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Case study of the Global Polio Eradication Initiative: analysis of current plan, shortcomings and communication barriers

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Case study of the Global Polio Eradication Initiative: analysis of current plan, shortcomings and communication barriers

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Content CASE STUDY OF THE GLOBAL POLIO ERADICATION INITIATIVE: ANALYSIS OF CURRENT PLAN, SHORTCOMINGS AND COMMUNICATION BARRIERS by Kamber Ruth ________________________________________________________________________ A Thesis Presented to the FACULTY OF THE GRADUATE SCHOOL UNIVERSITY OF SOUTHERN CALIFORNIA In Partial Fulfillment of the Requirements for the Degree MASTER OF ARTS (STRATEGIC PUBLIC RELATIONS) May 2009 Copyright 2009 Kamber Ruth ii Table of Contents List of Tables iv List of Figures v Abstract vi Chapter One: Introduction 1 Chapter Two: Background 4 Rampant Polio Epidemics of the 20 th Century 4 An Introduction to Polio 5 History of Polio 9 Introduction to the Global Polio Eradication Initiative (GPEI) 13 Coalition 14 Some Key Facts in Examining the History of the GPEI 16 Overarching Operational Objectives 17 Overarching Operational Strategies 17 Countries Currently at Risk 18 Current Impact of the Initiative 19 Future Benefits of Polio Eradication 20 Chapter Three: Organizational Goals 21 Chapter Four: Statement of Problem 23 Misconceptions About the Polio Vaccine 26 Uneducated Health Workers 32 Underutilization of Established Services 33 Cultural Barriers in Conceptions of Disease and Illness 34 Donor Attraction Issues 35 Poor Utilization of the GPEI Website and World Wide Web as Communication Information Dissemination Tools 42 Chapter Five: Research Methodology 45 Chapter Six: Situation Analysis 49 Chapter Seven: Communication Goals 55 Chapter Eight: Communication Objectives 57 iii Chapter Nine: Key Audiences and Key Messages 59 Chapter Ten: Strategies 65 Chapter Eleven: Tactics 67 Chapter Twelve: Budget 71 Chapter Thirteen: Evaluation and Proposal of New Communication Goals, Strategies and Tactics 74 General Recommendations on Communication 75 Specific Recommendations on Communication 79 References 82 iv List of Tables Table 1: Polio Infected Districts by Country from 2007-2008 8 Table 2: Timeline of Modern Polio 9 Table 3: Selected Vaccine Preventable Diseases (United States) 12 Table 4: Circulating Vaccine-Derived Polio Cases from 2000-2009 29 Table 5: Budget Breakdown for GPEI Activities from 2009-2013 in millions 72 Table 6: Expenses by Country and Year 2009-2010 73 v List of Figures Figure 1: Annual Rates of Recorded Polio Cases from 1980-2007 16 Figure 2: Map of Global Routes of Infection 19 Figure 3: Picture of Script Promoting Misinformation 31 Figure 4: Major Sources of Funding for GPEI and Funding Gap 37 Figure 5: Map of Polio Endemic Countries and Outbreak Types 44 vi Abstract This thesis aims to examine a multi-organizational initiative to eliminate polio worldwide, called the Global Polio Eradication Initiative (GPEI), through the lens of the strategic planning model. An overview of the global fight against polio and an analysis of current communication endeavors on the part of the GPEI’s backers, misperceptions about polio vaccinations among target audiences, and overall shortcomings are included. Issues facing the initiative in both the developing world with regard to populations targeted for vaccination as well as those in the developed world targeted for support and financial contributions are presented. These examinations inform a final set of recommendations for improving the communication efforts of the GPEI. 1 "We don't let children die because it is fatiguing to save them." -Bill Gates “In 1736 I lost one of my Sons a fine Boy of 4 Years old, by the Small Pox...I long regretted bitterly and I still regret that I had not given it to him by Inoculation.” -Benjamin Franklin Chapter One: Introduction Judy Cottier, a 70-year-old California resident, was eight years old when she contracted a mild case of polio in the 1940s. Poliomyelitis, commonly referred to as polio, is a crippling disease caused by three related viruses and was quite common in the United States at the time. It spreads through oral contact with water or food contaminated by feces. After human contact, the virus multiplies in the intestinal tract before entering the bloodstream. Certain types of nerve cells can be damaged or destroyed by the poliovirus, causing muscle weakness, paralysis of multiple body parts including the legs, arms and lungs, and even death from suffocation. Although Judy’s case was mild, the disease caused one of her legs to shrivel and atrophy, leaving her too weak to enjoy the experiences of any normal childhood. Judy’s large family was poor and had recently left their one-room wooden shack in Pennsylvania and traveled across the country to live in California. It was here that she contracted the illness: I had a lot of pain, especially in my left leg, which was where most of the effect was noted. I had to learn to walk all over again. Luckily I had a mild case and my left leg was only two inches smaller around the calf area. This is not enough to be really noticeable. It did limit my ability to do strenuous types of activities since I tired easily and didn’t have the stamina for hard play. I wasn’t chosen for the ball teams and did a lot of jobs on 2 the sideline. The kids thought that I was the teacher’s pet because I always got the jobs and didn’t play. I was picked on quite a bit because of this. I think that would be the hardest part of growing up…. not fitting in. I had to go to doctors all the time. Luckily I only spent a few days in the hospital and I was very lucky that I didn’t have to spend any time in an iron lung. They don’t know for sure how I got it. They surmised that maybe I got it from playing in the water hose. I don't think any reason was ever really established. There were lots of cases at that time. One of Judy’s most heartbreaking memories includes a visit to Santa Claus at a holiday party hosted by the sugar factory where her older brother worked. She remembers how her brother had carried her all the way to the factory to see Santa. They waited in line patiently while Judy’s excitement grew watching all the children before her visit with Santa. When her turn came, however, the costumed man refused to let “that crippled child” near him, instead instructing his assistant to “give her an extra box of candy and get her out of here.” Although she made a near full recovery, Judy now suffers from post-polio syndrome, which limits her mobility as the already weakened nerves in her legs become too tired to continue functioning at a normal level. She wears a brace on her left leg which has begun to drag. She uses a walker for moving around the house and for short trips out to restaurants with her family. Any activity which requires walking farther than a few steps in or out of a building requires her to use a wheelchair. Although Judy is sometimes frustrated by her increasingly limited independence, she is grateful that she is as able and healthy as anyone can be in her position. 3 This thesis aims to examine a multi-organizational initiative to eliminate polio worldwide, called the Global Polio Eradication Initiative (GPEI), through the lens of the strategic planning model. An analysis of current communication endeavors on the part of the initiative’s backers, misperceptions among target audiences, and overall shortcomings will inform a final set of recommendations for improving the communication efforts of the GPEI. 4 Chapter Two: Background Rampant Polio Epidemics of the 20 th Century Until a vaccine was widely available in the late 1950s, polio crippled and killed thousands of children each year in industrialized countries alone. 1 Estimates are difficult to make for how many millions of children and families were affected in developing countries during the twentieth century. Poor living conditions in places like India, China, South America, Africa and Southeast Asia bred innumerable local polio epidemics. Soon after the introduction of effective vaccines in the 1950s and ‘60s polio was, for the most part, eliminated as a public health concern in industrialized countries. Developing nations, however, have not fared so well. It took a great deal of time before polio was even recognized as a major problem in countries where a healthcare infrastructure is non-existent and efficient means of tracking polio victims were lacking. Without proper tracking of polio cases, the percentage of children disabled by the illness can be overlooked and polio can be given free-range to spread. ‘Lameness surveys’ during the 1970s brought attention to the fact that polio was common in developing countries, crippling thousands of children every year. During these years immunization programs through international and government health organizations helped to control but not eliminate the disease in many countries. 2 1 “The disease and the virus: What is Polio?” Global Polio Eradication Initiative. 2008. <http://www.polioeradication.org/disease.asp> 24 Dec 2008. 2 “Polio in industrialized and developing countries.” Global Polio Eradication Initiative. 2008. <http://www.polioeradication.org/disease.asp> 15 Oct 2008. 5 An Introduction to Polio The majority of people who contract polio do not actually become visibly ill and many are never aware they are infected. This can become a problem when one keeps in mind that the virus can be shed intermittently in waste for several months after infection. In areas with low immunity rates, a single person with no symptoms can infect hundreds of others, causing paralysis and death in a very short period of time. Two classifications of polio separate infections based on paralysis: a. Nonparalytic polio- Also referred to as abortive poliomyelitis, is a type of polio that doesn't lead to paralysis. It causes flu-like symptoms and most people recover from this type in less than a week. Five to ten percent of people infected with nonparalytic polio develop nonparalytic aseptic meningitis, which causes severe headaches, pain in the neck, back or extremities and inflammation of the layers lining the brain. 3 b. Paralytic polio: One percent of people who become infected with polio develop this most serious form of the disease. It often begins with a fever and may not be given the amount of attention necessary by parents or medical workers. Paralytic polio can cause acute flaccid paralysis, making limbs appear floppy. There are three sub-types of paralytic polio, which include: 4 3 Babcock, Dr. Hilary M. “Aseptic meningitis.” Medline Plus. 2008. <http://www.nlm.nih.gov/medlineplus/ency/article/000614.htm> 24 Dec 2008. 4 “Infectious disease: Polio.”Mayo Foundation for Medical Education and Research. 2008 <http://www.mayoclinic.com/health/polio/DS00572/DSECTION=symptoms> 12 Dec 2008. 6 1. Spinal polio: This is the most common form of paralytic polio, which attacks motor neurons in the spinal cord and causes paralysis. Simple neuron damage is reversible, whereas neuron destruction is not. Thus, some children or adults who contract paralytic spinal polio may have only temporary damage and paralysis to the limbs. This damage can last for years but may subside as the body begins to repair damaged neurons. If neurons are completely destroyed by the attacking virus, paralysis will last a lifetime and can never be reversed. 2. Bulbar polio: This form of the virus affects motor neurons in the brainstem, damaging or destroying a patient’s ability to see, hear, smell, taste, swallow, breathe and speak. Paralysis of the body’s breathing muscles can be fatal. One of the most common images of polio from the past is that of the iron lung, a breathing apparatus which compresses a patient’s chest and allows him or her to breath with assistance. Many patients who entered the iron lung in decades past have lived the rest of their lives lying motionless in these massive machines, some for more than 50 years. 5 3. Bulbospinal polio: This form of polio manifests as a combination of both bulbar and spinal paralytic polio, causing both paralysis of the limbs and damage or destruction of motor neurons in the brainstem. 5 Jarvie, Jenny. “Woman in iron lung dies during power outage.” The Los Angeles Times. 29 May 2008. 7 In addition to the temporary and permanent effects of polio during infection, many patients experience devastating damage decades after their infection has subsided in the form of post-polio syndrome. It can cause new muscle weakness in extremities which may or may not have been affected initially, breathing or swallowing problems, and decreased tolerance of cold temperatures. 6 Table 1 shows recent data on polio infections by district from 2007-2008. Note that the number of infected districts in endemic countries grew by 98. What is even more disturbing, however, is the fact that the number of infected districts in NON-endemic countries nearly doubled from 2007-2008. This means that polio is being imported into countries where it has been wiped out. 6 Chasens, Eileen R. and Mary G. Umlaut. “Post-Polio Syndrome.” The American Journal of Nursing. Vol. 100, No. 12. 2000: 60-61. 8 This table shows polio infections by country for the years 2007 and 2008. Table 1: Polio Infected Districts by Country from 2007-2008 7 7 “Poliomyelitis.” World Health Organization Online. Sept 2006. <http://www.who.int/mediacentre/factsheets/fs114/en/> 12 Oct 2007. 9 History of Polio 8 The following outlines a short history of notable events in the examination of polio as well as efforts to eradicate it. Table 2: Timeline of Modern Polio Year Event ~ Medical evidence of polio epidemics pre-date recorded history. First known record of polio infection recorded in 3,000-year-old Egyptian carving. 1789 Michael Underwood, a British physician, records first known clinical description of the disease. 1894 First U.S. polio epidemic occurs in Vermont. 132 cases are recorded. 1916 Large epidemic of polio sweeps across the United States. 6,000 people die. 27,000 are permanently paralyzed. Countless others become temporarily paralyzed or seriously ill. 9 1921 Franklin Delano Roosevelt contracts polio at the age of 39. 1929 Philip Drinker and Louis Shaw develop the “iron lung” apparatus to aid in respiration for paralytic polio victims. 1930s Two of the three strains of the poliovirus are discovered. 1947-1950 Dr. Jonas Salk begins work on the development of a polio vaccine. 1953 Salk and his associates develop an injectable polio vaccine. 1954 Two million children participate in field trials of the Salk vaccine. 1955-1957 Polio infections in the U.S. fall by almost 90 percent through routine immunizations. 1957-1959 Trials of Albert Sabin's attenuated oral vaccine occur in Russia. 1962 Salk vaccine replaced by Sabin vaccine- The oral form is found to be easier to administer and less expensive than the injected form. 1979 Last case of polio caused by “wild” virus in the U.S. After an eradication campaign, the last case of smallpox in the world is recorded. 1988 Global Polio Eradication Initiative started by Rotary International, Pan American Health Organization, World Health Organization, Centers for Disease Control, and UNICEF 8 “Whatever Happened to Polio?” Smithsonian National Museum of American History. 