Reflections on Polio Lessons from Conflict-Affected Environments [In Summary]

In Summary

Over the past 30 years, and in spite of severe challenges, there have been multiple instances of successful eradication programs in conflict-affected environments. As the lessons from these experiences have coalesced, several critical strategies and approaches have emerged.

Figure 2 illustrates major strategies that have been applied over the years and serve as broad outlines for organizing polio eradication efforts in conflict-affected environments:

• Neutrality and trust are critical to the polio program's ability to operate in any context and have to be founded on widespread belief that the GPEI has no agenda other than polio eradication and the health of children. This has not always been the case; there are many instances where rumors and misinformation have led to suspicion that the GPEI has hidden and negative agendas linked to outside interests and/or that the polio vaccine is a tool for reducing fertility or spreading diseases like AIDS.¹⁶ In conflict situations, misinformation and distrust are constant companions, and the GPEI has had to work hard to maintain and, sometimes, regain public trust and belief in its neutrality. Neutrality can be maintained only if the polio program is conscious of its actions, partnerships, and communication as critical elements of how others perceive its agenda. It is also essential that this belief in program neutrality be strongly held at all levels—from government or AGE leadership to local communities to the most vulnerable and marginalized populations.
• Negotiation is profoundly linked to neutrality and trust. Without acceptance of, and trust in, the GPEI agenda, it becomes almost impossible to negotiate successfully at any level—whether it be for arranging ceasefires, gaining access to areas controlled by nonstate actors, or being allowed into a community or minority group suspicious of outsiders. Equally, trust and neutrality are not sufficient in themselves without well-developed technical and communication capacities that support negotiation with different actors at different levels from national to local.
• Surveillance and monitoring are essential for confirming coverage and being able to verify if the virus is still circulating. Surveillance of acute flaccid paralysis cases is the most important tool to identify polio cases and each case is investigated thoroughly (World Health Organization 2019). Each acute flaccid paralysis case is analyzed to determine if it is polio or not, the number of polio vaccinations the child has received is checked, and the virus is genetically tested to determine its genotype, which can help identify its origin. Because the virus can circulate without cases of paralysis appearing, environmental sampling is also done. However, for surveillance to work, it needs to reach into conflict zones.¹⁷
• Safety of staff, caregivers, and children in conflict-affected environments has to underpin every action. Risk to safety needs to be measured using well-informed security assessments and responded to in ways which can range from stopping all activities in an area to adjusting campaign tactics, changing communication materials and mass media approaches, or engaging with new partners who may have better relations with those in the conflict-affected area.
• Flexible tactics are also important. This is especially true where access needs to be negotiated and conditions that compromise quality may need to be accepted. Nevertheless, regardless of the tactics negotiated, the goal has to remain reaching enough children on a sustainable basis to increase population immunity to eradication levels. Where routine immunization is low and negotiated changes have led to lower-quality campaigns, negotiations need to continue building trust and highlight where the gaps are so that ongoing problem-solving dialogue to reduce missed children (at all levels from the very local to the most senior representatives of all parties to the conflict) can lead to a level of intervention sufficient for eradication. Where routine immunization services are available, they should be neutral, encouraged, and strengthened—every dose provided helps. In some cases, catching up after a period of limited or no access requires considering immunizing older children and using combinations of oral polio vaccine and inactivated polio vaccine to quickly boost immunity (Duintjer Tebbens et al. 2014). Where health services have entirely broken down and reliable, recurring access for campaigns cannot be negotiated, or when negotiations are moving slowly, other tactics have been developed that focus on surrounding the inaccessible area with a range of alternative opportunities for vaccination.¹⁸
• Rapid response is essential to enable the polio program to respond quickly and at scale when the opportunity for access arises. This is no small thing; it involves vaccination teams, vaccine, ice packs, vaccine carriers, transportation, training, supervision, monitors, and much more, all prepared for deployment at a moment's notice and matching negotiated strategy.
• Partnerships have been used for many aspects of the polio program to engage the support of religious groups and leaders, medical associations and professional staff, humanitarian and UN agencies, nongovernmental organizations (NGOs), and government ministries. In conflict-affected environments, religious, traditional, and medical leaders can help counter misinformation and rumors. Humanitarian and UN agencies can help with contacts to different actors in the conflict and help with incorporating polio vaccination into the delivery of emergency services to displaced populations. NGOs that have existing relations with marginalized groups or operations in otherwise inaccessible areas can facilitate access, provide much-needed services, and conduct community-based surveillance. Government ministries can help with a range of things such as education, transportation, vaccination sites, policing and security, and public support of influential leaders. Partnerships play a major role in building trust, maintaining neutrality, countering rumors, coordinating and bundling services, and extending program reach.
• Local engagement is important in any context to build trust, gain knowledge of local realities and perceptions, help identify solutions to seemingly intractable problems, and identify appropriate people to work for, or support, the polio program. Because conflict and security issues manifest themselves at all levels, it is just as important to focus on gaining the trust and involvement of local communities as of government or AGE leaders. This is done by being engaged with, and listening to, those communities. As much as possible, staff need to be local and supported by trusted local influencers. Information about local issues and concerns needs to be an integral part of program planning and implementation. Communities need to feel engaged in that they have a voice that is not just heard, but has an impact on program approaches and how they relate to each community's needs and priorities (Habib et al. 2017; Hussain, et al. 2016).
• Reaching the hard to reach is in part an aspect of local engagement, but it requires a deeper understanding of community groups and of social, cultural, and economic differences among them. Some groups may be marginalized by religious or ethnic identities, others by gender, class, or citizenship, and still others through mobile lifestyles, as in the case of migrant workers and nomads. Challenging terrain, weather, or illicit activities may make accessing some communities difficult for extended periods. Newborns and pre-walking children can be missed due to cultural practices that limit exposure outside of the house or make such children inaccessible if there is no female vaccinator. Inability to keep up with new birth cohorts can increase the number of susceptible children.

