|Polio - The Beginning of the End (WHO, 1997, 113 p.)|
One of the greatest threats to polio eradication is armed conflict. And it is on the rise. Since the end of the Second World War, there have been more than 150 major conflicts - most of them civil wars and the majority in developing countries. As the number of internal conflicts has escalated, civilians have been increasingly targeted and millions of refugees and displaced persons forced to take flight. Children are especially vulnerable. Thousands are killed or maimed every year by bombs, bullets, and landmines. But many more children fall victim to a war-related upsurge in malnutrition and vaccine-preventable diseases.
In Afghanistan, a survey in Kandahar province, one of the most heavily mined areas in the country, revealed that the most frequent cause of disability among children was not landmines - which kill more often than they maim - but polio. The 1996 study, by Handicap International and the Catholic University of Louvain in Belgium, found that one in 200 children under 15 was disabled by polio paralysis. A parallel survey on the level of routine polio immunization coverage among children aged 1-3 years in Kandahar found that only 13% were fully immunized.
In some regions, countries have been literally gutted by years of bloody conflict and neglect. Roads, vehicles, hospitals, health centres, and vaccine-storage refrigerators have been destroyed or fallen into disrepair - making it impossible to deliver routine immunization. Transportation systems grind to a halt when supplies of fuel and spare parts dry up. Water and sanitation systems no longer function - adding to the risk of transmission of disease. In Peru in 1991, the last case of polio in the Americas involved a three-year-old boy, Luis Fermin Tenorio, who was unable to complete his polio immunization after the local health centre was destroyed by guerillas. In a number of countries, the disruption of immunization services has triggered out- breaks of polio and other vaccine-preventable diseases. In war-torn Chechnya in the Russian Federation there were 150 cases of polio in 1995 - following a 3-year stoppage in immunization. In Iraq, there was an upsurge in polio cases in the aftermath of the Gulf War. The number of cases leaped from 10 in 1989 to over 120 in 1992. But the number of cases may have been even higher in 1992 as many cases went undetected following the collapse of the surveillance system. The imposition of long-term sanctions on Iraq by the international community also had an unintended detrimental effect on child health. Although medical supplies were exempted, political disputes and administrative delays resulted in critical shortages of essential drugs and vaccines.
Elsewhere, the mobility of refugee populations and internally displaced persons continues to hamper efforts to organize and follow-up both routine immunization and national immunization days - leaving many children only partially immunized and therefore unprotected. The United Nations High Commissioner for Refugees (UNHCR) estimates that in 1996 as many as 50 million people throughout the world had been uprooted from their homes - almost 1% of the world's population. The UN refugee agency is today assisting 26 million refugees and returnees - the victims of war and persecution. About 80% of them are women and children. In Mozambique, during a decade of conflict that ended in 1993, 800 000 children were internally displaced and 450 000 fled to neighbouring countries. At least 200 000 were orphaned or separated from their families. The carnage in Rwanda in 1994, which claimed up to one million lives, prompted one of the largest refugee movements in history. Over two million people fled their homes - many escaping to neighbouring countries. Hundreds of thousands of people returned to Rwanda in late 1996 - too late to benefit from polio national immunization days held in June that year. By the beginning of 1997, many Rwandans were still on the move and unaccounted for - the immunization status of their children unknown.
Polio will be eradicated globally only when transmission of polio-virus has been halted in every country throughout the world. This strategy allows for no exceptions - including countries at war. If the polio eradication target is to be met on time by the year 2000, immunization must be carried out in conflict zones. The polio eradication initiative does not have time on its side.
The mobility of refugee populations continues to hamper efforts to organize and follow up both routine immunization and national immunization days.
Photo: UNICEF/Betty Press (DO194-0175)
For more than a decade, efforts have been made to provide routine immunization for children caught up in the midst of wars. The need for this humanitarian intervention - not just for routine polio immunization but for other vaccine-preventable diseases as well - was first highlighted in 1983 by Nils Thedin, former head of Ra Barnen, the Swedish Save the Children organization, and a member of the Executive Board of UNICEF.
In 1985 in El Salvador the number of children dying from vaccine-preventable diseases surpassed the number of people killed in the war.
