GPEI announced a series of commitments to advance gender equality at the Generation Equality Forum in Paris, organized by UN Women and hosted by the Governments of France and Mexico between June 30 and July 2, 2021. The Forum kickstarted a 5-year journey to accelerate ambitious action and implementation on global gender equality.
Through its new Eradication Strategy 2022-2026, the GPEI committed to integrate a gender perspective into programming to support countries to address gender-related barriers to polio vaccination, to increase women’s meaningful participation and decision-making across all levels of the program, and to utilize gender-sensitive indicators to ensure girls and boys are reached equally. This will be realized through policy, programmatic, advocacy and financial commitments with the goal to eradicate polio through a gender lens.
GPEI joins the World Health Organization (WHO)’s ambitious and bold commitments for gender equality and the empowerment of women and girls in all their diversity, announced during the Generation Equality Forum. The GPEI looks forward to working with a broad range of partners to deliver not only on polio eradication, but also on gender equality, for future generations.
Even long before the GPEI was formed, Monaco played a leading role in early initiatives to develop a polio vaccine. In the 1950s, Her Serene Highness Princess Grace was an advocate for the National Foundation for Infantile Paralysis in the United States of America, founded by President Franklin D. Roosevelt (himself a polio survivor).
The Foundation became known as the “March of Dimes”, so called because of its far-reaching call for funds to research a cure for polio, which at the time was one of the most serious communicable diseases in the USA. Grants from the NFIP facilitated the work of researchers such as Dr. Jonas Salk, creator of the first successful vaccine against poliovirus. But it also facilitated the work of unsung heroes, such as Dr. Leone Farrell at the University of Toronto’s Connaught Medical Research Laboratories. Farrell devised the “Toronto method” for mass production of vaccines, which made the massive field trials of Salk’s vaccine possible, paving the way for the mass vaccination campaigns which have brought us so far in eradicating polio.
Farrell is one of thousands of women past and present at the forefront of the GPEI. The role of women in polio eradication is supported by Polio Gender Champions, who work to raise the voices of women engaged in the programme, and keep gender equality high on the global public health agenda.
And today, Monaco’s proud tradition of support for gender equality and polio eradication continues, with the announcement that H.E. Ms. Carole Lanteri, Ambassador and Permanent Representative of Monaco to the United Nations Office at Geneva will become the newest Gender Champion for Polio Eradication. The Ambassador, formerly co-chair of the GPEI’s Polio Partners Group, explains the significance of this new role:
“As the Covid-19 pandemic continues to affect our lives, women pay a higher price with regressive effects on gender equality. If gender dynamics are not taken into consideration, polio interventions will not be as effective, with the potential risk of exacerbating existing inequalities. More than ever before we must advocate for a meaningful inclusion of women in decision making processes and adopt policies in health programming to reflect this. Today my commitment to these causes is even stronger thanks to my new role as Gender Champion. Following in the footsteps of Princess Grace and taking forward Monaco’s longstanding commitment to gender equality and polio eradication, I am determined to use my voice to advocate for gender mainstreaming in polio eradication to reach every last child.”
Ambassador Lanteri joins the ranks of other gender champions striving to raise awareness of the role of women in polio eradication and on the importance of addressing gender related barriers to immunization. Their work will be instrumental not only in eradicating polio, but also in creating a legacy for recognizing and empowering the role of women in major public health initiatives.
Therese and Léonie reminded me of this hard truth in a recent visit to a hospital in N’Djaména, Chad. One is a newborn girl and the other is a veteran of the campaign to eradicate a human disease for only the second time in history –polio-.
As a Gender Champion for Polio Eradication, I have committed to supporting the global initiative to eradicate polio and the women who work tirelessly to protect children from lifelong paralysis. During my visit to Chad, I had the honour of giving two drops of life-saving oral polio vaccine to two newborns.
Protected from a disease which once struck millions of children, Therese now has a better chance of a healthy life. Thanks to the Global Polio Eradication Initiative (GPEI) – spearheaded by Rotary International, national governments, the World Health Organization, UNICEF, CDC, the Bill & Melinda Gates Foundation and Gavi, the Vaccine Alliance – she is one of more than 2.5 billion children who have received the oral polio vaccine, as the global polio caseload has been reduced by 99% since 1988.
But as I looked at Therese, I also wished that she would have a better chance not just for health, but also for opportunities to prosper. I thought of a recent WHO report I had read – Delivered by Women, Led by Men – which observed that women make up 70% of the global health workforce but hold only 25% of senior roles – a situation that is no different for the polio program. Would Therese’s future reflect that disparity?
I found both frustration and hope in answer to my question when I listened to Ms. Léonie Ngaordoum, the woman responsible for the campaign which brought the vaccine to Therese.
Léonie is head of vaccine operations for Chad’s immunization programme. It is women like her who have brought us this far in the long fight against polio. It is women like her who have gone the extra mile to keep their countries safe when, in 2020, the polio programme faced unprecedented challenges in the face of a new pandemic- COVID-19.
Her journey to a senior public health position in Chad has been difficult. Driven to remote areas on dangerous roads to oversee vaccination campaigns, she has twice suffered accidents, one of which left her with severe spinal injuries. She has faced gender discrimination, countered vaccine misinformation, convinced vaccine sceptics, and stayed the course despite the severe strain of COVID-19, and struggling for respect and recognition in a male-dominated environment.
Today she has a clear vision to share: “I speak about vaccination as if it were a vocation…the program change needed to achieve polio eradication is to empower enough women.” Léonie’s experience highlights the necessity of increasing senior roles among women in the health workforce and involving them in policy decisions.
Women like her frequently operate in dangerous and conflict-affected areas, putting their own personal safety at risk – all in efforts to protect communities from deadly diseases. Women have a greater level of trust with other women and thus are able to enter households and have interactions with mothers and children necessary to deliver the polio vaccine. And this way they can also provide other services, such as health education, antenatal care, routine immunization, and maternal health.
The knowledge and skills gained by this workforce are already being deployed against COVID-19, in surveillance, contact tracing, and raising public awareness. Indeed, more than 50 percent of the time spent by GPEI health workers is already dedicated to diseases and threats beyond polio. It’s clear that the future of public health is inextricably linked to the status of women. Their heroic actions provide nothing less than a blueprint for the future of disease prevention. The Resolution on “Women, girls and the response to COVID-19”, adopted last year by the UN General Assembly, should play a key role when addressing these challenges and the specific needs of women and girls in conflict situations.
The centrality of women to the success of public health projects has for too long gone unrecognised, and must be formalized. That is why today, on International Women’s Day, we must pay tribute to the tremendous contribution of women like Léonie around the world in protecting their communities from deadly diseases such as polio. But at the same time, thinking of the world in which Therese will come of age, we need to commit to empower every woman and girl. It will not only make for a more just world – but a healthier one too.
Throughout her career as a Resource Mobilization Officer for WHO’s polio eradication programme, Heather Monnet has held onto her vision of a polio-free world. A respected communicator with a deep understanding of the polio programme, she was one of the first in the programme to realize that considering gender is crucial to defeat the poliovirus. Since 2017, she has successfully “led from behind”, supporting the Global Polio Eradication Initiative (GPEI) to develop a gender strategy and workstream which has become a model for other United Nations programmes, and which is designed to overcome some of the most intractable challenges facing polio eradicators.
Describing her motivation, Heather describes “putting on her gender glasses”. She explains, “We had reached a point where it seemed like we had turned nearly every stone to eradicate polio, and yet we had not defeated the disease. At the same time, the introduction of the sustainable development goals had led to an increasing awareness of gender. I began to think more about how gender affects health and health-seeking behaviors.”
“I was not, and am still not a gender expert, but as Member States began to speak more about this issue, it was increasingly on my radar. Putting on my “gender glasses”, I realized that gender was an unexplored intersection for polio eradication, and it could be transformative for our work.”
In polio eradication, areas where gender intersects with health delivery include exploring whether boys and girls are equally as likely to receive the polio vaccine, and if gender norms impact whether mothers are able to take their children to health centres for routine immunization.
In some places, such as in Nigeria, women are often more effective at delivering the polio vaccine than men, as it is more culturally acceptable for them to interact with mothers and enter homes to vaccinate the smallest children. The GPEI Gender Technical Brief showed how the presence of female health workers in Pakistan has been associated with substantial increases in tetanus vaccine coverage, attended births, and full immunization coverage of children.
To explore and respond to the gender dynamics of polio eradication, the GPEI has published a comprehensive gender equality strategy. A dedicated gender analyst works in the polio programme at WHO headquarters, and gender focal points have been appointed at regional levels and in some country offices. Data is now routinely disaggregated by sex, and there has been a concerted effort to use gender analyses to inform programme policy. The team are currently engaged in implementing the GPEI gender strategy as well as supporting efforts to mainstream gender across WHO, including through a dedicated gender data working group.
Advocating for consideration of gender within the programme has not always been easy. Heather explains, “The polio programme is huge and so many people are involved. Encouraging people to put on their ‘gender glasses’ even for five minutes can be a challenge. But what is really encouraging is that once we educate people about how gender impacts their work, they often have an “aha” moment.”
“The next and crucial steps are striving to ensure that the gender strategy is implemented. This requires all those involved in polio to be engaged – whether it’s designing a gender-inclusive microplan, collecting sex-disaggregated data during a campaign, or considering how gender impacts the way we pay vaccinators. As we integrate gender into our work, we also need to identify the building blocks to ensure that this workstream is sustainably mainstreamed. This is not dependent on one person – rather it takes everyone having exposure.”
Polio Gender Champions
The GPEI gender workstream is supported by Polio Gender Champions, who work to raise the voices of those engaged in the programme. Champions include Senator Hon Marise Payne, Australian Minister for Foreign Affairs and Minister for Women, Wendy Morton, Minister of European Neighbourhood and the Americas at the Foreign, Commonwealth & Development Office in the United Kingdom, and Arancha González Laya, who is the Spanish Minister for Foreign Affairs, European Union and Cooperation.
Heather explains that the vision and leadership of the gender champions is crucial for achieving change. “The gender champions amplify the voices of those who don’t have a megaphone on the global stage and whose voices need to be heard. For instance, female frontline workers have a lot to say, but their voices aren’t always listened to. Our gender champions raise up these voices from the field.”
“This feeds into our attempts to improve the way that health is delivered. We know that most healthcare is delivered by women, but the systems to deliver it are designed by men. Practical steps to support women employed by the programme may include ensuring that polio vaccination training materials can be understood by individuals with lower literacy, and ensuring that there are safe, private bathrooms available for women to use during long campaign days. When we plan routes to deliver vaccines from house to house, we should consider that women might prefer to take a different route which gives them a greater feeling of personal security. Women may not feel comfortable speaking about these issues to a male supervisor, so we must also ensure that enough female supervisors are recruited and trained. Gender champions are key to keeping these issues high on the global agenda.”
Over the last few years, the GPEI’s gender work has been recognized in multiple high-level forums, and is leading the way for other programmes. Heather identifies two moments when she felt particularly proud – when the Polio Oversight Board adopted and endorsed the GPEI gender strategy, and at a high-level meeting hosted by the Government of the United Arab Emirates in advance of the Reaching the Last Mile Forum in November 2019, during which the Canadian representative described GPEI’s gender strategy as one of the strongest in global health and noted that it should stand as an example for others.
