This is the fifth and final piece in a five-part series on global polio eradication based on interviews in Washington, in Atlanta at the Centers for Disease Control and Prevention, and at National Immunization Days in northern Nigeria.
Leaders in the global polio eradication initiative expect to wipe out the disease by 2005. They hope that strategies used in one of polio's last holdouts - Nigeria - may have an impact on other childhood diseases.
Conditions are ripe for polio in Nigeria. It is a densely populated country, with poor sanitation, low rates of routine immunization and a weak public health network. Yet health officials there are determined to stop the transmission of the disease by the end of the year.
Between 2000 and 2001, the number of new polio cases in Nigeria dropped from 2000 to just 57. Dr. A. Awosika is director of the National Program on Immunization. She said the combination of good surveillance techniques and door-to-door campaigns - carefully synchronized with neighboring African states - has proved effective. She said the campaign has fostered a powerful sense of purpose among all those involved.
"I see a sense of mission. I see a sense of calling," said Dr. Awosika. "I see a responsibility to the people, and all this inculcated in service. It has brought people to feel that [they] can do something for other people."
Leaders in the global polio eradication initiative - officials at World Health Organization, UNICEF, Rotary International and the Centers for Disease Control and Prevention - often remark that the program has gone beyond the eradication of a major disease. They say the program has developed new international partnerships, created a disease surveillance system, established a global laboratory network, strengthened routine immunization and set the stage to tackle other diseases.
Stephen Cochi, the director of the Global Immunization Division at the Centers for Disease Control and Prevention in Atlanta, said, "We've taken some new steps in improving primary health care of children worldwide, and I think the work of polio eradication is going to improve the status of children, the survival of children, the well-being of children in a major way."
"I certainly think that polio needs to be eradicated," said Robert Steinglass, who runs a child survival project for the U.S. Agency for International Development. "I think polio has a lot to teach us, but I think that many people are completely overstating the case in terms of what polio eradication will leave behind in terms of a legacy that will be useful for further development efforts."
Mr. Steinglass believes that where the polio eradication initiative has missed the mark has been its failure to improve routine immunization programs. "For a long time and even now, there has been a lack of finance to finish the job on polio eradication," he said. "Polio needs to be eradicated. The finance needs to be found for it. Part of the marketing strategy that has been used is to say that we have to eradicate polio, and by the way, by investing in polio we are going to benefit the entire routine immunization program.
"But it is so clearly not the case for people who work in the field, who understand what the routine program requires," he continued. "Throughout the 1990s, despite the existence of new vaccines, none of these new vaccines were being introduced in routine immunization programs, and they couldn't be introduced through a polio platform. Are you going to directly solve injection safety issues through a polio platform? Polio, as you know, is an oral vaccine."
What will it take to strengthen routine immunization programs? "It will take the commitment of all the partners, including the ministries of health," said Mr. Steinglass. "It requires skilled staff and manpower. In many countries that had successful routine immunization programs, the staff had been recruited to work on polio in other countries on international assignments. So there has been in fact a brain drain during these past years away from routine immunization," he continued. "So you typically in a country have 30, 40 or 50 people working on polio and one, two or three working on the routine immunization program. So it will require the redirection of resources and the commitment of ministries and their partner agencies to working on routine immunization."
The USAID program that operates in Nigeria is training men and women in villages to play a greater role as advocates for their own health care needs. They learn grassroots organization and problem solving.
In Yargunda, a small farming hamlet, five women have been designated as child health promoters. They have taken a USAID seminar on breastfeeding. Their job is to teach others in the village what they have learned. One day, one of the CHPs took her file of large picture cards to show a neighbor.
Salamatu Bako, a USAID health and nutrition officer, walked us through the village where women are pounding dried okra for soup stock. "This is the place," he said. "You can see the well. This is where they keep their goats and chickens, and that is where the grandmother is taking care of the corn … This is the mother who has just delivered. She delivered yesterday, and you can see the health promoter has told her that she should be breastfeeding the baby."
Women in this program gain status among their peers. They feel empowered and want more training. They promote the National Immunization Days and vaccinate their children against polio. But these mothers say they also worry about more widespread diseases and conditions like AIDS, measles, malaria, malnutrition, respiratory infections and diarrhea. They wonder, how can they protect their children?
They start by educating each other. Seated on straw mats in a courtyard in front of their home, they begin to sing a song written for them by one of their husbands. He joins them to plead, "Listen people. Listen to the preaching!"
"He talks about diet during pregnancy, about exclusive breast feeding," explained Salamatu Bako. "He even talks about developmental milestones of a child and advantages of breastfeeding, then the importance of immunizations and then the chorus is saying, 'Listen brothers and sisters, listen!'"
The women are forming a drama group. They want to spread their health message at weddings, at festivals and naming ceremonies. Just how well they practice the lessons they preach may determine the future well being of their community and their nation.
Photos for this series provided by Rosanne Skirble