision.

Are there lessons in India’s success for other countries?

What helped the programme most was the high level of political commitment and funding by the government. Another key factor was the accountability that existed at all levels,particularly at the district level. For example,when a pulse polio round is on,the chief medical officer and the district magistrate hold evening meetings where the data for the day is reviewed and corrective actions taken right then. That ensured the programme was watertight. This kind of accountability is still weak in many other countries that are struggling to eradicate polio.

What are the challenges ahead of you?

The challenge right now is complacency. If we lower our guard and think that the job is done,that would be the real disaster for the programme. Second is the risk of resurgence of the polio virus,mainly as a result of importation. The challenge is to maintain the intensity of the programme in the absence of the disease—maintain commitment,funding,the high level of alertness and intense vaccination campaigns.

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