Heather explains, “I have been inspired by what we have achieved – we have planted the seeds and the soil is now being nourished. Our work on gender is growing into something amazing – and the world is watching what it will become.”
Henrietta Lacks was diagnosed with cervical cancer in 1951, at the age of 31. Doctors in Baltimore, USA took a small sample of her tissue during the treatment to remove her tumour, without her knowledge – a not uncommon way to treat minorities at that time. Up to that point, attempts to grow human cells outside the body had failed. However, Lacks’ cells were different: they were able to divide and replicate indefinitely. These cells became the source of the HeLa cell line – one of the most important cell lines in medical research – and contributed to developing the first polio vaccine. While the world has benefited greatly from Henrietta Lacks’ cells, the unethical use of her cells raised concerns about longstanding medical racism towards marginalized or minority communities – and has contributed to the movement towards more people- and community-centred care.
Margaret C. Snyder is often called the UN’s First Feminist. Her pioneering career refocused the mechanisms of global development aid to include women. As she wrote last year: “There was a failure to realize that the most serious problems of development defy solution without the involvement of women.” When she began working at the UN, in the early 1970s, most women did secretarial work. Under her influence, that began to change. By 2021, women make up a significant portion of UN professional staff, and applying a gender lens to the UN’s work has become essential. This thinking was foundational to the systematic adoption of gender-based planning that has underpinned polio eradication. Margaret C. Snyder died earlier this year at the age of 91.
Dr. Folake Olayinka has spent over 20 years working in public health, including at the frontline of efforts to eradicate polio and strengthen immunization.
“At local levels, where the rubber meets the road, we need to make things work. Frontline health workers should be supported with tools that meet their needs, and training that truly values their insights, local innovations and problem solving,” said Dr. Olayinka.
Today, as a global health leader and former John Snow, Inc. (JSI) Project Director for the USAID-funded MOMENTUM Routine Immunization Transformation and Equity Project, she continues to exchange lessons and innovative strategies from the frontlines with other parts of the world impacted by polio and low immunization coverage.
On August 25, 2020, Nigeria, previously the last stronghold of endemic wild polio in Africa, was officially declared free of wild poliovirus. One of the factors contributing to this success was the ability to provide high-quality capacity building and support to improve health workers’ competencies at all levels of the health system.
“The health workers on the frontlines – particularly the community-based workers, many of whom are women – are the backbone of all of these efforts. They operate under incredible circumstances to ensure that their communities have access to life-saving health services,” said Dr. Olayinka.
Dr. Olayinka began working on polio in 2002 in Nigeria. She worked closely with colleagues at the Nigerian Ministry of Health, the World Health Organization, the EU and UNICEF to ramp up health worker training in support of the Nigerian government’s National Program on Immunization.
Her team’s dedication was remarkable. “We were willing to go everywhere to reach the last child. Once I walked four hours to support an immunization team,” she recalls.
Shaking things up
Dr. Olayinka emphasized training quality and the use of feedback to continuously improve the training experience for health workers. She led the development of numerous training guides and materials for polio eradication and developed the country’s first Basic Guide for Routine Immunization Service Providers. She also worked closely with WHO and EU colleagues to develop the first measles campaign field training materials in Nigeria.
Knowing that training of health workers must be continuous, she introduced mentoring as an important post-training approach in Nigeria’s immunization program.
“We needed to move people towards a more interactive approach,” said Dr. Olayinka. “These approaches transfer knowledge while maintaining dignity and recognize that people in the global South have something valuable to contribute.”
Recalling her experience training different types of health workers and trying to promote adult learning methods, she said, “I once walked into a room of senior health commissioners from all over the country. The room was filled with the usual PowerPoints, and people were not engaged – even sleeping.”
“When I went to the front of the room for my session, I introduced myself using my first name and explained the more interactive approach that I was proposing for the training. At first people were silent, but as the training went on, they really came alive. They were engaged and now identifying the real issues and generating the types of ideas that could truly change policy and improve services – you could see their passion coming through. I felt the ship took a turn.”
Dr. Olayinka also tackled training needs at the community-level and strongly promoted the use of local languages in the training of frontline health workers, particularly social mobilizers for polio eradication.
“At local level in northern Nigeria, most people spoke Hausa; however, training materials were largely in English at the time, and many of the women who were able to enter the homes to provide polio vaccinations did not understand English.”
“The polio programme was at a crisis point and was also facing a lot of refusals. As people in the region were not receiving other basic health services, they began not to trust polio vaccination efforts as it was one of the only services they were receiving.”
A pivot was needed, with a closer examination of what was working – and what was not – for all aspects of the eradication effort.
“These women were looking for the basics: how do I answer questions from caregivers, how do I provide polio drops, how do I enter my data?” remembers Dr. Olayinka “With this insight, I developed a flip chart using pictures – I even included a photo of my own son receiving the oral polio drops. We also used the local languages, role play, peer to peer methods, and songs as part of the training methodology.”
In the area of routine immunization, Dr. Olayinka worked with her team and other partners to introduce a stronger supervision system. The system included a checklist with clear standards for supervision of routine immunization, as well as a checklist on training quality as part of the pre-campaign preparedness. This helped National Primary Health Care Development Agency staff to provide ongoing support and mentorship for health workers. Many of these approaches and materials are still being used today and are updated periodically.
At the heart of the response, you will find a woman
Dr. Olayinka worked in a particularly challenging environment in northern Nigeria. “There are gender dimensions tightly linked with socio-cultural and deep-seeded religious beliefs in the northern state”, she recalled.
Oftentimes mothers had to seek permission from their husbands before they could allow the children to be vaccinated or access health services. “Even when they understood the value, women did not have decision-making power.”
The polio programme was able to reach women in new ways. Men originally started out as polio workers, but it quickly became apparent they were missing children under five because they were not allowed into homes due to cultural norms. The solution: hire women to go door-to-door and reach populations being missed.
“The polio programme brought women out into the workforce in an unprecedented way, says Dr. Olayinka. “Women were powerful mobilizers, particularly older, respected women and could enter any home. The polio programme was one of the first programmes bringing the women out, training them how to speak to other women and community members, which gave them a standing in the community. They also received some stipends which empowered them a bit financially.”
Many of these women later transitioned to supporting broader immunization and other health efforts in their communities, leading to higher child survival rates and less disease in communities.
“This is part of my passion when I talk about integration – these women in the communities, after getting a start from the polio programme, can be trained to talk about routine immunization, use of long-lasting insecticidal nets to prevent malaria, breastfeeding, WASH etc.”
“As a result of the polio programme they have social capital that can be expanded to improve health outcomes in their communities.”
To women leaders of the future
Dr. Olayinka remains committed to elevating the contributions of frontline health workers operating in challenging situations across the world.
When asked what advice she would give to women beginning their careers in public health, Dr. Olayinka said, “Be persistent and do not give up on your dreams. Even where you face discrimination because you are a woman, be focused and persist. Ensure that you are constantly building your capacity and equip yourself.”
“Women at all levels can make a difference, so take the leap—there are no limits to what you can achieve.”
From her first polio vaccination campaign in 1997 to the present day, Dr. De Sousa has never lost her passion for increasing access to immunization. The National Expanded Program on Immunization (EPI) Manager for Angola, she remembers her first impressions of the country, “At the time, I could see that most children in the country were not vaccinated and I was excited to help them.”
From the outset, she knew that taking on polio eradication would be challenging. “Angola had just emerged from an armed conflict and there were areas that were very difficult to access, due to dilapidated roads, broken bridges and mining activity, and for that reason there was low routine vaccination coverage. Nevertheless, I felt that I had a duty to fulfill for our children, so I accepted the challenge.”
In 1998, Dr. De Sousa was appointed by the National Directorate of Public Health to help implement the Epidemiological Surveillance System for Acute Flaccid Paralysis (AFP) – one of the primary symptoms of polio. It was a position that required grit and resilience.
She explains, “This was a big responsibility because highly sensitive surveillance for AFP, including immediate case investigation and specimen collection, are critical for the detection of wild poliovirus. AFP surveillance is also critical for documenting the absence of poliovirus circulation for polio-free certification.”
“One of my most vivid memories of the programme is from 1999 when I was trying to reach conflict-affected areas after a polio epidemic had registered more than 1190 cases and 113 deaths. I was early in my career with only two years of service and the sheer number of cases and deaths led me to be proactive and persistent in my day-to-day activities toward the eradication of the disease.”
“Another standout moment occurred on the second time that I went to coordinate a vaccination campaign in the province of Moxico; one of the vehicles in our convoy triggered a mine, so we were forced to stop the vaccination campaign as our colleagues were stranded in conflict zones for a few days. This incident captures the difficult circumstances we were operating in as health workers.”
Eradicating wild virus in Angola
For years the polio team worked to improve operations to detect polio and deliver vaccines, but the virus fought back. After registering a last case of indigenous wild poliovirus in September 2001, Angola recorded four successive outbreaks imported from India and Congo. Dr. De Sousa remembers that this caused many people to doubt that the eradication of polio would ever be possible.
“But I refused to be discouraged. I’ve never backed down from a challenge and I don’t plan to soon.”
After years of work, Angola finally received wild polio-free status in November 2015. Dr. De Sousa describes it as her proudest moment.
“I felt that I made a great contribution to my country and our children as the person managing the Extended Program on Immunization in Angola.”
A new challenge
In 2019, Angola’s immunization team faced a new challenge when the polio programme detected an outbreak of circulating vaccine-derived polio type 2, a type of polio that emerges in places with low immunity. Dr. De Sousa again found herself at the forefront of the action, starting by supporting the Government to respond with vaccination campaigns.
One of her key tasks since has been recruiting new immunization health professionals, who can help reach the children missed by routine immunization and polio campaigns. She explains, “my goal is to train my colleagues so that we can work together to reach the vast number of Angolan children missing out on lifesaving vaccines.”
In July 2020, Angola held its first polio campaign after a pause on vaccination activities in the early months of the COVID-19 pandemic. More than 1.2 million children were reached by over 4000 vaccinators.
Gender and leadership
Dr. De Sousa explains that being a woman leader in Angola isn’t easy. “It requires a lot of time, dedication and a balance with domestic, family, and social life, which has not been easy to manage. However, with the help of God and my family – especially my husband – I am managing to carry out my work.”
“It has all been worth it for the results I’ve helped to achieve, and even though we have some way to go in relation to vaccination coverage, I’m grateful for the opportunity to ensure the health of our children and serve my country.”
In Angola, at the provincial and municipal level, there are very few women compared to men. However, in public health programmes at the national level, women outnumber men. Dr. De Sousa says that, “In general, I think there should be more women leading and administering vaccination programmes”.
In 2021, the polio programme is aiming to implement more outbreak response vaccination rounds to reach children with low immunity to the poliovirus. Driven by her passion and sense of duty, Dr. De Sousa will continue to be on the frontlines of this effort.
In 2018, Jawahir Habib, a Programme Officer in UNICEF’s Polio Outbreak Team based in Geneva, received a letter. It was from a Pakistani woman she had met while working in the Quetta block – one of the most high-risk polio areas of Pakistan. The letter read:
“I have four daughters, and my daughters are in school because of the polio programme. I can afford to teach my girls which my husband opposed. Now they too can get education and live an independent life. I will make sure every child is covered and this is my mission.”