2008. <http://americanhistory.si.edu/polio/timeline/index.htm> 12 Nov 2008. 9 “Vaccines and Preventable Diseases.” Centers for Disease Control and Prevention. 2008. <http://www.cdc.gov/vaccines/vpd-vac/polio/default.htm> 8 Nov 2008. 10 The oldest clear reference to paralytic polio is a 3,000-year-old Egyptian engraving depicting the disease. Due to poor sanitation, polio was relatively rare in ancient times since mild childhood exposure to the virus increased immunity against the disease. With the growing use of indoor plumbing in the 20th century, however, polio epidemics began to grow larger and occurred regularly in the developed world, especially during summer months. Public swimming pools, watering holes and summertime diversions became points of contact for the disease to spread; crippling and killing children in its wake. With the separation of sewage and drinking water, which helped combat numerous other diseases and vast outbreaks of cholera, babies were much less likely to be exposed to polio and were not able to gain protective immunity and being infected with the virus at an older age was more likely to cause serious cases of paralytic poliomyelitis. 10 It has been said that polio was one of America’s greatest fears during the Great Depression. Crutches, wheelchairs, giant iron lungs, and shriveled limbs all became synonymous with a disease that accumulated victims every year. Many argue that only the fear and panic surrounding AIDS in the 1980s and 90s can rival that of polio in the first half of the twentieth century. 11 As an adult victim of polio, Franklin Roosevelt declared a war on the disease during his time as president and used the resources of postwar America to push for the development of a vaccine for what was known at the 10 Dove, Alan. “A Brief History of Polio: From Ancient Egypt to the 20 th Century.” Polio Information Center Online- Columbia University Microbiology Department. 2002. <http://microbiology.columbia.edu/pico/Chapters/History.html> 4 Nov 2008. 11 Dove, Alan. “A Brief History of Polio: Vaccination and Eradication.” Polio Information Center Online- Columbia University Microbiology Department. 2002. <http://microbiology.columbia.edu/pico/Chapters/History.html> 4 Nov 2008. 11 time as “infantile paralysis.” It was thought that a vaccine was at least feasible for the disease, unlike many of the serious ills of the time such as malaria. In the early 1960s, the first effective defense, the Salk vaccine, was introduced, followed soon after by the Sabin vaccine. 12 Salk used chemicals and heat treatments during the cultivation of the vaccine to “kill” the virus and then injected the inactivated virus into vaccine recipients. As with other vaccines, the proteins of the destroyed poliovirus in each vaccine invaded the immune system of patients. Too weak to cause any damage, the virus was quickly destroyed in the body by the patient’s immune system. Polio antibodies remained in the body, protecting the person from subsequent infection. Sabin approached the problem differently, however, and grew the virus in a laboratory under a variety of conditions to allow it to accrue mutations and variations. This resulted in what is referred to as an attenuated virus (a viable yet weakened strain) which could be given to a patient orally. In contrast with Salk’s method, Sabin’s weakened viruses were introduced to the digestive system in the same manner a person traditionally becomes infected. The virus then replicates normally in the intestinal tract without the strength to invade the central nervous system. The immune system then “learns” to recognize the virus and mobilizes antibodies to protect the patient. In developing countries where sterile needles and trained care-givers are lacking, this oral vaccine has been extremely useful. 12 Dove, Alan. “A Brief History of Polio: Vaccination and Eradication.” Polio Information Center Online- Columbia University Microbiology Department.2002. <http://microbiology.columbia.edu/pico/Chapters/History.html> 4 Nov 2008. 12 After the widespread introduction of the Sabin and Salk vaccines polio was quickly wiped out in most of the industrialized world. In studying polio and its economic effects on the United States, Columbia University’s Microbiology Department has declared that the economic effects of polio’s eradication within the U.S. have been enormous; it has been calculated that the polio vaccine pays for the costs of its development approximately every three weeks. The benefit to the United States alone for this single breakthrough runs into the trillions of dollars. The social impact has been incalculable. The crutches, wheelchairs, and iron lungs of polio victims have at last been banished from children’s and parents’ nightmares, at least in the developed world. 13 The following table shows the dramatic reductions in disease rates in the United States thanks to advances in vaccination technologies and population coverage rates. Table 3: Selected Vaccine Preventable Diseases (United States) 14 13 Dove, Alan. “A brief History of Polio: Vaccination and Eradication.” Polio Information Center Online- Columbia University Microbiology Department. 2002. <http://microbiology.columbia.edu/pico/Chapters/History.html> 4 Nov 2008. 14 CDC. “Impact of vaccines universally recommended for children-United States, 1900-1998.” MMWR 8(12): 243-8. 13 In developed nations, where healthcare infrastructures were strong and children’s vaccination history was well recorded and monitored, health officials found little resistance to eliminating polio as a health concern. In countries where governments lacked the necessary funds to devote to public health measures, however, the disease took much longer to eradicate. Polio is now endemic to only four countries around the world: Pakistan, Afghanistan, Nigeria, and India. Yet the threat and reality of spread are imminent. Epidemics have spread in more than a dozen countries in Africa but were quickly controlled. The countries surrounding Afghanistan are threatened by infected refugee populations, and religious pilgrims in Afghanistan, Pakistan and India threaten to spread the disease during travels within their own borders and across those of other nations. Introduction to the Global Polio Eradication Initiative (GPEI) The World Health Assembly of 1988 saw the adoption of a resolution for the global eradication of polio. Thus began what is termed the Global Polio Eradication Initiative (GPEI), led by Rotary International, the World Health Organization (WHO), the United Nations International Children’s Emergency Fund (UNICEF) and the U.S. Centers for Disease Control and Prevention (CDC). With high hopes after certification of the eradication of smallpox in 1980, the polio virus became the next global killer slated for extermination. 15 15 “Poliomyelitis.” World Health Organization Online. Sept 2006. <http://www.who.int/mediacentre/factsheets/fs114/en/> 12 Oct 2007. 14 Coalition 16 The polio eradication coalition includes the aforementioned organizations as well as governments of countries affected by polio, private sector foundations, development banks, donor governments, the European Commission, humanitarian and nongovernmental organizations and corporate partners. Volunteers also play an enormous role in the GPEI as 20 million people have participated in organizing and carrying out mass immunization campaigns. The WHO provides the overall technical direction as well as strategic operational and communication planning for the coordination of the GPEI. The WHO is responsible for ensuring the components of the GPEI Strategic Plan are implemented. The organization plays a key role in monitoring and evaluating the implementation of the plan and coordinates research, provides support to ministries of health, and oversees the training and deployment of human resources. The WHO currently plays a lead role in establishing certification standards for Acute Flaccid Paralysis (AFP) surveillance, donor coordination, resource mobilization and communication of information. Rotary International is the world’s first and largest humanitarian service organization. Its PolioPlus program was the first to promote the idea of a polio-free world before the inception of the GPEI and has given way to numerous other programs working toward the same goal. It plays a critical role in the GPEI as more than one million Rotary members have volunteered their time and personal resources to the initiative. In addition, 16 “Spearheading Partners.” The Global Polio Eradication Initiative. <http://www.polioeradication.org/partners.asp> 19 Nov 2008. 15 Rotary has contributed more than $500 million to the GPEI and its Polio Eradication Advocacy Task Force has worked with donor governments to procure contributions of over $1.5 billion to the GPEI. Its funding and supply of manpower is one of the keys to the GPEI’s success thus far. The CDC contributes to the GPEI through deployment of its epidemiologists, public health experts, and scientists. It also contributes many grants to fund research and staffing needs for GPEI member offices around the globe. The CDC also puts up funding to pay for the oral polio vaccine required for international mass immunization campaigns and works with its laboratory network to identify strains of the poliovirus involved in outbreaks. The CDC also conducts research to facilitate the development of post- certification polio immunization and surveillance policies. UNICEF is the lead partner in distribution of polio vaccines to children. It also provides technical assistance to national coordinators in the development of action plans and secure routes to access hard-to-reach areas, including in countries affected by war or conflict. UNICEF develops materials for training and public information and is an active partner in advocacy and resource mobilization. 16 The following graph shows the substantial reduction in global polio rates, in addition to highlighting the increases in polio cases in recent years. Figure 1: Annual Rates of Recorded Polio Cases From 1980-2007 17 Some Key Facts in Examining the History of the GPEI 18 a. Since the Global Polio Eradication Initiative was launched, the number of cases of polio has fallen by over 99% globally. Currently, only four countries in the world remain polio-endemic (although others remain at risk). b. Recurring polio transmission in India, Nigeria and the border between Afghanistan and Pakistan are current challenges. 17 “WHO vaccine-preventable diseases: monitoring system 2008 global summary.” 2008: 22. <http://whqlibdoc.who.int/hq/2008/WHO_IVB_2008_eng.pdf> 12 Jan 2009. 18 “The History.” The Global Polio Eradication Initiative. <http://www.polioeradication.org/history.asp> 19 Nov 2008. 17 c. By 1994, the 36 countries in the WHO Region of the Americas were certified polio-free, followed in 2000 by 37 countries in the WHO Western Pacific Region and 51 countries in the WHO European Region in June 2002. d. In the year 2007, more than 400 million children were immunized during Supplementary Immunization Activities (SIAs). Polio surveillance is currently at historical highs and cases of acute flaccid paralysis are detected more quickly than ever before. Overarching Operational Objectives The operational objectives of the Global Polio Eradication Initiative include: a. To interrupt transmission of the wild poliovirus b. To achieve certification of global polio eradication c. To contribute to health systems development and strengthening routine immunization in all countries 19 Overarching Operational Strategies There are four main strategies to stop transmission of the poliovirus in areas affected by the disease or which are considered at high risk for re-infection: a. Gain high infant immunization coverage b. Administer supplementary doses of OPV to all children under five years of age c. Improve surveillance for wild poliovirus through reporting and laboratory testing 19 “Poliomyelitis: Objectives.” Fact Sheet No 114. The World Health Organization. Jan 2008. <http://www.who.int/mediacentre/factsheets/fs114/en/> 23 Nov 2008. 18 d. Implement targeted ‘mop-up’ campaigns in areas of re-infection 20 e. To close the gap in funding necessary to complete the eradication of polio 21 Before a WHO region can be certified polio-free, there are three conditions that must be met: a. At least three years without a reported polio case due to wild poliovirus b. Disease surveillance methods in countries must meet international standards c. Countries must show that they are capable of detecting, reporting and responding to “imported” polio cases. Laboratory stocks of polio must be contained and inactivated polio vaccine manufacturing sites must be secure 22 Countries Currently at Risk Individuals in all countries are at risk of contracting polio because the infection can be spread across borders and travel silently in carriers without symptoms. Between 2003 and 2005, 25 countries were re-infected with polio due to importations of the virus from outside sources. 23 20 “Poliomyelitis: Strategies.” Fact Sheet No 114. The World Health Organization. Jan 2008. <http://www.who.int/mediacentre/factsheets/fs114/en/> 23 Nov 2008. 21 “Poliomyelitis: Priorities for Polio Eradication.” Fact Sheet No 114. The World Health Organization. Jan 2008. <http://www.who.int/mediacentre/factsheets/fs114/en/> 23 Nov 2008. 22 “Achieving Certification of Global Polio Eradication.” Global Polio Eradication Initiative. <http://www.polioeradication.org/content/fixed/achievecertification.shtml> 18 Dec 2008. 23 “Poliomyelitis: Key Facts.” Fact Sheet No 114. The World Health Organization. Jan 2008. <http://www.who.int/mediacentre/factsheets/fs114/en/> 23 Nov 2008. 19 Endemic countries can spread polio quickly through plane travel and religious pilgrimages. The following map shows some transmission routes of polio re-infection: Figure 2: Global Routes of Infection 24 Current Impact of the Initiative a. Since the GPEI’s launch in 1988, more than five million people who would be paralyzed today are walking because they have been immunized against polio. b. More than two billion children worldwide have been immunized for polio and other diseases during SIAs. Health interventions can reach even the poorest, most remote and conflict-affected areas. 24 Pallansch, PhD, Mark A. and Hardeep S. Sandhu, M.D. “The Eradication of Polio- Progress and Challenges.” New England Journal of Medicine. Vol 355, No 24. 2006: 2508. 20 c. The GPEI is helping to reduce poverty and give children a chance at leading economically productive lives. d. The GPEI has provided key demographic data on targeted populations as efforts are made to “find” children in remote villages for the first time. e. The GPEI has expanded public health networks’ capacity to address other infectious diseases, such as Ebola, by building surveillance systems, training local doctors and epidemiologists and establishing a worldwide lab network for data analysis. f. On average, one out of 250 people in a country has participated in a polio immunization campaign. g. By working together to synchronize SIAs, countries have established a new way to coordinate cross-border health initiatives, which has become a model for regional and international cooperation. 25 Future Benefits of Polio Eradication Polio eradication will benefit all people equally. It will enhance economic conditions in developing nations as well as protect children in every nation from experiencing this life-threatening disease. 