There are many reasons for groups to become marginalized. In conflict situations, a significant issue is often around population movement, which creates large numbers of people who have only a transient relationship to a particular area. Whether they be nomads, seasonal laborers, IDPs, refugees, or ethnic or religious minorities, there are populations that have less access to, or lower expectations of, services such as health care. These groups are harder to identify and reach in any context, but in conflict-affected environments they can be larger in number, in poorer health, and harder to access. Population movements need to be tracked, strategic vaccination points need to be set up along the routes that people take, new settlements of refugees or IDPs need to be identified, and partnerships need to be formed with appropriate agencies and organizations to ensure polio vaccination is incorporated across multiple health interventions. In many cases, traditional patterns of movement among nomadic and mobile populations are disrupted. These changes need to be identified and polio program activities adjusted accordingly. Technologies such as satellite tracking can be used to help with locating new settlements, but equally important are close relationships with other agencies working with these populations and with members of the communities they settle in, whether temporarily or more permanently.

¹⁶ The spread of misinformation about the GPEI and the polio vaccine have a long and complex history in which both have been linked to modern political struggles (Peckham 2016), political events (Scientific American 2013), and misinformation that emerges, disappears, and then reemerges over time (Larson 2014).
¹⁷ Such systems vary depending on the context. In Syria, for instance, two systems were set up for areas under versus not under government control (Ismail et al. 2016). In Afghanistan, a single acute flaccid paralysis (AFP) tracking system compares "silent reporting" areas against statistical expectations to map areas where surveillance may be inadequate (Martinez et al. 2018).
¹⁸ As mentioned previously, such tactics include vaccination transit points or sites at strategic places of entry and exit which help by providing a kind of "firewall" around an inaccessible area that can immunize children as they move in and out. Health camps that bundle polio with a range of other services can attract families to travel to fixed points outside the inaccessible area. Events like religious ceremonies, naming ceremonies, marriages, and funerals also provide opportunities to immunize children moving from inaccessible to accessible areas. None of these tactics offers systematic approaches to ensuring high coverage and they are not alternative eradication strategies, but they do offer ways to keep population immunity higher than it would have been otherwise and can help build community solidarity for immunization.

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Editor's note: Above is an excerpt from "Reflections on Polio Lessons from Conflict-Affected Environments". The full table of contents is here.

The next section in this paper is Conclusion.
The previous section in this paper is Lessons: Strategies and Activities.