Words like these inspired Jawahir and set her on a path to a ten year career in polio eradication. She recalls her first day at work, “That day was very interesting – I was chased by dogs in the Kharoatabad area of Quetta. Although I managed to save myself, I spent the whole day crying and realizing that polio workers face this type of adversity day to day. I knew that I must become a part of this and ten years later, I am still working to eradicate polio”.
Jawahir has over ten years’ experience in polio eradication. Despite the challenges, she has stayed motivated throughout.
The more Jawahir became involved in the polio programme, the more she witnessed women facing social challenges. At the time, suboptimal campaigns in the polio reservoirs was one of the major hurdles faced by the programme and the number of missed children in Quetta block remained very high. More than 70% of frontline workers were male or non-locals, resulting in limited access to households.
It was then that the Pakistan programme began looking at success stories from other parts of the world, including Nigeria, where Volunteer Community Mobilizers (VCMs) were making significant strides in eradicating polio. The need to build a network of local female health workers who were trusted and could gain access became more and more clear. Balochistan, where Jawahir is originally from, is one of the most remote and conflict-ridden areas of Pakistan and strict conservative religious and cultural norms, tribal conflicts and insecurity would prove very challenging.
When Jawahir’s team started recruiting, training and deploying women frontline workers in Quetta block, she was told it was impossible. “I was told that there was no way we could manage a workforce comprising of women working in these areas”. As a team leader, Jawahir had to create an enabling environment for women to work, keep them motivated and ensure systems were in place for them to reach every child in the block. “At a personal level, I had to lead by example and show everyone that women could work in these difficult areas, face resistance and achieve what a man could – in this case, even more.”
Jawahir knew well the challenges of being a young woman in a male dominated society. Born in Kili Mengal Noshki, a remote village in Balochistan bordering Afghanistan, she faced a lot of challenges. Despite this, Jawahir got her bachelors degree, a postgraduate diploma in public health management and a masters degree in health communication from the University of Sydney.
While working on polio, she had to work twice as hard as men, facing threats, gender biases and intimidation. What kept her inspired and motivated was being a part of something much bigger which she believed could change the world.
During this time, Jawahir’s team managed to identify, train and deploy a workforce of 3500 Community Based Workers (CBV) where 85% of the frontline vaccinators were women. During the first few campaigns 700,000 children in the core reservoir area were registered and vaccinated and more than 150,000 children who had previously been missed during the campaigns were mapped and given oral polio vaccine. One of the notable success of female teams was seen in Chaman Tehsil, on the border with Afghanistan, where within four months, the number of chronic vaccine refusals went from 15,000 to 400 children. That was a huge success for Pakistan’s polio eradication goal.
Jawahir attributes the success to the brave women who have made a major contribution to their society. She sees the empowerment of woman in one of the most difficult parts of the world as GPEI’s legacy of social change now and for the future. “Imagine a workforce of thousands of women having access to every household – imagine the venues we have for routine immunization, for nutrition, health and even education”.
The COVID-19 pandemic has compounded a rise in polio cases in Pakistan in 2019 and 2020, and polio eradicators once more have their work cut out to bring down virus transmission and protect populations.
“I believe now it is the responsibility of each and every one of us in the polio programme, whether a polio worker in Chaman or an Officer in Geneva, to ensure that this disease is eradicated once and for all. We will carry on no matter the hurdles and obstacles placed on our road, and we will finish the race.”
Ms. Rina Dey has spent over 25 years working in health and development, including front-line efforts to eradicate polio in India and globally.
“Unless we work at the community level, we’re not getting the full story. Ensuring community participation is the only way to achieve social transformation and to ensure that all children get immunized,” she explains.
In her role as Director of Communications for the CORE Group Polio Project, Ms. Dey works tirelessly to bring community perspectives to decision-makers at the national and state levels. Ms. Dey also continues to share lessons and innovative strategies from her work in India with other parts of the world impacted by polio.
Regardless of the location, her message is the same, “We need to take the time to listen. All questions and concerns are valid when it comes to making decisions about the health of one’s family – each deserves to be heard, understood and acted upon – without this, we will not be successful in protecting children.”
India, once thought to be the most difficult place in the world to end polio, was declared wild polio-free on March 27, 2014. A large part of this huge success was the ability to work one-on-one with communities in high-risk areas.
Ms. Dey began working in polio as a front-line Health Information, Education and Communication Officer with UNICEF and WHO.
She remembers, “Early in my career, during a field visit to Meerut, Uttar Pradesh, I came with a vaccination team to a house for polio immunization. A man came to the door, armed with a sword, and shouted that he would kill his nine-month old daughter, if we tried to enter and give her polio drops. I took a step back and directed our team to leave the house. It shook me.”
After taking the time to listen to the man’s concerns, Ms. Dey learned that the man was receiving a lot of misinformation from friends as well as his workplace. Out of fear and misunderstanding, he made the most severe threat possible to try and keep the health workers away from his family – in his mind to protect them.
“After taking the time to really listen to him and his friends, we began talking. I assured him that no one would vaccinate his daughter without his permission.”
Health workers need the knowledge and skills to effectively deal with these types of situations and to ensure that communities are receiving accurate information to make choices about the health of their families.
“The key is to address their questions and to build trust. By the following day, he welcomed the vaccination of his daughter and even went on to become an influential member of the community helping to address the concerns of other families.”
Ms. Dey decided to re-shape the way frontline health workers were trained.
“We needed to equip the health worker and vaccination teams with accurate knowledge and enhanced communication skills to understand and address the concerns of the families. There were many myths and misunderstandings to dispel, so I have put a lot of thinking into developing simple and user-friendly materials and methods which are local and participatory.”
“Investing in building capacities of frontline workers works! If they are not technically sound, they won’t be able to answer people’s queries.”
The Moradabad district in Uttar Pradesh was once an epicenter for polio outbreaks globally. Today, a monument to the district’s success stands tall above the bustling traffic of Moradabad City.
The monument is comprised of a large mother and child sculpture surrounded by the slogan “Two drops of life“. A polio vaccine vial sits on a base with four panels describing the partnership, strategies and journey to a polio-free India.
“No one thought it could be done when we started, but people from Uttar Pradesh, Delhi and West Bengal supported the polio eradication cause with high spirit and the job was done peacefully. A sense of great pride remains in Moradabad, and the whole of India.”
“When communities are heard and feel a sense of pride in the effort, sustained change is possible. But the flip side is also true.”
Ms. Dey remembers how children would come running with excitement, waving and cheering to interact with her team.
“When we were out on visits, the children would run to greet us. They wanted to know who we were, why we were in their neighbourhood and what we were doing. We would talk with them – we knew their names and what they were studying.”
“However, after some time, I realized that the children stopped coming, and some even began hiding from us. This was heartbreaking.”
Communities were being told that the vaccines could cause infertility, and parents were telling their children to run away from immunization teams. Dey took these insights to heart. She pushed her team, government officials and partners to think differently.
“I never thought of quitting. I want to see a polio-free world in my lifetime. I love children. I am working so that they can have a healthy life.”
She decided to develop strategies that would ramp up the involvement of influential members of the community, parents, schools, local government and families to ensure that accurate information was accessible to community members.
“We worked hard, and the scenario changed. Parents deserve to have accurate information so that they can make informed decisions about their children’s health. Many of those we engaged in this project are still advocates for polio eradication and immunization today.”
Women’s contributions cannot be overlooked
The Moradabad monument celebrating polio eradication in India.
“At ground level, we have lots of female health workers. In many countries a majority of frontline health workers and vaccinators are women, but at the higher levels, we find that the majority of leadership positions are held by men.”
“Women can often be sidelined in meetings. Things have improved, but we have more work to do. When women are in leadership positions, you find that other women are promoted and women’s voices from community level are more often heard.”
Ms. Dey recalls her own experience, “Once during a discussion with community leaders, I was not allowed inside one of the prestigious religious institutions. Even as a senior member of the team, I was made to wait outside for hours, while my male colleagues were permitted to speak with the officials inside.”
When asked what advice she would give to women beginning their careers in public health, Ms. Dey says, “Be a good listener. You must visit communities, spend time with them and build strategies for your work that are grounded in the realities of the people you are aiming to reach. You must make communications simple and always put appropriate ingredients into your approaches.”
“The health of our children and families is a very personal and foundational aspect of human life. Ultimately to increase vaccine acceptance, we have to relate to people on a human level first before launching into the science.”
“We’re always ready to give answers, but we also have to listen – at every level,” says Ms. Dey. “We must move away from being instructive and take the time to see people’s concerns as valid and to help people understand the science behind what we’re asking them to do.”
Meet Sue
Whether in Pakistan, Seattle or Somalia, Dr Sue Gerber, a Senior Program Officer at the Bill & Melinda Gates Foundation (BMGF), is working with partner organizations to support polio workers – those delivering vaccines, educating the public or conducting disease surveillance.
Dr Sue Gerber (Senior Program Officer, Bill & Melinda Gates Foundation)
“The more time you can spend getting your shoes dusty walking and working together in the field, the better you will understand the challenges,” she says.
On one trip to Borno State in Nigeria, Gerber spent a week with community vaccinators – all well-respected women who, despite the massive geographic region they had to cover, maintained good spirits throughout their long travels. Across her work, Gerber finds motivation by staying closely engaged with the needs of those on the frontlines of the polio eradication effort.
Starting Out
While she studied to be an epidemiologist in college, one of Gerber’s first global health experiences was in the Peace Corps in Liberia, working with an immunization programme combatting childhood communicable diseases. Here, Gerber coordinated with Rotary International to secure meal funding for health workers travelling long distances to vaccinate children, foreshadowing collaboration integral to the GPEI. While in the Peace Corps, she found mentorship with legendary smallpox eradicator Stan Foster, who not only helped inspire her to work on polio eradication but also pointed Gerber toward her next role at the U.S. Centers for Disease Control and Prevention (CDC).
Gerber began work at the CDC on sexually transmitted diseases, first in California, and then later in Botswana and other countries in Africa. While in Los Angeles, she relied on frontline workers to help inform counseling and testing sessions assisting women with STD testing access in low-income areas.
Gerber’s next move was to CDC’s Global Immunization Division (GID) to support polio eradication in East Africa and Nigeria. She returned to the U.S. to lead GID’s Africa team for diseases of eradication and elimination, later serving as Deputy Director of CDC’s Namibia country programme.
Committed to Polio
Working collaboratively to combat other infectious diseases around the globe paved the way for Gerber to dedicate her career to polio. First at the CDC and now at the Bill & Melinda Gates Foundation, Gerber’s role in polio eradication efforts has evolved, but her drive to support health workers at every turn has remained steadfast.
“My responsibilities change over time depending on need and circumstance,” says Gerber. Currently, she supports polio eradication in Pakistan, by working with the national Emergency Operation Center (EOC) to improve supplemental vaccination campaigns and routine immunization services, and support integration with other primary health care services.
Gerber also supports efforts in Somalia, partnering with a variety of international organizations to work directly with in-country teams strengthening surveillance. As a member of the global surveillance task team, she develops strategic plans, guidance, trainings and assessments, incorporating frontline worker input on best practices for accessing hard-to-reach and insecure areas.
Innovating During a Pandemic
The resilience of frontline workers in the face of crisis continues to be the backbone of combatting diseases. This is especially true for today’s polio programme amidst the current global pandemic. While COVID-19 temporarily interrupted immunization delivery, Gerber remains optimistic about global health progress, adding that “during this pandemic, technology use has helped create innovative solutions to key problems.”
