WEBVTT 00:00:00.000 --> 00:00:03.353 align:middle line:90% [MUSIC PLAYING] 00:00:03.353 --> 00:00:07.633 align:middle line:90% 00:00:07.633 --> 00:00:09.800 align:middle line:84% SVEA CLOSSER: The last 1% of the world's communities 00:00:09.800 --> 00:00:13.350 align:middle line:84% affected by polio are socially, politically, 00:00:13.350 --> 00:00:15.860 align:middle line:84% and often economically marginalized. 00:00:15.860 --> 00:00:18.710 align:middle line:84% They may experience conflict and vibration, 00:00:18.710 --> 00:00:20.810 align:middle line:84% environmental hazards such as poor transport 00:00:20.810 --> 00:00:24.320 align:middle line:84% networks and flooding, or government persecution. 00:00:24.320 --> 00:00:26.510 align:middle line:84% These communities, already underserved 00:00:26.510 --> 00:00:29.630 align:middle line:84% by the health system, may be skeptical of disease oriented 00:00:29.630 --> 00:00:32.330 align:middle line:84% programs which deemphasize pressing health 00:00:32.330 --> 00:00:37.280 align:middle line:84% and economic priorities and come from distrusted state actors 00:00:37.280 --> 00:00:40.190 align:middle line:90% or distrusted non-state actors. 00:00:40.190 --> 00:00:42.370 align:middle line:84% In this section of the course, we're 00:00:42.370 --> 00:00:44.330 align:middle line:84% going to describe how polio eradication has 00:00:44.330 --> 00:00:47.140 align:middle line:84% engaged with and been affected by those forces 00:00:47.140 --> 00:00:49.790 align:middle line:84% and consider the intended and unintended consequences 00:00:49.790 --> 00:00:53.440 align:middle line:84% on community demand for health services. 00:00:53.440 --> 00:00:58.500 align:middle line:84% So one underlying issue is that communities with ongoing polio 00:00:58.500 --> 00:01:01.380 align:middle line:84% transmission are often ones with excellent reasons 00:01:01.380 --> 00:01:03.330 align:middle line:84% to distrust their own governments. 00:01:03.330 --> 00:01:07.290 align:middle line:84% So polio cases that still exist in the world 00:01:07.290 --> 00:01:10.230 align:middle line:84% are often in really marginalized populations. 00:01:10.230 --> 00:01:13.200 align:middle line:84% So as polio eradication's independent monitoring board 00:01:13.200 --> 00:01:15.870 align:middle line:84% puts it, they appear in isolated communities, 00:01:15.870 --> 00:01:18.120 align:middle line:84% tribal populations, and environments 00:01:18.120 --> 00:01:21.060 align:middle line:84% with extreme social and economic deprivation. 00:01:21.060 --> 00:01:23.713 align:middle line:84% These are people in places where trust in government is low, 00:01:23.713 --> 00:01:25.380 align:middle line:84% and I would add that trust in government 00:01:25.380 --> 00:01:28.920 align:middle line:84% is low for often excellent reasons. 00:01:28.920 --> 00:01:31.410 align:middle line:84% So communities most at risk for polio 00:01:31.410 --> 00:01:33.290 align:middle line:84% are at risk for a range of reasons. 00:01:33.290 --> 00:01:35.790 align:middle line:84% First, they may be beyond the reach of the government health 00:01:35.790 --> 00:01:36.520 align:middle line:90% system. 00:01:36.520 --> 00:01:39.510 align:middle line:84% And so may not be getting routine immunizations. 00:01:39.510 --> 00:01:41.400 align:middle line:84% Next, they may have limited access 00:01:41.400 --> 00:01:43.680 align:middle line:90% to fresh water and sanitation. 00:01:43.680 --> 00:01:47.220 align:middle line:84% So they may be highly at risk for fecal oral transmission 00:01:47.220 --> 00:01:48.380 align:middle line:90% of polio. 00:01:48.380 --> 00:01:51.960 align:middle line:84% And finally, and this is what I want to talk about here, 00:01:51.960 --> 00:01:53.490 align:middle line:84% they are also the communities that 00:01:53.490 --> 00:01:55.620 align:middle line:84% may have the least trust in the government. 00:01:55.620 --> 00:01:57.120 align:middle line:84% And so if a government health worker 00:01:57.120 --> 00:01:59.760 align:middle line:84% comes by offering oral polio vaccine, 00:01:59.760 --> 00:02:03.000 align:middle line:84% they may be less likely to accept that vaccine. 