26 By wiping out polio, people and governments around the world will benefit from enhanced economic productivity, improved physical health, and more equal social standing among healthy populations. 25 “Poliomyelitis: Impact of the Initiative.” Fact Sheet No 114. The World Health Organization. Jan 2008. <http://www.who.int/mediacentre/factsheets/fs114/en/> 23 Nov 2008. 26 “Poliomyelitis: Future Benefits of Polio Eradication.” Fact Sheet No 114. The World Health Organization. Jan 2008. <http://www.who.int/mediacentre/factsheets/fs114/en/> 23 Nov 2008. 21 Chapter Three: Organizational Goals The ultimate goal of the GPEI is to make the world a healthier place by ending suffering from polio. It achieves this by supporting governments in polio eradication and immunization endeavors and providing treatments, vaccinations, medications and preventive care for multiple conditions around the world. The GPEI lists six organizational goals in the initiative’s “Strategic Plan,” the highest-level document to be examined by all member organizations: 27 a. Interrupt wild poliovirus transmission b. Ensure sustainable surveillance for polioviruses c. Achieve certification and containment of wild polioviruses d. Plan for re-structuring of the Global Polio Eradication Initiative for the Vaccine- Associated Paralytic Polio (VAPP)/ Vaccine-Derived Poliovirus (VDPV) Elimination Phase e. Prepare for VAPP and VDPV elimination and the post-OPV era The GPEI’s status as an international public health initiative necessitates broad, yet clearly stated goals. The six goals the GPEI puts forth achieve this and speak to the weight the organization places on communicating its operational intentions and purpose to the international public and to national governments around the world. However, it seems that the GPEI has overlooked the importance of highlighting effective communication in its goals. Operational measures are of the utmost importance. However, the simple act of highlighting communication as an important goal can increase 27 “Global Polio Eradication Initiative Strategic Plan 2009-2013: Framework document.” 2008:2-12. 22 the focus on and attention paid to the process. Because all organizations and government entities turn to the GPEI website and Strategic Plan documents, it is imperative for the initiative to highlight the importance of unified and standardized communication goals and audiences. A plan’s leader must lead by example. 23 Chapter Four: Statement of Problem The overarching problem faced by the GPEI was summed up by a young man named Ramesh with whom I spoke. He is a polio survivor who moved to the Canadian Yukon after he was adopted from India at a young age. He recently completed a “cycle to walk” polio fundraiser to raise money and awareness for polio eradication. Ramesh volunteered in a Rotary International PolioPlus program in India and was deeply affected by what he saw there and by attitudes regarding polio here in North America. When I asked him what he saw as some of the biggest communication challenges to ending polio, he offered the following: This past November I was in India as part of Rotary International’s PolioPlus program. En route to a community I saw a young man in his mid to late 20s crawling on the ground with sandals on his hands and scraps of tires on his knees. This man had not had access to the polio vaccination and his legs were paralyzed for life. If I was not adopted after contracting polio this would have been my life. My biological mother in India didn’t have the resources for me to receive the rehabilitative support I needed. The World Health Organization has predicted that an additional 10 million children will be paralyzed over the next 40 years if we choose not to continue the fight against polio. In America 10 percent of the population has not received the polio vaccination – that’s about 30 million people! This is an alarming number since polio can spread quickly through global plane travel. I think a few reasons people have not received the polio vaccination or don’t support vaccination programs are that the problem is “out of sight and out of mind,” there is mis-education about the vaccine and the idea that it has links to autism, there is ignorance about the importance of preventive vaccination, and sometimes religious beliefs stand in the way. As a global community we have a once in a lifetime opportunity to rid the world of this disease. The only time this has been achieved was with smallpox but I believe it can be achieved with polio. We must continue to volunteer our time and resources to rid the world of polio. 24 The GPEI has done a phenomenal job of communicating operational objectives and standards. Every key document is well laid out, clear and concise in terms of how the initiative plans to address polio in the modern world as well as situation planning for a post-polio world. Hence, the initiative’s oversight in putting as much effort toward important communication activities seems odd. Even “calls for research” on the GPEI’s website consist of calls for scientific and operational research. Would the initiative not also benefit from research on how its backing members can better communicate with target audiences and how to co-opt the industrialized world into fighting against this disease? The GPEI has now been working to end polio for 21 years, nine years longer than anticipated. On March 1, 2007, the International Herald Tribune published an article titled “Experts wonder: Is it time to give up on polio eradication?” 28 Although polio cases are down 99 percent since the start of the Global Polio Eradication Initiative, rates of polio have yet to see a dramatic decline since the year 2000; the year set by the GPEI for complete global polio eradication. That year came and went, but polio has not and the number of reported cases has fluctuated from 719 in the year 2000 to 1659 cases and counting in 2008 (data is not yet complete). 29 One of the biggest challenges to estimating the number of polio cases each year is the fact that health workers are usually only notified that polio is filtering through a community by the presence of acute flaccid 28 Associated Press. “Experts wonder: Is it time to give up on polio eradication?” International Herald Tribune. 1 Mar 2007. 29 “Wild Poliovirus 2000 – 2009.” Wild Poliovirus Weekly Update. 24 Mar 2009. <http://www.polioeradication.org/casecount.asp> 25 Mar 2009. 25 paralysis. Thus, Someone must show symptoms of paralytic polio to spur testing. Keeping in mind that only one percent of cases results in paralysis, the number of individuals silently spreading polio is grossly underestimated. This leads many outside the medical community to believe that polio is under control. In addition to current statistics on new cases of polio each year, the following statistics show the lasting effects of the disease: 30 a. 10 to 20 million people are currently living with the lasting effects of paralytic polio. 1 30 percent of those affected by paralytic polio make a full recovery 2 30 percent of those affected by paralytic polio are left with mild paralysis 3 30 percent of those affected by paralytic polio live with medium to severe paralysis. 4 Polio kills 10 percent of those who contract the paralytic form. This paper will focus on seven main problems with regard to communication efforts within the Global Polio Eradication Initiative. The initiative’s backers have an admirable amount of experience in the operational measures of combating disease. Each organization has contributed vast amounts of time, resources and knowledge to health campaigns around the world and are to be applauded for the success with which many of these health initiatives have been accomplished. However, the GPEI’s backers face the mounting challenge of addressing communication issues within the campaign to end 30 “A Terrifying Disease.” Conquering Polio. 2009 < http://www.polio.info/polio- eradication/front/index.jsp?codeRubrique=12&lang=EN&siteCode=POLIO> 24 Oct 2008. 26 polio. With the strengthening penetration of media, increased access to the internet, and poor communication planning targeted at communities in need of vaccination, the GPEI has encountered unprecedented resistance in communities in desperate need of treatment and vaccination. The communication seven issues the initiative faces today include: a. Misconceptions about the polio vaccine b. Uneducated health workers contributing to the spread of misinformation and mistrust c. Underutilization of trusted established health services and knowledgeable practitioners to quell fears d. Cultural barriers in conceptions of disease and health e. Donor attraction issues f. Too little research on communication barriers g. Poor utilization of the GPEI website and World Wide Web as communication information dissemination tools Misconceptions About the Polio Vaccine One of the biggest obstacles the members of the GPEI face in ending polio is poor communication with and misinformation about polio vaccinations among populations targeted for vaccination. Health workers attempting to vaccinate children against the disease in rural villages of polio-afflicted countries, namely India and Nigeria, find that parents hide their children or refuse vaccination. The historical context of health work in these and many underdeveloped nations requires a closer examination to fully understand these refusals. 27 In 1976, the Indian government declared a state of emergency with regard to the expanding population of that country. The government then launched a massive campaign to sterilize men and women in poor neighborhoods. 31 Without proper communication through a reliable source, these villagers still regard health workers with suspicion. Why would anyone trust government-supported “health” initiatives if one’s government has a history of abusing the rights of individuals? Parents in Nigeria have also become increasingly hostile toward the GPEI. Two independent Nigerian university researchers launched a study to find out why parents in the African nation were refusing to let their children be vaccinated against polio. The study included 422 parents from the targeted community while 24 purposively selected parents participated in focus groups. The majority of parents (83.6%) said they believe that polio is a serious disease, but only 45.3% of all respondents knew how polio is spread. Almost 51% of the parents insisted that their children were simply not susceptible to the disease. The study found that some of the major reasons for parents not releasing their children for polio immunization included: a. That too much attention was being paid to polio at the expense of other childhood killer diseases (such as malaria, HIV, or Ebola). 32 b. The suspiciously high frequency of National Immunization Days (40.8%) 31 “The Issue that Inflamed India.” Time Magazine. Apr 1977. 32 Osowole, O.S. and J.A. Obute. “Parents’ awareness and perception of the polio eradication programme in Gombe local government area, Gombe state.” Department of Health Promotion and Education, Faculty of Public Health, College of Medicine, University of Ibadan, Ibadan, Nigeria. 2005. <http://iussp2005.princeton.edu/download.aspx?submissionId=50810> 24 Dec 2008. 28 c. Fear of a polio vaccine overdose (39.6%) d. Fear that the vaccine was mixed with HIV, malaria, and Ebola (7.3%) Based on these findings, it is clear that open channels of communication for information dissemination must be established. A campaign with emphasis on transmission route, the importance of immunization and information to dispel rumors and improve acceptance of polio vaccine is imperative. The GPEI cannot simply fall back on the notion that people will accept life-saving vaccines on common sense grounds. Parents in these countries make rational decisions about the health of their children based on conflicting information to the best of their ability. Arming them with the correct information through communication will help them see how they can save the lives of their children. Poor healthcare and lack of information, education, and medical knowledge in countries infected by polio cause skepticism in parents of young children in need of the vaccine. Without a base of knowledge regarding appropriate health standards, parents in these polio-infected areas have trouble recognizing signs of illness and the importance of preventive medicine in keeping their children healthy. Out of ignorance flows misinformation. Hence, people in areas with a high prevalence of HIV and other communicable diseases may mistakenly attribute the symptoms of these diseases to be the result of medical interventions by GPEI health workers. In areas with low immunity rates and limited vaccine coverage of the population, unvaccinated children can become infected with polio after coming into contact with vaccinated children due to the active 29 virus used in oral vaccines currently administered in developing areas. Numerous polio outbreaks in Nigeria in 2004 caused by this contact fed rumors that the GPEI was intentionally infecting children with the disease. 33 Fear and panic spread, and parents erroneously thought they were protecting their children by keeping them unvaccinated. The following table indicates global rates of vaccine-derived polio cases: Table 4: Circulating Vaccine-Derived Polio Cases From 2000-2009 34 The GPEI must work to emphasize the need for all children to receive the vaccination to gain full immunity. In addition, children living in poor conditions may require more oral administerings of the vaccination before their already overwhelmed immune systems are able to produce antibodies. Effective communication can help make parents aware of this information. 33 Hopkin, Michael. “Health officials fear Nigeria polio setback.” Nature. 12 October 2007. 34 “Circulating Vaccine-Derived Poliovirus.” Wild Poliovirus Weekly Update. 24 Mar 2009. <http://www.polioeradication.org/casecount.asp> 25 Mar 2009. 30 In 2003, government officials in the Nigerian state of Kano banned polio vaccination efforts for ten months as rumors swirled that the vaccines were tainted with impurities which would sterilize girls and infect children with cancer or HIV. Muslim clerics in the state condemned the campaign as a western Christian plot to sterilize, kill and reduce the numbers of Muslims worldwide. (This assumption may stem from the fact that even outside of Nigeria a large number of the populations targeted by the GPEI are Muslims in Afghanistan, Pakistan, and India, the only other endemic countries remaining.) After the nearly year-long ban and a lengthy investigation, the state of Kano was able to have independent scientists certify and approve the use of a polio vaccine produced in Indonesia (a predominantly Muslim country) for use in Nigeria. 35 Eighty percent of the 339 Indian polio cases in Uttar Pradesh occurred in the Muslim community in 2007. A Rotary-led initiative dropped that rate to 30% of 20 cases during the first three months of 2008 by working with the new Ulema Committee for Polio Eradication. Ulemas are legal experts in Islamic law and the Ulema committee spearheaded an effort to distribute booklets published by India’s National PolioPlus Committee that linked polio immunization to the duties of parents as explained in the Qur’an. This booklet also listed the names and phone numbers of Ulema committee members and encouraged people to contact them should any misconceptions about the polio vaccine need clearing up. 36 35 “NIGERIA: Kano state resumes polio vaccinations after 10-month ban.” Humanitarian News and Analysis. UN Office for the Coordination of Humanitarian Affairs. 