During the pandemic, polio programme assets have been instrumental in supporting COVID-19 response efforts. In almost every country with GPEI infrastructure and resources, polio staff have lent their expertise to conducting COVID-19 surveillance, combatting misinformation and sharing coordination mechanisms for pandemic response alongside programmatic activities.
The Role of Women
“Women have always been a critically important part of the programme, especially at the frontline,” says Gerber.
Across polio-affected countries, female vaccinators are crucial to building community trust and reaching all children, especially in communities where cultural norms prevent men from entering households. Despite this outsized importance to the programme, women are still heavily underrepresented in authority and management positions.
Ensuring that more women are at the table making decisions is a key part of Gerber’s drive. “Effective leaders lead from who they are,” Gerber says. By fostering strong working relationships, mentoring younger women and taking the time to listen to frontline workers, stakeholders and leaders, Gerber is able to channel her strengths and perspective as a woman into her role in eradicating polio.
Gerber adds, “I also think that representation matters. When women see women taking on a leadership role, they feel confident to lead and contribute in their own way.” In her own experience, seeing women mobilizing global resources, devising strategies or sparking catalytic action has provided an incredible source of inspiration.
What’s Next
Gerber is proud to be involved in eradicating polio – from working in the field to supporting new policies and approaches to bringing much-needed perspectives to the table – all while ensuring that “frontline workers are knowledgeable, prepared and protected.” Gerber is also working with Johns Hopkins University and their consortium partners on an academic course disseminating lessons learned from polio eradication efforts.
Her advice for the next generation of public health workers wanting to follow in her footsteps? “If you’re thinking about going into public or community health, please know you can make a difference.
After the World Health Assembly passed a resolution to eradicate polio worldwide in 1988, the Global Certification Commission led the way in establishing a formal certification process, asking each of the six WHO regions to set up a Regional Certification Commission. Then in 1996, the WHO Regional Director for Africa created the Africa Regional Certification Commission (ARCC) for Polio Eradication: a 16-person independent body tasked with overseeing this process, and later on containment activities in the African region.
Professor Rose Leke, an infectious disease specialist, has been the chairperson of the ARCC since it was set up in 1998. A trailblazer for women in global health, Leke has fought throughout her career to improve women’s representation in science and global health leadership. In 2018, she was one of nine women honored with a Heroine of Health award, recognizing her outstanding contribution to health care.
Stopping the ‘havoc’ of polio in Africa
Professors Leke explains her motivation to join the polio eradication cause, “When I was invited to be part of the ARCC in 1998, I was not involved in any polio-related work. But I could see the havoc that polio was reaping on the continent. I had a nephew who was paralyzed from polio and suffered brain damage, and another relative who contracted polio and continues to inspire me. Back then, you saw so many paralyzed young people on the streets. You don’t see that today.”
Ridding the African continent of wild poliovirus is a huge achievement, many years in the making. Nigeria, the last bastion of the wild virus, proved a particularly tough setting in which to vaccinate every child and ensure that no trace of the virus remained.
Professor Leke reflects, “It’s been such a long road. When Nigeria didn’t report any cases of wild polio for two years between 2014 to 2016, we were apprehensive but satisfied. We were so close to eradication as a region, everything was going so well, and then wild polio was reported again in Nigeria in August 2016, and certification had to go on the back burner.”
“The Nigerian response to their outbreaks has been extraordinary. Everyone is committed and highly involved. In Sokoto and Kano states, where I was recently for a field verification visit, and in all other states, everyone – from government officials, traditional leaders, health staff and field teams, community health workers and informants, polio survivors to traditional birth attendants – was heavily engaged in the response. The innovative technologies that have emerged have similarly been incredible. The Nigerian Emergency Operations Centre is a well-coordinated structure that is behind Nigeria’s success. Other disease programs in Africa are learning from this.”
Professor Leke never lost her drive to end polio, even during difficult years and despite the tough choices her role sometimes presented.
“When we started, we were aiming for wild polio to be eradicated by 2000; the thought of this success really kept me motivated and still does. At times it has been a huge sacrifice; as Temporary Advisers, ARCC members are not paid, and I’ve sometimes given up consultancies to do this work. My husband, children and grandchildren will tell you, there was a huge amount of traveling and many meetings. But I don’t regret the time spent for a moment on such a cause.”
“When Dr Moeti was appointed as WHO Africa Regional Director in 2011, this was further motivation to continue: I wanted to support a fellow woman. In the beginning, I was the only female in the Global Certification Commission. The commission has addressed this imbalance and we are now two females out of the six members. We need more women in senior positions on the African continent.”
Fighting for gender equality in global health and science
In 2011, Professor Leke won the Kwame Nkrumah Award for the best female scientist in Central Africa for her research on malaria. As part of her acceptance of the award, she took a pledge “to help promote the participation of women in science in Cameroon.”
Within a year, she had helped set up HIGHER Women, a mentoring programme for senior female scientists to deliver hard and soft skills training to their early career counterparts. To support the programme, Professor Leke contributed some of her own funds.
Professor Leke says, “As a woman I encountered blocks on the way during my career – at times men asked me to leave the laboratory space I was working in.”
“Science can be a pyramid – there are many early women researchers, but far fewer at the top of the field. Research and academia have a ‘publish or perish’ culture which disadvantages women who have responsibilities outside of the lab – such as raising a family.”
Professor Leke has continually used her position to promote women in science and global health, even sharing her favorite motivational track about women’s empowerment.
Whilst great progress towards gender balance has been made since she started her career, Professor Leke is firm in noting that there is more to do. In the African regional polio programme, women still lead only a small number of national committees.
Professor Leke is proud of the public health legacy that the polio eradication programme will leave in the African region. She says, “The polio response has brought many skilled technicians into Africa’s health systems. The GPEI paved the way for working closely with traditional healers and community leaders and has really helped to strengthen the systems that report on other diseases. The polio laboratory network is being used for other diseases, giving capacity in the region for doing all sorts of other diagnostics. You’ll find the one person in the health center who was there for polio is reporting on many other diseases.”
“After we declare Africa as free of the wild poliovirus, the ARCC will work with countries to ensure they keep up good quality surveillance, and improve routine immunization, keeping population immunity as high as possible. We will also continue to guide countries in continuing to monitor population immunity to prevent importations of wild poliovirus from outside the African region, while ensuring that the threat of circulating vaccine derived polio viruses (cVDPVs) is addressed.”
“Our work continues until all forms of polio have been eradicated globally.”
Dr. Ana Elena Chevez with her medical school cohort in El Salvador. During her career, Dr. Ana has made an immense contribution to polio eradication and broader public health. Credit: Provided by Dr. Ana Elena Chevez
Little Ana first learned about the importance of vaccines from her father, a pediatrician. Growing up during El Salvador’s 12-year civil war meant that electricity cuts were a common occurrence. Whenever the electricity went out, Ana’s father would rush the vaccines he kept in his clinic to the nearby hospital, where generators kept the cold chain refrigerators working. Seeing her father’s dedication to his work, Ana knew she would also become a doctor.
Fast-forward to 2020. Dr. Ana Elena Chevez has dedicated over twenty years of her life to protecting children from vaccine preventable diseases. She has worked in four countries across two regions, and currently serves as a Regional Immunization Advisor for polio at the Pan American Health Organization (PAHO), the Regional Office for the Americas of the World Health Organization, supporting the 52 countries and territories of the Americas to maintain polio-free status.
Throughout her career, she has never stopped dreaming high – advice given to her by family, mentors and colleagues.
Dr. Ana’s first job in public health was as a national immunization manager in El Salvador. Her mentor was PAHO/WHO immunization advisor Dr. Salvador Garcia. “Dr. Garcia taught me everything I needed to know about running an immunization programme. I knew that I could call him at any time, and I would get the answer that I needed,” she said.
The last mile of polio eradication in Nigeria
As polio cases surged in the African region in 2007, Dr. Ana was selected to go to Nigeria to support outbreak response. In a twist of fate, a three-month assignment turned into four years as Nigeria’s Supplementary Immunization Activity (SIA) coordinator.
It was in Nigeria that Dr. Ana refined her skills as a polio eradicator, as well as finding a ‘home away from home’. Credit: Dr. Ana Elena Chevez
This experience was pivotal for Dr. Ana’s career – it solidified her passion for polio eradication and introduced her to new colleagues and a new
country, which would soon become Dr. Ana’s second family and her home-away-from-home.
Dr. Ana was inspired by the constant innovation she saw in Nigeria. “We were always looking for ways to improve quality of the campaigns – improve training, surveillance, cold chain. It was always innovation, innovation, innovation.”
Dr. Ana believes that way of thinking really took Nigeria to the next level. “We started seeing fewer cases, more children vaccinated, and a higher level of acceptance among parents and leaders.”
As SIA coordinator, Dr. Ana oversaw all polio campaigns in the country. During these years, polio campaigns were happening on an almost monthly basis, alongside campaigns for yellow fever, tetanus elimination, and measles. It was overwhelming. “By the time we returned from the field to analyze one campaign, it was already time to start preparation for the next one. It was tiring for everyone – for us (the WHO staff), the partners, for the national/state/local health authorities, and of course for the vaccinators.”
Despite the pressure, Dr. Ana said, “If you were to ask me if I would do it again, I would say yes in a heartbeat. For me, it was being a part of an important moment in history – for the country, for public health, and for the polio programme.”
Maintaining momentum in a region certified free of polio for over 25 years
In 2017, Dr. Ana became PAHO/WHO’s Regional Advisor in charge of polio. The last case of wild poliovirus in the Americas was in 1991 and the region was certified free of polio in 1994. Although more than 25 years have passed since the Americas received polio free status, until polio is eradicated everywhere, the disease is still a risk.
25 years since the Americas were certified polio-free, Dr. Ana emphasizes that the region remains at risk until polio is eradicated everywhere. Credit: Dr. Ana Elena Chevez
Dr. Ana explains, “Even though new generations of nurses, doctors, and epidemiologists have not seen a case of polio firsthand, they understand the risk remains.” There have been 26 meetings of PAHO’s Technical Advisory Group (TAG) meeting on vaccine preventable diseases, and polio has been included on the agenda for every meeting.
It has not always been easy to keep this momentum. In recent years, countries in the Americas have had trouble meeting the indicators required to prove sensitive surveillance systems. For the last few years, PAHO has been holding almost yearly regional polio meetings to sensitize countries on the GPEI’s requirements for eradication and stress the importance of achieving high immunization coverage rates for polio and high standards of surveillance.
Dr. David Salisbury, chair of the Global Certification Commission for Polio Eradication, said at the regional PAHO polio meeting in 2017 that “there will be no free pass” for countries that are polio-free. All nations must provide documentation of certification standard surveillance to back up their belief that polio is eliminated amongst their population.
For Dr. Ana, these words hit home, “The work done by those that here before me has helped the countries to be aware. It has been my role to keep that momentum alive and help countries meet the required goals established in the Endgame Strategy.”
A message for the new generation of women public health leaders
In recent decades, women leaders in public health and immunization made important contributions to a field once dominated by men.
Dr. Ana recalls many of the women leaders that she’s worked with and considers that they have gone above and beyond what is expected. “They have raised the bar and have given the message that other women can work in public heath – it doesn’t matter your religion or colour – it matters that you care.”