00:02:03.000 --> 00:02:05.670 align:middle line:84% And the independent monitoring board for polio eradication 00:02:05.670 --> 00:02:06.930 align:middle line:90% puts it this way. 00:02:06.930 --> 00:02:09.960 align:middle line:84% Refusal of the polio vaccine is not a mere gesture. 00:02:09.960 --> 00:02:12.330 align:middle line:84% It's a distillation of the anger that communities 00:02:12.330 --> 00:02:14.460 align:middle line:84% feel when polio workers knock on their doors 00:02:14.460 --> 00:02:16.710 align:middle line:84% over and over again in the absence 00:02:16.710 --> 00:02:18.120 align:middle line:90% of other governmental services. 00:02:18.120 --> 00:02:20.940 align:middle line:84% So these are populations that have often 00:02:20.940 --> 00:02:23.890 align:middle line:84% been cleared from land multiple times in some cases. 00:02:23.890 --> 00:02:27.870 align:middle line:84% They may have been persecuted by the same government that's 00:02:27.870 --> 00:02:29.850 align:middle line:90% offering them polio vaccine. 00:02:29.850 --> 00:02:32.910 align:middle line:84% They may have had their rights violated 00:02:32.910 --> 00:02:35.250 align:middle line:84% in all kinds of different ways by that government. 00:02:35.250 --> 00:02:39.720 align:middle line:84% And so when a health worker carrying a government insignia 00:02:39.720 --> 00:02:42.340 align:middle line:84% comes to provide polio vaccine, there 00:02:42.340 --> 00:02:44.040 align:middle line:84% is, as we discussed before, a lot 00:02:44.040 --> 00:02:46.550 align:middle line:84% of layers to the reasons why parents might be hesitant. 00:02:46.550 --> 00:02:50.640 align:middle line:84% So these are challenging issues to overcome. 00:02:50.640 --> 00:02:52.860 align:middle line:84% I do want to positive note here that there's 00:02:52.860 --> 00:02:56.060 align:middle line:84% some models for how this might be done effectively. 00:02:56.060 --> 00:02:59.010 align:middle line:84% And one of them is the 107 Block Plan, 00:02:59.010 --> 00:03:03.030 align:middle line:84% which was used in India in the final stages of India's 00:03:03.030 --> 00:03:04.900 align:middle line:90% eradication of polio. 00:03:04.900 --> 00:03:07.110 align:middle line:84% So the 107 Block Plan was developed 00:03:07.110 --> 00:03:09.660 align:middle line:84% when it was realized that all the polio cases in India 00:03:09.660 --> 00:03:13.410 align:middle line:84% were coming from 107 subdistricts or blocks. 00:03:13.410 --> 00:03:16.040 align:middle line:84% So India is obviously a huge country 00:03:16.040 --> 00:03:21.750 align:middle line:84% and focusing just on 107 blocks were ways for government 00:03:21.750 --> 00:03:27.540 align:middle line:84% and UNICEF and WHO staff to focus on a few areas 00:03:27.540 --> 00:03:29.883 align:middle line:84% where there was ongoing polio transmission. 00:03:29.883 --> 00:03:31.800 align:middle line:84% And what they did was they designed this thing 00:03:31.800 --> 00:03:33.420 align:middle line:90% called the 107 Block Plan. 00:03:33.420 --> 00:03:34.890 align:middle line:84% And this was a really far reaching 00:03:34.890 --> 00:03:37.530 align:middle line:84% strategy that included a range of activities 00:03:37.530 --> 00:03:39.300 align:middle line:84% from filling vacant medical officer 00:03:39.300 --> 00:03:43.750 align:middle line:84% positions to constructing latrines in some areas. 00:03:43.750 --> 00:03:48.100 align:middle line:84% But what I want to focus on here is its communication strategy, 00:03:48.100 --> 00:03:51.030 align:middle line:84% which is on this butterfly up here. 00:03:51.030 --> 00:03:53.940 align:middle line:84% So specific targeted messages included information 00:03:53.940 --> 00:03:57.110 align:middle line:84% about diseases prevented by routine immunizations. 00:03:57.110 --> 00:04:00.090 align:middle line:84% There was a lot of messaging about routine immunization. 