Polio-free India Seemed Impossible

The World Health Organization (WHO) Eastern Mediterranean Region recently reported India completed 12 years free of polio, a remarkable achievement.

The WHO announced on January 13, 2023, that this achievement was realized due to consistent, determined efforts and genuine commitment at all levels. 

WHO Director Dr. Hamid Jafari reflected on his time eradicating polio in India and what lessons we can take to address the final challenges for achieving eradication in Afghanistan and Pakistan. Excerpts of his statements are inserted below.

'I spent close to six enriching years of my life as the National Polio Surveillance Project (NPSP) project manager for WHO India. My work entailed providing technical assistance and strategic guidance to the national program.

I was also in charge of poliovirus surveillance, monitoring mass vaccination campaigns, crafting corrective measures and strategies, and working closely with government counterparts at all levels to ensure every child was vaccinated enough times to build unity.

As a result, we delivered around 1 billion doses of polio vaccine to 172 million children each year over four the years leading up to the last case. And many more in the years after. 

Taking a step back to reflect on this journey, several factors contributed to the monumental success of ending polio in India. The first fundamental factor was government commitment that consistently translated into diligent administrative action at the operational level.

Even the district administrators were fully aligned with and committed to taking corrective measures based on evidence: accepting programmatic gaps and challenges and addressing them urgently. 

The second was the effective multi-actor system that allowed us as partners to provide the technical assistance needed at the implementation level. Finally, at the operational level, we had the evidence: real-time data, including monitoring data, that guided timely corrective actions.

This data was put to good use – to recommend changes that the government took on board. But, again, I must emphasize individual and institutional willingness to make changes based on evidence matters. 

We also focused on the infrastructure that could appropriately manage community engagement and deploy the right community influencers, which led to collective action. In addition, an effective technical and managerial workforce was instrumental in ensuring ideas turned into action.

At the same time, the workforce was fine-tuned to meet the program's needs which helped us as partners to work seamlessly together in our respective fields. 

2011, when the last polio case was confirmed, was a year of great anxiety for us in India, but it was also the year of great effort to search for the virus.

The more time that lapsed since the last confirmed wild poliovirus case, the higher the political stakes for any district or state to report a case of polio. And the media, in turn, began to set expectations that raised the stakes to match Mount Everest.

It almost felt like we had held our breath while working away. 

When we managed to end polio in India, this milestone significantly boosted public confidence in public health in the country, to the Ministry of Health, every health worker, caregivers, and our partners.

Our efforts had paid off. The jubilation was just exceptional.

Moreover, the momentum received a lot of support and enthusiasm from the ministers of health and the countries of the South East Asia region, which was very helpful for the polio program on multiple fronts.

We felt humankind's dual victory over one challenge, and regional and global solidarity and collective action of countries supporting and encouraging each other to eradicate polio in Nigeria, Afghanistan, and Pakistan. 

The most significant learning of all this would be that when entire countries and their leadership work in unison towards a shared vision of a healthier future for our children, a sense of mutual accountability is automatically established.

All parties feel responsible for their roles. 

It was always a constant process of program assessment and refinement. 

And it seemed impossible until it was done. 

That's how I feel today about Afghanistan and Pakistan, where polio is still endemic. 

The path potholed with challenges is the same path laden with multiple opportunities the need to seize. With the lowest level of wild poliovirus transmission, genetic diversity, and the smallest geographical spread, we have a slim but real window of opportunity to end polio.

However, the efforts of our courageous health workers at the forefront and the ongoing political commitment of leaders at all program levels have brought us very close to our goal. 

But we know there is more to be done to prevent the virus from paralyzing another child ever again.

This means reaching every child with polio vaccines enough times to boost their immunity, using evidence from the field to adapt our programmatic approach, being willing to make changes, maintaining highly vigilant surveillance for poliovirus, and, most importantly, making sure that everyone - from the highest political offices to the media, donors and the communities - works in concert to end polio, once and for all. 

The persistent threat of the virus spreading and paralyzing children far across the globe is a warning that we must heed. It shows us that polioviruses are tenacious and thrive when children are under-immunized.

It also serves as a reminder that we must constantly refine the program in our relentless pursuit of children we have missed.

This has to continue, even more so when we have a high level of control over the virus so that complacency doesn't steer us away from our path. 

There are major programmatic shifts in play for Afghanistan and Pakistan in 2023, mainly on concerted efforts to zero in on the virus through a risk categorization approach recommended by the Technical Advisory Group.

We have it in our hands to once again achieve the impossible. As long as the virus exists, there is no room for error. 

Once again, it feels like we are walking on eggshells. Every step we take matters.'

The unedited, full article posted by Dr. Jafari is available at this WHO link.