Public health practitioners sometimes have to learn the hard way: just because they offer a service, even with the best of intentions, the intended recipient may not take it up and in some instances will reject it violently. In a recent example, physicians tried to help a remote village protect itself from Ebola; village members did not understand the intrusion from strangers and attacked them with knives, stones, and machetes.1
Those seeking to eliminate polio in India confronted a similar conundrum. Participation in Booth Days, festival-style events where children collected at colorful tents to receive polio drops and small toys, had stagnated. Yet, many children remained unvaccinated and the disease continued to paralyze hundreds. Communications with target communities were minimal, often only involving announcements about where and when the vaccine would be available.
“When I say communication, I’m thinking more social change kind of communication. People in the field were putting out ads or posters for a press release, but I think in terms of what I would call real communication based on proper research and engaging with people, it just wasn’t accepted by the medical fraternity for a very long time.”
—Sue Goldstein, MD, Program Director, Soul City: Institute for Social Justice; and Member, Independent Monitoring Board, Global Polio Eradication Initiative
As polio immunization rates stalled, the government of India enlisted vaccinators to go door-to-door to deliver the polio drops to those not being reached. But some communities, including poor Muslim populations that often felt threatened by the government, felt targeted by the action and became suspicious. Why, in a community with open sewers and filthy water, with one of the highest disease burdens in the world, was the government arriving at doorsteps to offer only this one intervention? Rumors circulated that the polio drops were actually designed to cause infertility in Muslim children and thus reduce the population. After all, the government’s last door-to-door campaign in the 1970s promoted forced sterilization.2 This fear led parents to hide their children or even attack vaccinators. Others outright refused to let their children be immunized.
A resulting 20 percent vaccine refusal rate3 and a massive polio outbreak in the state of Uttar Pradesh that paralyzed 1,600 children4 forced the Indian government and the global polio eradication leadership into a crisis of confidence.
While the Global Polio Eradication Initiative (GPEI)—overseen at the international level by the World Health Organization (WHO), United Nations Children Fund (UNICEF), Rotary International, the U.S. Centers for Disease Control and Prevention, and Bill & Melinda Gates Foundation—was a remarkable success that had reduced the number of polio cases by more than 99 percent, it was struggling in areas with poor immunization services, conflict, dense populations, and/or poor hygiene.
Operating in an “if you build it, they will come” mentality, its largely male, physician-led, data-driven approach did not sufficiently consider cultural and social nuances. The lack of awareness led to vaccine refusals and caused the program to stall in the then four remaining endemic countries of India, Pakistan, Nigeria, and Afghanistan. With billions of dollars and two decades of work at stake, new ideas were needed and quickly.
“It became clear to me pretty quickly that if they didn’t have a strong communication approach this whole thing was going to fall apart.”
—Ellyn Ogden, Worldwide Polio Eradication Coordinator, USAID
Some donors involved in the program—including the U.S. Agency for International Development (USAID), which had been funding social mobilization efforts for years—had long argued that the initiative’s communications were not sufficient and had been urging a more intensive, localized, evidence-based approach. Posters, banners, and radio and television ads announcing vaccination days did not do enough to explain the risks of not vaccinating and did not always resonate with illiterate populations that were the most often missed.
Out of this conviction grew India’s Social Mobilization Network, or SMNet, a network of thousands of mostly young women from the communities they worked in, who met with parents and caregivers individually to understand their concerns and explain the purpose of the polio drops. Social mobilizers enlisted local influencers—religious leaders, teachers, and doctors—to support vaccine campaigns and help them talk to parents. They hosted “mothers’ groups” that addressed health issues beyond polio including hygiene and health, breastfeeding, and nutrition. Groups running the SMNet, UNICEF, and the CORE Group Polio Project developed indicators to measure the performance of social mobilization so they could prove to the data-driven epidemiologists and physicians running the polio program that the approach was working.
And it did work. While direct cause and effect is difficult to ascertain and can be attributed to many factors, the refusal rate fell below 1 percent by 20135 and the number of polio cases in high-risk districts in India dropped approximately 20 to 30 percent6 after the SMNet was instituted. The last case was seen in the country in January 2011. Polio elimination in India, which once produced the bulk of cases in the world, was considered an extraordinary success story that included, as one of its very important chapters, the work of the SMNet.
Similar approaches are now being tried in remaining endemic countries of Nigeria, Afghanistan, and Pakistan. Meanwhile, the Indian SMNet is helping the government improve the reach of other immunizations to under-immunized communities. However, its future is uncertain. The number of polio cases worldwide is in decline, and the funding for the program has diminished as focus moves to the remaining endemic countries. The government of India is now working to maintain at least parts of the network for the neediest communities and repurpose them to address broader health and social issues.
“[I]t’s not isolated to the GPEI. It’s a medical paradigm that’s been around for a long time. When you want to solve a problem, you give a person an injection or pill and it goes away.”
