Showing Polio the Finger: A Lesson in Public Health

As students of Public Health, we, in India, are witnessing history in the making. It is not often that one gets to see, and be a part of a revolution that is the eradication of a disease. I know that global polio eradication is still under threat because of multiple issues. And with countries in which eradication had been achieved falling prey to re-emergence of the virus, the question looms large whether we shall be able to achieve global eradication in time (or ever at all!). However, India is merely weeks away from reaching the third consecutive year without registering a single polio case and is well on its way to become one of the countries with eradication status. One prime driver for this sustained success has been the massive vaccination campaign that has targeted the disease in a way one has never seen before.

As part of the push for universal vaccination, monitoring of supplementary immunization activities is a critical event. We were posted as External Monitors working with the NPSP in order to monitor and report back on the efficiency of the booth-based, as well as house-to-house vaccination against polio. I was posted way back in February and ever since I have wanted to write about this experience of mine. The only thing holding me back, aside from my laziness, was the fact that I wanted to hear my colleagues’ experience of working in this posting.

During the monitoring, we were sent to vulnerable areas to assess vaccine coverage. I shall not go into the boring methodological details of how we were supposed to cover every area and sample kids in clusters in order to assess vaccination status. I shall try to distill in this narrative my experiences of working in the “trenches of Public Health”.

Although New Delhi has, officially, like less than 5% of rural areas, as a result of the rapid urbanization and growth of the city, it has seen development of urban slums and resettlement colonies and clusters of mobile populations who are at high risk for poor vaccine coverage as well as act as mobile disease vectors.

I was posted to one of the best areas in terms of vaccine coverage. All through the week, I had to wend my way through alley ways with clustered tenements. Sometimes, they were claustrophobic in their arrangement, and the population pressure was clearly visible there.

Some of the houses, which were usually only single storeyed, had a rigged together “upper floor” built on, and the only way one could access the family living upstairs was using a ladder that laid angled against the wall. There were other entrances, but sometimes, to access those stairwells, I would have togo through as many as four different families’ living quarters. It was an extremely uncomfortable notion for my city sensibilities, where we mark our territories with almost feline ferocity. Here I saw children from one family freely mingling with those of the next, families sharing space (or the lack thereof) with a sense of community that we, in our cubby-holed, pigeon-cooped flattened out lives would consider to be nightmarish. I am sure this extreme proximity also prompts friction that can add to the ardors of life, but there must be a feeling of community fraternity to balance the scales as well.

One thing that struck me was the efficiency of the ASHA and Anganwadi Workers in one particularly densely populated slum. The ASHA worker, one Ms. Shabana, was particularly impressive in her knowledge of the terrain of the slum and the residents thereof. If an External Monitor unearths unvaccinated cases, it comes down really heavily on these workers, since they are the interface between the system and the people, hence, sometimes, they tend to hurry the Monitor along as they traverse through areas they know are liable to carry missed children. This group of workers, on the contrary, would urge me to choose any house to go into, and even predict the names and numbers of children living in each of the blocks.

One could well argue the case that this group of workers were very close to the ideal model social health workers, who brought health and awareness to the homes and hearth of people.

During the course of my monitoring visits, I made it a point to talk to the locals, the mothers, the grandmothers, the mothers-in-law, and understand their perceptions of the disease and the process of vaccination. In this particular constituency, I was surprised with the high awareness levels, high routine immunization coverage and high socio-cultural acceptability of the concept of vaccination amongst the least educated groups. This was an eye opener that pointed out how effective a motivated social health worker might be in instituting change at the level that matters the most: the women of the household.

It was, therefore, a matter of great joy, when a whole group of children swarmed their “didi”s (elder sister) and gleefully held up their little fingers (that is the finger that is marked with indelible ink when a child has been given the oral polio vaccine) to show off their vaccinated status; and I got one of the most enjoyable, precious moments in my short life in the field of public health ad disease prevention.

Some other areas were, however, less impressive. One area was, in particular, very drastic. I detected a number of unvaccinated children in this area. It was basically a construction site, which spanned over a kilometer in length and width. There were scattered families of construction workers living in the half-built houses, behind plastic sheets, or in dark, dingy and damp underground basements which afforded protection from the merciless Delhi afternoon sun.

This was in the aftermath of the infamous Delhi rape case and because of the shifty nature of the area, the vaccinators, who were mostly women, were very wary of walking into the area or into the basements to seek out renegade children. Given the fact that these families were mostly nomadic construction workers who traveled in bands of 3-4 families (originating mainly from Uttar Pradesh and Bihar; and eastern fringes of West Bengal, as well as Bangladesh), there was an inherent mistrust as well. This led to the obvious result that the vaccine coverage was atrocious.

This experience further reinforced my belief that health is not attainable merely within the framework of investment in the halthcare system. We need a wide view, encompassing social, cultural and economic growth and inclusion, without which all efforts at attaining public health nirvana is like trying to stop a leaking dam with band aid. Organized terrorism or even local disturbances are an emerging socio-political threat to public health systems and we need to evolve with the changing nature of the threats we face if we are to continue on the train of disease elimination.