Dr. Ana is excited to see more women step into leadership roles. “The new generation is coming. We need them – we need to prepare them. We are close to polio eradication, but we must think about what is next and prepare the new generation to tackle these issues with confidence. I tell my nieces that they can go and contribute to the world and make an impact.”
Reflecting on her own motivation, Dr. Ana says, “I always believed that I could make an impact, I just needed the tools, time and opportunity.”
“Young women leaders: Keep dreaming high. Keep dreaming that you can influence the health of whole populations. Don’t be afraid to set high goals– don’t be afraid to think that it is possible to control, eliminate, or even eradicate a disease.”
In every corner of the world, women leaders in Rotary are leading the charge to make polio history. They are fundraisers, volunteers, polio survivors and advocates from all backgrounds and walks of life with one thing in common: working to ensure that no child ever has to suffer the devastating and paralyzing effects of polio. Meet five women in Rotary whose work is leading the way in the fight to end this disease.
Judith Diment
Diment, of the Rotary Club of Maidenhead Thames, England, leads Rotary’s UK advocacy efforts, and is a passionate fundraiser and International PolioPlus Committee member.
She recently spearheaded Rotary’s efforts to create polio eradication champions among UK political leaders, resulting in the country committing up to an additional $US514.8 million to the Global Polio Eradication Initiative (GPEI) to fund the 2019-2023 Endgame Strategy.
In 2019, former UK Prime Minister Theresa May and Queen Elizabeth II both publicly recognized Diment for her philanthropy to polio eradication and other causes. Hear more from Diment.
Ijeoma Pearl Okoro
“Until the last child is reached and immunized, no child in the world is free. Let us all support the cause to end polio now.”
Ijeoma Pearl Okoro is a member of the Rotary Club of Port Harcourt, Nigeria where she directs End Polio Now activities throughout sub-Saharan Africa. She leads efforts to build awareness around the fight to eliminate polio from Nigeria and engages other Rotary members and the public through events and promotional endeavors.
Through a range of activities like government advocacy, celebrity engagement and fundraising, Okoro’s leadership helps ensure that polio eradication is a priority and every child is protected from the disease.
In 2019, Nigeria surpassed three years without a case of the wild poliovirus, and the African Region is expected to be certified as wild polio-free in late August 2020.
Tayyaba Gul
A member of the Rotary Club of Islamabad (Metropolitan), Pakistan, Gul runs a Rotary-funded health center in Nowshera, working with teams of female vaccinators help reach neighborhoods of ethnic Afghan refugees displaced by conflict in tribal border regions. Gul’s teams use cellphones for daily data reporting on immunization progress, which helps health teams analyze data and report back in real time.
As one of only two countries that continues to report cases of the wild poliovirus, fighting polio in Pakistan is key in achieving a polio-free world. “I just contribute my part as a Rotarian. I’m happy to work in remote areas, especially with women, motivating them to play their role in society,” Gul says. Watch to learn more about Gul’s work in Pakistan.
Ann Lee Hussey
Ann Lee Hussey has led Rotary volunteers on nearly 30 trips to places like Pakistan and Nigeria to immunize children against polio, the disease that has affected her since she was 17 months old.
A member of the Portland Sunrise Rotary Club, Maine, USA, she is an outspoken advocate for polio eradication and immunization and has testified at state legislative hearings in Maine on the importance of vaccination.
In January 2019, Hussey spoke of her experience as a polio survivor and her Rotary service at Rotary’s International Assembly, highlighting the role of frontline polio workers: “Without question, the many health workers around the world—most of whom are women—are the unsung heroes on the polio front. Without them, we would not be where we are today.”
Marie-Irène Richmond-Ahoua
Richmond-Ahoua joined the Rotary Club of Abidjan-Biétry, Côte d’Ivoire, in 1991, making her one of the first female Rotarians in Africa.
When a general canceled a national immunization day during a 1999 coup in her country, Richmond-Ahoua appealed directly to the general’s family, pleading that innocent children had nothing to do with the war. Shortly afterward, the general granted her request and presided over the opening of the rescheduled immunization day.
Richmond-Ahoua coordinates national polio immunizations and serves on the Africa Regional PolioPlus Committee. She also spoke at Rotary’s 2018 World Bank International Women’s Day event.
Dr Fiona Braka holds one of the highest-stake roles in the African regional polio programme – supporting the Government of Nigeria in their fight to defeat wild poliovirus.
She is the first woman to hold her position in Nigeria, and before that was the first female polio team lead in Ethiopia.
Fighting the last wild virus in Africa
Dr Braka’s work involves leading the country team to strengthen routine immunization and maintain high quality disease surveillance systems in Nigeria. She is also heavily involved in the COVID-19 response, lending expertise established over decades of fighting polio.
In 2016, the detection of wild virus in Nigeria after nearly two years without cases was a devastating setback. “When the outbreak broke out, I was in Uganda on a break with my family. I was having lunch with a friend and my phone was ringing, persistently ringing – a Geneva number. When I picked up the phone it never crossed my mind it would be a wild virus,” Dr Braka remembers.
“A good proportion of Borno state was inaccessible due to armed conflict. Delivering vaccination services and conducting surveillance in that area had not been easy. With interventions going on to address the conflict by the Nigerian Government, some ground was gained, and people trapped for over three years were able to move out of the liberated areas to internally displaced persons camps. With population movement, a wild polio case was detected in an internally displaced child.”
Cutting short her family holiday, Dr Braka raced to Borno to help launch a truly innovative outbreak response with the government and partners. Adapting strategies for polio response to an insecure setting, the programme started settlement-based microplanning guided by local security assessments, innovative surveillance approaches, and the use of GIS and satellite imagery to estimate trapped populations.
The estimated number of children inaccessible to vaccinators has dropped from over 400,000 in September 2016 to less than 30,000 in May 2020 – an enormous achievement for the programme.
Balancing motherhood and a career in public health
The challenges were very different when Dr Braka was working on the 2013 Horn of Africa outbreak in Ethiopia’s Somali region. Cases of polio were occurring among pastoral communities and the programme had to rethink tactics to ensure the children of nomadic populations could be reached with vaccines. To maintain the cold chain, polio teams travelled on donkeys or on foot through the bushes. Community leaders among the nomads were employed to help vaccination teams reach families on the move.
“I recall the advice of a parent of a nomadic child who had contracted polio. He said, “We follow where the clouds and rain go – unless the polio programme also moves with the clouds and the rains as we do, you will never reach us and our children will never get the vaccine”. This became a guiding quote for us,” Dr Braka remembers.
This was also a time of personal challenge, as Dr Braka’s youngest daughter was less than a year old. On one occasion, Dr Braka brought her baby with her to a vital cross-border collaboration meeting in Somali region between the Somalia, Kenya and Ethiopia teams. She recalls, “I had to stay in the same hotel as the meeting so I could run upstairs during the break to breastfeed. That moment really stands out an example of the tough decisions you must make as a parent.”
Dr Braka praises steps taken so far to promote women’s professional development in public health and leadership, whilst noting there is more to do.
“The WHO Regional Director for Africa, Dr Matshidiso Moeti, has provided opportunities for capacity building for women. There has been the first training this year for senior women leaders in the African region – I am proud to be part of this.”
Part of the Global Polio Eradication Initiative Gender Strategy 2019-23 commits to promoting a gender-responsive organizational culture. By placing gender at the heart of operations, the strategy closely aligns with the policies of major donors to polio eradication including Canada, Germany, Australia and the United Kingdom.
Explaining why she is a strong supporter of gender equality at all levels of public health, Dr Braka finds, “Even occupying leadership roles you have to have gender in mind – you have to be prepared to prove yourself a bit more.”
“It remains our responsibility to create a policy environment that gives opportunities for men and women.”
Dr Braka emphasizes that many people forget how damaging the disease is.
“Whilst we have polio anywhere in the world, we are all at risk of cross-border virus spread. Until polio is eradiated globally, we must be on our toes with robust surveillance systems and infrastructure to deliver vaccines.”
Dr Braka has been able to sustain her demanding job in part thanks to the support of her family. She explains, “I have a very supportive spouse…He knows the polio programme as well as I do!”
“My late father was also very supportive of my career. My mother has been more than a mother – a strong pillar of support, mothering her grandchildren when I am not there and providing moral support in the background.”
She explains that she can’t imagine a next generation suffering from polio when a vaccine is available.
“Vaccines are a powerful tool and the evidence is clear for saving lives. They reduce burden on families, economically, emotionally, and they prevent the suffering of children.”
“We have a duty to secure children’s future to be healthy citizens.”
In 2003, Melissa Corkum received a call that would change her life. The World Health Organization wanted to interview her for a position in their polio eradication team. Like most people who are hearing about polio eradication for the first time, the story compelled her, and she packed her bags to embark on a new adventure. Seventeen years later, she remains a dedicated champion of polio eradication.
A self-proclaimed ‘virus chaser’, Melissa has worked in all three polio endemic countries – Afghanistan, Pakistan and Nigeria. She found inspiration in her first field job in Nigeria, where she realized the scale of the polio eradication programme and that she was a part of something tremendous in public health history.
“I was amazed and inspired when I first saw the efforts of the front-line workers delivering vaccines to the doorstep. It may seem simple to deliver a couple drops into a child’s mouth, but when you see it in motion for the first time, it is truly remarkable,” Melissa said.
To this day, Melissa remains in awe of the work required to make ‘reaching every child’ possible. From mobilizing financial resources, to getting vaccines where they need to be while keeping them cool. From the microplanning to ensure all children and their houses are on a map, to the mobilization of champions in support of polio and immunization. Along the way, the stewards of these processes play an essential role to deliver the polio vaccine.
Melissa has worn many hats during her time in polio eradication, but her current role may be the most challenging yet. As the Polio Outbreak Response Senior Manager with UNICEF, she must answer the formidable challenge of containing outbreaks, using her expertise to inform global policy, strategy and operations.
To do this Melissa spent 80% of her time in the field prior to the outbreak of COVID-19, working with partners of the Global Polio Eradication Initiative (GPEI), Ministries of Health and local health workers.
Her work is a mix of challenge and excitement – the challenges of containing outbreaks, including those affected by the COVID-19 emergency – and excitement in developing new tools and methods to overcome the evolving challenges that present barriers to eradicating polio.
“There is never a dull day no matter what hat you may be wearing within this programme. If we are going to put an end to polio for good, we are going to have to fight the fight on a number of fronts – endemics and now the emerging issue of outbreaks in a post-COVID world,” said Melissa.
“The key is a willingness to do whatever it takes to get the job done.”
At times, Melissa felt the weight of the enormous challenges to eradicate polio, especially during her time in Afghanistan, where protracted conflict has complicated efforts to deliver basic services to the most vulnerable. Melissa often reflects on her time as Polio Team Lead there and the emotional rollercoaster she faced trying to stay ahead of the virus, while watching the tragedy of war unfold in the country.
“But when I felt down, I would pick myself up and get ready to face the next challenge. I found hope and inspiration in the resilience of the Afghan people, especially the women who worked in the polio programme, risking their lives and demonstrating a courage that stood out amidst all the difficulties.”
Melissa sees gender as one of the keys to polio eradication. She firmly believes that the only way to tighten the gaps in the system is by involving and empowering women equally in all roles across the programme, and that the only way to reach every child is to ensure their caregivers are equally informed and engaged in the decision making process.
