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Skip to 0 minutes and 8 seconds ADITI RAO: Let’s first have a look at how global and national politics may affect health equity in agenda-setting for public health programs and its particular impact on the most vulnerable pockets of disease. We know communities commonly affected by polio make up the last 1% in large part because of political forces in play. These communities are typically excluded and underserved by health systems and are in countries that have serious competing priorities distracting attention from an eradication program, complicating efforts. Staying with our example, we know for some groups in Afghanistan and Pakistan, health systems are particularly hard to reach. This picture from 2010 shows a mobile medical team in Afghanistan reaching a village, which is a two-hour walk from the nearest road.

Skip to 0 minutes and 56 seconds People in this village only had access to a qualified health worker once a month. The recent decades of conflict in Afghanistan and Pakistan have had broad impacts on the health of their people. In Afghanistan, in the long war between the Soviets and the then US and Pakistani-backed militants, health facilities were neglected or destroyed. While militant groups received ample international funds for war-making, international aid to rebuild or staff health facilities in times of relative peace was woefully inadequate. Displacement and economic insecurity also took their toll on the Afghani people. The effects on health were severe and far-reaching. In 2002, adult life expectancy in Afghanistan was just 46 years, and infant and child mortality were among the highest in the world.

Skip to 1 minute and 47 seconds Pakistan has a slightly different story, but its health systems too have been neglected as a result of militarization. The government spends less on health than most other countries in South Asia. This is, in part, a result of conflict, especially including Pakistan’s ongoing dispute with India over the Kashmir region. Pakistan has poured resources into national defense at the expense of sectors like education and health. The result is that Pakistan’s health indicators lag behind its South Asian neighbors and are even worse in border areas where people often live far from government services. Most of these deaths are preventable and treatable from causes such as diarrhea, pneumonia, and relatively simple birth complications.

Skip to 2 minutes and 34 seconds The current struggle to end polio in both these countries is deeply affected by their history. Let’s look at the routine humanization coverage in both these countries. Routine immunization, a vital pillar in public health, is most often lacking in underserved and neglected areas with weak health systems. The Independent Monitoring Board for Polio Eradication reported that 78% of polio cases in Pakistan between 2012 and 2019 did not receive polio vaccine through routine immunization. That is, if vaccinated, it was only from campaigns. If Pakistan and Afghanistan had strong health systems with good routine immunization coverage, polio would have long ago disappeared from these countries.

Skip to 3 minutes and 18 seconds But because their health systems may fail to reach everyone with even basic services like childhood vaccines, especially the poor and marginalized, polio has gained a foothold. Another facet of the efforts to stamp out the virus completely has been the establishment of an intense program of vaccination across both countries. In Afghanistan and Pakistan– and especially their border areas– houses are visited by vaccinators as many as 10 times a year, attempting to find and vaccinate every child under the age of five. How might this situation reflect on a health equity agenda when communities who have failed to receive other basic and essential services are inundated with polio campaigns with strong political backing?

Skip to 4 minutes and 3 seconds For some communities, polio vaccination campaigns was the only health service received. As one can imagine, this can frustrate families who may desperately need obstetric care for high-risk pregnancy or medicine for someone dying of tuberculosis. While it is difficult to get these services from neglected government health facilities, particularly along the border, which are highly contested areas, the same government health system is able to bring polio vaccinators repeatedly to their doorstep. The stark difference between polio services received and other health services received has two causes. One is the low levels of government funding for health programs, and the other is the heavy international focus on polio which invests hundreds of millions of dollars a year in separate streams of International funding.

Skip to 4 minutes and 51 seconds International actors are committed to polio eradication as the prospect of being part of a historic initiative. Ending a disease forever is a significant motivator, and eradicating polio would also mean that governments could eventually stop vaccinating their own populations against the disease, resulting in long-term financial benefits. Refusals have remained a key issue in this region. Now given the fact, as we just discussed on repeated polio campaigns and an unequal focus in health services delivered, some communities, who are well aware of these dynamics, may reject the polio campaign and vaccine, which they know that international agencies and their government want them to accept as a way of drawing attention to other needs.

Skip to 5 minutes and 34 seconds Here’s an example of one of these demand refusals highlighted in the 17th report of the Independent Monitoring Board for Poverty Eradication describing the situation in Bannu, an area on the Pakistan side of the Pakistan-Afghanistan border, which had 23 cases of polio in 2019. The report stated, earlier in the year, it was announced that every member of the Bannu Chamber of Commerce and Industry would be boycotting the polio vaccination drive, resulting in thousands of refusals. The organization demanded that the newly elected Pakistan government withdraw a slew of new taxes that were, they say, crippling their ability to survive. The spokesperson for the Chamber of Commerce and Industry said it was the only way to get the government to listen.

Skip to 6 minutes and 19 seconds He also said that he has no doubts about the effectiveness of the vaccine and is also aware of the dangers of creating a gap in the herd immunity that full coverage of the vaccine offers, but that he and members of the community felt they had no choice. Take a minute and think about what you might do in such a situation. And do you think this issue is related to health equity? How so?

