Question

Polio and smallpox

• Short summary of the country, that includes the following: demographic indicator, political, economic, geographic, ethnic, and historical context.
• Reasons, why the health issue discussed, is important, what health policy is applied, and an analysis of the efforts.
• Analysis of the major challenges/limitations of these efforts (with examples).

An insight as to whether the policies and actions undertaken were successful and how these efforts may affect the future of the country’s health pertaining to smallpox.

Answer 1

Polio and smallpox

· Short summary of the country, that includes the following: demographic indicator, political, economic, geographic, ethnic, and historical context.

· Reasons, why the health issue discussed, is important, what health policy is applied, and an analysis of the efforts.

· Analysis of the major challenges/limitations of these efforts (with examples).

An insight as to whether the policies and actions undertaken were successful and how these efforts may affect the future of the country’s health pertaining to smallpox.

India, country that occupies the greater part of South Asia. Its capital is New Delhi, built in the 20th century just south of the historic hub of Old Delhi to serve as India’s administrative centre. Its government is a constitutional republic that represents a highly diverse population consisting of thousands of ethnic groups and likely hundreds of languages.With roughly one-sixth of the world’s total population, India is the second most populous country, after China. India functioned as a virtually self-contained political and cultural arena, which gave rise to a distinctive tradition that was associated primarily with Hinduism, the roots of which can largely be traced to the Indus civilization. Other religions, notably Buddhism and Jainism, originated in India—though their presence there is now quite small—and throughout the centuries residents of the subcontinent developed a rich intellectual life in such fields as mathematics, astronomy, architecture, literature, music, and the fine arts.

The global smallpox programme and India

The future prospects of eradicating polio across the globe, therefore, reveal more than a hint of anxiety. Yet, as options and new strategies are weighed up by members of the different United Nations organizations, national aid agencies and global funding bodies, one important set of lessons appear to have been consistently ignored: those presented by the successful eradication of smallpox, which was formally ratified by the World Health Assembly in 1980. As in the 1970s, the South Asian sub-continent and, in particular, locations within Northern and Eastern India is providing major hurdles for the successful completion of a major global disease eradication programme. There is a magnificent archive in the WHO's Geneva offices, which details how smallpox eradication outbreaks were located and then contained in cities, small towns and remote rural areas in this region, by teams of international workers working closely with local officials. A systematic assessment of the global smallpox eradication efforts indicates parallels between the early stages of the global smallpox eradication programme and the present situation of the polio campaign; as we will see here, it can also provide useful indicators for future action in South Asia and beyond.

Officials based in India, a major reservoir of smallpox cases, were brought into discussions soon after the passage of the 1958 resolution. These negotiations, which involved senior members of the WHO, WHO SEARO and Indian federal government, did not go smoothly in a situation where there was disagreement even about the most basic issues, like the exact definition of smallpox eradication. It also did not help matters that WHO officials based in Geneva attempted to impose a fixed set of ideas and policies on people based in New Delhi, including people serving in WHO SEARO. Interestingly, the problems continued even after the WHO officials based at different locations agreed upon specific policies the fact that these strategies were offered to the Indian authorities as an inflexible blueprint, without any substantive offer of financial support for making their implementation possible, did not go down well in the corridors of power. Indeed, this situation ensured that calls for smallpox eradication emanating from Geneva in the late 1950s and early 1960s received a rather frosty reception across the Indian political spectrum.

The tide of Indian disinterest began to slowly turn only in the mid-1960s, after the WHO departments charged with starting planning work on smallpox eradication re-organised themselves. Interestingly, this involved employing people who were more willing than their predecessors to engage with Indian politicians and public health officials, in order to develop common ground before an organised push to eradicate variola was launched3. An increased budget, which allowed the relevant WHO departments to fund agreed plans and share some costs with the Indian health departments in Delhi and the states, helped matters along. The results were impressive at one significant level. The Indian federal authorities agreed to organise district-level pilot projects within each state, based, at least on paper, the commitment of comprehensive numbers of local health staff. This was considered helpful within the WHO, as it held out the promise of allowing for the collection of information that would reveal if the smallpox eradication plan was workable.

