Reflections on Polio Lessons from Conflict-Affected Environments

"Understanding the experience and history of the program's work in security and conflict-compromised areas is arguably more important at this stage than ever before."

The Global Polio Eradication Initiative (GPEI) has worked in conflict zones since it began in 1988. This paper outlines the evolution of the GPEI's strategies and tactics and how they demonstrate an increasingly complex and sophisticated response to conflict. It describes the foundations and framework that guide today's polio interventions in conflict-affected areas, while arguing that more systematic analysis to help refine and critically analyse strategies and approaches in ways that strengthen future work is needed. Chris Morry argues that, given the certainty that polio will need to be eradicated in the context of significant conflict in the remaining endemic countries of Afghanistan, Pakistan, and Nigeria, as well as in several outbreak or high-risk countries such as the Democratic Republic of the Congo (DRC), Somalia, and Niger, understanding these lessons in greater detail should be a central concern for the GPEI and its stakeholders.

Morry explains that polio eradication is driven by the need to interrupt wild poliovirus (WPV) transmission by achieving very high levels of immunity ("herd immunity") accomplished through routine immunisation and supplemented with large-scale and necessarily high-quality campaigns designed to reach every child possible, with communities willing to accept the vaccine each time it is offered. All of this is considerably more difficult to achieve in the midst of conflict.

In this context, the paper looks back at several points in time where lessons have been captured, albeit sometimes only in summary form: the first was done at the end of the 1990s, capturing lessons from the first decade of the GPEI; the second after the polio outbreaks in Central Africa, the Horn of Africa, and the Middle East in 2013; and more recently in Afghanistan, Pakistan, and Nigeria. For example, by the 1990s, the GPEI had recognised the importance of negotiation, health infrastructure, surveillance, and community-level trust as foundational strategies in conflict-afflicted settings. Other lessons that emerged over time involved ensuring that communications reflected the GPEI's neutrality, vaccinating when and where opportunities arise, building alliances with military and/or police forces to ensure the safety of polio staff, and developing more detailed and dynamic security risk assessments.

To look at one of these strategies in more detail - community-level trust - Morry explains why eradication levels of coverage require deep engagement - not only with communities but with each household in the community. He explains why door-to-door provision of the oral polio vaccine (OPV), for example, can be difficult to accept for communities and groups who are suspicious of outsiders, possibly facing attacks from the air and ground, and worried about informers and intelligence gathering. Some of the techniques that have been explored in the literature include involving traditional and religious community leaders, providing respectful and accurate answers to questions, listening to local voices from all sides of a conflict and jointly identifying solutions, engaging local people as vaccinators and mobilisers, conducting ongoing education and training on vaccination, and building relationships with local gatekeepers who can help advocate for polio access and create an atmosphere where the vaccine and programme are trusted.

Trust and local engagement as a strategy can be seen in the case of Pakistan, where the polio programme itself has become the target of violence. Moving away from promoting polio campaigns with high-profile events, the focus of new media campaigns and materials was on humanising the vaccinators and other frontline workers and on emphasising the local nature and ownership of the programme. The campaign focused on vaccination being carried out by local community members - presented as local heroes - to achieve an important good for their children.

Figure 2 in the paper illustrates the major strategies that have been applied over the years and serve as broad outlines for organising polio eradication efforts in conflict-affected environments. In brief, they focus on:

• Neutrality and trust
• Negotiation
• Surveillance and monitoring
• Safety
• Flexible tactics
• Rapid response
• Partnerships
• Local engagement
• Reaching the hard to reach

Morry concludes by looking ahead to some of the critical issues he says polio actors will need to face and overcome in the next 5 years. For example, the meaning of "local engagement" may need to shift and evolve, considering the adaptations communities have made with regard to healthcare-seeking behaviour in the context of protracted conflict. In Afghanistan, for instance, the very-long-term nature of conflict means that "the 'void' left by deteriorating formal health care infrastructure can be filled by an often uncoordinated and usually poorly distributed range of new providers with varied effectiveness." Working effectively in such environments will require a well-informed understanding of the various actors and the services they provide, as well as an assessment of which ones can be effective partners in delivering vaccination and other health services. As always, Morry stresses, this work must also be shaped by a strong understanding of the perceived health priorities of communities living in these areas and respectful engagement with local leaders.

Finally, Morry calls for further research and documentation on the GPEI's experience in working in conflict-affected settings. "As the GPEI enters the final phase of stopping WPV while building the foundations for the sustained high levels of immunity required to achieve global eradication, navigating the complex environments it finds itself in requires a better understanding of past experience and further evolution of its strategies."

Click here for the 17-page paper in PDF format.