GLOBAL PROGRAMME OF POLIO ERADICATION IN INDIA*
April, 12, 2004
Debabar Banerji,
Professor Emeritus,
Centre of Social Medicine and Community Health,
Jawaharlal Nehru University,
B-43 Panchsheel Enclave,
New Delhi 110017
*This study is commissioned by the West Bengal Voluntary Health Association. The usual disclaimers apply.
SUMMARY
Poliomyelitis forms a miniscule part of the load of the health problems in poor countries. However, to save the cost of immunizing their own population against polio, the leadership of the rich countries, in connivance with the power elites of the poor countries have exercised their power to impose the GPPI on the poor of the world. Worse still, they have adopted a simplistic approach to a highly complex problem. International organisations like WHO, UNICEF and the World Bank have lent their considerable weight in favour of GPPI. There are vital flaws in the conceptualisation, programme design and in its implementation and monitoring and evaluation. Deodhar has rightly called it a multifaceted `cost disaster’, epidemiologically unsound and incapable of eradicating the disease.
The concerned authorities in India conveniently overlooked its glaring shortcomings and followed the line laid down for them. Data have been presented from a number of sources to show that the public health services in the country are in a stage of advanced decay. The state of the environmental sanitation and the human ecology in rural and urban areas is extremely poor. Efforts made for implementing GPPI contrasts sharply from those in implementing the NMEP during 1956-64. Despite mobilizing enormous resources, both in cash and kind, they have repeatedly failed to attain the goals set for it by the `donors’, the latest being in giving the `Last Push’ to make the year 2004 polio-free. In the `bargain’, preoccupation with the GPPI has had a devastating effect on the general health services This goes contrary even to the WHA resolution of 1988 on GPPI. Imposition of GPPI and UIP are a part of the trend of the barrage of `international initiatives’ let loose on the poor countries of the world after they `dared’ to declare self-reliance in health development in the Alma Ata Declaration in 1978.The sponsors of the Declaration, UNICEF and WHO, had to suffer the humiliation in making an about turn, and started to promote vertical programmes, like GOBI, GOBI-FFF, UIP, GPA, GPT. DCC and ARI. Each one of these porgrammes, which were launched with so much of fanfare, failed to attain the goals that were set for them. India’s National Health Policy of 2002, had, to finally confess that these programmes were exceedingly expensive, unsustainable and very damaging to the general health services. The failure of the prefabricated agenda of ill-conceived, badly designed, techno-centric programmes on the poor stand out sharply from the impressive efforts made in developing health services for the people of the country during the first two decades after Independence — PHCs as an integral part of an overall community development programme, social orientation of education and training of health workers, placing people at the centre of designing national programmes, educating and training Managerial Physicians, are some of the examples.
POLIOMYELITIS AS A GLOBAL PUBLIC HEALTH PROBLEM
UNDP reported in 2001 (1) that the (rich) countries containing 20 per cent of the world’s population accounted for 80 per cent of the total world consumption. Within the (poor) countries containing the remaining 80 per cent of the population, the power elites, who constitute less than a fifth of the population, cornered more than the half of the remaining resources, thus leaving less than 10 per cent to the more than the four-fifths of the population in these countries (the marginalised). This broad stratification – (a) the political leadership of the predominantly rich countries, (b) that by the rich power elites of the poor countries and (c) the marginalised – coincides with the political relations between and within the countries of the world. The decision to launch the Global Programme for Polio Immunization (GPPI) will be examined against this background of the extremely unequal and inequitable relations of political power among these three strata. .
For the large masses of the marginalised people of the world, compared with the overwhelming load (or `burden’) of the different diseases faced by them, that contributed by poliomyelitis (polio) is miniscule. However, the same problem looks quite different when viewed from the perspective of the most of the people of the rich countries. In terms of conventional criteria, they have attained very high level of health status because of high level of growth of their health services {not necessarily a `healthy’ growth, as pointed out, for instance, by Ivan Illich (2)} as a part of the exponential growth of their economy – 20 per cent accounting for 80 per cent of the global consumption. In their well `sanitised’ environments they have been building protective shields against a logical outcome of the highly polarised nature of the world — `invasion’ of communicable diseases from the poor countries. In their frantic, market driven economies, control, if not eradication, of communicable diseases in the poor countries makes eminent sense. Interestingly, the Rotary International has been lobbying for this programme since 1984 (3).
The rich countries have once again used their considerable economic and political power to `influence’ international health agencies to launch `global initiatives’ against polio and other communicable diseases and `persuaded’ the ruling elites of the poor countries to dutifully follow the lines laid down by them. In their case questions of human rights, medical ethics and medical negligence do not come in the picture. Cutting the cost of immunization of their population gets the overriding priority. The most outstanding example among them has been successful eradication of smallpox from the world. The Global programme for eradication of polio was launched with a similar end in view. Apart from determining the ends in their self-interest, the means adopted by them to attain those ends have not been very well conceived. GPPI has received many more setbacks because the complexity of the prorgamme was not adequately understood by its exponents.
Submitting to the pressure of the rich countries, in May 1988, the World Health Assembly (WHA) (4) unanimously resolved to eradicate polio from the world by the year 2000. This involved both halting the incidence of the disease and the worldwide eradication of the virus that causes it – the poliovirus. The rationale for launching the GPPI is that polio is one of only a limited number of cases (the others include measles and guinea worm) that can be eradicated, because (a) it affects humans and there is no animal reservoir; (b) an effective and inexpensive vaccine exists in the form of oral polio vaccine (OPV); (c) immunity is lifelong; and, (d) the virus can survive in the environment only for a short time (5).
The polio eradication strategy is based on the premise that the polio virus will die out if it is deprived of its human host through immunization. A four-pronged approach was adopted to implement this strategy: (i). routine immunization with OPV; (ii) supplementary additional doses of OPV during National Immunization Days (NID); (iii) Mop-up Campaigns; (iv) certification-standard surveillance for all cases of acute flaccid (floppy) paralysis (AFP) and wild poliovirus (5).