Skip to 6 minutes and 52 seconds One strategy developed in Afghanistan to address these barriers was to begin offering additional services to the communities during campaigns. Integration of services, such as the distribution of bed nets and nutrition video during vaccination campaigns, can provide the necessary motivation for families to bring their children for vaccination. Similarly, in Pakistan, the polio program evolved into a PolioPlus program, offering additional services as well as providing support to routine immunization. Here’s a table from Polio Eradication in Afghanistan laying out possible strategies based on different scenarios. Especially in the South and Southeast region of Afghanistan, door-to-door coverage was often not allowed. While in the Northern region, it was only partially allowed based on such restrictions the program would develop alternate implementation plans.

Skip to 7 minutes and 44 seconds The first column on the left lists strategies such as conducting supplementary immunization activities or integrating polio vaccination with routine immunization in high-risk areas. The green column is for accessible areas, while the red column is for areas with bans on vaccination. And the column on the far right indicates resource availability for implementing each of these strategies in various combinations. As we can see, certain strategies are equally possible and necessary in all three scenarios such as surveillance, while other strategies are more essential to one scenario such as putting in place special teams where vaccination is otherwise banned.

Skip to 8 minutes and 26 seconds Take a moment again to look through the table and think about how these strategies in the given scenarios link to equitable delivery of the program and which strategies you think might increase equity the most.

Skip to 8 minutes and 48 seconds Thinking specifically of strategies in areas of conflict and insecurity, which are hard to penetrate safely, in order to reach these pockets, polio staff calmly coordinate with different opposition groups and military forces to negotiate peaceful days and gain access to unsafe areas. This includes coordination with insurgent groups such as the Taliban. You may also remember from the map we saw earlier a significant portion of cases are present in areas where the two countries border each other where populations are particularly mobile. Knowing this has allowed the program to establish special vaccination costs at formal and informal crossing points mapped between Afghanistan and Pakistan wherein vaccination teams deployed are able to reach thousands of children on the move.

Skip to 9 minutes and 36 seconds Important to note is also that the two countries synchronize their cross-border activities. The programs in Afghanistan and Pakistan maintain close coordination with each other, particularly in three corridors to increase access to high-risk mobile populations. Additionally, to reach nomadic groups specific supplementary immunization activities are conducted in the Southeast region upon entry to Afghanistan, and prominent transition teams are deployed in movement routes in the Southern and Western regions. Over the years, the goal of eradication has sparked great discussions and debates in the global health community, particularly when thinking about politics and public health agenda-setting. So let’s consider this question. Does polio eradication or other similar global programs contribute to health equity?

Skip to 10 minutes and 28 seconds Take a moment to think about what arguments you might make on either of both sides of the debate.

Skip to 10 minutes and 43 seconds Now that you’ve had a chance to think about this, let’s go over some examples. Examples of arguments to support the notion that the polio eradication program has contributed to health equity may include the goal of eradication inherently means that every last person will be reached, and everyone will benefit when the goal is achieved. The GPI has made special efforts to reach the hardest-to-reach populations and perhaps allowed other programs to launch from it or piggyback onto their efforts, essentially opening doors to a more holistic care provision. And the GPI has particularly recently also worked to integrate with other health services and ensure that all populations also receive essential services, and that the overall systems are standard.

Skip to 11 minutes and 30 seconds On the other hand, here are some arguments to refute the notion. Large amounts of money have been expended and health systems distorted in trying to reach this one often isolated goal. Other health services have been neglected due to the singular focus of GPI in some contexts, and the burden on populations where polio remains, such as repeated immunization campaigns, is disproportionately on disadvantaged groups. And, of course, you may come up with any number of other reasons on either side of the debate.

The Importance of Politics: Equity and Public Health Agenda Setting

Aditi Rao, MSPH
Bloomberg School of Public Health, Johns Hopkins University, USA

Review the readings:

Ethical dilemmas in current planning for polio eradication

Comment: Ethical dilemmas in current planning for polio eradication

In the video, the lecturer quotes from page 46 of the 17th report of the Independent Monitoring Board for Polio Eradication. The report reads:

Earlier in the year, it was announced that every member of the Bannu Chamber of Commerce and Industry would be boycotting the polio vaccination drive, resulting in thousands of refusals. The organization demanded that the newly elected Pakistani government withdraw a slew of new taxes that were, they say, crippling their ability to survive. The spokesperson for the Chamber of Commerce and Industry said it was the only way to get the government to listen.

He also said that he has no doubts about the effectiveness of the vaccine and is aware of the dangers of creating a gap in the herd immunity that full coverage of the vaccine offers, but that he and members of the community felt they had no choice.

Reflect on the following question and post your response in the discussion:

What might you do in such a situation? Do you think this issue is related to health equity? How so?

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