2 Aug 2004. <http://www.irinnews.org/report.aspx?reportid=50902 KANO> 19 Nov 2008. 36 “Rotary’s Ulema Committee Pledges to Eradicate Polio from Muslim Population.” 22 Mar 2009 <http://www.ashokmahajan.com/news/UlemaMeetReport.pdf> 22 Mar 2009. 31 Although the reinstatement of vaccinations in Kano was to be applauded, the World Health Organization stated that during the ten months of vaccination bans, polio cases in Nigeria spiked and led to the re-infection of ten surrounding African countries where polio had been eradicated. It is important to note that with increases in travel and religious pilgrimages, polio can spread to populations in countries where the disease is no longer present. The following picture was taken by my UNICEF contact in Pakistan. The script reads: “Jews have made the vaccine from the fat of pigs, monkeys, mice and chimpanzees.” Figure 3: Picture of Script Promoting Misinformation 32 Uneducated Health Workers One obstacle the GPEI faces is the use of untrained health workers in countries targeted for eradication. Eradication in any country may be impeded by a government’s lack of funds, personnel or equipment. The number of trained personnel in developing countries may be lacking for even routine health tasks. Piling on the burden of polio eradication only worsens the problem in countries where the national budget is inadequate and the proportion allotted for health purposes is small. 37 In one study of polio eradication drives, the example of uneducated polio drop providers was illustrated in the following vignette: Some collectors had put teachers/revenue inspectors/village patwaris [to] administering doses. They had never done this work and were scared also. I saw in one OPV booth an industrial inspector trying to mix OPV of two vials in one and then administer. When I asked him why he was doing it he said he had taken two vials from the vaccine carrier without knowing and hence, he wanted to mix in one when both vials were half. In this process of mixing the temperature of the vaccine gets affected. He was not aware that vaccine mixing will lead to temperature distortion and also loss of efficiency. 38 The front lines of communication for any health initiative are those who work directly with the public. When citizens trust a health worker with the lives of their children, they reasonably expect that these health workers are knowledgeable about the issue at hand, educated about possible complications, and well-trained in how to combat rumors. However, when persons with little knowledge about health are used to spread the 37 Cockburn, T. Aidan. “Eradication of Infectious Disease.” Science. Vol. 133, No. 3458. 7 Apr 1961: 1052. 38 Kulkarni, Manu N. “How Useful Is Pulse Strategy for Polio Eradication?” Economic and Political Weekly, Vol 32, No 11. Mar 1997: 520. 33 messages of preventive medicine and health care, the response may be less than desirable. Many communities have designated care-givers and the GPEI must take into consideration the importance of this position in a community before designating volunteers, teachers, or others to administer polio drops. Underutilization of Established Services The problem of uneducated health workers goes hand in hand with the underutilization of existing health workers and health facilities as: In many areas the large number of private urban clinics, which regularly offered routine immunization, were not allowed to open their clinics. Some families are attached to a certain clinic and they did not quite trust a school teacher giving polio drops. In one city nearly 70 private clinics were denied the facility of providing pulse polio. 39 If people already have an attachment to a particular clinic or a particular doctor, why not utilize these established bonds of trust and put them to work in the fight against this disease? Few mothers will willingly put the health of their child at risk. When a mother or caregiver has an established bond with a health care provider, it can be disconcerting when said care provider does not participate in polio vaccination drives. By capitalizing on established trust, vaccination drives can reach the greatest number of individuals in a given period. In addition, it may lessen the burden on volunteer health workers and encourage caregiver-health care provider conversation and an open dialogue about rumors and misconceptions. 39 Kulkarni, Manu N. “How Useful Is Pulse Strategy for Polio Eradication?” Economic and Political Weekly, Vol 32, No 11. Mar 1997: 520. 34 Cultural Barriers in Conceptions of Disease and Illness With regard to public health, any organization must take into account the conceptions of health and disease within its target audience. The way illness is perceived, not just in the medical profession, is as important as having a treatment or cure. It is significant to keep in mind those community members who have responsibility for caring for the sick and what methods of treatment are preferred in the targeted community. Co- opting a community to deal with health problems is more economical and less conflict- causing in general. If we look to the research conducted in the Cornell-Navajo project we see that when the researchers carried out their tuberculosis detection program they uncovered important cultural approaches to health and disease that could prevent the success of medical interventions based on western science. For example, when they found a patient with tuberculosis who needed immediate medical attention and hospitalization, they became aware that sending the person to the hospital immediately would result in the patient’s escape from the facility almost without delay. However, if the patient was allowed a few days back on his or her reservation for any necessary ceremonial requirements before undergoing treatments, he or she would come back to the hospital and be a willing and cooperative patient. 40 40 Suchman, Edward A. and Lois Alksne. “Communication Across Cultural Barriers.” The American Catholic Sociological Review,” Vol 22, No 4 (Winter). 1961. 311. 35 The Cornell-Navajo project also found that different cultures have different interpretations of scientific knowledge. After showing Navajo tribe members the organism through a microscope which causes tuberculosis, these individuals incorporated the scientific data into their own base of knowledge in a rather surprising way: They let the Indians look through a microscope and showed them the tubercle bacillus, explaining that this bacillus, and not a spirit, had caused the disease. The Indian would say ‘Ah, so you have found the demon that we knew all along caused the disease.’ 41 Keeping the Cornell-Navajo findings in mind, it is essential to construct any public health measures with the target population’s attitudes and beliefs in mind. By communicating with a population in a manner they understand and through communication channels they already trust, a well-researched campaign can be implemented in a highly successful manner. As highlighted by Osowole and Obute’s study of Nigerian parents resisting the polio vaccination, we see that many parents’ conceptions of health and disease hinder their ability to understand how their children are vulnerable to polio. Donor Attraction Issues The GPEI faces problems not only with populations targeted for polio vaccination, but also with potential donors. Many newspapers and public opinion leaders have questioned the efforts being put into an eradication campaign which has failed to 41 Suchman, Edward A. and Lois Alksne. “Communication Across Cultural Barriers.” The American Catholic Sociological Review,” Vol 22, No 4 (Winter). 1961. 312. 36 reach its objective for so long. While writing this thesis, the Bill and Melinda Gates Foundation took the bold move of stepping up to support polio eradication efforts with a $225 million donation and encouragement for global leaders of the GPEI. 42 A few key issues exist which hinder even the basic prerequisite of providing funding for this massive campaign. a. The GPEI has long faced a large shortage in funding to complete even the most basic operational tasks of immunization. The year starting 2007 saw a $425 million funding shortage. Thanks to the Bill and Melinda Gates Foundation’s generous donation at the start of 2009, the GPEI is one step (and a lot of media coverage) closer to raising the necessary funds to make the initiative an operational success. Figure 4 shows the where much of the GPEI’s funding comes from as well as highlights the shortage of funds for this important global health campaign. 42 Grahl, Arnold R. and Dan Nixon. “Bill Gates announces new US$255 million grant for ending polio.” 21 Jan 2009. Rotary International. <http://www.rotary.org/en/MediaAndNews/News/Pages/090121_news_gates255milliongrant2009ia.aspx> 24 Jan 2009. 37 The following pie chart shows the current funding gap for the GPEI for the upcoming year. Figure 4: Major Sources of Funding for GPEI and Funding Gap 43 b. A second issue is the widespread belief that polio is not a relevant health issue. The GPEI has a problem on its hands: a lack of people who know about, care about and recognize polio as a global health issue. In my own research, the percentage of people who knew what polio is dropped dramatically for younger generations compared to older ones. Only 42% of the people under 25 years of age whom I asked could describe polio. Many could only vaguely describe the 43 “Financial Resource Requirements: Financial contributions since 1988 and funding gap for 2009-2010” Jan 2009. <http://www.polioeradication.org/content/general/FundingGapPieJanuary09.pdf> 30 Mar 2009. 38 disease’s symptoms or effects and some said they had heard that polio was “some kind of disease” when studying Franklin Delano Roosevelt in school. Almost all the individuals over 40 whom I interviewed knew about polio and could describe some symptoms or effects of the disease. Many of them had a parent or relative who had been afflicted with the illness. In addition to the generational knowledge- gap regarding the disease, most people who had at least heard of polio were under the impression that the disease was either eradicated or only affected a “few” people each year and that it was no longer a relevant global health issue. It appears that Americans extrapolate their own experiences with disease to the experiences of other nations: since we don’t have polio, it is most likely not a problem globally. In addition to lack of knowledge, the GPEI must deal with the issue of those people overzealous to proclaim a disease “wiped out” when rates of infection drop to extremely low levels. Many believe that since polio infection levels have dropped so dramatically there is no reason to fight so furiously against it. Yet as we see from the following account of an eradication program in Haiti, this devastating mindset can undermine all the efforts, money, and time put into the campaign for so many years. [I]n Haiti, where yaws eradication [was] attempted[, there] had been 45,356 cases of yaws reported in 1949 in the island; in 1950 the general population had been given penicillin, and in 1953 only about 400 cases of yaws could be found. Every year since then the program has continued, and the early eradication of yaws has been eagerly expected, but each year up to 1959 there continued to be a hard core of about 300 cases. In nearby Jamaica, the yaws eradication program had made considerable progress when the 39 teams for checking and surveillance were withdrawn prematurely. In 1959, 415 new cases of infectious yaws were reported, and the program is to be resumed. The kind of experience underlines the difficulties in the later stages of an eradication program. Once the first enthusiasm for the program has dwindled and the disease to a large extent has disappeared, it is difficult to keep the teams in the fields and at a high level of efficiency. 44 Using this example as a lesson to fight vigilantly until the end of polio, it is apparent that the GPEI must make the public aware of this fact as well. Recent measles outbreaks in the news in the U.S. have made the American public aware, for example, that contagious diseases can spread rapidly through travel and cannot be ignored. c. People do not see the economic benefits of ending polio worldwide. The problem of funding and cooperation also arises when trying to enlist the assistance, funding or cooperation of communities not visibly or greatly affected by polio. When any one community does not see the benefits of putting up its time, money and resources, then what would be compelling enough to encourage these communities to do so? Many countries have run into problems when trying to tackle the issue of wiping out malaria when their neighboring countries do not experience the same problems with mosquitoes and malaria infection. 45 44 Cockburn, T. Aidan. “Eradication of Infectious Disease.” Science. Vol. 133, No. 3458. 7 Apr 1961: 1055. 45 Cockburn, T. Aidan. “Eradication of Infectious Disease.” Science. Vol. 133, No. 3458. 7 Apr 1961: 1052. 40 d. Parents’ “right” to not vaccinate children in the developed world also impedes understanding of the need for vaccination in the developing world. There is currently a debate on the ethics of forced vaccination in the developed world. In more and more industrialized countries, parents turn to the internet to research information pertinent to the health of their children: “Is my child growing normally?” “At what age should I introduce solid food?” “Is my child sick?” When one types the word “vaccinations” into a search engine, say, Google, the results are surprising. Of the 10 results that pop up on the first page, four paint vaccinating one’s child in a risky or negative light. Meanwhile, the growing number of anti-vaccination movements in the United States seems to be strengthening. Vaccinationdebate.com claims “doctors and scientists condemn vaccination,” while www.shirleys-wellness-cafe.com offers parents anti- vaccination support groups for parents resisting forced vaccination of their children. 46 Issues within the anti-vaccination debate have been spearheaded by celebrities and political activists alike. A growing number of parents, including high-profile celebrities, claim that a link exists between immunizations and autism, Attention Deficit Disorder (ADD), and other neurological disorders. Jenny McCarthy’s son was diagnosed with autism and the star claims it was caused by his vaccinations as a baby. She has founded an entire non-profit organization devoted to “educating” parents about how vaccinations cause ADD, 46 Sinclair, Ian. “Doctors and Scientists Condemn Vaccination.” 2002. <www.vaccinationdebate.com> 12 Dec 2008. 