—Sue Goldstein, MD, Program Director, Soul City: Institute for Social Justice; and Member, Independent Monitoring Board, Global Polio Eradication Initiative
While social mobilization and India’s SMNet are now cited as instrumental to immunization efforts in hard-to-reach communities, those running the polio program did not always appreciate the value of interpersonal communications. Those involved talk about several turning points for transforming communications from simple awareness of campaign dates to truly mobilizing communities to vaccine acceptance.
The first was a 2003 polio outbreak in Nigeria that grew out of suspicion about the vaccine and a surge in vaccine refusals, problems that could only be addressed through better personal communications. The virus spread to 20 other countries and hundreds of children were paralyzed.7 The episode resulted in communications being taken more seriously at the GPEI, but they still did not have the funding needed to be successful.
The India outbreak of 2006 mostly involved Muslim children whose parents were refusing the vaccine and was the biggest wake-up call that something needed to change in that country. But while the GPEI began to devote more resources and attention to mobilization, it was not until 2010 that the Gates Foundation made a large contribution to UNICEF to improve communications and the SMNet began to grow and professionalize.8
While understanding community culture and responding to it was always part of social mobilization, UNICEF began to commission surveys and analyze data to give the program more legitimacy with its epidemiologist partners.9 Questions focused on caregiver trust not only of the health workers, but of the government and other organizations running the program, including WHO and UNICEF, and how that affected decisions to have children vaccinated.
Through the surveys they were able to quantitatively affirm, for example, that in many places, caregivers were much more comfortable having a female health worker come to their door. Some places distrusted the international organizations involved in the program, viewing them as Western driven and anti-Muslim. Others distrusted their own governments. The surveys helped the program tailor its operations to respond to community attitudes. They added more female health workers and downplayed initiative sponsors where communities viewed them skeptically. By listening to communities and responding to their concerns, the program reached more children and reduced the violence aimed at health workers.10
India’s SMNet began in 2003 and is a collaboration between UNICEF and the CORE Group Polio Project, a USAID- funded consortium of NGOs focused on child health, along with Rotary and the Indian government’s National Polio Surveillance Project (NPSP).11 UNICEF and CORE Group, which had been funded for polio work by USAID since 199612 and 199913 respectively, had the same type of training and similar communications materials but worked in different areas where they historically had the strongest presence. The network was set up in a pyramidal structure with community mobilization coordinators (CMCs) at the base below various levels of supervision (see chart).
CMCs serve as health promoters and as the eyes and ears of the health system. At its peak, UNICEF had more than 6,000 CMCs14 while CORE had 1,400.15 They perform community-based surveillance, report cases of disease not seen by physicians, and keep track of pregnant mothers and newborns to ensure they get the care they need. Through mothers’ groups and other avenues, they expanded their health promotion beyond just polio to other issues being faced by the community. They helped facilitate communications between the community and the government, in some cases getting roads paved and garbage collected. Over the years, their credibility grew both as they solidified their relationships with the community and as polio cases began to decline.
The SMNet implemented several innovations that helped achieve polio elimination in India and became iconic symbols of the eradication initiative. The first was micro planning maps. The often hand-drawn maps charted every house in a neighborhood and documented the number of children there. This helped vaccinators ensure they were reaching every house.
Another innovation helped keep track of the status of each household. Using surveillance information collected and analyzed by India’s NPSP, mobilizers used chalk to mark each house, showing whether children within were seen during the campaign and if not, why. For example, a “p” chalked onto the house indicated children in the house had been given drops while an “x” meant they had not. Later, again using data from the NPSP, the “x” markings were further delineated into markings that indicated why a child was not vaccinated, be it related to parental refusal, an illness, or that the child was not home. This information helped the work of a second wave of vaccinators who returned later in the day for another attempt.
Social mobilizers are helping to stop poliovirus transmission in the remaining endemic countries as well. In Afghanistan, the Immunizations Communication Network is tracking chronically missed children, maintaining a register of households with children, promoting routine immunization, hygiene and sanitation, and identifying and tracking high risk populations.16 In Pakistan, community-based vaccinators provide vaccination and social mobilization/communications are currently working on community engagement plans. In Nigeria in recent years, Volunteer Community Mobilizers reduced the number of children missed during vaccination campaigns by 68-90 percent in states that are high risk for polio.17
“I think that disbanding the SMNet would be like pouring expensive drinks down the drain. I don’t think it’s a good idea at all.”
—Deepak Kapur, Chair, Rotary’s India PolioPlus Committee
While its contribution to polio elimination in India is widely recognized, the SMNet’s future will become uncertain as polio funding winds down. Providing funding for the intense interpersonal communications fostered by the SMNet is expensive: the SMNet functioning costs in India totaled more than $6 million per year.18 Further, the government of India has developed a cadre of health workers, known as ASHAs (accredited social health advocates), that serves a similar function to CMCs.
