2017 is a year in which the fewest number of polio cases have ever been recorded. There is only 1 type of wild polio virus left, and reaching the last case is in our sights. This has not happened by chance or through luck but, rather, through a massive coordinated effort, which required huge political and resource commitment. I am not qualified to write about the epidemiological investigations, surveillance and monitoring advances in the field carried out through the Polio Eradication Initiative (PEI). Nor am I qualified to talk about the emergency centers set up in epidemic countries, the vaccine development and distribution breakthroughs - all of which are major contributors to the eradication effort.
What I would like to discuss is the role of communication and social change communication in the process and the need to retain the lessons and human resources that have been developed through this extensive effort.
My hope is that with these lessons we can go onto improving the health of millions of people worldwide, particularly in developing countries.
* The most important lesson in my view is basing of communication on evidence and not on the "knowledge" of the implementers. This is a lesson that the health communication field seems to have to learn over and over again. Whether it is mass media or face-to-face communications, understanding the key issues and then addressing them well is the cornerstone of good health communication. The polio eradication campaign came to this understanding fairly late, but, as it did, it brought in new partners, improved its formative research, developed more robust ways to gather administrative and third party data during campaigns and triangulated this data with in-depth qualitative research to understand the complex dynamics of communities. This shifted the emphasis from understanding "every missed child" as a refusal based on poor knowledge of polio to understanding that the real reasons for a child being missed were more complex:
* poor campaign quality where teams missed houses or some children in them,
* children being away playing or in the market, at school or working,
* parents believing that sick or very young children should not be immunized,
* suspicion that the vaccine and the programme were harmful, and/or
* the practice of hiding children to use the polio campaign as leverage to gain other resources.
This is far from an exhaustive list but underscores the reality that reasons for missed children are as complex as the communities they live in. This recognition and the shift to evidence-based planning enabled the programme to target its strategies and communications in a more accurate and relevant fashion and, in so doing, find many more of the children being missed. As the world gets closer and closer to the eradication goal, this work must continue to deepen to ensure that the remaining hard-to-reach communities are understood and innovative ways to reach missed children continually sought.
* A model of change needs to be used. In this eradication programme, as in many other fields, the confirmation that knowledge doesn't equal change in behavior was repeated. Many external issues influence behavior, such as social and cultural norms, economic imperatives, other family priorities, and gender inequity. Unless these issues are addressed, change will be slow, if it happens at all.
* Social mobilization is a critical component to reaching every last child and every last virus. Community support and engagement is not a cheap and dirty option but a strategy, dating back to the Declaration of Alma Ata (1978) on primary health care acknowledging that communities' participation in their own health is a critical component of a successful system. Social mobilization needs health service commitment, well informed and trained front line workers, and political and financial commitment.
* Stakeholder communication has to be well planned and include all stakeholders. An important group are the frontline workers who work long hours (in often dangerous situations) with minimal pay, yet they are often ignored. A lesson from the polio eradication campaign is that communicating with and about these workers to the general population has been motivating and helps their work by legitimizing them and giving them visibility.
* Integration of polio immunization with other services (e.g., health camps, or providing commodities such as soap) is important, as people in poverty face many daily challenges, and polio vaccination is often of far less concern to them than other, more immediate needs. This need for integration of services at a primary level isn't new but continues to be forgotten in every vertical campaign.
* The final lesson is the integration of communication into plans and programmes. This has been difficult and slow in the Global Polio Eradication Initiative (GPEI) and is no less difficult in many other contexts, but it has been an invaluable element of the programme's success in reducing the numbers of missed children to a point where eradication is within sight. The full integration of communication into health services may still be a distant hope, but the value shown by its integration as a core element within the GPEI demonstrates that it should be seen as a necessity and not an add-on.
My fears are:
* That these lessons won't be retained, and that the world will go back to a way of operating where primary health care and routine immunization continue in a vacuum of no communication and no change model. That the World Health Organization (WHO) and countries exclude communication (in all its aspects) from strategies and planning to achieve health goals.
* That any communication that is commissioned is not based on any evidence but on the desire of the authorities to look good and to tell "the community" what is best for them.
* That communication strategies, when implemented, are not evaluated and are assumed to be effective because they exist.
* That the implementation of primary health care becomes the problem for the health department, and no other agencies are engaged or partnered with.
* That advocacy for health becomes the domain of civil society organisations (CSOs).
* That funding for health programmes keeps getting diverted into the "sexy" areas of the moment for short periods and not focused towards a long-haul engagement.
* That countries are left to deal with difficult health situations on their own and are not supported in this by the international health community.
Getting to the last incidence of the virus in ending polio worldwide is an amazing, coordinated international achievement that must be celebrated. The best celebration would be to take all the lessons, examine them and find ways to implement them in ways that improve the health of the poorest and most vulnerable on planet earth.
Sue Goldstein is a member of the Independent Monitoring Board (IMB) of the Global Polio Eradication Initiative (GPEI) and is a past member of the Task Force on Immunisation (TFI) - World Health Organization (WHO) Regional Office for Africa (AFRO) and the WHO Strategic Advisory Group of Experts (SAGE) Working Group on Vaccine Hesitancy. She is Programme Director at Soul City: Institute for Social Justice, where she works on health communication and health promotion.