Why Community Health Workers May Be the Reason We Eradicate Polio

Polio transmission will continue until every last child is vaccinated. Photo courtesy of BBC News.

We are once again at the cusp of eradicating a human disease. Over the past thirty years, since the start of the Global Polio Eradication Initiative (GPEI), the largest public-private partnership for health, including national governments and major multilateral leaders like WHO, UNICEF, and CDC, the once devastating disease has reduced its number of cases from an estimated 350,000 then, to 29 reported cases in 2018. However, polio transmission will continue until every last child is vaccinated.

Today, wild poliovirus (WPV) remains endemic in just two countries: Pakistan and Afghanistan, where children are still missing out on vaccination due to structural and socio-political barriers. These obstacles include a lack of robust infrastructure, remote territories, population movement, political conflict, and vaccine hesitancy. Thus, eradication success lies primarily in full implementation of vaccination strategies — a goal that requires fervent support from community health workers (CHWs) to achieve. Here’s why:

The eradication issues that plague Pakistan and Afghanistan today are issues that can only be solved by locals.

In 2011, foreign mistrust and vaccine refusal surged in both countries after the US CIA used a fake vaccination campaign in Abbottabad to obtain DNA samples from community members surrounding Osama bin Laden’s compound to confirm his whereabouts. Nowadays, public qualms against vaccination persist due to misinformation from anti-polio propaganda spread by conservative Islamic clerics. That’s why strengthening vaccine trust in “last mile” — or hard-to-reach — settings requires the help of local polio workers, who, more than anyone, understand the concerns of their neighbors best.

Take Yar Mohammad, for example, from Kandahar, Afghanistan who became a community activist to convince friends and neighbors to vaccinate their children. His refusal to vaccinate his children earlier in life led his daughter to be paralyzed by the virus. Now, he, along with his wife and mother, educate parents in nearby neighborhoods about the dangers of WPV and the importance of the vaccine.

In addition to administering polio vaccines to their neighborhoods, CHWs wear many hats, often supporting eradication efforts in more ways than one. These include drivers and religious scholars, who play a vital role in improving vaccination uptake by dispelling myths about polio vaccines. Molvi Hameedullah Hameedi, a religious scholar from a rural mountainous region of Balochistan, Pakistan, is one prime example. Once a proponent of anti-vaccine campaigns, Molvi Hameedullah was inspired by a conference held by the Islamic Advisory Group (IAG) for polio eradication, where his apprehensions about the vaccine were relieved. Now Hameedullah advocates for polio eradication by administering the vaccine to children himself and recruiting women vaccinators in the community. Including females into the polio workforce is important in these regions because they, unlike men, are able to enter private homes and ensure that every child has been vaccinated. As a rural religious scholar with a degree of authority, Molvi Hameedullah is easily able to foster trust and cohesiveness among his community members. Since his efforts, there have been no polio cases in the areas he serves.

The resilience of CHWs is essential for successful disease eradication.

The history of smallpox eradication provides one of the best-case examples of this phenomenon. Until now, smallpox is the only human disease that has been eradicated. While major multilateral organization like WHO and UNICEF, advocacy groups, governments, and global/local NGOs contributed immensely to this success, CHWs were essential in the final push towards eradication. D.A. Henderson, an American epidemiologist who led WHO’s smallpox eradication campaign, tells a similar story. In his book Smallpox: Death of a Disease, he describes a trend in final stages of national smallpox eradication programs, where the optimistic attitude of CHWs was often followed by ultimate elimination of the disease.

In Indonesia, for example, Henderson describes the exceptional outlook of workers towards their national eradication campaign. Despite struggling with their own issues: delays in getting transportation devices through customs, repeated governmental financial crises, and problems in communication with the many scattered islands across the archipelagic, the performance of the WHO advisors, members of commission, the Indonesian government and staff, especially field workers, was exemplary. Tens of thousands of CHWs carried out the grand plans — reaching individuals in remote regions and helping them understand or accept the vaccine — and pressed on, despite personal comfort and safety, to reach the common goal. In the end, the strong belief among Indonesian workers that eradication was possible made smallpox elimination possible within three years, exceeding WHO’s expectations.

If the only eradicated human disease owes much of its ultimate success to the resilience of CHWs, then we can expect the same for final stages of polio eradication.

CHWs are the current face of eradication efforts.

Today’s media places CHWs in the spotlight, giving them a chance to voice their personal victories in the battle against polio and inspire others by doing so. Shafiullah, for one, uses his identity as a polio survivor to educate and convince families in nearby Afghan villages to vaccinate their children. His efforts alone have ensured the safety of over 150 children in those villages. There is Afia, who, at 19, leads a team of polio vaccinators and simultaneously fights against societal and patriarchal norms in her community, where women are often forbidden to work.

Moreover, images of polio health workers are going viral — one showing a man trudging through waist-deep snow in Swat while on duty and another depicting four female polio workers walking knee-deep in the muddy waters of Dadu, Sindh for an anti-polio drive. Pakistan’s Prime Minister Imran Khan and UNICEF Pakistan have taken the initiative to further support these health workers with hopes of harnessing national support and inspiring others to do the same.

Photos courtesy of Rotary International.
Photos courtesy of The News PK.

Ultimately, CHWs are able to project their optimism towards both the general public and public health leaders who push for eradication. In the words of Dr. Thomas R. Frieden, former director of the CDC: “Without eradication, a resurgence of polio could paralyze more than 200,000 children worldwide every year within a decade.”

GPEI tentatively plans to rid the world of polio by 2023, urging everyone involved in polio eradication to use proven resources and excel in their roles as advocates of a polio-free world. This requires consistent grit and persistence from all, with CHWs paving the way.