41 Attention Deficit Hyperactivity Disorder (ADHD), autism, seizures and other conditions. Her organization went so far as to hire an independent research firm to confirm her assertions. Issues arise as to the suitability of the methodology this firm employed in its study and the conclusions arrived upon by what I see as faulty data. Despite these flaws, McCarthy’s celebrity status exerts some influence over parental perceptions of vaccinations. If people in the developed world feel they need to fight for their rights not to vaccinate their children, why would they donate to a program to force vaccinations on people in other countries? In addition to Jenny McCarthy’s campaign to spread awareness about possible links between vaccines and autism, a woman named Barbara Loe Fisher spoke before the California state Legislature and offered a heartbreaking account of her son: I come here as a parent of a son who had a neurological reaction to his fourth DPT shot at age two and a half that caused brain dysfunction, including multiple learning disabilities and attention deficit disorder (ADD), but who was fortunate not to lose his life or be left with mental retardation, uncontrolled epilepsy, autism, or other severe disabilities like so many of the vaccine injured children I have come to know. When my son had his vaccine reaction in 1980, children in America were told to get 23 doses of 7 vaccines. Today, children are told to get 37 doses of 11 vaccines. In those 22 years since my son had his vaccine reaction, the numbers of American children with learning disabilities, attention deficit disorder and asthma have doubled; diabetes has tripled; and the incidence of autism has reached epidemic proportions, increasing 200 to 600 percent in every state, marking a staggering 3400 percent increase in the prevalence of autism in our children. 47 47 Fisher, Barbara Loe. “Childhood Immunization Mandates: Politics Vs. Public Health.” Quote from Informational Hearing of the Senate Committee on Health and Human Services. 23 Jan 2002. 42 Although Fisher lacks hard evidence of her son’s “brain dysfunction” or ADD being caused by his vaccinations and her claims about asthma, diabetes and ADD do not take into account changes in American lifestyles, health standards or medical diagnostic techniques, Fisher’s account can incite fear among parents concerned about the well being of their children. Poor Utilization of the GPEI Website and World Wide Web as Communication Information Dissemination Tools The GPEI has done a commendable job in communicating its operational objectives, strategies and tactics. Yet the organization has failed to devote any relevant amount of its web materials to communication issues, standards and practices. When examining each member organization’s website, one can see the disjointed nature of communication efforts between the organizations. Each has its own set of unclear and poorly operationalized communication-related materials. It is disturbing to see organizations so versed in the operational aspects of the polio eradication efforts to simply ignore the need for unified communication goals. To reiterate, the GPEI faces the following problems: a. Misconceptions about the polio vaccine b. Uneducated health workers contributing to the spread of misinformation c. Underutilization of trusted established health services and knowledgeable practitioners to quell fears d. Cultural barriers in conceptions of disease and health e. Donor attraction issues 43 f. Too little research on communication barriers (to be address in the following section on research methodology) g. Poor utilization of the GPEI website and World Wide Web as communication information dissemination tools 44 The following map shows polio endemic countries and outbreak types occurring in those countries. Different regions are currently combating different strains of the virus in their children. Figure 5: Polio Endemic Countries and Outbreak Types 48 48 “Map of Polio Cases Worldwide.” Wild Poliovirus Weekly Update. 24 Mar 2009. <http://www.polioeradication.org/content/general/casemap.shtml> 25 Mar 2009. 45 Chapter Five: Research Methodology The most updated research on communication barriers available to the public from the GPEI consists of a decade-old, small-scale study. For two months in late 1999, a series of case studies were performed in five African nations. The objectives were to document communication activities for polio eradication, exchange effective experiences, and formulate recommendations for improving communication interventions. The research methodology was as follows: The case studies were conducted by inter-agency teams of four to five persons in each country over a period of 10 to 15 days. In general, teams visited the capital and two provinces. Visited provinces were to include one with high National Immunization Days (NIDs) coverage and another with low NIDs coverage. Within each province, the teams visited two districts, again one with high NIDs coverage and another with low coverage. Data collection involved primarily document review, semi- structured interviews among key informants and observations. Going into 2008, the following data-collection subjects on communication efforts were made available to organizations within the GPEI for guidance on communication endeavors and research. This information is quoted directly: 49 The following indicators could be collected through specific research activities such as: • General KAP / social norms—standard questionnaire (samples available) to gather the same data to identify trends guide federal communication strategies. • Systematic data collection from sentinel sites identified from high risk areas where activities will be more closely monitored, and where enhanced data collection can occur prior to or after and SIA for a specified number of immunization events. 49 “State of the Field: Country Level Programme Communication and Social Mobilization in the Polio Endemic and Re-infected Countries.” 2007. <http://www.unicef.org/immunization/files/State_of_the_field.doc.> 02 Jan 2009. 46 • Qualitative inventories—including focus groups of women, religious figures, or other key categories from high risk states, to identify concerns, perceptions and proposed modifications to PEI. Communication effects (periodic through surveys, focus groups, or from inclusion in PCM): This data will be important for establishing baseline information, to serve as formative data for communication planning for setting objectives for communication effects, such as improvements in knowledge among mothers regarding dates of service from X% to Y% in a specified population. Knowledge Dates of service delivery measured prior to event Source of information Location of services (door to door, health post, booth) Benefits of services (disease prevention, or other intervention specific information including safety) Attitude Safety and efficacy of OPV / routine immunization Perceived norms a) perceive enacting behavior has benefit (immunization is a good thing) b) affinity with referent group / source of information that immunizes (others in my community immunize their children) c) view attitude or behavior as central self concept (I am an immunizer) Behavior (decision maker / caretaker with agency to act) Report intent to engage in behavior Report engaging in desired behavior Observed engaging (data on coverage, other quantified measures) in desired behavior The India polio eradication effort was the first to integrate the use of social and epidemiological data into its strategic planning initiatives in 2002 and 2003. 50 Social research revealed political and cultural barriers to acceptance of the polio vaccine. Prior to the above outline research guidelines being released (after being pioneered by India), data collection had been on the shoulders of individual organizations and health workers 50 “State of the Field: Country Level Programme Communication and Social Mobilization in the Polio Endemic and Re-infected Countries.” 2007. <http://www.unicef.org/immunization/files/State_of_the_field.doc.> 02 Jan 2009. 47 for nearly three decades. This is especially disconcerting when one keeps in mind that the GPEI faces vast challenges in researching its target populations: many of the people whose children need vaccination do not read, write, or have access to mainstream media outlets. Thus, primary research becomes a complicated process in which health workers must conduct impromptu interviews and community focus groups in the field. For a project of this size, scale and importance, research information is and has been sorely lacking. It is unthinkable that research on target audiences has been neglected for so long by organizations so skilled in working with these populations. Most of the strategies and tactics for communicating with parents of children in need of vaccination, the media, and the public at large rest on information gleaned by harried health workers in the field. This is certainly not the best nor the most efficient way of collecting, recording and communicating what may be some of the most imperative information to the success of this initiative. (There is no information available on whether or not the GPEI conducts research on public attitudes and opinions in the developed world, something necessary if the organizations want to co-opt the industrialized world into solving a problem many citizens see as remote from their lives.) In addition, little research methods or findings are available on attitudes of parents with children in need of vaccination. Many problems and communication issues can be pre-empted if sound research is employed before approaching a problem. The GPEI cannot be blinded by enthusiasm and fail to address different support, acceptance, and knowledge levels of the public and those targeted for vaccination. 48 The use of question and answer sessions to inform community members about polio would be one way to simultaneously glean information on attitudes and opinions of community members. Examining secondary research on polio statistics from government sources is much easier than the independent compilation of research, but the validity of these sources must be questioned. In India and Nigeria, where polio is most prevalent, how is the GPEI to be sure that government polio statistics are correct since these nations have poor public health programs and may have ulterior motives for reporting low polio infection rates? 49 Chapter Six: Situation Analysis The idea of eradicating a disease from the globe is an extremely exciting prospect. The GPEI-backing organizations have already realized this goal with the eradication of smallpox from the world in the late 1970s. With this achievement under its belt, the GPEI’s eradication of polio seems possible in the near future. The following highlight some strengths, weaknesses, opportunities and threats the GPEI faces: a. Strengths: 1. GPEI members’ previous experience in eliminating smallpox from the globe 2. GPEI made up of world’s largest public health organizations 3. Has strong backing from numerous governments 4. Has strong backing from a group of dedicated public and private donors 5. Partnerships between high profile organizations such as WHO, United Nations, Rotary International and UNICEF gives GPEI more access to governments, people, and resources 6. Established relationships with community leaders 7. Established relationships with government leaders 8. Strong operational research background 9. Influence in vaccine production 10. Strong laboratory network worldwide 11. Recent high profile donation from Bill and Melinda Gates Foundation 12. Numerous communication professionals within member organizations 50 13. Strong backing from Non-Governmental Organizations (NGOs) 14. Recent shift toward collection of information on community perceptions of the polio vaccination program b. Weaknesses: 1. Budget constraints in relation to an expanding global population 2. Initiative’s use of oral polio vaccine causes outbreaks of polio among unvaccinated children 3. Lack of trained health workers necessitates reliance on untrained citizens and local medical workers 4. GPEI must also devote resources to other health initiatives of member organizations 5. Member organizations seen as a “western” organizations, which may strip the GPEI of legitimacy among historically subjugated communities 6. Lack of allocation of time and funds to communication-focused research (as opposed to operational research) 7. Numerous organizations working on the initiative with different levels of funding, guidance and influence as well as differing approaches to communication and emphasis 8. Poor history of communication 9. Poor use of centralized website as information hub for vast number of entities seeking information and guidance or best practices 51 c. Opportunities: 1. Improved medical technology helping to improve ease of delivery of medications 2. Improved medical transportation systems helping to improve viability of medications, vaccines, and preventive care measures after transportation to rural areas 3. Spread of TV and other communication media in impoverished areas facilitates communication with people who cannot read 4. Trends in birth control and family planning have heightened awareness of the need to take better care of fewer children 5. Recent high-profile donation by Bill and Melinda Gates Foundation gives new awareness to the global polio issue 6. Development of media in target nations sheds light on polio for said nations as well as the world 7. New American refocus on war in Afghanistan brings opportunity to highlight resurgence of the disease in that nation d. Threats 1. Wars in Afghanistan, unrest in Pakistan, and recurring civil conflicts in West Africa all threaten the campaign by putting health workers in danger and bringing about uncleanly living conditions 2. “War on Terror” and perceived threats to the Muslim community make Muslim leaders in suspicious of “western” health measures 52 3. Vaccine suppliers may stop provisions of free and low cost vaccines/medications due to perceived failure of GPEI in ending polio 4. Political instability makes working with governments difficult 5. Donors may stop giving money since the GPEI has failed to meet its goal of polio eradication for so many years 6. Journalists and reporters write articles which exploit the stories of polio outbreaks without relaying facts on vaccination 7. India, an endemic country, has the fastest growing population in the world 8. Vaccine suppliers may stop provisions of free and low cost vaccines/medications due to economic downturn and falling profits 9. Economic downturn forces governments to allocate resources differently, possibly cutting what leaders perceive as unnecessary public health measures 10. Donors may stop giving money due to economic hardship 11. High profile yet misinformed celebrities and “help” websites threaten to misinform even the most educated people. e. Strategic Implications: 1. The GPEI should use some independent research monitored by a variety of religious groups to enhance trust between GPEI health officials and religious leaders who discourage vaccination among their followers. 2. The GPEI should utilize non-written and non-televised communication, such as speaking groups, to raise awareness of the GPEI in poor areas. 53 3. The GPEI should promote its status as an independent international coalition not run exclusively by western governments in order to gain the trust of communities wary of western political motives. 