Focus on challenges of eradicating polio

In 2001, only seven cases of the wild polio virus were reported to health workers in Somalia. A small figure by all accounts, but precisely because the goal of wiping out the virus is so close to being reached, the eradication programme is at its most crucial stage. "We have reached the most dangerous time in the programme now," Athalie Christie of the World Health Organisation (WHO) told IRIN in the town of Baidoa. "People think the global programme is already over which means the political commitment to finish is in danger of wearing away." She said this could have the effect of the programme no longer being a priority for governments, coupled with financial constraints. "Secondly," she added, "local people tell us polio is not the biggest health problem in the country any more, so the will to eradicate it on the ground is in danger of diminishing as well." The countrywide polio eradication programme is being carried out by WHO and the UN Children's Fund (UNICEF). The Somali context also brings its own, very particular challenges to the programme. The local governor in Baidoa commended it, stating "it is something very remarkable to get vaccinations in your home without any money to offer". But gaining access to all Somali children under five years of age is by all accounts a "logistical nightmare", the UN agencies said. Difficulties caused by insecurity Baidoa is relatively peaceful at the moment, which means that health workers can mobilise interest in the programme through radio broadcasts, musicians performing in the town, announcements from the local Imam after Friday prayers, religious leaders debating the issue, banners, flags, and sporting events. Mothers know that vaccinators will arrive in their homes to give their children the necessary two drops of vaccine. "We heard the microphone announcing that they are coming, and we are now waiting for the vaccines in our home," one old woman told IRIN. In contrast, the areas where the seven cases of the virus were found in 2001 - the regions of Lower Shabelle (in which the capital, Mogadishu, is located) and Benadir - are plagued by insecurity. The previous year, there was a large outbreak of polio, with 46 reported cases, nearly all of which were in Mogadishu. "For me to go to Mogadishu, I have to get clearance from New York, I have to go with numerous militiamen and I can only stay for three days. It's a nightmare," says Lieven Desomer of UNICEF. Even in relatively peaceful Baidoa, each car carries an armed security guard at all times. "Just in case," the security men say. Using "windows of opportunity" is the only way to access the most insecure regions. "If an area opens up for a week, we have to be ready to move immediately," says Christie. In Mogadishu, local vaccinators have to carry the vaccines in their pockets in "hit and run campaigns". The sight of a cool box containing the vaccines can put a vaccinator's life at risk. "Around Mogadishu, because there is a mixture of clans it is most insecure. Our polio coordinator on the ground has to sleep in a different house each night," says Christie. Just last week, medical workers from the African Medical and Research Foundation International (AMREF) were killed in Gedo, southern Somalia, which means that area is now closed, she said. In 2001, three vaccinators were killed and a number of other polio eradication employees injured in firefights and car accidents. In March, nine UN staff members and aid agency staff, two of whom were part of the polio programme, were taken hostage and held for between three and nine days in the capital. "Everything is an issue here," adds Desomer. "We are currently running one of the most successful programmes in the whole of Somalia, we have about 6,000 people working for us. Which means in some cases, people will spread rumours that it's bad to take the vaccines, if their clan members didn't get hired by us, or if we hired a car from the wrong clan. If we're in Baidoa we have to hire cars from Baidoa, when we go to the next town we have to hire another one from that town..." Every decision, no matter how small has to be negotiated and renegotiated, he says, so that everyone "gets a slice of the cake". Vaccinators have to be changed regularly to ensure that each clan gains from the employment on offer, which means that each time they have to be trained. "It's not very beneficial to the programme," he says, "but there is no other way of doing it." Aims of the programme Of the seven cases of the virus found in 2001, four reported no history of vaccination. In two of those cases, parents had refused to allow their children to receive the drops because of clan rivalry. The other three reported receiving more than three rounds, but in the Somali context where intestinal infections are rife, six or seven rounds are necessary to immunise fully. Once a child contracts the virus, little can be done to help in a country with no central government, no reliable population statistics and minimal health facilities. Often children who are suffering from paralysis are brought to see sheikhs and traditional healers, instead of doctors. One local woman says her child - who looks three or four years younger than his nine years - contracted polio three years ago which left his hand and leg paralysed. "We treated him with traditional methods, we read the Koran and we did traditional massage," she says. By July 2002, WHO/UNICEF aim to have cut transmission of the virus and by 2005, to have eradicated the disease on a global scale. The main focus for the vaccinators in Somalia are the urban centres, particularly those where access is limited. "We have a virus corner in two areas now, and if all goes well, we can get rid of it," says Christie. Asked about the chances of success, Desomer adds "we're well on track". So far this year, no cases have been reported and the country-wide surveillance system is improving all the time. "Remember that the programme began in Somalia as recently as 1997," he points out.