“Unless we involve more women in the programme in certain corners of the world, we will continue to reach the same children and miss the same children, making polio eradication ever more difficult,” Melissa said.
“Change won’t happen if we don’t change the way we think about involving women. We need to listen to their views and open the doors for more women to join and participate equally from the community level and all the way to the leadership, decision-making level.”
Melissa was born in a small town in Nova Scotia, Canada. Her views on the critical involvement of women and gender equality in the polio programme very much align with her government’s Feminist Aid Policy. The Government of Canada has been a long-time champion of polio eradication and recently generously pledged C$ 190 million to assist the GPEI achieve its objectives of polio eradication.
Greater gender equity is one of the legacies that the polio programme is working to leave behind after eradication. Reflecting on her career, Melissa explains what keeps her working to defeat polio after all these years.
“It is so inspiring to be part of something tangible and something that is completely possible if we commit ourselves to doing everything possible to find every last child”.
In the midst of the COVID-19 pandemic, it is more critical than ever to recognize the power and importance of vaccines, which save millions of lives each year. Canada, the first government to contribute to the global effort to eradicate polio in 1986, has announced new investments to support immunization. Alongside renewed funding for Gavi, the Vaccine Alliance, the Honourable Karina Gould, Canada’s Minister of International Development, committed C$ 47.5 million annually over four years to support the Global Polio Eradication Initiative’s Endgame Strategy.
Due to widespread polio vaccination efforts over the past 30 years, more than 18 million people are walking today who would otherwise have been paralyzed, and cases have dropped by 99.9% thanks to the tireless efforts of health workers, local governments and global partners. The GPEI is proud to count on generous donors, including Canada, who have helped make this progress possible. This new investment will help the programme ensure gains made to date are not lost, resume activities as soon as it is feasible, implement strategies to overcome the remaining barriers to eradication, and further the dream of a polio-free world.
Minister Gould stated: “As a global community, we must work to ensure that those most vulnerable, including women and children, have access to vaccinations to keep them healthy wherever they live. COVID-19 has demonstrated that viruses do not know borders. Our health here in Canada depends on the health of everyone, everywhere. Together, we must build a more resilient planet.” The Minister added “The world has never been closer to eradicating polio, but the job is not done. With continued transmission in Afghanistan and Pakistan, we cannot afford to be complacent.”
Frontline polio workers in countries around the world are currently supporting the COVID-19 response, using networks established by the GPEI to focus on case detection, tracing, testing and data management. The G7 and the G20, including the Canadian Government, have recognized the important role GPEI assets play in strengthening health systems and advancing global health security, especially among the most vulnerable populations of the world.
In line with its feminist international assistance policy, Canada has encouraged the GPEI to build on the important role played by women in the programme, from the front lines to programme management and political leadership.
Akhil Iyer, Director of the Polio Eradication Programme at UNICEF said, “The new funding from the Canadian government is a testament to the major role played by the Canadian people in the historical fight against polio, and I am proud to be part of this endeavour as a Canadian citizen myself. Back in the 1950’s in Canada, poliovirus outbreaks could have paralysed or killed so many more children, and could have plagued the economy and pushed millions in vicious circles of poverty and ill health. But thanks to the scientific breakthrough of Dr. Leone Farrell who made mass production of polio vaccines possible, strong leadership and a learning health system, Canada was able to overcome the polio outbreaks and thrive during the following decades. It is more inspiring than ever, as we strive together to end polio from the world for good.”
Rotary clubs throughout Canada welcomed the new pledge as a continuation of the country’s leadership and partnership to end polio. Canada has worked closely with Rotary clubs in Canada since 1986 when Canada became a donor to GPEI. To date, Canadian Rotarians have raised and contributed more than US$ 41.3 million to eradication efforts.
Michel Zaffran, Director of the Polio Eradication Programme at the World Health Organization said, “I would like to express the profound gratitude of the GPEI partners to the Government and to the citizens of Canada for their tremendous support and engagement to end polio globally. The pandemic we are facing today is a stark reminder of the critical need for solidarity at all levels, international cooperation and of the power of vaccines and immunization. Canada is walking the talk: it is demonstrating once more its exemplary commitment to ensuring access to essential vaccinations, leading efforts to advance gender equality and reducing the burden of infectious diseases.”
Noora Awakar Mohammad was only sixteen years old when she started working as a volunteer for the Polio Programme in Somalia. Since then, she has lived through civil war and armed conflict in her country, which have left the health infrastructure in tatters. Recalling the days of war, Noora’s face tenses. “During the civil war years, on many occasions the polio campaign was stopped because of intense fighting. As soon as the fighting would stop, we would run to communities to vaccinate children,” she recalls.
During those days, it was mostly elderly women and mothers who trained as vaccinators. The adolescent Noora had to work hard to build community trust. “Often, I stayed with the community and vaccinated the children amidst war. The community trusted me even though I was a young health worker,” she remembers.
Noora still faces challenges in her fight against polio. Many areas in Somalia are unreachable because of the presence of non-state groups. These groups, who oppose vaccination, have been responsible for creating fear among parents by spreading misinformation. Noora has also encountered vaccine-hesitancy among parents because of inadequate health awareness. “I have seen fathers refusing to vaccinate their children on one hand, while mothers request us to vaccinate them on the other. Under such trying circumstances, we have to seek the help of religious leaders to convince the refusing fathers,” Noora explains.
Alongside polio vaccination, Noora works as a midwife. As part of her role, she educates pregnant women and young mothers about the benefits of vaccination. She also builds awareness of Acute Flaccid Paralysis (AFP) in the community, a key symptom of polio. “I share information about AFP with mothers and now I see more and more mothers bringing their children to health centers even with the slightest symptom of AFP,” Noora says.
Noora emphasizes that closing the current polio outbreak in her country remains tough given the climate of insecurity and inaccessibility, but she remains determined to carry on with her work.
Zainab Abdi Usman is a midwife in Madina district in Banadir state in central Somalia. For the last twenty years, she has volunteered for the polio eradication programme. A source of frustration for Zainab is the children missing out on vaccination in inaccessible areas. The barriers health workers face to access populations in desperate need of basic healthcare and community services are sometimes insurmountable.
“During the civil war, I used to carry the vaccine in a thermos kettle to keep it cold and I would hide it under my Abaya. If fighters got suspicious, they would not allow me to go into the communities to vaccinate the children. Today, many areas remain inaccessible,” Zainab says.
Whenever the access situation changes, the polio programme is amongst the first health initiatives to reach children. Zainab explains, “In a conflict situation, there is an immediate need to treat victims of the conflict. However, at the same time, it is important that we save our children from paralysis resulting from polio. Therefore, reaching out to children in insecure areas is very crucial in our fight against the disease.”
Feriha Abdur Rehman Yusuf is the young mother of a one-year old boy. She sees the fight against polio as personal and has been part of over 30 immunization campaigns in Somalia.
An incident from Feriha’s past stays with her years later. “One day, during a door-to-door campaign, I knocked at the door of a house. A man carrying a gun opened it. He yelled at me and started shooting in the air. I was shaken for days,” she remembers. Thankfully, the situation has changed in Feriha’s district since then.
Thanks to efforts to educate parents, the public is more aware of the long-term benefits of vaccination. However, Feriha still faces a few families who reject the polio vaccine during campaigns. She tries to convince parents using the examples of her own son, and her nephews and nieces. If families continue to be worried, she seeks help from religious leaders and community members.
Working during campaigns is not easy for Feriha now she has her son. Feriha says that her mother is the biggest supporter of her work and source of encouragement. “When I am in the field during the polio campaigns, my mother practically moves into my house and takes care of my child,” she says.
Feriha believes that despite the climate of insecurity and inaccessibility, things are improving in Somalia. “Health services are getting better than before. More and more children are getting vaccinated, so they have a better shot at life,” she says.
Thousands of women work in the Pakistan polio eradication programme as scientists of many specialties, managers, data experts, vaccinators, front-line team supervisors and social mobilizers. We asked a few of them about gender equality in their work.
Dr. Maryam Mallick: The Medical Rehabilitation Specialist
“Women face extra difficulties in trying to prove themselves and often compete in an outnumbered male dominated work environment. But with the right support, they persevere and excel in their tasks.”
Dr. Maryam Mallick is one of the first female technical advisors for disability and rehabilitation at the World Health Organization in Pakistan. Her job involves assessing children with polio paralysis to ensure that they receive medical and social rehabilitation care.
Dr. Mallick works to ensure that all children, especially girls, are given access to quality healthcare as well as equal opportunities in society.
“There were many instances where parents did not want their polio affected daughters to be sent to the schools. We need to start perceiving gender equality as a fundamental human right inherently linked to sustainable development, rather than just a women’s issue,” she says.
“Women’s empowerment in achieving sustainable development has now been globally recognized as the centrality of gender equality. It does not mean that men and women become the same, rather it means that everyone can have equal rights and equal opportunities”
Under Dr. Mallick’s supervision, one thousand children have been assisted by the Polio Rehabilitation Initiative since 2007.
Dr. Iman Gohar: The first female Provincial Rapid Response Unit Lead in Sindh province
“Many women in the programme have enormous talent and endless potential. These women are key to enabling success across the polio eradication effort.”
Dr. Iman Gohar joined the Pakistan polio eradication programme six years ago, working as a Polio Eradication Officer in Peshawar and then as the Divisional Surveillance Officer in Hyderabad. Today, Dr. Gohar is the first woman to lead the Provincial Rapid Response Unit in Sindh.
Dr. Gohar’s work involves leading investigations into suspected polio cases and organising case response campaigns. An increased number of environmental samples found positive for the poliovirus in Sindh in the 2019-2020 period has meant a busy workload.
“Polio eradication is an incredibly demanding job. I work for long hours and enjoy one day off in the week. While performing my job, I work hard to take complex goals and convert them into high quality deliverables,” she says.
“The programme has provided women with a very conducive environment to grow, learn and voice their opinion. For this, I am very grateful.”
When talking about how the programme can improve gender equality, Dr. Gohar stressed the role and support of her male colleagues.
“I believe for us to achieve true gender equality, it is essential that our male co-workers become advocates for equality. Men and women must both hold each other up, celebrate each other’s successes and recognize that each and every person, regardless of gender, is playing an important role in safeguarding the health of Pakistan’s children.”
Salma Bibi: A Health Worker in Killa Abdulla district, Balochistan province
“Nothing gives me greater satisfaction than knowing how I have helped people through my duties. I believe that creating opportunities for women is one of the best ways to empower them.”
Salma has been a community health worker for over a decade, working in Killa Abdullah district in Balochistan province. Around 90% of the district is overseen by male health workers, so Salma is one of the few women who go door to door to ensure that children are vaccinated.
Salma often feels greater resistance from community members than her male counterparts. “I hear a lot of negative comments from community members, especially when covering vaccine hesitant families. These words can sometimes de-motivate and de-moralize us from our duties,” she says.
Despite this challenging environment, Salma recognizes that her role is integral to get parents to understand the importance of vaccination.
“When our male colleagues cannot enter the homes, we play an important role in filling that gap. We go in and we sit with the mothers to help them understand that vaccinating against polio is the only way to protect their children. Often, the time spent talking to them is enough, and this makes us feel good, like we are truly helping our nation’s children.”