00:04:00.090 --> 00:04:03.300 align:middle line:84% There was messaging about the importance of oral rehydration 00:04:03.300 --> 00:04:06.510 align:middle line:84% solution in cases of diarrhea and how to prepare it. 00:04:06.510 --> 00:04:09.600 align:middle line:84% There were instructions about how to breastfeed infants 00:04:09.600 --> 00:04:12.320 align:middle line:84% and to exclusively breastfeed for six months, 00:04:12.320 --> 00:04:14.520 align:middle line:84% and also information to wash your hands with soap 00:04:14.520 --> 00:04:16.620 align:middle line:84% at specific times throughout the day. 00:04:16.620 --> 00:04:18.060 align:middle line:84% So one thing I'd like to note here 00:04:18.060 --> 00:04:21.570 align:middle line:84% is that all of these things actually along 00:04:21.570 --> 00:04:24.570 align:middle line:84% with vaccination, which is the center of the butterfly, all 00:04:24.570 --> 00:04:27.480 align:middle line:84% of these things work to prevent polio transmission. 00:04:27.480 --> 00:04:29.640 align:middle line:84% If children have complete routine immunization, 00:04:29.640 --> 00:04:32.400 align:middle line:84% they're going to get the polio vaccine there. 00:04:32.400 --> 00:04:36.270 align:middle line:84% If kids and parents are washing their hands with soap, 00:04:36.270 --> 00:04:39.570 align:middle line:84% that will interrupt polio transmission. 00:04:39.570 --> 00:04:41.820 align:middle line:84% Actually, diarrhea is an issue that 00:04:41.820 --> 00:04:44.370 align:middle line:84% leaves kids vulnerable to a range of diseases, including 00:04:44.370 --> 00:04:45.540 align:middle line:90% polio. 00:04:45.540 --> 00:04:48.360 align:middle line:84% And breastfeeding gives kids maternal antibodies 00:04:48.360 --> 00:04:49.210 align:middle line:90% against polio. 00:04:49.210 --> 00:04:53.370 align:middle line:84% So all of these issues are broader than vaccination, 00:04:53.370 --> 00:04:55.620 align:middle line:84% and they also protect against polio. 00:04:55.620 --> 00:04:58.640 align:middle line:84% Additional staff were hired to disseminate these messages. 00:04:58.640 --> 00:05:02.400 align:middle line:84% Over 1,000 community mobilizers were deployed in Bihar, 00:05:02.400 --> 00:05:03.750 align:middle line:90% and even more in Neutra Pradesh. 00:05:03.750 --> 00:05:05.880 align:middle line:84% So these are two states in northern India 00:05:05.880 --> 00:05:08.460 align:middle line:84% where there was ongoing polio transmission. 00:05:08.460 --> 00:05:11.250 align:middle line:84% Initially, there were concerns about these people's ability 00:05:11.250 --> 00:05:13.890 align:middle line:84% to quickly learn and disseminate these messages, 00:05:13.890 --> 00:05:15.810 align:middle line:90% but those proved unfounded. 00:05:15.810 --> 00:05:19.590 align:middle line:84% One UNICEF official said that the mobilizers embraced it-- 00:05:19.590 --> 00:05:22.740 align:middle line:84% so excited that after the years of the same polio messaging, 00:05:22.740 --> 00:05:24.270 align:middle line:90% they could do more. 00:05:24.270 --> 00:05:26.940 align:middle line:84% One staff member described her work, quote, 00:05:26.940 --> 00:05:28.590 align:middle line:90% we're promoting hand washing. 00:05:28.590 --> 00:05:30.300 align:middle line:90% We're promoting breastfeeding. 00:05:30.300 --> 00:05:32.760 align:middle line:84% We're promoting zinc and oral rehydration solution 00:05:32.760 --> 00:05:34.560 align:middle line:90% for controlling diarrhea. 00:05:34.560 --> 00:05:37.130 align:middle line:84% We conduct counseling meetings with the targeted families 00:05:37.130 --> 00:05:39.420 align:middle line:84% and slowly, slowly, it has developed 00:05:39.420 --> 00:05:41.220 align:middle line:90% awareness in their behavior. 00:05:41.220 --> 00:05:43.743 align:middle line:84% So this communication package is a way 00:05:43.743 --> 00:05:45.660 align:middle line:84% of getting at some of the questions we've been 00:05:45.660 --> 00:05:47.250 align:middle line:90% asking throughout this section. 