From a viewpoint of basic principles of public health, the strategy followed for GPPI is an astonishingly simplistic approach to solving to a highly complex problem. It has overlooked many vital inputs needed for conceptualization, planning, formulation and implementation and evaluation of the polio eradication programme. Six such needed groups of inputs are being briefly mentioned below:
- Even if the enormous and very challenging commitment to worldwide polio eradication by WHO is taken as given, WHO should have presented a reasonably reliable set of data on the prevalence and incidence of the disease and its natural history in individuals as well as in communities on a time scale among billions of people residing in different parts of the world. Determining the dynamics of incidence of a few thousand cases among the billions is much worse than finding a needle in a haystack. The epidemiological data are necessary to lay the foundation for the planning, formulation, implementation and monitoring and evaluation of the programme (6, p.70). Determination of the minimum coverage required in different population groups in different parts of the world for getting the eradication level is a needed input of another set of critical epidemiological data. Apparently, the pressure to undertake the task was so intense, that, even if WHO had the financial and technical wherewithal to undertake such a gigantic venture, it would have been compelled to commit itself to the deeply flawed simplistic rationale and strategy it had adopted on the advice of `experts’ from the rich countries in implementing the eradication programme.
- The global problem of polio is essentially a problem of the ecology of one of the innumerable diseases that afflict mankind. The ecological balance of the problem is in a constant state of flux. There are the bewildering changes in the state of the triad of the human host, the environment and the virus. Little efforts were made to determine the consequences that follow when individuals are infected with the virus under given conditions. One `estimate’ that can give some idea is that in the tropics only one per cent of the infected children in the 0-5 years age-group develop some symptoms of the disease and 0.15 per cent develop severe paralysis (7). Eradication will require that the more than 99 per cent of the asymptomatic infected people, who harbour the virus, will have to be sterilised and prevented from spreading it to other non-infected persons. Human beings have also used their ingenuity by developing mechanisms (for example, potent vaccines) to tilt the balance in their favour. This explains the natural histories of the disease among individuals in different parts of the world – the claim of the polio-free status of most of the rich countries of the world through long periods of very high coverage of polio vaccination and claims of polio-free status of the entire continent of South America (which includes `difficult` countries like Colombia, Bolivia, Ecuador and Guatemala), of China and other countries of the Pacific Rim and of many other countries like Bangladesh, Nepal, Sudan, Democratic Republic of Congo, Chad and Malawi, as a result of a successful drive to provide adequate protection through immunization (7). The assumption here is that WHO is satisfied that, defying the formidable obstacles of local insurgency, maintenance of cold chain and transport and communication, local GPPI staff have been able to reach out to the children in the remotest corners of these inaccessible countries (such as Nepal or Southern Sudan) to protect the required percentage of the eligible children. Beyond all that, such countries are assumed to have a reliable system of identifying cases of Acute Flaccid Paralysis (AFP), mechanisms for collection of their stool samples and their dispatch under a cold chain to WHO approved laboratories for virological tests. Over and above, these countries are to continue with immunization with the same zeal for quite some years before they are declared polio-free. Those familiar with such countries will feel that the claims of these achievements stretch the imagination a bit too far. Given the exceedingly low rates of prevalence and incidence of the disease, the `success’ could as well be due to the natural history of the disease in these countries. It is, however, noted that the experience of countries such as the Netherlands, the United States, Spain, China and Taiwan, demonstrates that, even with high vaccination coverage, there are opportunities for epidemics in unvaccinated segments of the populations(7). There have also been outbreaks of the disease in Haiti (8) and Namibia (9) many years after they were declared polio-free. How, then, can the WHO hope to eradicate the disease from the face of the earth? On the other hand, in the case of India, the exponents of the GPPI have overlooked the epidemiological fact that huge areas, which contain populations equivalent to scores of the polio-free countries of the world, were `polio-free’ long before the polio immunization programme was even thought of.
- A fundamental principle of practice of public health is to obtain an understanding of its `public’ component (10). This is vitally important when that `public’ embraces the entire population of the world. Apparently, WHO, which had identified understanding the `public’ as the cornerstone of the Alma Ata Declaration in 1978 (11), was made to make an about turn soon after by their mentors from the rich countries (which included their very powerful private sectors) and advocate imposition of scientifically flawed, prefabricated, techno-centric programmes on the poor people of the world under the garb of what they called Selective Primary Health Care (12). Ironically, the importance of taking into account social and cultural considerations belatedly dawned on them when the GPPI encountered serious obstacles in implementation from some Muslim groups in many parts of the world (13). This led to spread of the disease in many of the neighbouring countries which earlier were declared polio-free by WHO. They became suspicious when, for the first time, health workers for polio vaccination made house to house visits. So low was their trust in the state and in international agencies that they feared that the drops were meant to sterilise them and give them AIDS. `Why are they coming to our homes only for this disease, when they did not care for other more important ones?’, they seemed to argue (14). Apparently, the ongoing clash of cultures and the polarisation between the rich and the poor has some correlation with this phenomenon. This did not show on the radar screen of the experts who were employed by WHO to draw up the design of the GPPI. When the problem emerged in the open, they made frantic efforts to mobilise their considerable power and influence over the concerned governments to take steps to alley the fears of these people (15).
- Implementation of the GPPI was preceded by intense lobbying for the choice of the vaccine – oral (OPV) or injectable (IPV) – before the choice went for the OPV. There are, however, important unanswered questions regarding the number of rounds of immunization required and the degree of its efficacy and the frequency of its side effects under different epidemiological situations in different parts of the world. Jacob John (14), for instance, had seriously questioned the approach followed by WHO on the basis of field trials of OPV he had carried out in Vellore in South India. He has been expressing serious reservations about the approach adopted for GPPI from the very beginning. WHO appears to have tried to circumvent these questions by adopting the strategy of a sledge hammer approach by following the vague `premise that polio virus will die out if it is deprived of its human host through immunization’ (5), by launching a number of rounds for giving doses of the vaccine to children. Children in many populations have already received as many as 28 doses of OPV.
5. Developing an appropriate organizational structure and using management processes (which include management information and evaluation system– MIES) to carry out what WHO has termed as the largest public health programme of the world, has been a major concern. There were two types of infirmities in developing the organisatioal structure for GPPI. One concerns the factors that are inherent due to flaws in the epidemiological, social science and technological factors that have been discussed in the foregoing and inadequate efforts to optimize the system of GPPI (16), being presented under 6, below. The other was the enormous task of setting up an operational system that will ensure that the immunization will be comprehensive enough to ensure that the polio virus will die out when it is deprived of the human host.
