In the last twenty years, since the 1980s, there have been key milestones in the fight against polio: public campaigns, community-led immunization campaigns championed by local volunteers and elevating the dialogue at the global level by philanthropists.

At the heart of the advancement was ensuring communities were at the table in the decision-making process. This is one of the key insights produced by an emerging model of healthcare delivery that shows great promise in finally stamping out some of the most stubborn killers of children, including polio. The central message of this model is in one word: “Listen.”

It was listening to the concerns of staff administering polio vaccines in the mountainous Khyber Pakhtunkhwa (KPK) province in north-west Pakistan that uncovered one of the reasons communities were resisting polio vaccination. Improvements have been made in delivery, supply lines and community cohesion. One of the major initiatives that changed the landscape was the Lady Health Workers who went door-to-door to implement the program. Being responsive and the bottom-up approach has been working well in delivering community health programs in Pakistan, particularly in polio eradication.

So how does the global health community develop healthcare programs – particularly for stubborn diseases like polio in a way that works in the places where they are most needed?

Meet Brad and Zarah

To see how this works, I’d like to introduce you to two people: “Brad” and “Zarah.” They’re metaphors, actually, for two different approaches to disease eradication.

We might visualize Brad as a man in his late 50s, who has a Master’s degree in Public Health, lives in New York City and works with a UN-associated agency in the UN Plaza complex.

The traditional model of eradication – delivered by the formal healthcare system – is the one that “Brad” represents. It’s one in which the healthcare experts know what to do and are decisive about telling the “non-experts” what needs to happen. And the Brad model works well in some circumstances, particularly places like White Plains.

Now imagine a different model of disease eradication, which we’ll call “Zarah,” which can be visualized as a young Pakistani woman dressed in a traditional clothing as a community worker going door-to-door to parents– something like Pakistan’s Lady Health Workers who have been so crucial in the fight against polio.

The Zarah model involves these key success factors:

Listen, and be willing to change based on what you hear. Even after the local resistance to the made-in-the-West vaccines, it took a lot of effort to change the supply-chain to regionally made ones. Now, vaccines destined for Afghanistan and Pakistan originate from the Middle East.

Local languages spoken here. It’s becoming clear that for parents in the target areas to accept the advice of health workers about how to protect their children, the advice has to be offered by people who speak the local language and even the local dialect. This means recruiting healthcare workers locally.

Gain local community support. Recruiting local people goes a long way towards building community support – including local formal and informal leaders, as well as religious authorities. It can be somewhat more difficult to relate to the military – healthcare programs need the support of people in uniform, but not necessarily their involvement.

Multi-faceted support: All possible ways to support the drive towards immunization must be enlisted. In recent years, even Bollywood films included story lines to support immunization – an important communication vehicle given the huge popularity of movies and other popular culture with which local people can identify.

Appropriate to the local culture: In KPK, community organizations found that having women doing the work of delivering the vaccine was essential – in traditional areas in particular – it would have been culturally prohibitive to have male health workers interacting with the mothers of the children. Sometimes, this means that it is female volunteers who take part of their weekend to administer vaccines to children in their community.

Brad and Zarah team up

All of this is very different from the traditional “Brad” model.

What’s crucial about successful immunization is that Brad and Zarah have to work together. People who look at healthcare through the “Brad” lens tend to trust and understand other people who look, act and think like them. So, it may be that the interface between donor groups, the global healthcare community, and government aid agencies must be done in Brad-friendly terms of reference. Championing and cheerleading is an important role.

And the world of technology is essential – such as using satellite-based GIS data to count every child under age five, which will also benefit other public health efforts.

But it must be made clear that implementation decisions must be made by people on the ground in the endemic areas, using the Zariah frame of reference. Only then will an implementation plan be able to respond to the concerns of parents who make decisions on behalf of their children.

Another crucial element of success is long-term involvement. “Zarah” needs to know that “Brad” will be there on a multi-year commitment, so that the vaccines are there when needed.

Key success factors for this model of public health are:

• Global coordination of the effort – such as changing the manufacturing locale of the vaccines
• Cross-border meetings to arrange the roles of each country
• Centralized monitoring by WHO
• Social mobilization by Unicef

Being a Cheerleader

Now, imagine a third ingredient: donor champions. Take for example, Canada, a country that has been a key champion in polio eradication. Canada took the decision in 2008 to invest in polio eradication in Afghanistan. A country of war and one of the most difficult terrains in the endemic countries. If polio is eradicated in Afghanistan it will because of the leadership of Canada: to remain engaged until the job is done. Canada has applied its full resources: engaging Canadians, volunteer efforts, matching funds, government funding and technical coordination support with other partners to the fight against polio. Other donors need to champion polio eradication so that the global health community can learn, as a community on how to eradicate a disease. Canada will have the institutional knowledge on how to eradicate a disease when it and given the resources and networks it has created. Canada will be the library of global health resources on eradication.

The global health leaders that came out of the smallpox effort are known worldwide as these amazing figures in public health. Today the global health leaders are a diverse group of professionals from across the developing world.  The polio program of today is shaped by Nigerians and Indians and Pakistanis and Afghan officials and citizens alike. While all these professionals may not have connections with top-tier global institutions but offer expertise that a Harvard Master of Public Health needs to have as they face the disease each day.

The WHO reports that Economic modelling has found that the eradication of polio would save at least US$ 40–50 billion between 1988 and 2035, mostly in low-income countries. Most importantly, success will mean that no child will ever again suffer the terrible effects of lifelong polio-paralysis. The world will also learn from its successes and failures to energize the fight against malaria and tuberculosis. I can’t think of a better return on investment.

Raseema Alam is a former Canadian diplomat and manager for Canada’s polio eradication program in Afghanistan. The views expressed in this article are those of the author.