Saba Irshad: The first female Programme Data Assistant in Multan district, Punjab province
“The greatest challenge that the majority of the professional women face is the perception that they are not as qualified or competent as their male colleagues, irrespective of their experience, education, potential or achievements. Because of this, women often have to work twice as hard.”
Saba Irshad has worked with the Pakistan polio eradication programme for eight years. She is known by her colleagues for her quick problem-solving skills and meticulous work. As a Programme Data Assistant, Saba is responsible for collecting and analyzing data from campaigns implemented in Multan district, in Punjab province.
Saba emphasizes the need for the polio programme to continue to support and encourage their female workforce, and promote an inclusive work environment.
“On average, 62% of the vaccinator workforce in Pakistan are women. This shows just how important women are to polio eradication.”
“Without these women, the programme would be unable to reach thousands of children with the vaccine.”
To learn what the Global Polio Eradication Initiative is doing to promote gender equality, visit the gender section of our website.
Dr Faten Kamel is on a flying visit to the WHO Eastern Mediterranean Regional Hub, stopping for meetings and to deliver a lecture on the relationship between polio and patients with primary immunodeficiencies. Then she’s off again – to Pakistan to take part in a polio programme management review.
Dr. Faten has travelled to every country in the Eastern Mediterranean Region, and many more besides. Alongside working as a Senior Global Expert for the programme, she is a wife, a mother, grandmother, and an informal mentor to women in public health.
Growing up in Alexandria, Egypt, Dr. Faten was exposed to the life-altering effects of polio on the people around her and was inspired by the work of her father, a surgeon and a Rotarian.
“My father was my role model, he had great passion for helping others and was also a Rotary Club president in 1989. His project for that year was on polio eradication.”
“Polio was prevalent in Egypt in those days. A number of people around me were affected. I was touched by their suffering in a place which was not highly equipped for people with special needs at that time.”
After graduating from her Medical Degree and Doctorate in Public Health, and lecturing for several years at Alexandria University, Dr. Faten moved into a role for WHO. She found her niche working in the immunization team. “Immunization is the most cost effective public health tool – it can prevent severe and deadly diseases with just two drops or a simple injection – I strongly believe in preventive medicine,” she explains.
“I became the Eastern Mediterranean Regional Medical Officer for polio eradication in 1998. At that time many countries were still endemic.”
The 1990s and early 2000s were years of rapid gains against the virus. However to fully eradicate polio, it was becoming clear that the programme would have to be more ingenious than any disease elimination or eradication project that had come before.
Dr. Faten took a leading role. She explains, “Strategies for immunization and disease surveillance were established, and these methods evolved over time. We pushed the boundaries to make the programme more effective – shifting to house to house vaccination, detailed microplanning and mapping, retrieval of missed children and independent monitoring.”
“We started as a small team – covering different aspects of work and supporting all the countries. My team started the regular analysis and publishing of data in “Poliofax”, we supported the shift to case based and active surveillance and gradually added different supplementary activities including environmental surveillance.”
“I was blessed to have the support of my parents, my husband and my son. As a married woman I think it is very important to have the support of your family. I also had wonderful supervisors who believed in my capabilities and gave me opportunities. I am similarly impressed with many of the young women in the programme today.”
Sometimes the biggest challenges for Dr. Faten and her team came out of the blue, such as when the programme faced huge polio outbreaks in areas that had become free of the virus.
“We didn’t expect polio to cause large outbreaks, but we were faced with them. To overcome the situation we started to work together as partners on effective response strategies within and across regions. The virus does not stop at borders and we had to coordinate multi-country activities.”
“In the polio eradication programme we cannot be satisfied with 80% or 90% coverage – we need to reach each and every child no matter where they are, even in the hard to reach and insecure places. So there was always a lot of innovation and adaptive strategies, we were thinking how can we bridge this, and reach these children.”
“That’s how we came up with access analysis and negotiation, days of tranquility, using windows of opportunities and short interval campaigns, community involvement and collaboration with NGOs, intensifying work at exit points, thinking out of the box all the time.”
Dr. Faten was determined to possess firsthand information on polio cases, no matter where they occurred. Sometimes, this led her down unexpected paths – such as when she travelled 21 hours through the Sudanese bush to track down a polio case in a remote village.
“I’ll never forget when a wild poliovirus type 3 (WPV3) case appeared in a very faraway place in Sudan after years without WPV3. I said, “I have to see it myself”. This mission was one of my most challenging fieldtrips.”
“We faced many difficulties, it was the rainy season, the car slipped on its side on our way and we arrived after midnight.”
“I thought the virus must have been hiding in this place for years. But I found the disease surveillance to be very good. Then by investigating, we found there was a wedding, and relatives were coming from another province, so I could nearly point my finger to where the virus came from. The virus was detected in that area and we managed to curtail its spread.
In 2016, Dr. Faten set up the Rapid Response Unit in Pakistan – a dedicated ‘A team’ that can jump into an at-risk area to mitigate virus spread. Today, she is working with medical professionals to ensure that individuals with primary immunodeficiencies get tested for poliovirus, as some of them are at risk of prolonged virus shedding.
What keeps her awake at night?
“I care about where we are not reaching. Polio eradication is beyond health – it needs all the sectors to come together especially in a big country. In the last strongholds of the virus we have population movement across the border, some areas that are difficult to reach, and there are some misconceptions.”
“If someone comes and says this area is inaccessible, this is not an answer for me. I ask: What should we do to reach? I like to make use of the ideas and experience that come from local people. The virus strongholds are in certain areas, so let us work closely with the people in these areas, empower them, and allow them to change the situation.”
Dr Faten is proud to be part of the polio eradication programme and looks forward to the day when polio eradication is achieved, so she can spend more time with her family in Australia.
“As a grandmother, I am especially determined to finish the job. I want my grandkids to grow up in a world free of polio. This will be my contribution to their futures.”
In Jere Local Government Area, in Borno State, Nigeria, a team of male surveillance officers have been dispatched to look for the poliovirus.
They make a first stop at the home of Hajiya Liman Bello, a mother of three and a housewife.
“Who are all of you and what do you want?” Hajiya asks.
“We are health workers please. We need to collect stool samples from your children as there has been a case of Acute Flaccid Paralysis (AFP) in this area”, they reply.
Hajiya isn’t comfortable with the idea of a male health worker handling stool sample collection for her children. She requests that surveillance officers return with a female colleague if they wish to go ahead.
Recognising the links between gender and disease surveillance
In line with the Global Polio Eradication Initiative’s gender strategy, Nigeria’s polio programme has been quantifying the gender aspect of its work. While women make up 95% of frontline workers delivering polio vaccines, a 2017 study conducted by the World Health Organization found there were significantly more men than women engaged in polio surveillance activities in Nigeria.
In 2016 there were 29 men employed in Nigeria as state epidemiologists compared with just eight women doing the same job; 23 male state disease surveillance and notification officers (DSNOs) compared with 14 women, and at a Local Government level, 609 male DSNOs versus 218 female.
The results of the study prompted reflection by programme staff. Gender, like other factors such as age, education and socioeconomic status, is an important determinant of health-seeking behaviour and outcomes. In the case of disease surveillance officers, gender diversity amongst personnel helps the programme build trust and acceptance amongst parents.
“I believe gender strongly influences disease surveillance and access to immunization services,” says Dr Kabir Yusuof, a health worker who has worked with the Nigerian Government polio programme for over ten years.
“Nigeria is generally a culturally attuned country. There are some communities where men only feel comfortable with female health workers, especially when it comes to house-to-house outreach and matters of maternal health. For this reason, I believe the role of women in both polio surveillance and response cannot be overlooked.”
Surprisingly, the report showed there were more men than women working as surveillance focal points in health facilities in northern zones of Nigeria, compared to the south. Using gender-disaggregated data helped the programme see where things need to change.
“WHO advocates for breaking…illusions that women cannot ‘fit in’ when it comes to disease surveillance practice,” says Dr Fiona Braka, Team Lead for the Expanded Programme on Immunization at WHO Nigeria.
Polio eradication was the first disease programme at the World Health Organization to develop a dedicated gender strategy. The Nigeria AFP surveillance gender study had never been done before and has helped lay the groundwork for further examination of the programme through a gender lens. The authors of the study found that the number of AFP cases detected in boys and girls was similar, as were polio vaccination rates.
Dr Braka observes, “Integrating or mainstreaming gender into all facets of socio-economic life is key to tackling gender inequalities.”
Reposted with permission from Rotary.org When we talk about PolioPlus, we know we are eradicating polio, but do we realize how many added benefits the programme brings? The “plus” is something else that is provided as a part of the polio eradication campaign. It might be a hand-operated tricycle or access to water. It might be additional medical treatment, bed nets, or soap. This series takes a look at the ‘Pluses’, starting with prevention of other diseases. A 2010 study estimates that vitamin A drops given to children at the same time as the polio vaccine had at that time already prevented 1.25 million deaths by decreasing susceptibility to infectious diseases.
We take you to Nigeria, which could soon be declared free of wild poliovirus, to show you some of the many ways the polio eradication campaign is improving lives.
Polio vaccination campaigns are difficult to carry out in northern Nigeria, where insurgency has displaced millions of people, leading to malnutrition and spikes in disease. When security allows, health workers diligently work to bring the polio vaccine and other health services to every child, including going tent to tent in camps for displaced people.
The Global Polio Eradication Initiative (GPEI), of which Rotary is a spearheading partner, funds 91% of all immunization staff in the World Health Organization’s Africa region. These staff members are key figures in the fight against polio — and other diseases: 85% give half their time to immunization, surveillance, and outbreak response for other initiatives. For example, health workers in Borno use the polio surveillance system, which detects new cases of polio and determines where and how they originated, to find people with symptoms of yellow fever. During a 2018 yellow fever outbreak, this was one of many strategies that resulted in the vaccination of 8 million people. And during an outbreak of Ebola in Nigeria in 2014, health workers prevented that disease from spreading beyond 19 reported cases by using methods developed for the polio eradication campaign to find anyone who might have come in contact with an infected person.
Children protected from polio still face other illnesses. In Borno, malaria kills more people than all other diseases combined. To prevent its spread, insecticide-treated bed nets — such as the one Hurera Idris is pictured installing in her home above — are often distributed for free during polio immunization events. In 2017, the World Health Organization organized a campaign to deliver antimalarial medicines to children in Borno using polio eradication staff and infrastructure. It was the first time that antimalarial medicines were delivered on a large scale alongside the polio vaccine, and the effort reached 1.2 million children.
Rotary and its partners also distribute soap and organize health camps to treat other conditions. “The pluses vary from one area to another. Depending on the environment and what is seen as a need, we try to bridge the gap,” says Tunji Funsho, chair of Rotary’s Nigeria PolioPlus Committee. “Part of the reason you get rejections when you immunize children is that we’ve been doing this for so long. In our part of the world, people look at things that are free and persistent with suspicion. When they know something else is coming, reluctant families will bring their children out to have them immunized.”
Rotarians’ contributions to PolioPlus help fund planning by technical experts, large-scale communication efforts to make people aware of the benefits of vaccinations, and support for volunteers who go door to door.
Volunteer community mobilizers are a critical part of vaccination campaigns in Nigeria’s hardest-to-reach communities. The volunteers are selected and trained by UNICEF, one of Rotary’s partners in the GPEI, and then deployed in the community or displaced persons camp where they live. They take advantage of the time they spend connecting with community members about polio to talk about other strategies to improve their families’ health.
