As Israeli armed forces continue to rain lethal rockets and bombs over Gaza, its devastated children and their families, as it turns out, are sitting on a different time bomb – an imminent polio outbreak of a highly infectious nature.
While millions of people the world over have protested the near-genocidal conditions in Gaza and the International Court of Justice (ICJ) has voiced a fear of “physical destruction in whole or in part” of the besieged population, should we be worrying about a likely polio outbreak there as a matter of priority?
Not only is the World Health Organisation (WHO) “extremely worried” about this possibility, but so are Israel’s highly respected epidemiologists and public health experts who have made an ardent plea for a ceasefire through Israel’s Haaretz newspaper.
“The response to the threat of the highly infectious poliovirus, recently detected in sewage in Gaza, must be coordinated and comprehensive. As Israeli public health professors, we call for a cease-fire to stop it spreading,” they write. They remind all parties to the hostilities that children in Gaza and Israel “are not guilty of any crime, other than the dangerous circumstances they were born into.”
Gaza’s health ministry announced on Friday (August 17) that it had detected the coastal strip’s first case of polio in years, after a highly infectious vaccine-derived poliovirus Type-2 (VDPV2) was found in six sewage samples collected in late June from the Khan Younis and Deir al Balah camp areas.
Gaza has been polio-free for the past 25 years and immunisation rates in the Occupied Territories – Gaza, East Jerusalem and the West Bank – were “optimal” at 99% till 2022 according to WHO. They came down to 89% last year; but immunisation coverage in Gaza could be lower than that due the decimation of its health system – with only 16 out of the territory’s 36 hospitals partially functioning and more than half of its primary health facilities destroyed.
Add to this the lack of security, access difficulty, continuous population displacement, shortages of medical supplies and absence of cold chain equipment to keep the vaccines for polio and other diseases in the necessary temperature range, and you have the perfect recipe for a “health catastrophe” as described by Gaza’s health ministry.
Dr Ayadil Saparbekov, head of the WHO’s team in the Palestinian territories, has been desperately trying to attract world attention to the dire situation of sewage contamination and lack of clean water.
Wastewater is running freely between displacement camp tents and and inhabited areas; about 600 people are having to share one toilet; as many as 70% of sewage pumps have been destroyed and not a single wastewater treatment plant is working in Gaza, presenting the “perfect breeding ground” for polio and other vaccine-preventable disease to spread, he told the media.
Also read | Polio in Gaza: What Does this Mean for the Region and the World?
Historically the origin of polio is the ‘wild poliovirus’ that spreads through faecal matter-contamination and poor hygiene. There is evidence that through the centuries, the rulers and the ruled, the rich and the poor, and colonising countries and colonies were equally affected by the virus.
The United States, a superpower, was humbled by the polio epidemic of 1952, reporting 57,628 cases that year with 3,145 dead and 21,269 left with mild to disabling paralysis. This speeded up the development of the oral polio vaccine (OPV), and a dramatic drop was seen in the number of cases in countries that could afford the vaccine.
And then came 1988. The entire international community represented by member states at the World Health Assembly unanimously adopted the resolution to eradicate polio from the face of this earth. The polio vaccine became free for every child, marking the launch of the Global Polio Eradication Initiative (GPEI) spearheaded by national governments, WHO, Rotary International, the US Centers for Disease Control and Prevention and UNICEF.
The GPEI – of which movie star Amitabh Bachchan has emerged as an ally on Indian TV – was later joined by the Bill & Melinda Gates Foundation and GAVI, the global vaccine alliance. Billions of dollars have backed the initiative, and the commitment for turning the aspirational goal of polio eradication into reality has been driving the programme for more than three and a half decades.
There are two kinds of polio vaccines, WHO tells us: OPV, which contains an attenuated or weakened live virus and is given orally; and the inactivated polio vaccine or the IPV, which is given through intra-muscular injection.
If more than 95% of the targeted population is not vaccinated at the same time, the vaccine-derived poliovirus (VDPV) can emerge when children vaccinated with OPV excrete the vaccine virus, and it spreads to under- or unimmunised people. If not quickly tackled with a vaccination campaign, it may mutate over time to become a virulent virus that circulates and causes paralysis in populations with low levels of immunity.
