Ridding the world of polio is proving to be an elusive goal. And a key problem may well be that organizers of the global anti-polio initiative, and of other global health programs, are not listening to the people they want to help — or to each other.
As a result, in many communities targeted by the programs, people perceive a gulf between global programs like polio eradication and more immediate local health needs.
As one man in Northern Nigeria asked me, “Why polio, polio, polio, when we cannot get a health clinic near our village?”
In fact, in the parts of Nigeria, Pakistan and Afghanistan where polio survives, the disease is not a major health issue. Malaria, pneumonia and diarrhea are the major killers of children under five, and they dwarf polio as a subject of concern for parents.
But it is polio that tends to get the attention and the resources. Polio teams come knocking at the doors of homes with free vaccine, while treatment for other, more urgent diseases need to be paid for. This leads to suspiciousness among parents, and eradication program workers struggle to get them to vaccinate their children.
In towns and settlements in India, residents protested against the polio campaign by demanding they receive clean water and sanitation before the polio vaccine. They were called vaccine resisters, and elaborate communication campaigns were devised to get them to change their minds and allow their children to be immunized.
The questions people at the receiving end of the polio program ask are usually dismissed as coming from ignorant, unsophisticated people. But the questions are legitimate: Why are some diseases given more attention than others? Is it not more important, or at least equally important, to deliver clean water and sanitation as it is to deliver vaccines? It is cold comfort to save a child from polio if the child later succumbs to malaria or diarrhea from dirty drinking water.
This raises the question of why global health programs are fragmented along disease-specific lines, rather than addressing multiple diseases and helping to strengthen basic health services. The same children who need to be vaccinated against polio also need to be reached by other immunization programs, receive bed nets from the malaria program, and benefit from nutrition and safe-water initiatives.
While donors have often pledged to work together to integrate disease initiatives, the way global health programs are structured makes integration, or even cooperation, difficult.
Most aid and donor funding is earmarked for specific health issues; the campaigns in turn are required to meet specific targets related to the diseases for which they have received money.
Thus the malaria program has no real interest in helping polio immunization, since this is not what its funding is for. The polio program similarly has no stake in helping measles immunization, which it would see as a distraction from its primary aim of eradicating polio.
The structure of global health is top-down. Donor countries, aid agencies, international financial organizations and philanthropies like the Gates Foundation call the shots in deciding which programs should be funded.
They do this out of genuine humanitarian impulse, but the process is too often devoid of consultation or input from the people who are supposed to benefit from these programs.
The fault largely lies with developing country governments that are often content to accept whatever donors propose rather than try to set their own agenda. This leads to a situation in which donors and global program managers push countries to implement projects, while it should be countries knocking on the doors of donors and international organizations asking for help to implement the projects they need.
The polio eradication campaign keeps close track of the technical problems that have led to missed deadlines: poor implementation by local governments and unrest that makes it difficult to carry out vaccine campaigns. But the most important reason is probably the lack of engagement by local communities and leaders because polio eradication was not something they asked for.
Global health programs need to be rebuilt from the bottom up, responding to the most urgent needs of communities, rather than what donors feel they want to fund.
Thomas Abraham, an associate professor at the Journalism and Media Studies Center at the University of Hong Kong, is working on a book about the global polio eradication program.