4. The GPEI should highlight economic benefits of polio eradication during this global economic downturn to maintain donor levels 5. The GPEI should highlight economic benefits of polio eradication during this global economic downturn to maintain government support 6. The GPEI should enhance the use of new media to spread the word about the initiative in the developed world to garner support, volunteers and donations The GPEI has many obstacles to overcome in dealing with numerous governments internationally, but it utilizes its strengths to a great degree. It also examines itself internally each year and evaluates progress toward achieving goals, which has been beneficial in improving operational strategies. This helps the organization stay on top of challenges and continually alter plans which seem to be failing. However, the GPEI has, for some length of time, underestimated it threats and weaknesses, which shows its lack of communication and public relations-oriented research. Because the eradication of smallpox was a great success, it seems as though the GPEI’s backing organizations have approached this campaign with the same attitude. While a positive attitude is desirable, polio and smallpox are inherently different diseases whose symptoms inspire different feelings in communities around the world. Smallpox’s much more visible nature and higher death rate appear to have been a more threatening 54 disease for many communities. Polio’s more silent nature makes some communities wonder why it is being tackled at all when Ebola, HIV, and malaria are running rampant through their communities. The suspicions, fears, and anger in these communities must be addressed before success can be achieved. 55 Chapter Seven: Communication Goals a. Advocate for and mobilize resources to support communication efforts b. Design, produce and disseminate communication materials c. Support the training, assistance and supervision of provincial communication activities d. Document and evaluate communication strategies and activities e. “Assess community perceptions every 6 months and tailor social mobilization strategies accordingly.” 51 f. Improve monitoring and evaluation of communication activities. g. Ensure adequate staffing and capacity h. Support functioning country level communication planning forums; i. Link global, national and sub-national advocacy efforts j. Integrate social and epidemiological data for planning in Strategic Plans k. Identify and reach underserved populations through focused communication initiatives 52 One of the main problems the GPEI faces in eradicating polio is under- and miscommunication with publics who need vaccination (namely in India and Nigeria). The GPEI’s documents do not include communication objectives in a centralized location for all member organizations to examine. Instead, each organization completes its own 51 “Global Polio Eradication Initiative Strategic Plan 2009-2013: Framework document.” 2008:2-12. 52 UNICEF. “State of the Field: Country Level Programme Communication and Social Mobilization in the Polio Endemic and Re-infected Countries.” 2007:1. 56 communication objectives. This lack of coordination between organizations with regard to standardized communication efforts and guidelines may breed confusion and hinder progress. The above goals were taken directly from the GPEI’s 2009 Strategic Plan framework document in progress as well as UNICEF’s “State of the Field” documents on communication and social mobilization in polio endemic countries. Both documents are new and present a shift toward more a focus on communication issues However, although the GPEI is attempting to actually open lines of communication in underserved communities, it appears that it may be lacking goals focused on the actual communication process. I would recommend that, in addition to focusing on opening lines of communication, the GPEI should better state how it needs to utilize communication opportunities it has already established. Having a clear written goal can help people and organizations work together more efficiently. The GPEI should use pre- and post- campaign research on communication, which is an excellent way to gauge communication success for shaping future policy write-ups and communication endeavors. 57 Chapter Eight: Communication Objectives The GPEI has a few key measurable operational objectives in the fight to end polio, illustrated in its annual reports and numerous other documents. However, finding communication objectives is extremely challenging. Although approaching each targeted community with specific and tailored communication objectives is the correct course of action, the GPEI’s oversight in not publishing readily available standards and overarching global communication objectives leaves the burden of creating such information on the shoulders of health workers in every district and targeted area. Some of the following are overarching goals, while others are more regionally specific. The disjointed nature of information availability makes finding communication goals for the plan difficult even with time and honed internet searching skills. I can only imagine how difficult it must be for health workers and plan organizers in developing countries who lack these resources. a. By July 2005, secure $50 million dollars to fill funding gaps in polio campaign 53 b. Secure $200 million by January 2006 to continue polio eradication campaign 54 c. In Pakistan, province-specific eradication plans, which include the mix of polio vaccines to be used in each area, should be established by end-2008, fully implemented, and reported back to ACPE by end-March 2009. 55 53 Global Eradication Initiative: 2004 Annual Report.” World Health Organization. May 2005:10. <http://whqlibdoc.who.int/hq/2005/WHO_POLIO_05.03.pdf> 12 Oct 2007. 54 Global Eradication Initiative: 2004 Annual Report.” World Health Organization. May 2005:10. <http://whqlibdoc.who.int/hq/2005/WHO_POLIO_05.03.pdf> 12 Oct 2007. 55 “Conclusions and Recommendations of the Advisory Committee on Poliomyelitis Eradication (ACPE).” 19 Nov 2008. <www.bvv.sld.cu/download.php?url=123298865331.pdf> 23 Nov 2008. 58 d. Objective data (e.g. finger-marking) should be provided to the ACPE in April 2009 to demonstrate that all children are being reached in campaigns. 56 e. “The primary communication objective for PEI in Afghanistan was for targeted communication and social mobilization efforts to reach caregivers of repeatedly missed children in 70 high-risk clusters in 17 high-risk districts of southern and eastern Afghanistan.” 57 The GPEI desperately needs to form a set of overarching multi-organizational communication objectives for member organizations to look to for guidance in writing up their own. 56 “Conclusions and Recommendations of the Advisory Committee on Poliomyelitis Eradication (ACPE).” 19 Nov 2008. <www.bvv.sld.cu/download.php?url=123298865331.pdf> 23 Nov 2008. 57 “Polio Eradication in Afghanistan.” UNICEF. 2008. <http://www.unicef.org/immunization/index_46028.html> 21 Jan 2009. 59 Chapter Nine: Key Audiences and Key Messages The GPEI lists four target audiences for operational communication: 58 a. Communication/social mobilization planners and managers at national, provincial and district levels b. District and sub-district supervisors c. Vaccination teams, vaccinators, mobilizers and communication specialists d. International consultants and staff The GPEI also lists six key audiences for direct communication about the importance of the program. I will list those here as well as include key messages laid out by GPEI for each target audience, then give an analysis: Key Audience #1: Decision-makers/politicians a. President/prime minister b. Ministers of health, planning, finance c. Local administrators d. Legislative bodies (national, regional, local) Potential Concerns: a. Budgetary implications b. Public opinion c. Opportunity to show leadership and take credit for success d. The liabilities of inaction 58 Mikulencak, Mandy (WHO). “Advocacy: A Practical Guide.” 1999: 17. 60 Key Messages: a. Immunization is the most cost effective health intervention b. Immunization is the right of every child c. Polio eradication is establishing access to children who have never been reached before d. As long as polio exists, every child is at risk e. Eradicating polio will save the world US$ 1.5 billion annually Key Audience #2: Donors a. Foundations b. Bilateral agencies (e.g. Swedish International Development Cooperation Agency (SIDA), United States Agency for International Development (USAID), UK Department for International Development (DFID), Japan International Cooperation Agency (JICA), etc.) c. Multilateral agencies (e.g. World Bank) Potential Concerns of Donors: a. Ability to produce and document results b. Cost-effectiveness of an intervention c. Feasibility of integrating strategy with existing initiatives d. Sustainability of project e. Potential domestic benefits 61 Key Messages: a. Immunization is the most cost-effective health intervention b. Immunization is the right of every child c. Polio eradication is establishing access to children who have never been reached before d. As long as polio exists, every child is at risk e. Eradicating polio will save the world US$ 1.5 billion annually Key Audience #3: Journalists a. Health reporters b. Foreign correspondents c. Editors d. Feature writers e. Columnists f. Economics/labor reporters g. Women’s issues reporters Potential Concerns: a. News value and timing b. Potential “CBS” (Controversy, Big names or Sensation) c. Has the story been told before? d. Are there good visuals and spokespersons? e. Misconception among journalists that polio is “wiped out:” No news value. 62 Key Messages: a. Key messages will depend on the outlet; e.g., highlight the economic benefits for a financial publication b. Feature stories on the success of the eradication initiative and immunization and the people who deliver and benefit from it c. News stories on outbreaks, trends, NIDs, ceasefires d. Human interest stories about volunteers delivering vaccine Key Audience #4: Non-Governmental Organizations (NGOs) a. Relief organizations b. Development organizations c. Human rights organizations d. Children’s organizations e. Practitioner organizations Potential Concerns: a. Donor and membership support b. Impact on beneficiaries c. How message fits with mission statement d. Common agendas and shared visions e. Potential to play a unique role 63 Key Messages: a. Polio eradication and successful routine immunization depend on mobilizing communities b. Your constituents can help c. Help build local infrastructure to improve the health of your constituents Key Audience #5: Corporations and Industry a. Multinationals b. Local businesses c. Labor Organizations Potential Concerns a. Impact on workforce b. Impact on markets c. Cause-related marketing potential Key Messages a. Polio eradication and routine immunization are good and measurable social investments b. There is no such thing as a “local” health problem anymore c. Your investment can help the local community d. Investing in polio eradication offers good exposure in local markets e. Helping tackle problems in poor countries can make good business sense 64 f. Poliovirus can be imported into a country in a matter of hours g. The savings from eradicating polio can be used for other purposes Key Audience # 6: General public a. Issues popular with the public find their way onto the political agenda and a groundswell of public opinion can have a strong influence on governments Key Messages: b. Personal level of risk c. Response of government/health authorities to protect the public d. A moral duty to help others The above mentioned key audiences are extremely well laid out although the GPEI still must clarify the ways strategies and tactics with which it will contact these audience, which will be addressed below. 65 Chapter Ten: Strategies Seven communication strategies for the GPEI to help end polio worldwide can be gleaned from a number of sources: a. Develop national communication strategies and plans for routine immunization, supplemental immunization, and disease surveillance b. Identify communication needs and provide recommendations to address these c. Work with local NGOs that provide assistance to these families and use local mobilizers/educators and community groups/leaders to provide information d. Develop and implement training, data collection and analysis to strengthen immunization communication at all levels 59 1. Strengthening communication will remove the panic, fear and uncertainty about vaccination among infected communities. e. Place a strong emphasis on public information 60 f. Gain endorsement by high profile celebrities g. Brand communication materials to increase visibility 61 The GPEI has room for dramatic improvement in the outlining of its strategies as an organization in need of communicating with the public. Since there are so many organizations working together on this initiative, it would be immensely beneficial if the 59 “Communication for Polio Eradication and Routine Immunization.” Global Polio Eradication Initiative. 2002:26-73. <http://www.polioeradication.org/content/publications/2002_commschecklists.pdf> 24 Apr 2008. 60 “Global Polio Eradication Initiative Strategic Plan 2004-2008.” 2004: 33. <http://www.polioeradication.org/content/publications/2004stratplan.pdf > 24 Oct 2008. 61 “IEC Social Mobilization Initiative.” 2004: Slide 8. <http://www.polioeradication.org/content/presentations/genevadeclaration2004/India/sld008.htm> 25 Oct 2008. 66 document they all looked to for guidance was clear, concise, and meaningful. Since the organization has done such an excellent job of outlining key audiences and messages, strengthening strategies would make its utilization of these key audiences categories more efficient and effective. As it stands, organizations currently write their own strategies and tactics even though some may be working side by side targeting the same populations. 67 Chapter Eleven: Tactics The tactics for the GPEI do not correlate directly with the strategies outlined for the program through the WHO. Instead, the GPEI lists “problems” and tactical communication solutions to address these problems. This may be exacerbating the seemingly disjointed nature of some of the GPEI’s operational and communication operations globally. a. Problem: Parents’ low motivation to immunize because of their vague understanding about immunization and its importance: Tactical Solutions- 62 1. Encourage community leaders to talk to parents and children. 2. Encourage positive radio and press coverage. 3. Teach about immunization in health fairs and other events. i. These three tactics will raise awareness among parents of why they should vaccinate their children and how it will make a difference in their lives and the community. 62 “Communication for Polio Eradication and Routine Immunization.” Global Polio Eradication Initiative. 2002:29. <http://www.polioeradication.org/content/publications/2002_commschecklists.pdf> 24 Apr 2008. 68 b. Problem: Parents’ fear of side effects from the polio vaccine: Tactical Solutions- 63 1. Develop a counseling aid to remind health workers to tell mothers or caretakers when to come for the next immunizations, that side effects may occur, and what to do if they do occur 64 i. This tactic will help normalize the side effects of vaccination and emphasize that small side effects are better than getting polio. ii. It will also encourage regular and effective immunization. c. Problem: Mothers don’t know their baby’s immunization schedule: Tactical Solutions- 65 1. Learn the strategies of mothers who take their babies in on time and then disseminate their stories. 