In 2009, India had reported 741 polio cases, the highest in the world, according to the Global Polio Eradication Initiative. In January 2011, India reported its last polio casein West Bengal’s Howrah. The turnaround, in the face of huge challenges, was a major success story of India’s healthcare system, and learnings from the process were utilized during the Covid-19 vaccination drive recently.

India beat polio through coordination between various levels of government and international aid agencies, successful messaging, overcoming cultural barriers, and ensuring last-mile coverage. Here’s a brief account of how the story unfolded.

First, the challenges

India had a huge population, with millions living in crowded settlements with inadequate hygiene arrangements. Challenges in different parts of the country were entirely different. Many parts of the country were geographically difficult to access. On top of this were fears of the vaccine, born out of religious beliefs and a mistrust of the government machinery.

Narrowing down on the problem

Vaccination against polio began in 1972, and expanded in 1985 as the country-wide Universal Immunization Program (UIP). For polio, one immunization day would be fixed for the whole country and awareness created about it. The fact that polio drops could be given orally and not as an injection was an advantage, as local health workers could administer them even without special training.

Vaccination drives would be held on festivals, at railway stations, and any place where a large number of people gathered.

Special awareness camps were held for mothers, where they were addressed by women of their community and social class, speaking their language.

Celebrities like Amitabh Bachchan were roped in to create awareness. According to a UNICEF report, “Building on the huge reach of soap operas, polio and other health messages were woven into storylines and episodes.”

The polio vaccination tagline — do boond zindagi ki (two drops of life) — still has recall value.

Polio often spreads through the feces of the infected person, which others can come in contact with from contaminated food and water, poor hygiene, etc. Thus, along with vaccination, the importance of washing hands, boiling drinking water, giving only breastmilk to babies below six months of age, etc. was also communicated to people.

The efforts were led by the Center and state governments, supported by the World Health Organization (WHO), UNICEF, US Center for Disease Control.

and Prevention (CDC), Rotary International, and donors like the Bill and Melinda Gates Foundation.

By 2008, cases had begun to decline in many parts of the country. According to a UNICEF report, “In 2009, the polio partners found that more than 80 percent of polio cases were persistently occurring in just 107 blocks of Uttar Pradesh and Bihar.”

Efforts were scaled up to target these regions.

Monitoring

A cornerstone of the strategy was effective surveillance and monitoring of high-risk groups. According to a research paper by Toronto-based Reach Alliance, “Availing itself of the expertise of the World Health Organization (WHO), India developed a robust surveillance system… Without this multilayered surveillance system, cases of polio among the hardest-to-reach groups were being missed, leading to continued transmission.”

This involved monitoring the occurrence of acute flaccid paralysis in children, which is often caused by the polio virus, and then immunizing those around the affected child. For this, a network of ‘informers’ was built, including community health workers, local residents, doctors, faith healers etc.

Special strategy for migrants

A big problem in Uttar Pradesh and Bihar was seasonal migration for work, which meant a set of people fell through monitoring cracks. To cover migrants, vaccination drives were conducted at their residential camps. Daily wage workers did not want to miss a day’s earnings in taking their kids for immunization, so vaccination camps were organized keeping in mind their work timings.

Overcoming religious, cultural barriers against polio vaccine

Vaccine hesitancy stemmed from rumors that it could make children impotent. The Muslim community had religious objections. For this, community leaders like imams and Maulanas were roped in. Aligarh Muslim University and Jamia Millia Islamia also made awareness efforts. “For example, one rumor was that the OPV was manufactured using pig blood which is deemed to be haram or forbidden in Muslim culture. To dispel this, influential Islamic leaders issued a fatwa (a ruling in Islamic law) to confirm that the OPV was halal,” the Reach Alliance paper says.