Reaching Special Populations: Marginalized Populations, Health Services, and Refusals

SVEA CLOSSER: The last 1% of the world’s communities affected by polio are socially, politically, and often economically marginalized. They may experience conflict and vibration, environmental hazards such as poor transport networks and flooding, or government persecution. These communities, already underserved by the health system, may be skeptical of disease oriented programs which deemphasize pressing health and economic priorities and come from distrusted state actors or distrusted non-state actors. In this section of the course, we’re going to describe how polio eradication has engaged with and been affected by those forces and consider the intended and unintended consequences on community demand for health services.

So one underlying issue is that communities with ongoing polio transmission are often ones with excellent reasons to distrust their own governments. So polio cases that still exist in the world are often in really marginalized populations. So as polio eradication’s independent monitoring board puts it, they appear in isolated communities, tribal populations, and environments with extreme social and economic deprivation. These are people in places where trust in government is low, and I would add that trust in government is low for often excellent reasons. So communities most at risk for polio are at risk for a range of reasons. First, they may be beyond the reach of the government health system. And so may not be getting routine immunizations.

Next, they may have limited access to fresh water and sanitation. So they may be highly at risk for fecal oral transmission of polio. And finally, and this is what I want to talk about here, they are also the communities that may have the least trust in the government. And so if a government health worker comes by offering oral polio vaccine, they may be less likely to accept that vaccine. And the independent monitoring board for polio eradication puts it this way. Refusal of the polio vaccine is not a mere gesture. It’s a distillation of the anger that communities feel when polio workers knock on their doors over and over again in the absence of other governmental services.

So these are populations that have often been cleared from land multiple times in some cases. They may have been persecuted by the same government that’s offering them polio vaccine. They may have had their rights violated in all kinds of different ways by that government. And so when a health worker carrying a government insignia comes to provide polio vaccine, there is, as we discussed before, a lot of layers to the reasons why parents might be hesitant. So these are challenging issues to overcome. I do want to positive note here that there’s some models for how this might be done effectively.

And one of them is the 107 Block Plan, which was used in India in the final stages of India’s eradication of polio. So the 107 Block Plan was developed when it was realized that all the polio cases in India were coming from 107 subdistricts or blocks. So India is obviously a huge country and focusing just on 107 blocks were ways for government and UNICEF and WHO staff to focus on a few areas where there was ongoing polio transmission. And what they did was they designed this thing called the 107 Block Plan. And this was a really far reaching strategy that included a range of activities from filling vacant medical officer positions to constructing latrines in some areas.

But what I want to focus on here is its communication strategy, which is on this butterfly up here. So specific targeted messages included information about diseases prevented by routine immunizations. There was a lot of messaging about routine immunization. There was messaging about the importance of oral rehydration solution in cases of diarrhea and how to prepare it. There were instructions about how to breastfeed infants and to exclusively breastfeed for six months, and also information to wash your hands with soap at specific times throughout the day. So one thing I’d like to note here is that all of these things actually along with vaccination, which is the center of the butterfly, all of these things work to prevent polio transmission.

If children have complete routine immunization, they’re going to get the polio vaccine there. If kids and parents are washing their hands with soap, that will interrupt polio transmission. Actually, diarrhea is an issue that leaves kids vulnerable to a range of diseases, including polio. And breastfeeding gives kids maternal antibodies against polio. So all of these issues are broader than vaccination, and they also protect against polio. Additional staff were hired to disseminate these messages. Over 1,000 community mobilizers were deployed in Bihar, and even more in Neutra Pradesh. So these are two states in northern India where there was ongoing polio transmission. Initially, there were concerns about these people’s ability to quickly learn and disseminate these messages, but those proved unfounded.

One UNICEF official said that the mobilizers embraced it– so excited that after the years of the same polio messaging, they could do more. One staff member described her work, quote, we’re promoting hand washing. We’re promoting breastfeeding. We’re promoting zinc and oral rehydration solution for controlling diarrhea. We conduct counseling meetings with the targeted families and slowly, slowly, it has developed awareness in their behavior. So this communication package is a way of getting at some of the questions we’ve been asking throughout this section. Is there a way to do communications for polio that might include a bit more? Now, is this going to be enough to overcome entrenched political and historical reasons to be distrustful of government intervention? Maybe, maybe not.

In northern India, it was enough to eliminate polio. This was part of the 107 Block Plan which included this communications package– successfully ended transmission of polio in India. So more currently, some other strategies are being tried. So in Afghanistan, they’re working on distribution of bed nets and nutritional material during vaccination campaigns as a way of giving families a few other things in addition to just polio vaccine. So a polio worker said, our volunteers in villages distributed bed net and nutrition materials to children. It is effective in some areas.

So a question for you is, do you think this sort of thing would be enough to address the sorts of problems we’ve talked about in the previous section– these entrenched problems of mistrust and legacies of political and historical marginalization? And perhaps the answer is maybe not. But it can’t hurt and it will get us closer. Here’s another example of service integration from Bangladesh. During polio vaccination campaigns, they provided vitamin A. And this was something that was organized at the national level. A national level policymaker said, they realized that they could reach the doorstep of people via our national immunization day for polio. And vitamin A and polio vaccine are both targeted at young children.

You can give them both orally, so it makes a lot of sense to put those campaigns together. In Bangladesh, they also integrated surveillance of AFP with measles, and they also integrated tetanus vaccination with polio immunization. So they worked very hard on integrating polio activities with other activities. As one policymaker in Bangladesh said, we used the routine immunization as the backbone because routine immunization was our gateway. Through it, we had brought success in polio eradication. In Pakistan, too, there are initiatives underway to provide what’s called polio plus services in some areas. So these are areas that have had a lot of vaccine hesitancy, and so there’s efforts to provide some additional services and to provide more support to routine immunization.

Along the same lines in Pakistan, the integrated services initiative is working in the water and sanitation sector to try to provide some more water and sanitation support to high risk polio areas in Pakistan. So these are all promising initiatives and ways that the polio eradication initiative is trying to get at these bigger problems of distrust in certain populations. There is a challenge inherent here in maintaining momentum for polio while also addressing the broader health needs and the priorities of underserved populations. But there are some key actions that you can think about as being useful in such an effort. Involving communities in defining how to address the challenges and what they need.

To monitor communication activities through using and sharing data, particularly with communities. And to strengthen communication not just for polio, but for broader health services, as well– for example, water, sanitation and hygiene, routine immunization and child health. None of these are a be all, end all, and none will overcome the problem of inadequately supported health systems. But given this, there’s an important lesson here for eradication programs. The example of polio tells us they can’t work everywhere in the world in a truly vertical format. That approach can work for 99% of the world, but it won’t get to those last 1% of polio cases. In the words of one policymaker, quote, it has to be polio plus plus plus plus.