In 2023, WHO reported 524 polio cases in 32 countries caused by vaccine-derived poliovirus. The strain of vaccine-derived poliovirus that has been detected in the wastewater in Gaza is the circulating VDPV Type-2. This was a clear signal that the virus was lurking and could attack any moment.
Keeping a polio-free Gaza is critical not only for Gaza’s children, but also for the region and for this entire global village we live in. We have been warned time and again that viruses, pathogens and toxic exposures know no borders.
The circulating VDPV Type-2, the same as in Gaza, was isolated in wastewater in Jerusalem, London and New York in early 2022. Some researchers have attributed this to high concentrations of Orthodox Jews in these urban neighbourhoods who may have refused vaccination. Later in the same year, a young man of twenty, living 65 kilometres north of New York City, became the first case of local polio transmission in the United States in three decades.
Global polio data tells us that in 2023, most outbreaks of VDPV Type-2 were in the Democratic Republic of Congo, Yemen, Nigeria, Sudan and Somalia, where ongoing armed conflicts obstructed and considerably reduced access to vaccination. There was also one case reported in Egypt, from a place that borders Gaza. Did the virus found in Gaza’s wastewater hop across from Egypt? Epidemiologists will tell us in due course.
As part of an assignment with UNICEF, I had the opportunity to work intensively with the polio eradication programme in India, Afghanistan, countries in central Asia as well as west and central Africa. “Why this fuss? Why make this monumental effort to eradicate one disease?” was the question that bothered me initially as I worked long hours in the field with health workers, community mobilisers, government officials, teachers, religious leaders, celebrities, parliamentarians, media persons, and of course children and their families.
But as I allowed myself to see, hear, smell and feel what it took to reach every child through scorching heat, flood waters, snow and war, the principle of health equity, gender rights, diversity and inclusion that the programme stood for sank deep into my heart and made a permanent home there.
To many experts, ending polio in India had seemed impossible until it was done. Representative photo. Credit: RIBI Image Library/Flickr. CC BY 2.0.
India accounted for 60% of the world’s polio cases when the then Congress government of PM Narasimha Rao rolled out the Pulse Polio Immunisation Programme in October 1994. To many experts, ending polio in India had seemed impossible until it was done. The last polio case reported was in Howrah, West Bengal on January 13, 2011 and India was certified ‘polio-free’ three years later.
The sheer size and complexity of India’s polio operation was baffling. Over 172 million children were vaccinated with approximately 1 billion doses of OPV administered every year through several campaign rounds. In addition to obvious impediments such as lack of clean water, poor sanitation and hygiene habits and malnutrition among children, differences of religion, caste, access to services, mistrust and superstition created social and cultural barriers giving rise to numerous ‘high-risk’ pockets that were reservoirs of transmission for the poliovirus.
To overcome this problem by engaging with resisting communities on a regular basis, UNICEF deployed a network of over 7,000 community mobilisers to assist an army of vaccinators more than twice the size of India’s armed forces.
The problem was mainly with the underserved sections of the society and minorities whose dominant fear was that the vaccine was a ploy to induce sterility among male children. Minority communities such as Muslims in UP, Dalits in Bihar, Adivasis in Chhattisgarh and Jharkhand, and tribespeople in the northeastern states were suspicious of the programme and hid their children from vaccinators.
During one of the campaigns, I was with my team of community mobilisers in a village close to Aligarh in Uttar Pradesh, which had reported vaccine hesitancy and active refusal to vaccinate children, particularly boys, with the polio vaccine. From a 0% coverage, we were desperate to reach at least 95% to make the round successful – an incredible task of turning night into day, I thought!
We had a convincing narrative, we thought. We enriched it with anecdotes, adapted it to the local situation, did a few street corner skits, reasoned with the younger people, pleaded with the elders; but it was a firm “no” from the villagers.
Suddenly, Bibijan, a respected woman with ash-coloured hair and a wisened face, made a proposal. “Give your polio drops to my hen, and if she lays an egg tomorrow, I will make sure that all the children in this village and the next will take polio drops from you.”
Sheela, our pragmatic community mobiliser who knew every household in that village inside out, jumped at the bait. I made big eyes at her and shook my head fearing the worst. But Sheela had seen her opportunity and did not wish to let it slip by. She slipped two OPV drops promptly into the hen’s beak that Bibijan had held open.
I didn’t sleep that night. How could we tie the future of this rigorously data-driven, globally watched programme to the whims of a hen?
