In 1988 the World Health Organisation started the Global Polio Eradication Programme. India also committed itself to eradicating polio from the country. Since 1995 the Ministry of Health and Family Welfare started intensive immunisation to eliminate the virus and in 1997 the National Polio Surveillance Project was launched in collaboration with the WHO. Today there are few who are not aware of the Pulse Polio Campaign the visible face of this programme. There are many rounds of immunisations that are held ever so often and many famous personalities lend their names and faces to the appeal that the two drops of the vaccine are necessary to save lives.
On the appointed dates booths are visible all over cities in India, and health workers fan into the villages. House to house mop up rounds are held soon thereafter and the campaign proceeds with a kind of military precision that is not often evident. In many ways the Pulse Polio Campaign provides evidence that the otherwise listless government machinery is capable of delivering the goods.
The Indian Government is committed to eradicating polio and a huge investment in money, human resources and other resources are being made regularly on this issue. Unfortunately the claim of eradicating polio by 2005 is not going to come true because in the first three months of this year there have been reports of nearly 2000 cases of acute flaccid paralysis and confirmation of 8 cases of polio. However the total number of confirmed cases is coming down steadily over the last few years, excepting in 2002 when there was a nearly five fold increase in the numbers. But before congratulating the Government of India and its global partners on this achievement a couple of related realities need to be considered.
Polio is a disease that affects the poor and the poorer nations. However it is one among many health conditions that are poverty related. Polio is not among the most virulent, or the most devastating or the most common among the many diseases. Tuberculosis affects 10 million new persons in the world every year, killing over 500,000 persons in India alone. Childbirth kills over 600,000 women each year the world over (a fourth of them in India) and seriously impairs the health of over 2.5 million women in India. Diarrhoea continues to be a very important reason for death in children and nearly one million children die the world over. But polio had one advantage over many such conditions, being easily controlled by vaccination and that it had already been controlled in most parts of the world.
India is one of the global hotspots of polio. Of the 136 cases reported in India last year 123 cases were from UP and Bihar. As is well known UP and Bihar have some of the poorest health related statistics, so this information is not surprising. The high reporting of cases from UP and Bihar have had the desired effect; the polio eradication campaign is also going to be intensified in this region. Health workers will carry out more intensive search and vaccinate campaigns and the district health administration will remain on high alert. And international experts will be satisfied that the world is close to eradicating polio after 17 long years and after spending close to 4 billion US dollars and one of the largest global public health campaigns is coming to a successful closure.
The grassroots management of the polio campaign in India is under the supervision of the Surveillance Medical Officer, an additional medical officer at the community level. This person is aided and assisted by existing functionaries of the health department. In times of the pulse polio campaigns additional workforce is required and all government officials at the community level like schoolteachers are also recruited for this work.
The unfinished war on polio
Rural health mission is promising
Polio is transmitted from human to human without an intermediary host and is preventable by mass vaccinations. Policy makers also make assumptions in polio eradication planning, that socio-economic variables do not intervene substantially, and correspondingly that biological/technological control alone is going to be very effective. In reality, even with polio eradication, two or three socio-economic variables are intervening tremendously. They are 1) poor service delivery mechanisms, which continues to miss children, 2)cultural beliefs and practices and 3) war and forced migration (especially in Africa). For diseases like TB, diarrhoea or maternal morbidity/mortality, socio-economic variables influence the disease condition to a great extent, and biological elimination/prevention mechanisms are not as simple or well developed. Given this, when governments put most resources into the polio basket, other health care priorities suffer.
At Madhepura, in Bihar where the last case of polio was found, the illiteracy rate among women is close to 80%, prevalence of tuberculosis, malaria and blindness are very high, complete antenatal checkup was available to 11% pregnant women and only 1.4% deliveries took place in a government hospital. Less than 1% women stated that any health worker had visited them. Full immunization had taken place in a little less than a fourth of all children.
In the district of Saharanpur in western UP, not very far from the nations capital the situation is not much better. Tuberculosis and malaria prevalence is high, full antenatal check up was available to less than 8% women and a little more than 5% women had their deliveries in a government hospital. A little over 5% women said that a health worker had visited them. Full immunization had taken place in a little less than a third of all children. UP has been the most problematic state in India over the years. Rural women in UP now complain of the repeated polio drives and the absence of other services.
What this data indicates is that the people of these communities not only suffer from a large number of ill-health conditions but they also lack basic services. In these districts the service delivery mechanisms are also perhaps weak. But significantly, whatever little health related resources are available are all being dedicated to the pulse polio campaign. It is not difficult to anticipate the impact of this single mindedness on these other conditions. Routine immunization suffers, and there is emerging evidence that overall immunization coverage is static or coming down. Infant mortality has remained stagnant over the years. Health workers have no time for routine antenatal care and delivery.
The data bear this out. Maternal mortality and morbidity show no signs of coming down and despite ambitious desires of institutional delivery, government hospitals are not equipped to handle normal deliveries let alone complications. It is not surprising that a miniscule proportion of deliveries take place government institutions. Tuberculosis continues to take lives despite the DOTS programme, perhaps because the DOTS workers also double up to do polio duty.
(DOTS - Directly Observed Therapy Short course - is a WHO recommended treatment regimen for TB where, people with TB (especially those who have TB of the lungs and are transmitting the bacteria) are identified, diagnosed and administered treatment in the presence of a healthworker to ensure that the person is taking the drugs. Treatment continues for 6 months.)
While the world will soon be free of polio, the lives of the community in rural districts of Uttar Pradesh and Bihar may not see much of a difference. However they will have borne a disproportionately heavy cost. For seven years now the women and children of these communities have been deprived of essential health services so that this campaign could go on. Many lives have been lost and many more have suffered because the health-workers were busy with the polio drive. What is crucial note here is that this need not be.
The National Rural Health Mission has provisions for village level health problem identification and planning. Local priorities will be part of the overall planning and health implementation process along with the National Health Programmes. If the mission's plans do proceed in the spirit in which it has been conceived, the lopsidedness can be addressed.