6. For a programme of such a magnitude, involving so much of cost and organisational effort, it was all the more essential that the system ought to have been optimized with the use of the technique of operational research (OR) (16) before rushing to implement it on a global scale. For reasons that need not be gone into here, WHO has repeatedly failed to use OR in optimizing systems when it had started its numerous `global initiatives’ (17). Even some of the top economists of the world, who constituted the WHO Commission on Macroeconomics and Health (18), have not properly understood the significance of optimising the system through the use of OR. They have used the terms OR very loosely and improperly (19). The accepted method of OR is highly complex, often requiring research on a very large scale. In the context of the GPPI, it involves (i) definition of the complex problem of polio as a public health problem in all its interdisciplinary dimensions; (ii) collecting relevant data required for problem solution; (iii) identifying possible alternative solutions for problem solving; (iv) identifying the solution(s) which promise to give the maximum returns from the resources; with or without use of mathematical models, (v) conducting test runs to check the validity of the choice through built-in feedback data system and further rectifying the chosen alternative, if required; and, (vi) implementing the chosen solution, with a constant feedback system of data through MIES (16). .
The brief recounting of some of the key issues for implementing GPPI not only gives a staggering example of how a syndicate of decision makers from the rich countries can force all the poor countries of the world to give primacy to a health problem which is not only miniscule when compared with the others, but also the degree to which some of the basic principles of a scientific approach to so complex a public health problem got almost grotesquely distorted because of gross shortcomings in the formulation and implementation of the GPPI. It is a symptom of the grave malady that is afflicting the contemporary academic field of international health (20). Failure to attend to far more important health problems, which affect billions of the marginalised people of the world, while pouring so much of resources in GPPI raises profound ethical questions and questions of human rights. Vicente Navarro (21) has rightly termed this trend as `intellectual fascism’. The recklessness and the indifference shown by the international organizations like WHO, UNICEF and the World Bank almost resembles a case of pampered kids playing `doctor doctor’, jeopardising the health of millions of the marginalised. It is not surprising that this class of `scientists’ should have gathered around them a large crowed of loyal fellow travelers from the poor countries, who have very limited background in public health and health administration and who are prepared to vouch for the scientific and operational soundness of GPPI (22).
Under such conditions it becomes also inevitable that the programme administrators make massive use of tools of high pressure salesmanship to cover up the distortions in GPPI by spreading disinformation, misinformation and suppressing information about the programme (23). To push the programme in the poor countries of the world some of top scientists, who have been associated with the formulation and implementation of GPPI, have not hesitated to make vital compromises not only with basic requirements for adopting a scientific approach, but also with the mandate of resolution of the World Health Assembly on GPPI (4). All these had tended to abort scientific discourse on so important a public health programme as GPPI. Even well articulated scientific data that contradict certain postulates of GPPI are shunned. This is a matter of grave concern to the scientific community of the world as a whole.
For instance, the WHA resolution specifically emphasises the strengthening EPI and primary health care through polio eradication activities. Plans for eradication implicitly calls for a well developed strategy that emphasizes both general health services objectives as well as special vertical efforts (7). There is little evidence of adhering to these admonitions in the WHA resolution on GPPI implementation in most of the poor countries of the world. On the contrary, mobilisation of enormous resources for implementing GPPI as `by far the largest public health programme ever undertaken’ in a vertical mode, and its repeated failures in achieving its objectives, has had a devastating impact on the primary health care services, particularly in the very countries where they are very weak and their need is most acute..
Thus, whatever has been done in implementing the ill-advised WHA resolution on a miniscule public health problem, which includes the widely publicised success stories from Latin America, ought to be considered as a severe indictment of the public health competence of those who have directed its implementation over the years. It is a glaring instance of exercising authority without taking the responsibility.
Even a journal of stature of The Lancet is unable to recognize the fundamental flaws in the conceptualization and the design of the GPPI. In a recent Editorial (Jan. 10, 2004), it fears that despite its high profile and longevity of 15 years and a staggering cost of $3billion (with an additional 2 billion US$ in kind), the campaign to eradicate polio still faces considerable obstacles (24). It goes on to join the powerful GPPI backers to further pressurize the Ministers of Health of the five lagging countries in the Jan. 15 2004 `summit’ meeting at Geneva to increase the `political will’, increase financial support, supply high quality vaccine, improve and maintain population immunity and public information. Terms such as `political will’ or `social mobilisation’ is profoundly derogatory to the people. Political will – for what? To betray the people by giving them false information? Again, social mobilisation for what? To motivationally manipulate the people to force a pre-determined agenda on them?
Citing numerous infirmities in GPPI, such as limitations of the OPV, coverage and exclusion of those above five years and epidemiological data from the investigation of the big epidemic in Uttar Pradesh in India in 1999 by the Center for Disease Control, Atlanta, USA, N S Deodhar , one of the eminent scholars of public health in India, in a public lecture on GPPI (25) categorically concludes that it is a multi-faceted `cost disaster’, it is epidemiologically unsound that and it cannot eradicate the disease.
INDIA AND GLOBAL POLIO ERADICATION
When the World Health Assembly unanimously passed the resolution on global eradication of poliomyelitis in 1988, it is very unlikely that the rich countries had to exert much pressure on the political representative of the government of India, as indeed on those of any other poor countries, including China, for getting the unanimous support. Indeed, the `representatives’ of the poor countries were equally enthusiastic about joining the rich ones, significantly, along with organisations of private sectors like the Rotary International and many individual corporations associated with it, in what they considered to be the crusade for the extermination, once for all, of the scourge which has been killing or condemning `so many’ children in different parts of the world to live a life of a cripple. The advisors of the Indian delegation, both top generalist bureaucrats as well as public health experts from the Union Ministry of Health and Family Welfare, perhaps also shared similar sentiments. The government of India seemed to be eager to demonstrate to the rich countries their `political will’ to sell the programme to the people of the country without caring to examine its relevance to their health problems and health services. It had also made valiant efforts to use opinion leaders to educate and mobilise those among the marginalised who became suspicious about the motives of the programme due to reasons which may look so childish and unfounded (23).