2. Develop and disseminate local calendars. 3. Coordinate with primary schools and adult literacy classes to ensure that these programs teach how to read the immunization schedules of children. i. These tactics help ensure that parents will remember vaccinate their children on time, which is crucial to keeping immunizations current and preventing the spread of polio between children. 63 “Communication for Polio Eradication and Routine Immunization.” Global Polio Eradication Initiative. 2002:29. <http://www.polioeradication.org/content/publications/2002_commschecklists.pdf> 24 Apr 2008. 64 “Communication for Polio Eradication and Routine Immunization.” Global Polio Eradication Initiative. 2002:29. <http://www.polioeradication.org/content/publications/2002_commschecklists.pdf> 24 Apr 2008. 65 “Communication for Polio Eradication and Routine Immunization.” Global Polio Eradication Initiative. 2002:29. <http://www.polioeradication.org/content/publications/2002_commschecklists.pdf> 24 Apr 2008. 69 d. Problem: Husbands, partners or other influentials don’t want mothers to take babies for immunizations because of time constraints or lost labor, expense, or fear of side effects 66 Tactical Solutions- 67 1. Encourage radio and press coverage that addresses the barrier. 2. Encourage community leaders to carry out advocacy in community groups. 3. Teach about immunization in health fairs and other events. i. These tactical solutions will help quell fears and raise awareness of the importance of proper immunization of children. By convincing influentials that a day’s lost labor is well worth the life of their children, they may encourage or be open to vaccination. e. Problem: Parents’ refusal to have their children immunized due religious beliefs 68 Tactical Solutions - 1. Educate religious leaders in order to gain their support and empower them to encourage their followers to get children immunized. i. By co-opting religious leaders to convince followers to vaccinate children, parents may place more importance on immunizations. 66 “Communication for Polio Eradication and Routine Immunization.” Global Polio Eradication Initiative. 2002:29. <http://www.polioeradication.org/content/publications/2002_commschecklists.pdf> 24 Apr 2008. 67 “Communication for Polio Eradication and Routine Immunization.” Global Polio Eradication Initiative. 2002:29. <http://www.polioeradication.org/content/publications/2002_commschecklists.pdf> 24 Apr 2008. 68 “Communication for Polio Eradication and Routine Immunization.” Global Polio Eradication Initiative. 2002:29. <http://www.polioeradication.org/content/publications/2002_commschecklists.pdf> 24 Apr 2008. 70 The tactics implemented on GPEI’s behalf are focused considering budget and infrastructural constraints within the countries whose population it is trying to vaccinate. Yet within these tactics there exists a lack of focus on targeting mass media and donors in the developed world to garner support and donations for the initiative. Once again, this speaks to the fact that the GPEI has done an excellent and extremely thorough job of researching and carrying out operational plans while neglecting to see the importance of communication efforts complementing this work. 71 Chapter Twelve: Budget The GPEI is currently experiencing a funding gap of hundreds of millions of dollars. The initiative’s backers struggle to carry out the day-to-day tasks of routine immunization in some of the poorest and least accessible places on earth. Adding the burden of communication to this problem only worsens the initiative’s financial state. As Table 4 shows, operations (which the GPEI says communication expenses falls under) accounts for $252 million of $736 million in projected expenses for 2009 without factoring in the current funding gap of $55 million. Add to this the need to split this money across multiple continents (shown in Table 5 below) and the financial situation becomes even more ominous. However, by maximizing communication efforts and utilizing new media, the GPEI would be able to reach out to the developed world in a cost effective manner while capitalizing on word-of-mouth marketing, thus preserving its budget for communication materials in the developing world. 72 The following table shows the budget breakdown across activities for the GPEI’s activities for the next four years: Table 5: Budget Breakdown for GPEI Activities from 2009-2013 in Millions 69 69 “Global Polio Eradication Initiative Partners in the Global Polio Eradication Initiative Budgetary implications of the GPEI Strategic Plan and Financial resource requirements 2009 – 2013.” Jan 2009: 15. <http://www.polioeradication.org/content/general/FinalFRR_English2009-2013_January09.pdf> 22 Feb 2009. 73 The following table shows budget breakdowns for GPEI activities by country. Some countries require a greater amount of funding and attention than others. Table 6: Expenses by Country and Year 2009-2010 70 In the next section, I will address the overall success of the campaign in addition to giving a set of recommendations and insights. 70 “Global Polio Eradication Initiative Partners in the Global Polio Eradication Initiative Budgetary implications of the GPEI Strategic Plan and Financial resource requirements 2009 – 2013.” Jan 2009: 19. <http://www.polioeradication.org/content/general/FinalFRR_English2009-2013_January09.pdf> 22 Feb 2009. 74 Chapter Thirteen: Evaluation and Proposal of New Communication Goals, Strategies and Tactics The GPEI’s backers successfully eradicated smallpox from the globe three decades ago. Thus, these organizations believe that they can achieve the same results with polio. Opponents of the polio program say that the GPEI failed at achieving the target goal of 2000 for eradication and does not take seriously enough the changes that have occurred politically, economically, and culturally around the world since the times of the smallpox eradication campaign. However, examining the GPEI’s dedication to ending polio and the massive amounts of program revisions it completes, it is clear that the organization does indeed understand the magnitude of the world’s problems today. However, they have underestimated the amount of resistance they face with certain populations and continue to approach these populations with the notion that people see the inherent benefits of vaccination. Poor immunization acceptance rates are the result of rational questions from targeted populations about vaccinations, reoccurring national immunization days in the context of more serious health concerns (like malaria or HIV) which populations feel are being ignored, concerns about religious infringements and how vaccination keeps with religious duties and beliefs. The GPEI currently lacks an updated and user friendly website for a centralized location for the storage of information from the numerous organizations attempting to cooperate on the initiative. The GPEI has done an admirable job of communicating its operational objectives, strategies and tactics. Yet the organization has failed to devote any 75 relevant amount of its web materials to communication issues, standards and practices. When examining each member organization’s website, one can see the disjointed nature of communication efforts between the organizations. It is unfortunate to see how the need for unified communication goals is overlooked as a means to success. With regard to donors and the public at large; many people simply do not see polio as a public health concern or do not know that polio still exists. Since the world faces global health issues such as SARS, the rapidly growing rate of HIV and AIDS, hazardous environmental pollution and starvation, many simply do not understand the importance of focusing on these last few thousands of cases of polio each year. How can we get people to focus on a problem they do not know exists? How can we get journalists to write about a health problem much less glamorously inflammatory than AIDS or starvation? How can we get donors to give to an initiative that is viewed by many as a miserable failure? The following is a list of recommendations for communication endeavors. It begins with general recommendations and ends with more specific, targeted strategies and tactics. General Recommendations on Communication a. Strengthen communication efforts worldwide to populations targeted for immunization. Strengthening communication will remove the panic, fear and uncertainty about vaccination among infected communities. For example, in 2001, it was found that 22 children in Haiti were permanently paralyzed by polio after being infected by mutations of the attenuated virus they received in their oral 76 polio vaccines. Many more became ill. This was the first documented case of a vaccine causing the illness, although the GPEI now believes that this same thing happened before the Haiti cases, including during an epidemic in Egypt. In 2007, Nigeria fought an outbreak in which more than 70 cases of the country’s 1,300 polio cases were caused by vaccine-derived polio. 71 Many in the community claimed that the World Health Organization and other member organizations hid the information from Nigerians and the public, insisting that the only way to protect children from the mutated virus was to continue vaccinating children. This assertion upset and confused many parents, who blamed the vaccine for infecting the community in the first place. The initiative’s members need to realize that communities in need of vaccination are similar to any community in the world: They want information on the safety of their children and steps being taken to ensure their children receive the best care possible. b. Set standards for minimum amounts of research prior to launching any type of communication efforts. It is imperative that groups targeted for communication are well understood. Taboos, religious beliefs, fears, and rumors can stand in the way of even the best and most efficient operational strategies and tactics. c. Establish crisis plans for dealing with rumors specific to four endemic countries and establish means of preventing rumors from starting. 71 Associated Press. “Experts wonder: Is it time to give up on polio eradication?” International Herald Tribune. 1 Mar 2007. 77 1. Find the source of rumors and co-opt that person or organization into being a part of the solution. 2. Co-op key opinion leaders (employers, politicians, religious or community leaders) into immunization and communication plans. 3. Hold question and answer sessions at public gathering spaces and community meetings where opinion leaders can ask questions on behalf of the community and get answers in front of them. a. This will strengthen the community’s knowledge base while publicly co-opting opinion leaders and ensuring community members that all parties are working on their behalf. 4. Ensure that health workers have a firm grasp of information regarding vaccinations, vaccination drives, and how the vaccine works in the body. a. By ensuring that the front line is well-versed in correct and positive information, the GPEI can ensure that rumors do not start from health workers. b. As previously mentioned, volunteer health workers are often misinformed about the vaccine themselves. Thus, they are a key group for information dissemination and educational materials. 78 5. Conduct mass media campaigns with the appropriate media. (This information would have to be gleaned from research on communication channels common in communities targeted for vaccination.) a. Seek out media outlets and journalists which have previously disseminated false or inflammatory information to correct and misunderstandings about the GPEI’s mission in the area. 6. Ask high profile persons to publicly immunize their own children to set a positive example of trust in GPEI efforts. 7. Use established community groups (NGOs, religious organizations, or other health organizations) that already have trust from the community and opinion leaders. 8. Actively involve community leaders, opinion leaders, and mothers in planning and implementing health activities. a. If these people feel that the campaign is their own, they are much more likely to not only participate, but spread the word to their friends and families—free word of mouth! 9. Present the eradication of polio as more economically sound that costs incurred in simple containment. a. Emphasize the fiscal benefits of healthy and economically productive children for each family. 10. Discuss planned immunization days with community health leaders in advance so they can spread the word and ensure their constituents attend. 79 Specific Recommendations on Communication a. Strategy: Capitalize on attention from donations by the Bill and Melinda Gates Foundation. High profile donors are excellent sources of publicity and can raise awareness for many people in search of a worthy cause in need of donations. 1. Tactic: GPEI should post a thank you message on its website to the Bill and Melinda Gates Foundation and create a link for the public to make donations 2. Tactic: Appeal to technology magazines to couple a pro-donation message with stories about Bill Gates b. Strategy: Use local sports and entertainment figures to spread the message of polio vaccination 1. Tactic: Have popular cricketers vaccinate children at games in India 2. Tactic: Have popular cricketers spread a pro-vaccination message during television and radio interviews in India 3. Tactic: Show pro-vaccination messages from Bollywood stars in the opening previews at movie theaters 4. Tactic: Have popular footballers (soccer players) in Nigeria spread a pro- vaccination message during television and radio interviews 5. Tactic: Use cricketers, field hockey and squash players in Pakistan to vaccinate children before games and during vaccination drives 6. Tactic: Use cricketers, field hockey and squash players in Pakistan to spread a pro-vaccination message during television and radio interviews 80 c. Strategy: Use local religious leaders to spread the message of polio vaccination 1. Tactic: Use Muslim leaders in Pakistan, India, and Nigeria to accompany health workers on immunization visits to houses to answer questions regarding safety of immunization 2. Tactic: Use Muslim leaders in Pakistan, India, and Nigeria to accompany health workers during immunization events to answer questions regarding safety of immunization d. Strategy: Raise awareness about the GPEI among young potential volunteers in the developed world 1. Tactic: Create “Facebook” page to update users on the progress of the initiative as well as raise awareness about the initiative’s need for volunteers, researchers and donors. 2. Tactic: Create a “Twitter” account where GPEI representatives could send out tweets about current news as well as raise awareness about the initiative’s need for volunteers, researchers and donors i. The GPEI could hire volunteer “tweeters” to track outside tweets about polio, vaccinations, etc. and reply with information from the GPEI 81 e. Strategy: Better inform member organizations to ensure all organizations are following recommended approaches to communication 1. Tactic: Create an updated and better organized website to enhance the likelihood of member organizations finding the information and key documents they need 2. 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Abstract (if available)