One particularly humbling experience was what led me to my second biggest catch of unvaccinated children. There was a huge mound of refuse and stinky garbage lying in between two building blocks. The stench was so repulsive and the leaching fluid around the mound of refuse so nauseating, that it was inconceivable for anyone to venture in that direction. I was on the verge of turning back on the abhorrent effluvium when I noticed a few children playing and running past the mound, even looking at which brought tears to my eyes.

And then I saw three children run off behind the noisome dunes of refuse. For a moment, I considered giving up the chase and dithered. There wasn’t much of another way into the block, unless I considered going the whole length around a block of barricaded and scaffolded buildings. But that would definitely take too long and there was scant opportunity that I would be able to get to the children in time to get a look at their left hand little fingers for the tell tale mark. So, after a moment’s hesitation, I took off after the children, running through the squishy gunk, my boots sinking into the soft, quick sand like ground underfoot, as I tried to switch off my mind from the revolting wave of odor that hit my senses. In a moment, I had gone across the huge pile of refuse and was standing in a clearing, dotted with children playing and running around. I sensed the vaccinator team warily making their way across the swamp of bubbling, rotting refuse that I had navigated, like the children, with scant consideration of what I was stepping on.

As expected, it turned out that several children living in the huts there were unvaccinated and with good reason too. It would be unreasonable to expect the poorly paid, almost-voluntary activists to take so much pains to find children living in such difficult to access areas.

Another thing that caught my attention was how the existing routine immunization and ICDS/Anganwadi system infrastructure was being utilized to implement oral polio vaccination. The commitment of the teams all across the boards was laudable. Indeed, without such highly committed people, toiling for little money, and even lesser appreciation, the whole program would have fallen flat on its face. The warmth with which the teams received me was also humbling. I found these under-appreciated people, who work far from the highlights of acclaim and fame to be much more committed to the cause of eradicating polio than many of their much vaunted, celebrated bosses. In fact, even the areas in which I uncovered unvaccinated children and recommended repeat immunization activities, the teams were not just apologetic for missing out, but resolved to change the picture over the next times. Although I would not go back to those areas again, I am confident that the steely resolve I saw in the eyes of some of the center coordinators where I had recommended repeat activities would bear fruits in the times to come.

We still have some distance to go before we are certified polio-free, but I guess we are one helluva lucky generation of public health people. We are witnessing the eradication of a disease so early on in our careers, that we might become one of the few clutches of people to have seen multiple diseases being wiped out from the face of the earth.

However, at this juncture, I would be failing this post if I did not mention one rather discouraging aspect of the whole business that struck me: the tendency of the general public to be relaxed and casual about the business of vaccination. Most of the children who had been vaccinated were given the oral polio vaccine during the house-to-house trips by the vaccinator teams. Fewer and fewer people seemed to be motivated enough to go to the booths that are set up on “Polio Sundays” in order to get their kids the vaccine. Their argument was the workers come over anyways, so why bother finding time from an already packed “family day” to go get their children vaccines? I consider this a disconcerting trend because the house-to-house visits are not, primarily, for vaccinating children. They are a safety net to catch children who may have slipped through the system and stayed unvaccinated. However, with more and more parents assuming the rather passive role where they now demand as a right that the vaccinators come and provide vaccination at their homes, this might not be a good trend. In fact, if this mentality was to spread into the matter of other vaccinations, it could be a major disaster for the routine immunisation activities. In our centers we are often non-plussed to find parents who bring in children late for vaccination, sometimes by months, simply because they were too passive or too casual about it.

This trend apart, the system that has been worked up to kill polio is fantastic on so many levels. In his book “Better”, Atul Gawande talks about his brush with the massive polio vaccination work that is going on in India. He talks about the mop up activity following the detection of an index case of polio in Karnataka. We have been fortunate enough to not have a brush with a case of polio in almost three years now, but the scale on which the polio eradication and surveillance program is running has left me dumbfounded. It is one thing to read about it in the drab and dreary textbooks, and an entirely different experience to see it in action, on the ground, in the real world, in real time.

Gone are the days of wards filled with patients on negative pressure respirators that helped the polio afflicted people tide over the acute phase of respiratory muscle weakness. Now the polio afflicted can be counted on your finger tips (well, not anymore this year, thanks to the explosive outbreak in the Horn of Africa). The disease that once made us gasp for breath is now gasping its final breaths.

Put out the light, and then put out the light.
If I quench thee, thou flaming minister,
I can again thy former light restore
Should I repent me. But once put out thy light,
Thou cunning’st pattern of excelling nature,
I know not where is that Promethean heat
That can thy light relume. When I have plucked thy rose
I cannot give it vital growth again,
It must needs wither.
- Othello, Act 5, Scene 2
William Shakespeare

Polio patients on rion lungs

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