At that momentous hour, the Indian delegation `forgot’ (a) the glaring fact that poliomyelitis forms a miniscule component of the phalanx of staggering health problems facing the marginalised people of the country; (b) that had they had the very recent memories of the disastrous failure to achieve the stated objectives of the much trumpeted Universal Immunization Programme (UIP) (26), (27) – it ought to have `reminded’ them that they were once again committing the country to undertake a gigantic task without adequate scrutiny and which will be extremely difficult to perform ; and (c) that it would be so expensive (even as in kind contribution) that it would siphon off a substantial part of the pitifully meagre health resources that are available to the marginalised. Such `forgetfulness’ is built into the social and economic (or class) structure of the population of the country. Milan Kundera has aptly observed that “man’s struggle against oppression is a struggle between memory and forgetfulness”.
According to the Constitution of India, health is a state subject. However, the political, bureaucratic and public health leaderships in the state governments, including the ones ruled by Marxists, too did not care to scrutinise the programme and its far reaching operational implications while accepting the WHA resolution and meekly submitted to the line laid down by the Union government. The dominant theme in the acceptance of resolution, which had such far reaching implications for the health services of the states and the country, as was the case with UIP and other vertical programmes, was that of trust and confidence in the technical and operational soundness of the GPPI as recommended by WHO. As mentioned earlier, this aspect of the increasingly one-sided relationship on certain developments in health services between the rich and the poor countries represents a fundamental shift in the practice of international health (20). The increasing importance of the somewhat demeaning `donor-recipient’ relationship is a pointed example of this trend. This contrasts sharply, for example, with the intensive debate that culminated in the Declaration on Primary Health Care at Alma Ata in 1978 (11).
It is significant that the WHA resolution was passed when WHO and its backers were in the midst of a massive drive to implement the UIP to ensure a worldwide coverage of a minimum of 85 per cent of the infants of the 13-24m age-group against the six diseases included in it, during 1985-90, so that these diseases ceased to be public health problems (27). Poliomyelitis was a part of the six diseases. Why was this disease not allowed to be controlled/eradicated as a part of UIP implementation? This was presumably because of the intense pressure from the private sector spearheaded by those forming the Rotary International (3) and WHO’s strong advocacy for `Public Private Partnership’ (28).
Interestingly, if one follows the guidelines laid down for GPPI, by claiming to have attained very high coverage of 90.1 to 95.9 per cent during 1990-1999 in implementing the UIP (29, p.250), India ought to have already attained the goal of eradicating polio from the country and implementation of GPPI was redundant. However, the country could not demonstrate that it had indeed achieved that stage of `eradication’, because UIP was launched without even having the baseline epidemiological data on the six diseases. Some feeble attempts were made after the launch of UIP to measure the prevalence of polio by conducting some patchy and statistically suspect `lameness’ surveys (7). There has also been the looming question of reliability of the data concerning coverage and whether OPV had remained viable when it was administered to the children. The two National Family Health Surveys has shown that the record of the government in implementing the UIP has not been very good (30, p195).
WHO employed mathematical modelers who, because of their inadequate understanding of some key issues involved in GPPI formulation, used highly suspect epidemiological and operational data and fed them into equally suspect mathematical models to produce the now ubiquitous `WHO estimates’ which were doctored to support WHO’s preconceived contentions about such areas as the extent and the cost of the disease. This might also explain why WHO hired so many mathematical modelers, economists, clinical pediatricians and plain non-medical bureaucrats in the conceptualisation, formulation and implementation of the GPPI. A very disturbing example of such disinformation is the claim by the chief of the GPPI in India’s largest circulating English newsmagazine that `Treating India’s polio affected costs Rs 3000 crore (Rs 30 billions)’. In working up the crusading zeal for GPPI, he seems to have forgotten the annual budget of the ministries of health in the country. It is not that WHO ought not to use such specialists; but they ought to be parts of balanced, interdisciplinary teams. To respond to the interests of the rich people, WHO constructed an entirely new set of idioms of principles and practice of public health? This manifested the awesome power of the rich to mobilise international organizations to manipulate knowledge to their advantage.
It is ironical that a country, containing over a fourth of the marginalized people of the world, with bewilderingly varying ecological and socio-cultural and economic conditions prevailing different parts, along with widely different health problems and health services, was once again made to follow the intrinsically defective line of action on GPPI. Each installment of imposition of such `international initiatives’ by them had caused a virtual upheaval in the budding and manifestly rudimentary health service system of the country. This put the clock back by several years. The marginalised had to bear the brunt of such reckless adventures. Perhaps the most unfortunate aspect of the entire process was that those responsible for taking decisions at different levels – political, bureaucratic and technical – neither had the capacity, nor the `will’ to call into question the serious distortions that had taken place in the principles and practice of public health at international levels. A very brief attempt will be made below to locate the polio problem as one of the myriad child health problems and the GPPI as a component of the health service system of the country.
STATE OF THE HEALTH SERVICES IN INDIA
Despite some remarkable positive changes that have taken place over the years, the conditions still remain very disconcerting. The Sample Registration Scheme (SRS) of the Registrar-General of India indicates that the infant mortality rate in the country fell from 129 in 1971 to 80 in 1991, and it was recorded as 70 in 1999 (29, p.39), .. The SRS also shows that even in 1998, the mortality rate among children in the 0-4 age group still remained 24.8 per 1000 (29, p.45). In the report on Causes of Death, as recorded in the Model Registration Scheme of the Registrar-General, under the head, `diseases that are peculiar to infancy’, shows that 45 per cent of these infants died of `pre-maturity’; 18.5 per cent died of `respiratory infection of the new born’; 4.7per cent died of congenital malformation; 4.3 per cent died of diarrhoea of the newborn’; 3.8 per cent died of `birth injuries’; 2.4 per cent due to `cord infection, including tetanus’ and 24.3 per cent were labeled as `non-classifiable’ (29, p.230). Poliomyelitis as a public health problem in India has to be seen against this background.
