“When I worked on the Polio Vaccine, I had a theory. I guided each (experiment) by imagining myself in the phenomenon in which I was interested. The intuitive realm……… the realm of imagination guides my thinking.
-Dr. Jonas E.Salk, American Virologist and Discoverer of Polio Vaccine.
(Dr. Araveeti Ramayogaiah)
Dr. Araveeti Ramayogaiah
On January 13, 2014, we achieved three years of Wild Polio Free India (WPFI), a historical mile stone occurs only once. I am thrilled and satisfied but not on cloud nine and I am equanimous. For me it is – “Justice delayed – Justice denied” for the people at the helm it is – “Better late than never”.
8.5 lakh Accredited Social Health Activists (ASHAs), 2 lakhs Auxillary Nurse Midwives (ANMs), 1.5 lakhs supervisors, 13 lakhs Anganwadi teachers, Several lakhs of volunteers, community mobilisers, several activists, media etc contributed for success. The Nation salutes all those soldiers who made it.
On January 14, 2012 almost all print media including ‘The Hindu’ published beautiful photograph of Honorable U.S. Secretary of Health and Human services Madam Ms. Kathleen Sebalius administering oral polio vaccine – OPV (Sabine vaccine) to a child in New Delhi. The irony is that US do not use this vaccine to its children. US uses inactivated polio vaccine – IPV (Salk vaccine) which is injectable and safe.
On February 11, 2014 India celebrated the success on Polio in the presence of Dr. Margaret Chan, Director General of World Health Organization at an official function held in New Delhi. It was attended by honourable President of India, Prime Minister of India, Union Health Minister and Leader of opposition in Loksabha. What pains most is that except Doordarshan, hardly any TV channel telecasted the event live. It is my practice to read 10 daily news papers on every day. None of the papers of February 12, 2014 reported that event. I could not decipher the reasons, but this trend discourages future elimination programmes and also discourages the millions of volunteers who made it possible!. As a matter of fact the whole country should celebrate it.
Pulse Polio Immunization (PPI) is the one of the key interventions in elimination of Polio. Our country launched nationwide pulse polio programme in 1995-96. In 1994 itself, the programme was started in State of Delhi.
In the long journey spanning two decades, we have brought down polio cases from 28,587 in 1997 to 1 in 2011 and Zero in 2012, 2013 and 2014. The nation passed through mixed feelings of enthusiasm, complacency, euphoria and distress. The country has traversed from enthusiasm to ritual mode, from people’s participation to bureaucracy driven, from volunteerism to fee for work, from no special allocation of budget to PPI to allocation of special budget for P.P.I. When there was less budget it was every body’s programme and with huge budget it turned into one sided programme.
Peoples’ participation:
Peoples’ participation is one of the three pillars of primary health care. In the last few years, I have observed the programme at several places. In the year 2013, I monitored the PPI programme as a state programme officer in Nizamabad district of A.P. and covered 80 percent of the district.
Though we achieved wild polio free status of 4 years, the long term stumbling block still remains i.e., “missing peoples’ participation”. The 1978 Alma Ata declaration considers people as prime movers for shaping their health but not passive recipients. The 1946 Bhore committee report clearly says that it is essential to secure active co operation of the people for the development of health programmes. The world health day theme of 1988 was’ Health for all-All for health’, which explains self. The 1994 International conference on population and development advocated community needs assessment (CAN) approach where planning itself should be from the community i.e., “Bottom up approach”.
Despite all these pronouncements, it is agonizing that people are not involved anywhere in the health delivery. The major cause could be growing capitalistic evolution of Indian society, kleptocritic and plutocratic phase of Indian democracy and plaguing chronic capitalism.
In this scenario, fee for service becomes a new mantra for delivery of any service and or for that matter a massive public health programme like polio eradication too. In a system of “fee for service”, the programme makes vast majority of people as aliens, simple recipients and not real players. This is a weak foundation and harms in long term and may even results in reversal of achievements already made.
Still there is a light at the end of the tunnel. Health functionaries at various levels should visit schools and create awareness in the school children and rope them in during their formative years. On every PPI day, non officials like ward members, sarpanches, corporators, mayors and members of legislative bodies should be roped in, in a big way for formal inaugurations and symbolic administration of polio drops by them. The ‘only booth approach’ of earlier years created massive peoples’ movement in the community, where as ‘house to house’ makes people sit in their houses for health functionaries to visit them. Thus it becomes one sided. House to house programme should be phased out. For the nation that is crying for tangible results in public health can’t afford to keep away any health functionary away from the programme. Massive main streaming of specialist doctors of secondary hospitals, practitioners of private sectors and corporate sector is the need of the hour. All the influential persons in the community should become part of the programme. A volunteer from a NGO or a student from a school is not peoples’ participation. In Turkey Imams played crucial role in improving immunization levels and in Srilanka Buddhist monks played vital role to improve public health. We need to emulate them. Several such innovations can be thought off to make PPI programme a really peoples’ participatory one. The best practices of eighties viz. Village leaders training [VLT] camps and Orientation training camps [OTCs] and the spirit of early years of PPI should be revived. As we make a sincere beginnings, new innovations will emerge and ultimately peoples’ participation becomes spontaneous and natural. Peoples’ participation in PPI helps in the success of other on going public health programmes and future public health programmes.
