A tale of two diseases

India is the shining star in the global battle to eradicate smallpox. It is also a branded villain as far as polio is concerned. How is it that we managed so well against a disease more virulent than polio? Why does Uttar Pradesh today contribute to about 88 per cent of all polio cases worldwide?

By Pranay Lal
Published: Tuesday 15 April 2003

A tale of two diseases

-- India is the shining star in the global battle to eradicate smallpox. It is also a branded villain as far as polio is concerned. How is it that we managed so well against a disease more virulent than polio? Why does Uttar Pradesh today contribute to about 88 per cent of all polio cases worldwide?

On January 2, 1967 the World Health Organization (who) launched the intensified Smallpox Eradication Programme. In order to exterminate the disease, a 100 percent vaccination strategy was undertaken. This was a necessity. In 1966 western Nigeria, where 90 per cent of the population had been vaccinated, had an outbreak (supposedly originating from a religious group that resisted vaccination). India did not wake up till a similar incident in Gulbarga, Karnataka in 1970. A smallpox epidemic affected 1200 people and claimed 123 lives in five city municipalities and in the outskirts. This prompted a military-like operation, using every health worker in the area to do a house-to-house search of cases and carry out compulsory vaccination.

The Gulbarga experience was India's first real success with surveillance and containment in a densely populated area. This strategy was slowly understood; thereafter rapid action became possible. In Bihar and Uttar Pradesh for example, it was worked out only in 1973; village-to-village searches found 10,000 new cases. India's health administration was too slow -- even then -- to develop a standardised and regimented protocol to fight the disease. But once this aggressive strategy was operationalised, things turned dramatically around.

Mass vaccination was a rational strategy. Neither the who, the government agencies nor donors had conceived it; it evolved organically. India was able to recast the problem through innovation in the field. Institutional learning and local adaptation were central to this campaign. The local administration had a free hand: to create mass awareness, to invent procedures that not only blended with local customs but were also effective in early detection and to report and control. In the tribal belts of Gujarat's Panchmahal district for example, medicine men and shamans were involved to report any of the classical symptoms of smallpox to local health workers.

Globally, effective vaccines and delivery methods for them were developed continuously. Each donor tried to out-do the other in mustering international goodwill, and pharmaceutical industries saw enough money from government-run programmes to be interested. Epidemiologists and sociologists of various nationalities travelled far and wide, enriching local understanding of how the vaccine could reach every person on earth. So far as there was social understanding of the disease, political will and the ability to stay ahead of the technological curve, smallpox could be defeated. In India, training was a very important component. Scenarios and simulation exercises, for doctors and village-level health workers alike, were designed. Village-level epidemiology held more importance than the dictates of a high-ranking official. Reporting cases locally was most critical. As the programme advanced, fixed targets were translated into unambiguous standards and practice. For example in 1974, standards for surveillance and containment were prescribed. Under this, 75 per cent of outbreaks should be discovered within two weeks of the onset of the first case. Containment had to begin within 48 hours of discovery or reporting, and no new cases could be allowed to occur more than 17 days after containment had begun.

With such stringent standards, data was collected properly, reported with utmost urgency and acted upon equally promptly. Those who did the reporting, saw their work rapidly acted upon; this spurred them on. Operation Smallpox Zero (osz) was thus launched in 1975 with crystal-clear vision. There were now house-to-house searches. Every case of fever and rash was recorded and notified to higher authorities, and vaccination done almost immediately to the sufferers and those in a one-mile radius. Rumours about the disease were quelled at its inception. The measures paid off. The rates of reportable smallpox cases fell by 40 per cent with every month. It took just 19 months to declare India smallpox-free.

Jack Hopkins, author of The Eradication of Smallpox : Organizational Learning and Innovation in International Health , recounts how one who official had commented that India's diversity was so daunting, if the campaign succeeded he would "eat a tyre off a jeep". When the last case was reported from Somalia in 1977, Donald Henderson, director of the smallpox programme and the one who had championed the idea of 100 per cent vaccination, sent the official a jeep tyre. The then who director-general, Halfdan Mahler, described the programme as "a triumph of management, not medicine". A year later, Mahler asked Henderson which would be the next disease humans could eradicate. Henderson replied that the next disease that needed to be eradicated was bad management in health programmes.

He had polio in mind?
The biggest failure of the polio programme has been the inability to generate confidence, in local communities and in grassroots workers, to innovate when local challenges were encountered. The government's health programmes are too rigid. Medical officers and health workers are reprimanded for any cases reported. As a result cover-ups happen, and under-reporting. The who-sponsored National Polio Surveillance Programme has squarely blamed poor implementation in Uttar Pradesh (up). They claim that up does not have even basic immunisation facilities. In 2001 for example, up conducted only two of the six earmarked National Immunisation Days (a day earmarked for administering the oral polio vaccine to children). One was in January and the other in September. The gap meant that at least 2.5 million children missed being immunised.

On top of inept implementation, the communication strategy too has failed to motivate people to come out and get their children vaccinated. In Mirzapur district, a rumour originated in the summer of 1999, that the oral polio vaccine would make every male child infertile. Many claimed that girls would attain sexual maturity sooner -- a rather serious cause of anxiety for parents, who have daughters, in a male dominated society. The rumour developed into a tremendous resistance from local Muslim communities. They suspected the government wanted to coerce them into adopting birth control measures. How did the rumour mills manage to work overtime, unlike in large eradication programmes in the past, like smallpox and guineaworm?

Some donors have expressed the possibility of funds being withdrawn in the near future if India fails to control this resurgence. Every year will cost India an additional Rs125 crore. There is already a discussion whether the time period should be extended because of the up experience. who is tight lipped about whether this would mean extending the programme globally, or only in pockets or countries where the re-emergence has occurred.

The government has now established the India Expert Advisory Group (ieag) for polio eradication, to advise on strategies to interrupt transmission of wild poliovirus in India. It met in November 2002 and recommended to increase political ownership of the program by the central, state and local governments, especially in up and Bihar. ieag has asked for supplementary immunization activities (sias) -- additional rounds of immunisation in target areas where the wild poliovirus is detected -- and that the sias use grassroots data, and improve management of operations in endemic areas. A special mention has been made to include Muslim leaders, medical societies, and grassroots organizations into the process of planning and implementing sias, given that Muslim children are at the highest risk for contracting polio. ieag expects a dramatic drop in cases, in the next few months, in what is traditionally the 'low transmission season'. This will present the opportunity to knock down the virus in the reservoir areas with sias, to reduce transmission to focal areas. Hopefully, eradication will occur soon after.

But all this is in the future. The story of polio eradication so far has been the victory of an innocuous virus, because poor eradication strategies have ensured that the war over polio will carry on for a few years more, But now, hopefully, India will remember its smallpox success story. And so create a realistic framework for grassroots workers to tailor programmes according to standard reporting, surveillance and containment protocols. Hopefully, politicians will emphasise participation and effective communication. Every grassroots worker and every bureaucrat should have the courage to take responsibility for every polio case that occurs from now on.

Pranay G Lal is coordinator, Health and Environment, Centre for Science and Environment, New Delhi

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