The Family Health Survey of 1998 (FHS-II) has revealed that, despite significant falls in the mortality rates, as many as 2.5 millions under 5-years olds died in the country in that year (31). This falls well short of the notional goals of the country for the year 2000 of reducing the under 5 years of age mortality to less than100 per 1000 live births; infant mortality to less than 60 per 1000 live births; and neonatal mortality to 85 per 1000 live births. The goals are called notional because they were not arrived at on the bases of careful projections of the key factors which determined the rates. The rates have changed only marginally since then. It was also revealed that, taking the country as a whole, 18.4 per cent children suffered from severe and 29.4 per cent suffered from moderate malnutrition, making a very disturbing total of 47.8 per cent (32) As much as 74.2 per cent of the children in India suffered from anaemia; the figure for the mothers is 51.8 per cent (32 ). A review of published literature to examine the evidence for a relation between malnutrition and child mortality from diarrhoea, acute respiratory illness, malaria and measles, showed that these conditions account for 50 per cent of child deaths worldwide (33). much as 74.2 per cent of the children in India suffered from anaemia; the figure for the mothers is 51.8 per cent (32).
In a recent article (34), Jean Dreze has drawn attention to the NFHS-II finding that at the time of the survey, 30 per cent of all the children under the age of 3 years had fever, another 29 per cent had diarrhoea and another 30 per cent had symptoms of acute respiratory infection. He goes on to observe that even after allowing some overlap between some groups, it suggests that at least half of all Indian children below three suffer from one of these conditions at a point of time.
Data produced by the World Bank itself (35) have revealed that poliomyelitis does not contribute substantially to the global burden of disease and its eradication will not substantially affect child mortality rates. The NFHS-I 1992-93, showed that that only 36.5 per cent of the children were fully immunized; 30.0 per cent received no immunization at all. The coverage for full immunization in the NFHS-II was 42 per cent (30, p.195). A report on disabled persons in the 47th Round of the National Sample Survey in 1991 (29, p.94) revealed that `locomotor disability’ forms around 55 per cent of the total disability in the country (about 9m out of 16m) and even if we make a most exaggerated `estimate’ of polio disability, it accounts for a miniscule proportion of the locomotor disability in the country. That GPPI, which has no scientific legs to stand on any count, could be imposed on all the countries of the world, despite the catastrophic failure of the UIP, is an awesome signal to those who are committed to work for equality and equity in health in different countries of the world. .
The upheaval caused due to the implementation of GPPI and other such vertical programmes in India has had a devastating impact on the already moribund health service system of the country. The Independent Commission on Health in India (ICHI) (36) of the Voluntary Health Association of India found the situation so alarming that it visited the then newly elected prime Minister of India in May 1998 to acquaint him with its findings. In the covering letter addressed to him, it described the health services of the country in an advanced stage of decay. The Prime Minister promised urgent action on the suggestions made by the ICHI. It has remained an empty promise and the decay has deepened still further. Giving a more detailed picture of the health services at the grassroots level, Jean Dreze (34) gives what he describes as `a chilling picture’ of the state of health centres around the country by referring to the recent health facility surveys carried out by the International Institute for Population Sciences, Mumbai (IIPS). He points out that `there are no public health facilities worth the name, except female sterilisation and polio immunisation’. Other findings of the survey show that 69 per cent of the primary health centres (PHC) have at least one bed; 20 per cent have a telephone and 12 per cent enjoy “regular maintenance”. These are national averages. In Bihar, for instance, a large majority of the PHCs make do without the luxuries of electricity, a weighing machine or even a toilet.
The Tenth Five Year Plan (30) too echoes the findings of the facility survey of the IIPS. For more than 25 years there has been a plan to have 25-bedded hospitals for every 100,000 of the rural population, now called Community Health Centres (CHC), to extend referral facilities to PHCs. A recent study of CHCs by the Plan Evaluation Organisation of the Planning Commission (37) draws a frightful picture of the working of the system. It was conducted in 31 CHCs in 16 districts located in 8 states. Eleven CHCs have not attended any referral case, while 18 have been working sub-optimally. As against the required strength of five specialists in each CHCs, more than 70 per cent of them were running either with one or no specialists at all. Indeed, even a not very deep analysis of the state of health services system in the Ninth Five Year Plan (1997-2002) (38) does not present a flattering picture of the state of affairs in this field. It points out :`( i ) Persistent gaps in manpower and infrastructure, especially at the primary health care level; (ii) Sub-optimal functioning of the infrastructure; poor referral services; (iii) Plethora of hospitals not having appropriate manpower, diagnostic and therapeutic services and drugs; (iv) Massive inter-state/inter-district differences in performance as assessed by health and demographic indices; availability and utilisation of services are poorest in the most needy states/districts; (v) Sub-optimal intersectoral coordination'(p.171). How could any well meaning international organization and their Indian counterparts ever think on embarking on the patently unimaginative GPPI under such conditions?
A survey of utilization of the health services in India by the National Sample Survey Organization (39) and another by the National Council for Applied Economic Research (NCAER) (40), both in 1992, revealed that people belonging to marginalised sections of the population have enormous difficulties in gaining access to health services when they fall ill. It was pointed in the NCAER study that for the most deprived group, expenditure incurred by them to meet the cost of serious illnesses is the second most important cause of rural indebtedness, next only to dowry payment. Delving on this issue, Dreze (34) goes on to state that even when health services are available, their utilization leaves much to be desired. He quotes a forthcoming Harvard study to say that the absence rate among health workers range between 35 and 58 per cent in different Indian States. It is not adequately understood that, along with the some basic changes that are taking place in the polity and economy of the country, the phenomenal growth of the medical care services in the private sector being a part of it, there have also been changes in the making of a physician and thus in the entire medical profession of the country. The class character of the physicians has tended to turn the Hippocratic Oath into a `hypocritic oath’ for most of them. As a consequence, local residents suffer from what Dreze calls horrendous levels of morbidity.