00:05:47.250 --> 00:05:49.620 align:middle line:84% Is there a way to do communications for polio 00:05:49.620 --> 00:05:51.840 align:middle line:90% that might include a bit more? 00:05:51.840 --> 00:05:54.750 align:middle line:84% Now, is this going to be enough to overcome 00:05:54.750 --> 00:05:57.960 align:middle line:84% entrenched political and historical reasons 00:05:57.960 --> 00:06:00.420 align:middle line:84% to be distrustful of government intervention? 00:06:00.420 --> 00:06:02.010 align:middle line:90% Maybe, maybe not. 00:06:02.010 --> 00:06:06.600 align:middle line:84% In northern India, it was enough to eliminate polio. 00:06:06.600 --> 00:06:09.750 align:middle line:84% This was part of the 107 Block Plan 00:06:09.750 --> 00:06:12.600 align:middle line:84% which included this communications package-- 00:06:12.600 --> 00:06:16.500 align:middle line:84% successfully ended transmission of polio in India. 00:06:16.500 --> 00:06:20.260 align:middle line:84% So more currently, some other strategies are being tried. 00:06:20.260 --> 00:06:23.700 align:middle line:84% So in Afghanistan, they're working on distribution of bed 00:06:23.700 --> 00:06:27.120 align:middle line:84% nets and nutritional material during vaccination campaigns 00:06:27.120 --> 00:06:29.940 align:middle line:84% as a way of giving families a few other things in addition 00:06:29.940 --> 00:06:31.800 align:middle line:90% to just polio vaccine. 00:06:31.800 --> 00:06:34.410 align:middle line:84% So a polio worker said, our volunteers 00:06:34.410 --> 00:06:36.630 align:middle line:84% in villages distributed bed net and nutrition 00:06:36.630 --> 00:06:38.620 align:middle line:90% materials to children. 00:06:38.620 --> 00:06:40.780 align:middle line:90% It is effective in some areas. 00:06:40.780 --> 00:06:43.628 align:middle line:84% So a question for you is, do you think this sort of thing 00:06:43.628 --> 00:06:46.170 align:middle line:84% would be enough to address the sorts of problems we've talked 00:06:46.170 --> 00:06:47.690 align:middle line:90% about in the previous section-- 00:06:47.690 --> 00:06:52.470 align:middle line:84% these entrenched problems of mistrust and legacies 00:06:52.470 --> 00:06:55.650 align:middle line:84% of political and historical marginalization? 00:06:55.650 --> 00:06:57.490 align:middle line:84% And perhaps the answer is maybe not. 00:06:57.490 --> 00:07:01.170 align:middle line:84% But it can't hurt and it will get us closer. 00:07:01.170 --> 00:07:03.150 align:middle line:84% Here's another example of service integration 00:07:03.150 --> 00:07:04.800 align:middle line:90% from Bangladesh. 00:07:04.800 --> 00:07:06.750 align:middle line:84% During polio vaccination campaigns, 00:07:06.750 --> 00:07:08.520 align:middle line:84% they provided vitamin A. And this 00:07:08.520 --> 00:07:11.010 align:middle line:84% was something that was organized at the national level. 00:07:11.010 --> 00:07:13.212 align:middle line:84% A national level policymaker said, 00:07:13.212 --> 00:07:14.670 align:middle line:84% they realized that they could reach 00:07:14.670 --> 00:07:17.640 align:middle line:84% the doorstep of people via our national immunization day 00:07:17.640 --> 00:07:18.930 align:middle line:90% for polio. 00:07:18.930 --> 00:07:21.510 align:middle line:84% And vitamin A and polio vaccine are 00:07:21.510 --> 00:07:22.995 align:middle line:90% both targeted at young children. 00:07:22.995 --> 00:07:25.370 align:middle line:84% You can give them both orally, so it makes a lot of sense 00:07:25.370 --> 00:07:27.110 align:middle line:90% to put those campaigns together. 00:07:27.110 --> 00:07:29.970 align:middle line:84% In Bangladesh, they also integrated surveillance of AFP 00:07:29.970 --> 00:07:33.000 align:middle line:84% with measles, and they also integrated tetanus vaccination 00:07:33.000 --> 00:07:34.230 align:middle line:90% with polio immunization. 00:07:34.230 --> 00:07:37.410 align:middle line:84% So they worked very hard on integrating polio activities 00:07:37.410 --> 00:07:39.090 align:middle line:90% with other activities. 00:07:39.090 --> 00:07:41.790 align:middle line:84% As one policymaker in Bangladesh said, 00:07:41.790 --> 00:07:44.610 align:middle line:84% we used the routine immunization as the backbone 00:07:44.610 --> 00:07:46.980 align:middle line:84% because routine immunization was our gateway. 