In the introductory essay (pdf) to their timely collection of ethnographic papers on global health, “When People Come First: Critical Studies in Global Health” (which I think everyone working in global health should read), the editors, anthropologists João Biehl and Adriana Petryna, referred to the need to interrogate the “realities that we encounter in the [global health] field… that are too often obscured by the lens of established thought.” The phrase obscured by the lens of established thought made me think about how the global health community is responding to the challenges of polio eradication. In a Policy Forum article published in the open access journal PLOS Medicine earlier this week, “The Final Push for Polio Eradication: Addressing the Challenge of Violence in Afghanistan, Pakistan and Nigeria” Asmat Malik (from Pakistan), Farooq Mansoor (from Afghanistan), and I (from Nigeria) tried to address these challenges, especially of violence, as attacks on polio workers pose a serious danger to the Global Polio Eradication Initiative. The paper was read by over 400 people, shared more than 75 times in social media and widely reported in the online news media within the first few hours of publication.
While these countries, with large Muslim populations, have obvious similarities that threaten polio eradication efforts such as militancy, political unrest, lack of trust, and insecurity, the reasons for the failure to eradicate polio, as well as potential solutions, differ from country to country. For example, attacks against polio workers in Pakistan and Nigeria are unlikely to be repeated in Afghanistan because of the Taliban’s ambition to regain its role in Afghan national politics. The cause of recent distrust in northern Nigeria is partly because polio eradication is now associated with Bill and Melinda Gates, who are also promoting contraception; people distrust this push for contraception because they don’t grasp the link between a reduction in population and improved child survival. In Pakistan, this distrust is partly due to concerns by some terrorist groups that the house-to-house movement of polio workers could be used to identify wanted persons as was the case when the USA used a fake hepatitis B vaccination campaign to hunt down Osama bin Laden.
We do need to retreat a little in our battle against polio, to remove the layers of established thought from the lenses through which the global health community views polio eradication. We need to retreat for the purpose of building trust, take a rest from international deadlines to eradicate the disease, and in the meantime focus energies and resources on strengthening routine immunisation and other primary health care services. We need to change our rhetoric to one which prioritises making polio eradication part of the routine health system rather than highlighting it as “the only” health problem and put the people first, be they health workers or communities benefiting from health interventions. Polio eradication will only be achieved with stronger health systems and bottom-up community engagement, which will likely require more time and investment than the newly designated deadline to eradicate polio in 2018 affords. For example, in Nigeria we need to start working directly with community members and their immediate leaders rather than engage only with regional or provincial religious leaders to avoid elite capture in the campaign to dispel myths about the polio vaccine.
The global nature of the push for polio eradication makes polio workers a soft target in a proxy war against the West, especially in places rife with anti-West terrorist sentiments. To preserve the life of health workers in these areas, we need to reduce the fanfare and publicity associated with polio vaccination campaigns. Until polio eradication is seen by the people as a social problem that deserves priority, it will continue to be part of a foreign agenda with no incentive for groups such as Boko Haram and al-Qaeda to protect vaccination as a means of winning people’s support. For example, polio vaccination could be integrated with other interventions that tackle problems that people rightly consider a priority such as poverty, sanitation, malnutrition, and the three big childhood killers: malaria, pneumonia, and diarrhoea. Improved access to health services by the general population and an overall increase in the coverage of health services might help build trust between governments and the people, and between health workers and communities. We must avoid the portrayal of any health intervention as a battleground between Western forces and terrorist groups.
Like Biehl and Petryna so eloquently discussed in their essay, local realities in global health are inevitably often messy, transitional, and contradictory so that our analysis and proposals in our PLOS Medicine Policy Forum are neither exhaustive nor perfectly suited to the myriad of circumstances in our countries, but could be the beginning of a conversation that is long overdue. There is a cost to every ambition; one must not only count the benefits, but also the costs. We must not allow our ambition to eradicate polio at a certain date, to blind us to what we know about terrorism, and the accumulated lessons we have learned about health systems since Alma Ata. Looking into a hopefully not too distant future, when our work on polio eradication is done, I can see insightful work on the ethnography of this our final push for polio eradication. It will make for interesting reading, in the style of the humanising renderings of on-the-ground field realities of global health interventions contained in “When People Come First: Critical Studies in Global Health”, with lessons on how to, and how not to plan and implement future eradication programmes in global health.
Seye Abimbola is currently a PhD candidate at the School of Public Health, University of Sydney, Australia, and a research fellow at the National Primary Health Care Development Agency, Abuja, Nigeria.
The views of the author are solely his and not of any affiliated institution.