THE STATE OF ENVIRONMENTAL SANITATION AND HUMAN ECOLOGY
With 260 to 300 million people living below the poverty line, one can readily imagine the state of sanitation in most parts of the country. The Tenth Five Year Plan document, quoting the 54th Round of the National Sample Survey carried out in July 1999, paints a grim picture (30, pp.601-57). Fifty per cent of rural households were served by tubewells/handpumps; 25 per cent from wells; and 19 per cent by from taps. Only 31 per cent had their source of water within their premises. Households still had to depend on supplementary sources, especially during the summer months. Apart from the very limited quantity, drinking water was often contaminated with fecal material. Practices of filtering or boiling water before drinking were almost non-existent (30, p.601). The NSS findings show that there has been little progress in sanitation standards as determined by availability of adequate quantity of safe drinking water and its safe handling, safe disposal of human excreta, including child excreta, management of solid waste and waste water, domestic sanitation and food hygiene, personal hygiene and control of village sanitation, including control of disease carrying vectors. Only 17.5 per cent of were using latrines; even these latrines were mostly not properly maintained and they breed flies; scarcity of water is one major reason for that (30, pp.607-08).
For urban areas, the NSS showed that 69 per cent were sharing a public source of drinking water; 15 per cent did not get sufficient drinking water during the months of April and June. The quality of water supplied was not always dependable. As many as 43 per cent of the households have either no latrines or connection to septic tanks or the sewerage system. Estimate of excreta disposal facility vary from 48 to 70 per cent. The Planning Commission states that out of the 300 Class I cities (with populations of 100,000 or more), about 70 percent have at least partial sewerage facilities. The levels of sewage treatment are stated to be `low’. The Plan document refers to a study of the Central Pollution Board in 1994-95 which found that the total waste water generated in the 300 Class-I cities was 15,000 million litres a day (mld), while the treatment capacity was hardly 3,750 mld. The fate of the smaller cities can well be imagined. The Planning Commission mentions that `Water borne diseases are major cause mortality and they impose a huge burden in terms of loss of lives and productivity. In the NSS, 90 per cent households were concerned about mosquito menace, 66 per cent regarding flies and 50 per cent regarding foul odour (30, pp.648-9).
In terms of human ecology, the overwhelming fact is that the population of the country has shot up from 361million in the 1951 Census to a figure of over a billion in 2001 (29, p.5). This major problem has not received due attention. What has been the process of absorption of an additional 640 million people within an already poverty-stricken, over-populated country during the last 50 years? It would have needed enormous efforts just to maintain the basic conditions in terms of housing, water supply, food, excreta disposal, sanitation, education, democratic polity, etc. of the 1951 levels, in 2004. Malthus’s grim predictions of outbreaks of massive epidemics and wars did not come true, even when the population increased by about three times. On the contrary, there have been significant improvements in terms such vital areas as people’s participation in governance, fall in the infant mortality rate, increase in life expectancy, rise in literacy and development of an extensive network of public health service system, despite its repeated disruption because of imposition of many vertical programmes by international agencies (29, pp.65-82). The situation has thus to be seen against a proper perspective. For instance, at the time when India gained independence from the colonial rule in 1947, 20 mothers had to lose their lives in giving birth to every 1000 children; of these children born at such a high cost, half of them died due to various diseases by the time they reached ten years of age (41. pp.20-21).
Considering the ecology of the polio virus, ecology of the vaccine and wild polio viruses under different conditions in different parts of the country ought to have been taken into account in understanding the ecology of polio in the country – a pre-requisite for chalking out a strategy for eradication of the disease. Ecology of the two groups of the virus should have included determination of the minimum immunization coverage required to break the transmission of the virus and to eradicate it finally. Such studies were not undertaken before finalizing the GPPI.
ACCOUNTABILTY OF THE DECISION MAKERS
Apparently, as they were in great hurry to eradicate the disease, the decision-makers from the rich countries and their counterparts from India did not have the patience to pay due attention to the state of the health service system and the bewildering environmental and ecological conditions in different parts of the vast country. Instead, these children of European Enlightenment and their camp followers from the poor countries took the easier route of adopting a `sledge hammer’ approach and flood `most’ of the children of the world in the 0-5 age group with OPV. Even this `flooding’ approach raised the key questions of minimum coverage required and leaving uncovered the 10 per cent or more of the polio virus carrying population who are above five years of age. Turning a blind eye to such serious infirmities in the programme, they unleashed a massive barrage of publicity (23) to sell such an ill-conceived decision. In a normal scientific discourse, it is unthinkable that such decisions, which affect literally life and death issues of many billions of people of the world, could have been taken so nonchalantly, without taking into account all the scientific issues involved in the process. This reflects the value system that governs the leadership of the rich countries. It is virtually impossible to think that the top scientists working with the decision makers were not aware of the ground situation before lending their considerable weight in favour of GPPI. Probably, they adopted such a cavalier approach because they enjoyed a blanket immunity bestowed on them by higher authorities, as had happened so often in the past. Incidentally, institutions such as the Indian Academy of Pediatrics ought also to be held accountable for indulging in such public health malpractice.
As referred to earlier (21), Vicente Navarro of the Johns Hopkins University School of Public Health had expressed a similar feeling of helplessness during the McCarthy era in the US of the 1960s, when making class-based analyses of the mortality and morbidity data was `forbidden’ in that country. Navarro has aptly described this phenomenon as `Intellectual Fascism’. Notwithstanding the blanket cover of immunity from accountability to the marginalized people bestowed on them by the power elites of the higher echelons, the actions of these scientists will go down as a major blot in the history of public health. .
IMPLEMENTING GPPI IN INDIA
The foregoing analyses of GPPI, both at the international and national levels. support Deodhar’s labeling it as epidemiologically unsound and a multi-faceted cost-disaster (25). It is a grossly ill-conceived programme. It should never have been attempted. It has diverted attention from some of the most pressing problems of child mortality and morbidity among the poor of the world. It has turned out to be highly expensive. It presents almost insurmountable problems of implementation. It also underlines the incompatibility of interests between public and private sectors. It might be noted that the resources used for GPPI during the past 15 years could have saved deaths and morbidity due to other conditions by several hundred times. It is conceivable that this alternate approach could, unwittingly have led to eradication of polio due to combined effect of trends in natural history and through polio immunization given as a part of `routine immunization’ from rejuvenated public health services.