At a time when children were affected by over 70 conflicts worldwide, Nils Thedin urged UNICEF to promote the idea of children as a "conflict-free zone in human relations". His idea took root and was the inspiration behind a series of negotiated ceasefires and "days of tranquillity" when children could be immunized. For one day at least the shots would be for protection, not slaughter. Elsewhere the idea was translated into the creation of demarcated safe zones or "corridors of peace".
The first time the strategy was attempted was in El Salvador in 1985, where - despite an ongoing war between government forces and rebel guerillas - President Napol Duarte was keen to boost routine immunization coverage from an all-time low of only 3%. At the time, the number of children dying from vaccine-preventable diseases in El Salvador surpassed the number of people killed in the war. But to achieve this goal, immunization would have to be extended to rebel-held areas of the country as well. UNICEF asked the Vatican to intervene and appoint an intermediary who could negotiate with the rebels and initiate a temporary ceasefire.
What followed was a three-month period of Church-sponsored, often tortuous negotiations involving the government, army, guerilla groups, the International Committee of the Red Cross (ICRC), the Salvadorean Red Cross, and WHO's Regional Office for the Americas. At first there was distrust among guerilla leaders who feared that a ceasefire would be used by the government to pinpoint guerilla strongholds and flush out rebel forces. In the end trust prevailed and the immunization campaign went ahead - not just in 1985 but each year until the war ended in 1991. On three days a year in consecutive months as many as 20 000 health workers and volunteers - including some from the guerilla forces - immunized 250 000 children against polio, measles, diphtheria, tetanus, and whooping cough. By the time the six-year campaign had ended, immunization coverage had surged from 3% to 80%.
Over the next decade, as more and more children were caught up in the stranglehold of war, the strategy of negotiating a ceasefire for children took hold. In 1986 it was tried again, this time in Uganda, where the Ugandan Government's National Liberation Army was engaged in a bitter conflict with President Yoweri Museveni's National Resistance Army. After lengthy negotiations, a geographical zone or "corridor of peace" was established for the first time ever - to allow the safe passage of vaccines, personnel, and equipment.
A year later it was Lebanon's turn to organize days of tranquillity and immunize its children. UNICEF worked for more than a year to negotiate a three-day ceasefire across the country - involving more than 120 groups to ensure that every possible faction was on board and agreed to participate. Immunization posts were established throughout the country. Vaccines, syringes, and cold chain equipment were supplied by UNICEF and the World Health Organization, the warring factions provided transportation and logistics, and health workers were provided by the International Committee of the Red Cross.
The success of these earliest attempts to negotiate a way to immunize children in the midst of war paved the way for a major humanitarian relief effort in Sudan in 1989. The country's civilian population was reeling from the effects of a protracted civil war and by a drought in 1988 that claimed 250 000 lives and uprooted nearly three million people. Between 1986 and 1988 as many as 500 000 people are believed to have died from disease and starvation. Many of the attempts by humanitarian agencies to provide relief were regularly blocked by the warring factions. But in 1985, the World Council of Churches had helped negotiate a temporary ceasefire to enable relief supplies to be delivered to children trapped for seven months inside the besieged city of Malakal in the south.
In early 1989, a UN-sponsored meeting in Khartoum, involving Sudanese officials, donors, and international organizations, drew up a plan of action. The aim was to provide over 100 000 tons of food, immunization, and essential drugs. The difficult task of "selling it" to both sides went to the UN-appointed lead agency, UNICEF. The rebel groups rejected outright any idea of a ceasefire but agreed to the establishment of eight corridors of peace in the conflict zone. They would guarantee the safe passage of food and medical supplies for an initial period of one month (later extended). In the end, Operation Lifeline Sudan completed this first stage of the relief effort within six months - making use of some of the distribution systems already built up by non-governmental organizations. Immunization posts were established in every garrison town and more than 90 000 children immunized in areas controlled by the Sudan People's Liberation Army (SPLA).
In El Salvador from 1985 to 1991, one-day truces were negotiated for immunization against polio and other diseases.