Also complicating the situation, the pay scale for the international organizations supporting the SMNet is higher than that of the Indian government. For several years, UNICEF has been in negotiation with the Indian states of Bihar and Uttar Pradesh, where the SMNet has the bulk of its resources, to secure its future. The states have agreed to gradually take on more of the funding and have altered the SMNet’s job responsibilities to respond to a broader set of challenges faced in their communities. However, it will be essential for the government ultimately to take on the bulk of the SMNet’s costs if it wants the program to continue since USAID and UNICEF likely will phase out their support.
Those involved in the program expect many of the CMC positions to be eliminated but supervisory roles of the SMNet may be retained. This is an important step for the Indian health system, which often has lacked effective oversight of government health services. Mobilizers who leave the SMNet also are seeking other training opportunities and finding jobs with NGOs, the government, and international organizations.
Even if most of the SMNet is dismantled, it has proven the importance of understanding cultural norms and experiences and adjusting programs to respond to them. In fact, a set of former polio professionals from UNICEF and WHO became so convinced of the approach that they started a business around it. Called Common Thread, the global enterprise designs applied social and behavior change strategies for public health. It aims to show that putting people at the center of public health is not only important, but essential for programs aiming to achieve impact.19 Clients include large multilateral organizations like the Red Cross, UNICEF, and WHO, which retain Common Thread to create and improve health communication programs. The founders of the firm saw a need to incorporate evidence-based social data with epidemiological data to create a more accurate portrait of public health.
While they were a long time coming and hard-learned, lessons from the SMNet are contributing to changes that span well beyond polio and India, embedding the belief that human behavior is often not only what spreads diseases, but is critical to stopping them.
“Communications has often been like a stepchild of public health programs. And I don’t think it’s just polio. I think it’s a broader phenomenon in public health.”
—Sherine Guirguis, Founder and Lead Strategist, Common Thread; formerly Senior Manager of Communications, Polio Eradication Unit, UNICEF
Senior Fellow, Global Health Policy Center
Nellie Bristol is a senior fellow with the CSIS Global Health Policy Center. She leads the Center’s work on efforts to repurpose polio eradication assets for long-term disease control and toward other global health priorities. In addition to an active working group convened to discuss eradication and transition as it relates to U.S. global health policy, she writes extensively on the issue and consults with other organizations focused on transition planning. She also writes about U.S. government relations with multilateral organizations, including the World Health Organization and the World Bank Group. Her major reports for CSIS include Catalyzing Health Gains through Global Polio Eradication, which focused on polio transition in India; Bolstering Public Health Capacities through Global Polio Eradication, which examined polio assets in Ethiopia; The Power of Straight Talk, which looked at the impact of the Independent Monitoring Board on eradication efforts. Bristol came to CSIS following a long career as a health policy journalist. She spent two decades writing about domestic health policy on Capitol Hill before expanding her coverage to global health in 2005. Bristol has written for top publications in the field including The Lancet, Health Affairs, and Congressional Quarterly, covering HIV/AIDS policy, foreign aid and national security, noncommunicable diseases, and efforts to combat maternal mortality. She holds a master’s degree in public health/global health from George Washington University.Full Bio Here
Program Coordinator and Research Assistant, Global Health Policy Center
Isra Hussain is a program coordinator and research assistant for the CSIS Global Health Policy Center, where she supports the program’s polio and immunization research agenda and facilitates event planning. Prior to joining CSIS, she supported research on immigrant mental health and substance abuse with the Disparities Research Unit at Harvard Medical School. She spent time in Lucknow, India, on an Urdu Critical Language Scholarship and a summer in Barcelona, Spain, evaluating institutional and social support mechanisms for unaccompanied minors from the Middle East and Northern Africa region. Ms. Hussain, a graduate of the Class of 2017 Gabelli Presidential Scholars Program, holds a bachelor’s degree in psychology with a minor in Arabic studies from Boston College.Full Bio Here
Special Thanks to:
- Sunil Kumar Bahl, Medical Officer, Polio Eradication, South East Asia Region, World Health Organization
- Michael Galway, Deputy Director of Polio, Global Development, Bill & Melinda Gates Foundation
- Sue Goldstein, Program Director, Soul City: Institute for Social Justice; and member, Independent Monitoring Board, Global Polio Eradication Initiative
- Sherine Guirguis, Founder and Lead Strategist, Common Thread; formerly Senior Manager of Communications, Polio Eradication Unit, UNICEF
- Dr. Pradeep Haldar, Deputy Commissioner for Immunizations, Ministry of Health & Family Welfare, Government of India
- Dr. Lalit Kant, formerly Senior Scientific Advisor, Bill & Melinda Gates Foundation
- Deepak Kapur, Chair, Rotary’s India PolioPlus Committee
- Ellyn Ogden, Worldwide Polio Eradication Coordinator, USAID
- Joshila Pallapati, Capacity Development Officer, Polio, UNICEF
- Dr. Roma Solomon, India Director, CORE Group Polio Project
This project is made possible through the generous support of the Bill & Melinda Gates Foundation.
A product of the Andreas C. Dracopoulos iDeas Lab, the in-house digital, multimedia, and design agency at the Center for Strategic and International Studies.