At another level, though, insurmountable problems began to make an almost immediate appearance, despite the announcement of reforms by the Indian authorities at frequent intervals. The preliminary Indian national smallpox eradication programme, which was planned in association with WHO representatives, was, therefore, fragmented and weak even as late as 1965. Several factors ensured this. The "liquid" smallpox vaccine was unreliable and the freeze dried variety was short in supply; international donors like the Unicef appeared to have relatively little inkling of the infrastructural situation in the country and provided items like electric refrigerators for vaccine storage in areas that had intermittent or no electricity; several state and district level administrators remained hostile to the eradication goal, there were wide variations in the capabilities of vaccinating and supervisory staff across states and their districts, and lack of ideological unity within the WHO offices and Indian government departments resulted in operational confusion in the field. It did not help at this stage that the WHO was unable to commit field workers to the pilot projects; instead, organizational field representatives appeared to quickly move in and out of districts, without developing any substantive links with local health workers. So, to the great frustration of several officials based in Geneva, most pilot projects started late, overshot agreed timetables and, often, came up with defective data.

The Indian polio eradication programme: contours, problems and futures

A 1983 meeting of public health experts in Bellagio considered, for the first time, the idea of polio eradication as a component of the Expanded Programme on Immunisation (EPI). The following year, Rotary International constituted a consultative committee to consider the potential of this goal; the result was a declaration that efforts would be made to eradicate polio by 2005. This was followed by the 1985 Pan American Health Organisation (PAHO) resolution to eradicate polio from the Western hemisphere by 1990 166 member countries adopted, in 1988, the goal of global polio eradication by 2000 at the WHA. The initiative was projected as an "appropriate gift, together with the eradication of smallpox, from the twentieth to the twenty-first century". The Global Polio Eradication Initiative (GPEI) was, thus, born.

Yet, the unanimity characterising the WHA 1988 resolution about the meaning of and the strategies required for polio eradication turned out to be inconstant. At this assembly, eradication had been defined as the complete absence of the disease following concerted public health interventions; however, discussions and declarations from within and outside the confines of the WHO subsequently displayed a far less clear cut approach to the issue. The Global Commission for the Certification of the Eradication of Poliomyelitis has, of course, defined the term "eradication" as the absence of circulation of all indigenous wild polioviruses for at least a three year period during which surveillance activities had been maintained. Alternative assessments about the form and possibilities of polio eradication have persisted side by side since the launch of the GPEI; a variety of constituencies and viewpoints appear to have been responsible for these definitional and attitudinal complexities. Some suggested that the disease could be eliminated through regularised immunisation programmes, based on careful surveillance and systematic OPV-based immunisation of infants; ideas that continue to be advocated tenaciously by those arguing for a changed approach towards the global fight against polio.

In India, OPV-based work was included in the EPI in 1978-79, which was subsequently upgraded to a Universal Immunisation Programme (UIP) in 1985. The "Polio Plus" programme was initiated in Tamil Nadu state in 1986 with a grant of US$2.6 million from Rotary International; this was followed by another US$20 million grant from the same source, for financing the procurement of OPV, cold chain support, surveillance activities and social mobilisation across the country. A staged approach to eradicate polio followed in eleven other states, and the stated aim was to extend the programme to other parts of the country after that. The expanded project took the shape of the so-called "Pulse Polio" initiative (PPI), which was initiated in the Tamil Nadu, Kerala and Delhi states during 1994. Also referred to as the "Supplementary Immunisation Activities", the strategy involved the mass immunisation of a target population of children up to five years of age, on pre-arranged immunisation days irrespective of their earlier vaccinal status. A country-wide pulse polio programme was put into place from July 1995, after the state governments responded to concerted federal calls for its extension across the board. Unfortunately, the deadlines proposed at that time, of eradication by 2000 and certification by 2005, have joined the list of missed opportunities in the history of public health in India.

What were the factors responsible for the missing of these targets in India, which appeared in 1995 to have broad-based political and scientific support locally? Most significantly, perhaps, the main tenet of eradication the strengthening of ongoing routine immunisation programmes (RI) was never followed. Instead, RI coverage appears to have been weakened following the introduction of the PPI strategy, which has been noted by the country's Planning Commission; this influential federal body has recorded these adverse trends in its Tenth Five Year Plan document, after drawing upon data gathered under the aegis of the National Family Health Survey (NFHS). The NFHS data, shows that Andhra Pradesh, Delhi, Gujarat, Himachal Pradesh, Karnataka, Kerala, Maharashtra and Tamil Nadu states have all registered a decline in the proportion of fully immunised children (12-23 months) and also for OPV-based work, which require three doses of immunisation (for the sake of simplicity, we will refer to these as OPV 1-3).

This pessimism has been confirmed by other analysts. The District Level Household Survey (DLHS), for instance, has reported a decline, nationally, in the proportion of fully immunised children; from 54% in 1998-99 to 48% in 2002-04 (large variations have, of course, also been reported in RI coverage across Indian states from 97% in Kerala to 21% in Bihar). Commentators have blamed the significance accorded to PPI for official and civilian "fatigue", which, it is claimed, has created vast pools of un-immunized children.