Abstract This thesis aims to examine a multi-organizational initiative to eliminate polio worldwide, called the Global Polio Eradication Initiative (GPEI), through the lens of the strategic planning model. An overview of the global fight against polio and an analysis of current communication endeavors on the part of the GPEI’s backers, misperceptions about polio vaccinations among target audiences, and overall shortcomings are included. Issues facing the initiative in both the developing world with regard to populations targeted for vaccination as well as those in the developed world targeted for support and financial contributions are presented. These examinations inform a final set of recommendations for improving the communication efforts of the GPEI.

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Asset Metadata

Creator Ruth, Kamber (author)

Core Title Case study of the Global Polio Eradication Initiative: analysis of current plan, shortcomings and communication barriers

School Annenberg School for Communication

Degree Master of Arts

Degree Program Strategic Public Relations

Publication Date 05/07/2009

Defense Date 03/30/2009

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Communication,OAI-PMH Harvest,polio

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Floto, Jennifer D. (committee chair), Cray, Edward (committee member), Wang, Jian (Jay) (committee member)

Creator Email Kambergler@sbcglobal.net,kruth@usc.edu

Permanent Link (DOI) https://doi.org/10.25549/usctheses-m2200

Unique identifier UC154745

Identifier etd-Ruth-2832 (filename),usctheses-m40 (legacy collection record id),usctheses-c127-240640 (legacy record id),usctheses-m2200 (legacy record id)

Legacy Identifier etd-Ruth-2832.pdf

Dmrecord 240640

Document Type Thesis

Rights Ruth, Kamber

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Repository Name Libraries, University of Southern California

Repository Location Los Angeles, California

Repository Email cisadmin@lib.usc.edu