00:07:46.980 --> 00:07:51.500 align:middle line:84% Through it, we had brought success in polio eradication. 00:07:51.500 --> 00:07:53.840 align:middle line:84% In Pakistan, too, there are initiatives underway 00:07:53.840 --> 00:07:58.260 align:middle line:84% to provide what's called polio plus services in some areas. 00:07:58.260 --> 00:08:02.660 align:middle line:84% So these are areas that have had a lot of vaccine hesitancy, 00:08:02.660 --> 00:08:04.160 align:middle line:84% and so there's efforts to provide 00:08:04.160 --> 00:08:06.620 align:middle line:84% some additional services and to provide more support 00:08:06.620 --> 00:08:08.390 align:middle line:90% to routine immunization. 00:08:08.390 --> 00:08:10.040 align:middle line:84% Along the same lines in Pakistan, 00:08:10.040 --> 00:08:12.410 align:middle line:84% the integrated services initiative 00:08:12.410 --> 00:08:15.530 align:middle line:84% is working in the water and sanitation sector 00:08:15.530 --> 00:08:19.310 align:middle line:84% to try to provide some more water and sanitation support 00:08:19.310 --> 00:08:22.670 align:middle line:84% to high risk polio areas in Pakistan. 00:08:22.670 --> 00:08:25.400 align:middle line:84% So these are all promising initiatives and ways 00:08:25.400 --> 00:08:28.130 align:middle line:84% that the polio eradication initiative 00:08:28.130 --> 00:08:31.490 align:middle line:84% is trying to get at these bigger problems of distrust 00:08:31.490 --> 00:08:33.320 align:middle line:90% in certain populations. 00:08:33.320 --> 00:08:34.850 align:middle line:84% There is a challenge inherent here 00:08:34.850 --> 00:08:38.600 align:middle line:84% in maintaining momentum for polio while also addressing 00:08:38.600 --> 00:08:40.429 align:middle line:84% the broader health needs and the priorities 00:08:40.429 --> 00:08:42.179 align:middle line:90% of underserved populations. 00:08:42.179 --> 00:08:44.630 align:middle line:84% But there are some key actions that you can think about 00:08:44.630 --> 00:08:46.910 align:middle line:84% as being useful in such an effort. 00:08:46.910 --> 00:08:48.890 align:middle line:84% Involving communities in defining 00:08:48.890 --> 00:08:51.710 align:middle line:84% how to address the challenges and what they need. 00:08:51.710 --> 00:08:53.660 align:middle line:84% To monitor communication activities 00:08:53.660 --> 00:08:57.130 align:middle line:84% through using and sharing data, particularly with communities. 00:08:57.130 --> 00:08:59.540 align:middle line:84% And to strengthen communication not just for polio, 00:08:59.540 --> 00:09:02.130 align:middle line:84% but for broader health services, as well-- 00:09:02.130 --> 00:09:04.160 align:middle line:84% for example, water, sanitation and hygiene, 00:09:04.160 --> 00:09:07.820 align:middle line:84% routine immunization and child health. 00:09:07.820 --> 00:09:09.830 align:middle line:84% None of these are a be all, end all, and none 00:09:09.830 --> 00:09:12.290 align:middle line:84% will overcome the problem of inadequately supported health 00:09:12.290 --> 00:09:13.048 align:middle line:90% systems. 00:09:13.048 --> 00:09:14.840 align:middle line:84% But given this, there's an important lesson 00:09:14.840 --> 00:09:16.910 align:middle line:90% here for eradication programs. 00:09:16.910 --> 00:09:18.343 align:middle line:84% The example of polio tells us they 00:09:18.343 --> 00:09:19.760 align:middle line:84% can't work everywhere in the world 00:09:19.760 --> 00:09:21.920 align:middle line:90% in a truly vertical format. 00:09:21.920 --> 00:09:24.260 align:middle line:84% That approach can work for 99% of the world, 00:09:24.260 --> 00:09:27.500 align:middle line:84% but it won't get to those last 1% of polio cases. 00:09:27.500 --> 00:09:29.360 align:middle line:84% In the words of one policymaker, quote, 00:09:29.360 --> 00:09:31.970 align:middle line:84% it has to be polio plus plus plus plus. 00:09:31.970 --> 00:09:35.320 align:middle line:90% [MUSIC PLAYING] 00:09:35.320 --> 00:09:40.000 align:middle line:90%