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Notes from the field entry 5 - India/Afghanistan, October 2013


Notes from the field entry 5 - India/Afghanistan, October 2013

Entry 5 from Chris Morry.

It's all about borders...

The team came back together in Kabul on October 28, after splitting into two groups, one travelling to the south in Kandahar, the other to Jalalabad in the east. These are two parts of Afghanistan that tell different yet similar polio stories. Two years ago, the south was in the grips of a large polio outbreak, while eastern Afghanistan was polio free. Since then, the tables have turned, and the south is now free of wild polio virus, while the east has 8 cases so far this year, with a high potential for more before the end of December.

Why has this happened? On the one hand, it is a story of the south gaining access to areas not controlled by government, where, in some cases, for years, anti-government elements (AGE) had refused to allow vaccination teams to enter. At the same time, significantly improved polio campaigns in both quality and number led to a decrease in the number of un- and under-immunised children in the region. On the other hand, it is a story of the east, where better overall immunisation coverage and campaign quality had allowed it to stay polio free in spite of a major and growing outbreak in Pakistan along its borders. Eventually, the pressure of the high virus circulation in Pakistan, the million or so people who travel from Pakistan to eastern Afghanistan through the Torkam border each year, and a deteriorating security situation in eastern provinces like Kunar, resulting in chronically inaccessible areas containing 10s of thousands of children, allowed the virus to establish itself in the east.

There is another part and party to the story: Pakistan. While, overall, Pakistan remains in the grip of a major polio outbreak (with at least 7 cases announced in the few days when we were in Afghanistan), there has been a decrease in cases in certain parts of Pakistan, especially around the major southern border crossing at Spin Boldak in an area known as Quetta Block and flowing down to Karachi. Better campaigning and access to children coupled with less viral pressure from Pakistan has helped south Afghanistan remain wild polio-free for almost a year. However, no one is celebrating yet. The region is complex and remains volatile in terms of access, fighting, and poorly run campaigns that miss children. There are vulnerable areas in the southeast of Afghanistan, bordering on North and South Wazirstan in the FATA area of Pakistan, where a ban on vaccination teams since June 2012 has led to an outbreak that has paralysed nearly 30 children.

Until Pakistan is able to get its outbreak under control, Afghanistan must continue to: improve its overall coverage with thorough door-to-door polio campaigns; improve routine immunisation wherever possible; and expand extensive coverage of mobile populations at inter- and intra-transit points where children moving from hard-to-access and/or high-virus-circulation areas can be reached and protected.

Our focus was on communication: there are many ways for communication to support Afghanistan's present success in the south and its need to stop the virus circulation in the East and keep it from being reintroduced from Pakistan. A few priorities are:

* strengthening capacity of the Immunization Communication Network (ICN) to conduct social communication activities that support vaccinator teams as they revisit households where children are missed in the first pass, responding to the community questions and actions responsible for large numbers of children being missed because they are 'not available' when the vaccinator team comes to their households. The ICN is presently more developed in the South than the East, and the East urgently needs to catch up by getting staff in place and trained to ensure that the network is as effective as it can be.
* finding ways to provide inter-personal communication (IPC) training materials and training opportunities for staff who are now in a context of conducting almost continuous polio vaccination rounds.
* recognising that the polio programme cannot do this alone. It needs to engage government line ministries, NGOs, and other UN agencies to identify community initiatives in areas such as water and sanitation, nutrition, and health outreach where polio messages could be incorporated and where influential leaders who care about their community's local development can be engaged as advocates for the programme.
* converging polio messages with a range of other relevant health messages (such as early breast feeding, hand-washing and sanitation, and routine immunisation) and, where possible, with services (such as inter-border area health camps and neo-natal information sessions in health centres) to place polio in the context of other vaccinations and other important mother/child health behaviours.
* continuing the mass media campaign focusing on polio being a shared responsibility with spots tailored to different groups such as mothers, fathers, mullahs, and teachers - but testing it soon to see if it is having the positive impact on awareness that people working in the programme claim.
* avoiding the impulse to lower the profile of the programme in areas where there is a lot of anti-polio vaccination feeling but increasing efforts to engage local media and local influential people to advocate for polio vaccination together with other immunisations and behaviours that improve child health.
* providing training opportunities for local influencers: journalists/radio disc jockeys, mullahs, teachers, traditional birth attendants, health care workers, and others - and they need simple materials to take away after such training to assist them in relaying key messages to their communities.
* coordinating media messages at the border to ensure that both the Pakistan and Afghanistan sides know what each other's programmes' media messages are, especially where the footprint of that media extends into areas in either country where there are significant levels of anti-vaccine propaganda.

In all of this, retaining the programme's neutrality needs to be paramount - the virus is everyone's enemy, and eradicating it will benefit all children, all families.

Ultimately, eradicating polio in Afghanistan is about immunising every child every time through multiple rounds until it ceases to circulate in the country and then maintaining this high level of immunity until the danger of importations from outside its borders is also eradicated. Getting to this stage will require a constant focus on the borders surrounding those places where children are denied access to immunisation. In some cases, this means breaking down the borders through negotiations to gain access to districts in Kunar or areas where there has been recent fighting in the south; in others, it means thoroughly immunising every child that enters Afghanistan from outside (and every child that leaves Afghanistan to places where they may be exposed to the virus). Quality counts; ensuring that communities are supportive and active seekers of polio vaccination counts; but, right now in Afghanistan, it’s all about the borders.

Chris Morry
Programme Director
The Communication Initiative

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