The next morning, we found the whole village gathered in the old lady’s courtyard. The chief medical officer (CMO) of Aligarh was also present, and so was the Aligarh Muslim University’s then-vice chancellor Prof Naseem Ahmed, nicknamed ‘Naseem Polio’ by the students for his devotion to polio eradication. There was tea for everyone with a dash of expectation and a lot of uncertainty.
The star of the event, Bibijan’s hen, clucked around smugly, fed on some soaked grain while time stood still for me. And all of a sudden before my glazed eyes, she started whirling around and ran to her box emitting croaking sounds. We watched her make a notional bed with the sawdust, spread her wings slightly, take position, and voila – a beautiful white egg was laid!
True to her word, Bibijan gathered all the children of the village and sent word to the neighbouring villages too. We vaccinated them and the job was done.
How could Sheela be so sure? “I know the hen. She is in her fertile period, and loves her virile rooster,” she explained with a smile. Her approach was controversial from a scientific point of view and was discussed threadbare at review meetings by the epidemiologists amongst us.
Sheela listened to her own inner voice and relied on her community-based intelligence network. The choice was between not getting children vaccinated either way by not giving the drops to the hen, and exploring the possibility of a positive result by going along with Bibijan’s logic. This experience taught the polio team to think on their feet and open our hearts and minds to communities whose interest we claimed to represent.
Also read | Vaccine Hesitancy: A View From a Polio Eradication Programme in Balochistan
During 2007-2009, the growing violence in Afghanistan, particularly in the polio ‘high-risk’ southern provinces of Zabul, Kandahar and Helmand, prodded us to adapt and innovate access strategies to get polio drops to every child. Since all our polio partners believed that public health should not be held hostage to political or military hostilities, we made a joint decision to work with government officials as well as the Taliban to access children in their respective areas of influence.
While health workers and volunteers of the government delivered vaccines in the districts governed by the then-government, the Taliban tanks with white flags and equipped with OPV vials in cool boxes vaccinated children at hub points in areas where they held sway.
In most countries, the polio campaign relied on communities themselves to provide vaccinators and mobilisers as a strategy to develop a sense of participation and ownership in the larger public good that the campaign represented. In Afghanistan too, community members came forward to join the campaign and got a small amount of ‘pocket money’ to buy ‘naan (bread), samboosa (savoury patties) and chai.’
As we waited to train these volunteers a week before the scheduled campaign, a solitary messenger came by to convey the regrets of the community members. They had been hired by the poppy growers on daily wages of US$18, a simple choice to make for the community in comparison to our ‘pocket money’ of US$4 a day.
Can you blame them for going for a better-paying option in a country that had practically no jobs for them? Lesson learned – don’t clash polio campaign dates with poppy harvesting.
One of the strategies to enhance outreach was to work with teachers who could immunise children in schools. In this context, I was waiting with a covered head and a ‘mahram,’ a male escort outside a decision-maker’s office in the department of education in the Taliban-held Kandahar province.
It was my first meeting with a senior Taliban official and I was somewhat apprehensive. He came out of his office to receive me, and I could see he was wearing a black patch under his Afghan ‘pagri’ (turban).
“I stepped on a mine and lost my right eye during the Mujahideen war in the early nineties,” he explained in fluent English. “I studied in Pune in India,” he told me, knowing that I was Indian. “I like Hindustani classical music a lot, and raag Bhairavi is my favourite,” he added, enjoying the stunned look on my face.
That broke the ice, and we went on to discuss Ustad Muhammad Hussain Sarahang, the famous classical singer from Kabul who had trained in Ustad Bade Ghulam Ali Khan’s Patiyala ‘gayeki’ (style of singing). Thus, the late Ustad Sarahang opened Kandahar’s schools for polio immunisation, and I happily dumped my stereotypes about Taliban administrators.
In 2008, the conflict between the 41,000-strong International Security Assistance Force (ISAF) led by NATO and the Taliban insurgent groups worsened. It was almost impossible to conduct mass campaigns, with rockets and bullets fired without warning and armoured vehicles humbled by improvised explosive devices.
WHO, UNICEF and ‘neutral’ Afghan intermediaries acceptable to both sides started negotiating ceasefire days with the warring factions. There was a lot of back-stage diplomacy involved, and it was also difficult to keep track of the number of factions involved.