Photo: UNICEF/Balazar, 1983
Significantly, in 1995, the SPLA became the first rebel army in dispute with a recognized government to commit itself to abide by the provisions of the 1989 Convention on the Rights of the Child which includes a commitment to "take all feasible measures to ensure protection and care of children who are affected by armed conflict." The success of Operation Lifeline Sudan, a massive US$ 400 million international relief effort, led to the creation of relief corridors in other war-torn countries in Africa, including Ethiopia, Angola, and Liberia.
By 1990 the concept of a ceasefire for immunization and other relief services for children was an idea that had arrived. At the World Summit for Children in New York in September that year 159 nations put their weight behind a declaration and plan of action that endorses the need for days of tranquillity and relief corridors. The World Declaration on the Survival, Protection and Development of Children states that:
"The essential needs of children and families must be protected even in times of war and in violence-ridden areas. We ask that periods of tranquillity and special relief corridors be observed for the benefit of children, where war and violence are still taking place."
The World Summit Plan of Action also endorses special measures such as days of tranquillity and corridors of peace, adding that:
"Resolution of a conflict need not be a prerequisite for measures to explicitly protect children and their families to ensure their continuing access to food, medical care and basic services, to deal with trauma resulting from violence and to exempt them from other direct consequences of violence and hostilities."
This was formal international recognition at last for groundbreaking efforts to mediate between warring factions to ensure that children were not spared the gun only to succumb to a vaccine-preventable disease. The mediators included UNICEF, the World Health Organization, the International Committee of the Red Cross, national Red Cross societies, church leaders, trade unions, and a wide range of other groups.
During the assault on Jaffna in 1995, polio vaccine was passed across the front lines so that children on both sides could be immunized.
And the work goes on ... In 1993 in the Philippines, rebel groups agreed to a ceasefire and brought their children to be immunized during a national immunization day. The Department of Health spent four months planning the logistics and social mobilization for the nationwide campaign, which also provided opportunities for immunization against measles for children aged 9-24 months, as well as the country-wide distribution of six million doses of vitamin A. Some children were also given other EPI vaccines (BCG, DTP) to catch up on missed immunizations, and women aged 15-44 were offered tetanus toxoid vaccine. Over nine million children were immunized against polio in two rounds of NIDs in April and May. Coverage for both NIDs was about 90%, and even in the areas with continuing rebel activities, over 80% of children were reached. Further NIDs were conducted in 1994 and 1995 and no cases involving wild virus have been identified since 1993.
In Sudan in 1994, relief corridors were again used to transport vaccines and other medical supplies to children on both sides of the conflict, following outbreaks of polio and measles. And in November 1994 in war-torn Afghanistan, where fewer than 25% of children were immunized against polio, the World Health Organization announced a jihad to fight vaccine-preventable diseases. WHO worked in collaboration with the Ministry of Health, UNICEF and non-governmental organizations to broker a one-week truce for immunization. Polio and other vaccines were provided in the provincial capitals, but elsewhere were only available in districts with an established cold chain. During 1997, Afghanistan is to hold its first nationwide mass immunization campaign against polio. In 1996 relief corridors were again used to deliver vaccines in southern Sudan. And in 1995 and 1996, the Sri Lankan Army and Tamil Tigers suspended hostilities to allow their children to be immunized. During the assault on Jaffna in November 1995, polio vaccine was passed across the front lines so that children on both sides could be immunized.
Although internationally brokered truces to boost routine immunization coverage are the ones that have been best documented, most of the ceasefires for polio eradication activities have been both low profile and unofficial. In Cambodia, Iraq, India, Myanmar, Turkey, several Latin American countries, and elsewhere, polio vaccine was made available as a result of unofficial truces in areas with rebel activities. In some cases health workers agreed to hand over polio vaccine in cold boxes so that rebel groups could immunize their own children. This pragmatic approach to Nils Thedin's visionary idea of days of tranquillity has enabled health workers not only to immunize against polio inside a conflict zone but also to provide access to additional health services not otherwise available to insurgent groups.
There is no firm evidence that a truce for immunization has been the spark that led to lasting peace in any of the conflicts involved. But on each occasion combatants have been united in one thing - a need to secure their children's future. And even a fleeting glimpse of peace must serve to highlight the futility of war - if only for a day.
Rotary has organized social mobilization campaigns for polio immunization.
Photo: Rotary International/Richard Franco