Nigerian Rotarians have been at the forefront of raising support for Rotary’s polio efforts. For example, Sir Emeka Offor, a member of the Rotary Club of Abuja Ministers Hill, and his foundation collaborated with Rotary and UNICEF to produce an audiobook called Yes to Health, No to Polio that health workers use.
This story is part of the Broader Benefits of Polio Programme series on our website, which originally appeared in the October 2019 issue of The Rotarian magazine.
The polio eradication campaign needs your help to reach every child. Thanks to the Bill & Melinda Gates Foundation, your contribution will be tripled. To donate, visit endpolio.org/donate.
Compared to the busy streets of Hargeisa, Somaliland, just 20 kilometres outside of the city are broad stretches of barren land—home to the nomads. Nomadism is part of Somalia’s culture, and there are thousands of families throughout the country who lead pastoral lifestyles, raising livestock and moving their animals and families as the seasons change. Their frequent movement means that children are not always nearby a health clinic to receive their scheduled vaccinations on time. Such disruption or delay in receiving vaccines can result in low or no protection against common childhood infections.
If children are not immunized against polio, they risk contracting the virus and developing paralysis. They also risk passing polioviruses to other under-immunized children. But the polio eradication teams are committed to reach every last child with polio vaccine notwithstanding challenging terrains.
Look through the lives of polio vaccinators in Somaliland on the third day of the vaccination campaign activities as part of the larger efforts to reach over 1.1 million children with the oral polio vaccine.
It’s 7am, and a late August dawn is stretching across a broad, sparsely populated landscape. At the side of the dirt track road, a man herds a group of camels to their grazing land for the day.
Today, their focus is the children living among nomadic communities.
Parking up amongst stones and tree roots, with arid scrub-land stretching away behind the 4x4, the vaccination team pull on their Somalia Polio Programme vests, which identify them as health workers, and retrieve their vaccine cold box from the back of the car.
The team is tired from the early start, but excited to provide vaccine to these communities.
Tiny newborn fingers are too small to mark with indelible ink to show that the child has received a vaccine today, so instead, Suad stains Abdirisaq’s big toe before he is tucked back into his warm blankets.
Suad discusses with the family that there are other vaccines that are essential for Abdirisaq to receive to stay well. She encourages his parents to take him to the nearest health clinic when the time comes for his next scheduled doses.
When he is 14 weeks old, he should receive the injectable polio vaccine, which will ensure he is fully protected against all polio virus strains.
As they vaccinate, the health workers are also busy greeting the local community and strengthening awareness of the importance of vaccination.
Being willing to have a discussion about the vaccine helps to build trust with families and gives health workers an insight into the lives of the children they are vaccinating.
By 11am, the teams have vaccinated every child under age five in this nomadic community.
Along the way, they’ve attracted interest from excited children, encountered curious goats and camels, and increased awareness of the importance of polio vaccination for every child.
The next time polio vaccinators encounter this community, they might be residing in a completely different spot.
Close community relationships help the Somalia polio programme know where nomadic groups are moving to, meaning that they can be visited again when the next vaccination campaign happens.
This campaign was the third round to take place as part of the latest stage of polio outbreak response in reaction to virus detected in the north of Somalia. The next campaign, using a different vaccine, is scheduled for this coming autumn.
Back in the car, the vaccinators set off for their next destination, driving slowly on the bumpy roads.
They are dedicated to delivering vaccines to all children, no matter where they live.
As the sun sets across Sindh province, exhausted polio eradication volunteers head home after a busy vaccination campaign. Each has personally vaccinated hundreds of children. In total, it has taken just a week for 9 million children under the age of five to receive two drops of oral polio vaccine, boosting their immunity against the virus.
In the crowded office of Jan Sayyed, Ali Raza and Muhammad Bilal Wasi Jan however, work is only just beginning. They work in the Polio Eradication Data Support Centre, located in Pakistan’s biggest city Karachi. During the campaign, vaccinators fill in paperwork every time they distribute vaccine drops. They record the number of children reached with vaccines, their existing vaccination status, any vaccine refusals and whether the children are local to the area, or visiting.
Across a typical vaccination campaign, this generates data referring to over two million children, recorded on thousands of forms. It is the challenging job of Jan, Ali, and Bilal to label and classify all this data so that it can be uploaded to an online system and analyzed to improve the next campaign.
Waqar Ahmad, Technical Officer for Data at WHO Pakistan, believes that if immunization and disease surveillance represent the heart of the programme, then data is the lifeblood that helps the programme inch closer to vaccination.
Different kinds of reliable data help the programme make decisions based on evidence. For instance, data that shows a high rate of vaccine refusals in one area allows the programme to investigate the cause further and act to persuade parents of the importance of vaccination.
But creating effective systems for gathering, sorting, and analyzing high-quality data hasn’t been easy. It has required rethinking approaches, overcoming bumps in the road, and thinking beyond the usual parameters of data management.
Pakistan’s polio data journey
Data collection and record keeping in Pakistan’s polio eradication programme began in 1997. Originally, data was collected only in very specific circumstances, such as when cases of Acute Flaccid Paralysis were detected. Such limited data collection meant that broader programme activities could not be analyzed, which increased the chances that vaccination campaigns could be ineffective. Data on other aspects could ensure that logistics were right-sized, and that human resources were deployed where they were most needed.
In November 2015, the programme introduced an online database designed to provide real-time data, named the Integrated Disease Information Management System (IDIMS).
The IDIMS database is used to store pre-, intra- and post-campaign data relating to multiple areas, including vaccination, disease surveillance, human resource planning, logistics planning, and mobile data collection. Data inputted into IDIMS is directly available for viewing and analysis at the provincial, national, and regional level. It can be cross-referenced with other polio eradication databases.
Young Pakistanis like Jan, Ali and Bilal are part of the workforce that keeps the whole system online. Once they have labelled and classified the paper forms, they pass the data onto their colleagues to be digitized and analyzed.
What’s next for polio eradication data management?
Open Data Kit software
In the Data Support Centres, employees are constantly thinking about how to further improve the IDIMS system. Jan, Ali and Bilal note that digitizing the whole data collection and management process would make the system more efficient, as well as environmentally friendly.
Data collection using Open Data Kit (ODK) software offers a way to do this. The data collection process is the same as with paper forms, except information is recorded in a mobile based application. Once vaccinators are in an area with internet, the data is directly uploaded to the ODK server and the IDIMS server. The ODK system has been rolled out in some areas of Pakistan.
Gender-disaggregated data represents a new area of work for the data management teams. Data included in the IDIMS database assists with gender-conscious campaign planning at the provincial level, while a separate system analyses gender-disaggregated information at the country level. Ensuring female vaccinators are recruited for campaigns is crucial, as women can often vaccinate children in places where for cultural reasons, men cannot.
Increasing user-friendly interfaces
As part of efforts to make systems user friendly, one year ago the polio programme launched online data profiles for Union Councils (UCs), the smallest administrative units in Pakistan. These profiles are available on the National Emergency Operation Centre data dashboard and allow polio programme staff to easily extract sizeable amounts of data about the local epidemiological situation within 30 seconds, as well as compare and analyze data for the past six years.
One of the most useful, innovative aspects of the UC profiles is that they collate information on children who were persistently missed during the last six campaign rounds, with information like contact details and the immunization history of the child. Such information assists the programme in follow-up engagement with the child’s parent or caregiver to encourage vaccination.
This requires speedy information sorting and uploading. Jan notes that his team is filing information more efficiently than they used to. This helps to ensure that details are up to date for nearly every town and village.
Over the coming months and years, further innovations will be introduced to improve data efficiency, range and quality.
Campaign by campaign, form by form, data handlers like Jan, Ali, and Bilal are helping to end polio.
Since its inception in 1988, the Global Polio Eradication Initiative (GPEI) is driven by a singular purpose: defeat the poliovirus and secure the world from this disease.
While there may be no cure from polio, it is preventable and eradicable. Thanks to global immunizations efforts of national health authorities backed by international partners – WHO, Rotary International, the US Centers for Disease Control and Prevention (CDC), UNICEF, the Bill & Melinda Gates Foundation and Gavi, the Vaccine Alliance — cases of wild poliovirus have dropped from 350 000 in 1988 to 33 cases reported in 2018, and four Regions of the world have been certified free of wild poliovirus.
Another milestone was achieved last week: Nigeria crossing three years without detection of wild poliovirus. With this, the African Region can now possibly start the official process to certify the WHO African Region free of wild poliovirus.
This milestone was a slow and steady win, which would not have been possible without the people who make up the very fabric of Nigerian communities. Trust-building efforts by traditional leaders and the network of women making household visits across the country, made it possible to overcome socio-cultural and operational barriers to vaccination.
Read about the innovative practices for polio eradication in Nigeria.
In Union Council Kechi Baig, Quetta district, Balochistan province of Pakistan, Asma needs no introduction. When she talks, people listen. First, when she was one of the few female religious scholars at her local madrassa (school), and of late, as a champion for the polio programme.
For Asma, the segue into community health sensitization was quite natural. Her religious vocation as a teacher, also known as an Alima, and her life-long aspiration to help her community, came full circle when she became a religious support person (RSP) for the polio programme.
“I always wanted to become a doctor… but (it just so happened) I joined a madrassa and became an Alima…when I heard that the polio programme is looking for female RSPs, I took the opportunity. Even though I did not become a doctor, I can workwith doctors to serve humanity,” said Asma about her motivations.
As one of three female RSPs out of a team of 118, she has given unique credence to the polio efforts in her community. Kechi Baig accounts for a significant number of refusals to vaccinate. Community health workers are sometimes unable to make headway with refusal families. In such cases, Asma plays an important role as a faith-based counsellor, drawing upon her knowledge and expertise on religious teachings with communication skills and personal friendships within the community. Asma convinces 15-20 ‘hard refusal’ families in each vaccination campaign.
“I visit the households and leave with grandmothers convinced. As a madrassa teacher, I have seen that most females are unaware of religious teachings of Islam and the role of women to improve society. The polio fatwa (Islamic rulings) book proves to be very helpful because it contains authentic fatwas from venerated religious scholars.”
Asma realizes that bringing an attitudinal change through one-off encounters with refusal households is not enough. She saw the need for a long-term counselling relationship. Now, the polio programme team also conducts community engagement sessions with a cross-section of women across the community — from mothers to grandmothers to young students to women training at Asma’s madrassa—to raise awareness about polio.
“It is a great achievement being part of the training sessions about polio and health where I get to talk about the fatwa book. In almost every campaign I work with community health workers and convince 15 to 20 hard refusals for vaccination. It’s a big opportunity to save children from polio,” explained Asma.
Religious support persons, particularly women RSPs like Asma, play a very important role in mediating how people consider their choices for and against polio vaccination through the religious interface. By incorporating educative, spiritual, and medical knowledge, faith-based counselling goes a long way in neutralizing any refusal predispositions within the community.
A member of the Rotary Club of Islamabad (Metropolitan), Pakistan, Gul runs a Rotary-funded health center in Nowshera, working with teams of female vaccinators help reach neighborhoods of ethnic Afghan refugees displaced by conflict in tribal border regions. Gul’s teams use cellphones for daily data reporting on immunization progress, which helps health teams analyze data and report back in real time.