India’s P.P.I. suffered from several infirmities also viz. Very low routine immunization , pockets of un immunized children during NID rounds, irresponsibility and non accountability of various functionaries , lack of political and administrative will, morbid individualism and poor environmental sanitation. For the District Magistrate whom I met in one of the rounds as the state program officer, it was a sarcasm. He said, “Pulse polio… ! it is signing the cheques and cutting the ribbon! Okay, I will do”. One of the Chief Ministers of this country openly expressed his fatigue and said this was not his priority. Several bureaucrats asked me, “How long this Doctor!”
During 1998 to 2002, I was a teacher in Government medical school at Guntur in the department of preventive medicine. During one of the PPI rounds, telling the dates of PPI to them, I asked 20 and odd internees about the importance of those days. None could answer. In fact the city was reverberating with huge I.E.C. (Information, Education and Communication) activities. There is paramount need to sensitize medical students on nation’s health needs.
Inter sectoral coordination:
Inter sectoral coordination is one of the 3 Pillars of Primary Health Care. There is even missing intra departmental coordination in our country. For a specialist in a Secondary Hospital, the programme is Greek and Latin. In fact one specialist confessed to me that he doesn’t know how many drops are put in to child’s mouth. In this scenario, the role of intersectoral coordination can be simply imagined.
India is one of the country with gigantic private medical care services. PPI is not their cup of tea. There is a need to main stream every medical system and functionary to a public health activity like PPI.
Yet we have achieved Three Year of W P F status! Let us salute mother nature for her benevolence. Most of the child survival interventions are interdependent and contribute for the success of multiple parameters.
With hunger index of 66, Infant Mortality rate of 41, 42% of undernourished children , skewed Juvenile Sex ratio of 914:1000, Poor breastfeeding and infant feeding practices, we are blessed at least in one area i.e. Poliomyelitis. Thanks to un-touchable practices of wild polio virus and let us all pray great nature to bless the virus not to change its mind.
Way forward:
Now maintaining Wild Polio Free Status for ever is a real challenge. I am neither an academician, nor an expert nor a scientist. I am an ordinary person involved at field level. Experts believe that the ensuing period is very critical and should be handled by introducing Injectable Polio Vaccine (IPV). I firmly believe that my country can do that and achieve the goal. Let us not hesitate as IPV being an injectable vaccine. After all we are already using injectable vaccines viz DPT, BCG and Hepatitis B in universal immunization programme. Let us meet the future ahead with IPV which is safe and prevents vaccine Associated Paralytic Polio (VAPP). Let us not debate on cost of IPV as nothing is costlier than lives of children.
On this occasion, let me warn the nation that there is a looming threat of importation of virus and prepare to face it. In 2009-2010 as per WHO fact sheet of October 2011, twenty three previously polio – free countries were reinfected due to import of the virus. With the prevailing internal turbulence, Pakistan and Afghanistan do not change to non endemic status even in far future and we are under constant threat of importation. The importation of wild polio virus in to China (which was free from Polio since 2000) poses a risk to us. Very recently importation took place into Syria. The Polio virus does not respect national borders. Let us be vigilant at our borders with high level of surveillance and stop any type of importation. With the present achievement we hope to give final push and tame the virus.
Still many people in our country think that PPI is the all and end all for eradication of Polio. Poliomyelitis is an infection transmitted from feco-oral route. We have to address the issues of safe water and sanitation on war footing.
For a nation that is committed, the issues of migrating populations , high-risk areas, remote and interior places , influence of opinion makers do not pose any threat and nation has all the will and wherewithal to face the challenge. The nation enjoys the work but do not get fatigued as the jumping children with joy is paramount priority to the nation.
No matter how much money we spent , how much networking we build , how much social mobilization we make – it is only winning the trust of people that can gain popularity for mission mode programme like pulse polio immunization.
The nation is heading for another PPI programme on January 18, 2015 and February 22, 2015. Let us all actively associate with this programme to make it a grand success.
“Once polio is eradicated , the world can celebrate the delivery of major global public good – something that will equally benefit all people, no matter where they live”, said the WHO.
“Our greatest responsibility is to be good ancestors” said jonas E salk. Do we have that spirit?
Bye, Bye Polio!
DR. ARAVEETI RAMA YOGAIAH
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