On one occasion I remember flying low in a chopper over a Taliban-dominated area between Kandahar and Helmand on a negotiation mission. All six of us in that rickety aircraft had our eyes glued to the barren, undulating terrain below us to make sure that no one was sending up a rocket to down our chopper!
Sometimes ceasefires, or ‘Days of Tranquility’ as they were called, were agreed to to give safe passage to vaccinators. They were broken on a few occasions, mostly by ISAF forces who wanted to use the safe passage opportunity to catch a wanted insurgent or two. This dealt a serious blow to the programme and put the lives of community mobilisers and the local intermediaries at risk, since the insurgent groups suspected them of double-crossing and sneaking on them in order to aid ISAF soldiers.
Trust is key for the smooth continuation of a public health programme, especially in war; and all parties to the conflict have the responsibility to keep their word. The polio programme in Pakistan saw the community’s trust broken in May 2011 by a trusted doctor in charge of the polio campaign in the town of Abbottabad in the Hazara region of Khyber Pakhtunkhwa province.
In Afghanistan, sometimes ceasefires were agreed to to give safe passage to vaccinators. Representative image. Credit: Canada in Afghanistan. CC BY-NC-ND 2.0.
Residents of the area alleged that the doctor had collected blood samples of children from the house where Osama bin Laden, the man most wanted by the United States for the 9/11 attacks, had taken shelter in. It is believed that the CIA was able to establish bin Laden’s identity based on a DNA analysis of the samples collected by the doctor and conduct a clandestine operation on the house that killed bin Laden.
The trust deficit created by this single incident set the campaign back by decades. It fanned an anti-vaccine and anti-vaccinator sentiment that resulted in the deaths of tens of vaccinators in subsequent years. It is a major reason why polio is still endemic in Pakistan and neighbouring Afghanistan. Have the CIA or the US government provided any explanation, leave alone an apology? I have not seen one.
Coming back to the original question, why prioritise polio vaccination when there is a dance of death going on in Gaza? Eradicating polio is undoubtedly the most comprehensive and rigorous public health initiative that embodies people, skills and programmes that will continue to strengthen the core functions of healthcare systems in every country, long after polio is gone.
Emergencies such as Ebola, COVID-19 and health crises after floods, tsunamis and earthquakes have built their response activities on the polio eradication blueprint using micro plans of streets, villages and towns, social networks and community mobilisation platforms, programme management mechanisms and coordination tools, etc.
“Polio workers go where even the rays of the sun do not penetrate,” a WHO report quotes a father in India as saying when the country was the polio epicentre of the world. But more importantly, the investment made in the eradication of polio is an investment in the future of public health in times when governments are stepping back from the public sector and handing over essential health care and health governance to commercial interests.
In a situation where Gaza’s health services are being reduced to rubble, it speaks volumes for ongoing polio surveillance that it was able to detect the presence of VDPV2 in the territory’s wastewater. While the polio surveillance system is primarily responsible for poliovirus detection, it has proven to be a resource for supporting much of the overall vaccine-preventable disease surveillance in many low-income countries.
Collectively, the system built to vaccinate every child against polio has invariably helped detect and respond to outbreaks of other preventable diseases such as measles, Ebola, yellow fever and neonatal tetanus, among others.
Mainstreaming polio programming elements into other health care priorities or using the existing capacities of the programme to respond to health emergencies that Gazans are facing are investments that will build a healthier life and surroundings for the Palestinian people, particularly children who have lost their families and have been robbed of their childhood.
There is a strong case for investment in organising polio campaigns for 600,000 children in Gaza as Dr Tedros Adhanom Ghebreyesus, the WHO director general, has proposed to do with 1.2 million doses. If two polio campaign rounds as proposed by WHO are allowed to happen, they could provide an entry point to other critical immunisations like measles and to an essential package of services including clean water, sanitation and hygiene promotion, nutrition services and psycho-social support to overcome trauma.
This strategy of riding on the back of polio campaigns would give Gaza’s health systems a boost and bring them back from the brink.
Nothing short of an immediate ceasefire is needed in Gaza for an effective immunisation campaign to reach every child with polio drops. “We know what needs to be done. It must be done for the sake of all residents of the region. This is not about politics. This is about health and life,” Israel’s leading epidemiologists have minced no words to make the point. Will they be heard?
The author worked in social and behaviour change communication for the International Red Cross and UNICEF in Afghanistan, central and south Asia, and francophone Africa.
