THE boat isn’t going anywhere. The 12 women on board pull their shawls tighter against the chilly smog that has blocked all visibility. We are trying to cross an especially wide stretch of the river Ganges just outside Patna, capital of Bihar, the poorest state in India.
The women work for India’s polio campaign. This boat is the only way to reach migrant families that farm seasonal floodplains across the river, and immunise their children.
Hoping to help, Ujjawal Sinha from the World Health Organization shows the boatman where we are on his iPhone, a small dot on the river’s big blue band. The boatman is unmoved: no visibility, no crossing. Hours pass. The nurses use their phones to inform people of the delay.
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They finally crossed later that day, then had a long trudge down muddy paths with the coolers of vaccine we had carefully stowed in the stern. That evening they were able to report that everyone had been vaccinated.
India . It is now only found in two nations: Afghanistan and Pakistan. So teams like the Patna nurses continue their efforts to give out drops of oral polio vaccine. But with , the WHO predicts the virus will be gone – or eradicated – by 2019.
The question now is what happens to the organisation, and the people, that enabled that to happen. If they can be redirected towards improving public health, the determination of the Patna nurses and others might give a badly need boost to the health of the world’s second most populous country – and with it, the nation’s economic and political stability.
By many measures India is a well-off country. It’s the world’s fastest-growing economy, and it builds nuclear weapons, aircraft carriers and spacecraft. By conservative estimates, 24 million Indians are middle class. Yet it bears a disproportionate burden of ill health (see charts). Shockingly, nearly .
“It would be a grave mistake to turn our backs on the knowledge and innovation accumulated with polio“
Its ramshackle healthcare system had led many to predict that eliminating polio in the country would be impossible. But India did it, and the UN agencies and other organisations that helped are now discussing with the government how to apply the lessons, and the leftover resources, of the campaign.
“India must continue to spend on health every dime now being spent on polio,” says Vikram Patel at the Public Health Foundation of India in Gurgaon. Whether it will is still unclear.
The key to defeating polio, I was told by everyone involved, was to go outside the existing health system and build dedicated networks of health workers, surveillance and laboratories, funded both by government and outside donors. People “micro-planned” in districts that proved hard to vaccinate because they were remote or resistant – health workers mapped how many children each family had and who had been vaccinated. Campaigns focused on public outreach. Eventually, all 27 million babies born annually were vaccinated.
I saw this when I accompanied another group of health workers to the slums of Aligarh, a town 140 kilometres from Delhi where the Muslim community has historically been resistant to the idea of vaccination. To win people over, teams of community mobilisers were created to raise awareness and call on mothers.
To announce the vaccination drive we paraded through the dusty streets to the mosque, chanting slogans and waving banners. The children flocked to neighbourhood booths to get their drops. The day concluded with everyone involved meeting to compare notes and make sure all was going to plan.
“There are fears some new virus could spread widely before being detected and spawn a global threat“
Scenes like this may be short-lived. External funding for India’s polio infrastructure will end when the virus is officially eradicated. When smallpox was eradicated in 1980, the organisation that did it withered. The WHO vows this time, the .
The biology of polio makes its legacy unusually useful. To ensure the virus is gone, you must test for it in sewage, and also test all cases of polio-like paralysis – which typically occurs in – to make sure it was triggered by something other than polio.
The Indian government has already taken over the labs that do this, and now they test for measles and rubella too. It also helps pay for community mobilisers and micro-planning.
Last year, the government launched to use the polio programme’s micro-planning, and the 1000 doctors of its surveillance arm, to make sure children in more than 200 difficult-to-reach districts get routine immunisations. “We are moving from polio to public health,” says Henk Bekedam, head of the WHO office in India. The infrastructure could help achieve India’s target of eliminating measles by 2020.
Indradhanush isn’t all about moving on: routine immunisation must also improve if polio is to be kept at bay. After eradication, vaccination will have to continue for some years, as the virus in live polio vaccine – the oral drops I watched the nurses giving – can persist. During this time, there is a possibility that it could become virulent and start spreading. For protection, the next generation of children must be vaccinated with killed vaccine – and unlike the live vaccine, this must be injected. Since the nurses I met are not trained to do this, it will have to happen as part of their routine immunisations. Right now, only 71 per cent of children are fully immunised. This is not high enough to protect against any resurgent polio, one reason India wants 90 per cent of children immunised by 2018.
To meet this aim, polio nurses now tell families about regular immunisation days. They also promote breastfeeding, diarrhoea control and better nutrition and sanitation. “Every effort is being made to retain the polio nurses in Mission Indradhanush,” says Carole Pandak, head of polio at the service organisation Rotary, a major funder of polio eradication. “Ideally, the government will employ these tireless women.”
Despite the positive signs, the situation remains uncertain. The government of Narendra Modi has not yet shown much enthusiasm for the country’s free but massively underfunded and understaffed public health system, considered by many the country’s best route to better public health. Modi has pledged healthcare access for all, but last year , and new money this year mostly went to helping the poor access the ill-regulated private system.
Some health experts say that the polio campaign siphoned resources away from public healthcare. Others say polio would still be around if the campaign hadn’t worked as it did. “We shouldn’t throw out all the capacity gained and lessons learned from polio,” says Steve Cochi at the US Centres for Disease Control and Prevention. “We have learned how to reach every child, the value of identifying high risk areas, community engagement, disease surveillance. It would be a grave mistake to turn our backs on this accumulated knowledge, capacity and innovation.”
Bekedam believes there is a new enthusiasm for improving India’s healthcare, kindled by the polio victory. The polio system may be relatively small, he says, but it could catalyse a broader change.
But so far the government has taken on only a small part of the polio infrastructure, and has no plans for funding it past eradication. Only one outside organisation, the global vaccine fund GAVI, has so far pledged funds to maintain the polio infrastructure beyond 2019.
If India’s polio investment is saved, it would be an example for the world. In 2014, Ebola got out of control in West Africa for lack of the kind of surveillance India’s polio programme built. When Ebola invaded Nigeria, it was its polio network that tracked and contained it. Nigeria is now polio-free and will be asking the same questions as India.
By 2019, the world will have spent $18 billion to eradicate polio. Keeping the tools seems a dividend we can ill afford to lose.
Why India’s health is a global concern
The mismatch between India’s wealth and health is a problem for the world. The country’s , yet prosperity cannot keep rising unless health improves, say development experts from to economics Nobel prizewinner Amartya Sen.
In December Richard Horton, editor of The Lancet, wrote that otherwise, “India will see epidemics sweep across the country, creating an unsustainable future and destroying national security”.
With little sanitation or healthcare, high crowding and poor nutrition, any infection can potentially become a huge problem, says T. Jacob John of Vellore Christian Medical College in Tamil Nadu. One big fear is that some emerging virus, such as yellow fever or bird flu – the ominous H5N1 variety is endemic – could spread widely before being detected, creating a global threat.
Yet India eliminated polio, and last year, neonatal tetanus. “We’re good at these one-off things,” says Ramanan Laxminarayan at the Center for Disease Dynamics, Economics & Policy in New Delhi and Washington DC. Everyday healthcare is the problem. For example, a government-led campaign slowed the spread of HIV in the 1990s, a notable achievement. But now funding has fallen, and HIV has spread in blood transfusions.
This article appeared in print under the headline “From polio success to better health?”
Article amended on 10 August 2016
Correction: we have revised the sum spent globally to eradicate polio
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