Even when GPPI is taken as given, a combination of a very poor level of public health leadership, the dilapidated state of the health services infrastructure and the highly unfavourable conditions of environmental sanitation and the ecological setting, both for the human host as well as for the virus, presented formidable problems for its implementation for the country to eradicate the disease. This is in sharp contrast with the efforts made by health administrators of this country in implementing its National Malaria Eradication Prgramme (NMEP) in 1956-64 (6, pp.95-106). Among other activities, NMEP implementation involved the stupendous task of visiting more than 56 million houses twice monthly, year after year, to detect fever cases, to provide presumptive treatment and obtaining blood slides from them and, after examination of the slides, offer radical treatment to those found positive. Over and above, during the attack phase of NMEP, each one of the 56 million houses was sprayed with DDT twice a year. Implementation of NMEP on such a gigantic scale brought down the incidence of malaria in the country from 70 million to mere 60,000 – a reduction of 99.9 per cent in the incidence. The experts who were brought to India by WHO to oversee the organization for implementation GPPI were perhaps not even familiar with the saga of NMEP in the country – another instance of intellectual arrogance and ignorance.
For the last three decades, senior health administrators belonging to the new generation also seem to have lost such capabilities in programme implementation shown by their predecessors during the first two decades after Independence. This trend got accentuated when mass programmes started to be administered by the department of family welfare which is headed by a bureaucrat, and not by the directorate-general of health services, as was the case with NMEP. Health administrators were assigned subordinate roles in that department. The limitations of the bureaucrats were already exposed when they took the leadership of implementing the UIP during 1985-1990. The National Family Health Survey of 1998 revealed that, in India as a whole, only 42% (as against 36.4% in NFHS-I) of the children were fully covered by vaccination in the UIP. Expectedly, the corresponding figures for Rajasthan, Assam, Bihar, UP, and Madhya Pradesh were, 16, 16.7, 20.2, 21.2 and 37.3. The percentages were in the seventies even in the better performing States – Kerala, Tamil Nadu, Maharashtra and Punjab, where, in any case, the child mortality and morbidity rates are low (30, p.195)..
When it came to implementing the GPPI (again under the department of family welfare), the limitations of the bureaucrats as policy makers and programme planners and executors became even more pronounced. Worse still, probably because of their lack of public health competence (42), they had to meekly give in to advice from motley of self-styled expert consultants from different countries, many of whom had never handled such complex issues of programme administration. With the leadership of the country committing to offering the `political will’ to go ahead with the GPPI, as a quid pro quo for receiving `donations’, foreign consultants were given increasingly greater say in running the programme. There seemed to be a common bond of interest among the political leaders, the bureaucrats, the health administrators and the `donors’ in glorifying and in perpetuating mediocrity in implementing GPPI. When the programme suffered the expected repeated setbacks and the government had to approach the donors from foreign countries for more funds, the latter became even more demanding in getting active role in seeing that it ran on the lines laid down by them.
There were two fundamental factors that affected the launching of mass campaigns during the last two decades. Firstly, as has been repeatedly shown earlier, for reasons (43), (6, pp.38-52) that need not be gone into here, the health services have reached such an advanced stage of decay that it was impossible to build a massive programme like GPPI, using the health services as a base. This created very serious problems for programme implementation. Administrators of GPPI had to search for other organizational structures to `take over’ for GPPI, such as the Angnawadi Workers (IW) of the already not well functioning Integrated Child Development System (ICDS) (30, p.342) and nebulous groups like NGOs and `volunteers’. This is a fatal flaw in the implanting GPPI in the country. Compared to the highly motivated and disciplined and well supervised malaria workers, these make-shift groups present a sharp contrast. Secondly, forgetting the earlier tradition of carrying out house to house health campaigns, fixed booths or posts were used in conducting mass campaigns. It started with UIP and the consequences, as have been noted earlier, were disastrous, including doctoring of data to please the superiors and the `donors’. This approach was also adopted for GPPI. However, it took some time to come to the obvious conclusion to sink in that house to house approach have to be added to that of using fixed booths. However, how can house to house immunization be done without a correct census of the `target’ population and reliable record of the coverage?
Not surprisingly, there has been a great deal of confusion in the way India went about implementing GPPI. Unlike the seasoned and well trained health administrators of NMEP, bureaucrats, who headed the department of family welfare, had no clue about running the GPPI in a country as vast and as varied as India. Health administers, who were assigned to implement the agenda that was handed over to them by WHO and the `donors’ who backed it, too lacked the competence in running the programme. Implementation of the GPPI thus started under even more inauspicious circumstances than the deservedly doomed UIP.
At first, it was claimed, rather tamely, that India had already a record of over 90 per cent coverage of OPV among 13-24 m old children during 1985-1999 under the UIP (29, p.250), (43). However, this time the data produced by the authorities were not taken at their face value by the `donors’. Apparently admitting doctoring of the UIP data, to attain the eradication goal by 2000, the authorities launched a mass campaign (also called Pulse-Polio Immunization – PPI) to immunize 75 million children below three years of age on December 3, 1995 and January 26, 1996. This was repeated yearly for two years. Despite apprehensions of the health administrators about having the logistical capacity of the system, the target group was increased at the instance of the `donors’ to `estimated’ populations of 150-160 by expanding it to increase the coverage to include the children up to 5-year age group (44). When this also did not seem to work, as yet another effort to give a boost to the campaign, during 1999-2000, the rounds of annual PPI was raised to 4 nationwide, with a further additional two rounds in four high risk States. This too was found to be inadequate for GPPI. Significantly, it was only in October 1997 – two years after the launch of the PPI, that the government of India set up the National Polio Surveillance Project (NPSP) in collaboration with WHO (44).
Thus far, the story has been that of missed targets and desperate bids to save the global programme by pouring, increasingly reluctantly, ever more resources, both from the `donors’ as well as from mobilizing the resources from the pitifully meagre internal resources, both in kind (about 30% of the cost) as well as a World Bank loan of US$210 million. The first target missed was in 2000. It was followed by missing the `zero goal’ for 2002. The extended goal of 2003 was also missed. Data are already available that show that `the Final Push’ for making the country polio-free from 2004 onwards has also failed (45). That between 1994 and 2003, as many as 26 National Immunization Days (NID) and 7 Special National Immunization Days (SNID) were observed, gives an idea of the efforts made to eradicate the virus from India. Special attention was also paid to the more vulnerable States. For instance, the States of Uttar Pradesh, Bihar, West Bengal and Delhi received 4 each of annual rounds, additional rounds and mop-up rounds. Western Uttar Pradesh was singled out for even more intensive vaccination by having as many as 21 rounds in 2001, each lasting 5-7 days (44), (14), (45),(46),(47). .
The number of confirmed cases recorded by the NPSP was 1918 for 1998; 1126 for 1999; 265 for 2000; 268 for 2001; 1600 for 2002; 223 for 2003. The more alarming features of the 2003 data were outbreaks of the disease in States of Karnataka and Andhra Pradesh, which had been polio-free for many years. It was found that as many as 40 per cent of the posts of AWs were lying vacant in the affected regions of Karnataka at that time (48). These followed the trend seen in Haiti and in Namibia, where there had been reports of outbreaks long after they were declared polio-free. The fear is that in these countries, the live attenuated vaccine virus might have become virulent through mutation. In 2003, 88 cases were reported from Uttar Pradesh; 36 from Karnataka; 28 from West Bengal; 21 from Andhra Pradesh; and 17 were from Bihar (48).
That 2003 recorded as many as 268 additional `polio compatible’ cases indicates the limitations of the Surveillance System (44). In addition, there was the `Vaccine Associated Polio Paralysis’ (VAPP) at a frequency of one per one to one and a half million vaccinations (44), (25). Then, there is what is called Provocative Poliomyelitis, which occurs when intramuscular injections are given to persons who have the virus circulating in the blood. A large number of such cases were observed during the renewed outbreak of the disease in Uttar Pradesh. A case-control study, conducted by the Center for Disease Control of US to investigate the 1,126 cases detected in UP in 1999, revealed that as many as 89 per cent of these cases had received three or more doses of immunization – the same as for the matched control group (25). While the mean age of paralysis was 16 to 18 months, children of up to 14 years of age were involved, indicating that there is weaning of immunity and that older children became susceptible to the disease.
Imposition of `political will’ on the marginalized people of the world is presented in the form of a hierarchy of `wills’, with the hapless marginalized people finding themselves at the: very bottom:
- The leadership of the rich countries, with support of their private sectors, imposing its Political Will on the leadership of the poor countries of the world, to save annually a billion or more US dollars and the rare complications (VAPP) arising out of polio immunization of the children there.
- The leadership of the poor countries, demonstrating their Political Will to their counterparts from the rich countries, by instructing the heads of the concerned government machineries, including those of India, to conform to the agenda drawn up by the rich countries.
- Bureaucrats in Union government instructing the health administrators to follow the line laid down implementing GPPI.
- Health administrators draw up the plan for action and pass it down the hierarchy of the Union government.
- The leaderships of the State governments demonstrating their Political Will by instructing its heads of concerned machineries of its government to follow the instructions given by the Union government.
- Health administrators of the State governments pass on the instructions down the line of the hierarchy, ending at the levels of the AWs, NGOs, and `volunteers’.
- At the receiving end, the marginalized people were `motivated’ to get their children of 0-5 age group vaccinated with OPV. Halfdan Mahler, the then Director-General of WHO, had aptly termed it as `motivational manipulation’ of the people (49).
Considering their `un-enlightened self-interest’ in reaping the harvest of savings in the polio immunization expenditure following the eradication, almost all the countries, some of the units of their private sectors and international funding agencies such as, the Rotary International and its various national chapters and the Bill and Melinda Gates Foundation and UN Foundation, have generously come forward with funds to make the GPPI a success (50). However, the `donors’ seem to be losing patience with the lagging countries like India, which has repeatedly failed to attain the eradication goals set for it. For instance, apart from meeting around 30 per cent of the cost in kind and giving top priority to GPPI over all other programmes of the country, India had to seek a World Bank loan for US$210 million to fund its programme. As has been discussed at length in the foregoing, the country still faces some formidable hurdles before it gets the certificate of polio eradication. Even with the best case scenario of success in India, global eradication still awaits successes in countries with large populations like Pakistan, Nigeria and Afghanistan (24). Besides, as has been mentioned earlier, there are lurking fears of reappearance of the disease, even after the certification of its eradication.
Among its other responsibilities enjoined by its Constitution, WHO is regarded as the top most technical body for drawing attention of the World Health Assembly to global issues in public health and in carrying out the mandate given to it by the latter. Its role in formulating and supervising global programmes like UIP and GPPI needs a scrutiny. It would serve a public purpose if a scientific audit is carried out to examine accountability of WHO to the WHA and to the people of the world.
It is unfortunate that in their crusading zeal to “win the battle against poliomyelitis” or the “war between the virus and the vaccine”, the key players in the GPPI managed to forget the other admonition in the WHA resolution, namely, to consider the eradication programme side by side with a healthy growth of the primary health care services, as envisaged in its earlier resolution of 1977 (51). Now that the vertical approach to health programmes stand discredited, both in terms of cost-effectiveness, acceptability, applicability and sustainability, it would be more chastening to them to consider such programmes as an integral component of the community general health services; such programmes should `sink or sail with the general health services’ (52).
If the general health services are weak, the best way for disease control/eradication will be to find ways to strengthen them. It may be noted that immunization was one of the main activities when India first set up Primary Health Centres (PHC) in 1952 to offer integrated preventive, promotive curative and rehabilitative services to rural populations (53). Due to reasons that will be mentioned later, this programme failed in its purpose because the PHCs were severely neglected by the concerned authorities. Had the PHCs been strengthened and covered the entire country, there would have been no reasons for the country to control/eradicate most of the communicable diseases in the country, as is the case in the rich countries. Cuba provides a good example.
RESPONSE OF THE RICH TO THE ALMA ATA DECLARATION
As has been discussed elsewhere, the WHA resolution on Primary Health Care in 1977 (51) and the Alma Ata Declaration of 1978 (11) mark a watershed in the practice of public health. The concept of primary health care turned `up-side down’, the practice of public health. The prime consideration was given to the people, rather than to `mobilising’ them by motivationally manipulates people to accept prepackaged, techno-centric programmes that are
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