Tag: india

How India defeated Polio

A blog on the New York Times has an interesting article on how India eradicated polio which makes for interesting reading.

The method in which India went about getting 95% coverage for the polio vaccine is impressive, and can serve as a blueprint for other campaigns and other countries.

Multiple agencies – governmental and non-governmental – worked together, with well defined distinct roles to make this happen:

The Global Polio Eradication Initiative began in 1988 as a huge partnership among Unicef, the World Health Organization, the Centers for Disease Control and Prevention and Rotary International. Each organization took on a different job and this continues today as the focus broadens from just polio to all routine immunizations. Unicef handles communications, makes posters and banners, and ensures that the “word” spreads about the campaign, even if it’s through old-school techniques like hauling loudspeakers on a rickshaw through the city center.

The W.H.O. is the data machine, responsible for tracking the virus, collecting stool samples of possible cases and studying the data for any gaps. Rotary International has a Delhi-based team, the National PolioPlus Office, with regional and city-level tentacles to execute polio vaccinations four times a year during National Immunization Days (more days for high-risk areas). Globally, Rotary has been the cheerleader of the campaign, raising funds and keeping the issue in the spotlight.

And it needed a lot of very low level, very localized effort to ensure that nobody got missed:

Health workers, usually women, stand at the booths for eight hours to ensure that every child in the neighborhood is vaccinated. The vaccinated children are marked on the nail of their pinky with black ink. The following day, the health workers search for missed children by going door-to-door, carrying the vaccine in an icebox.

Just having people going around running the vaccination booths is not good enough. The system does not work unless there is measurement that completes the feedback loop, identifies gaps, and fixes them.

The government had elaborate machinery to do this:

Dr. Vishwakarma’s job is tiring, illustrating the depth and breadth of the polio surveillance effort. Based in Agra, he travels daily across Western Uttar Pradesh; he monitors 12 districts of the state, which cover a distance of about 125 miles from Delhi to Agra. His days begin at 5 a.m. and he retires at 10 p.m., after endless cups of tea with local officials, shadowing health workers, combing through stacks of data and overseeing surveillance efforts at regional offices.

“I cannot miss any details,” he says. “That’s where the solution lies. That’s why I’m constantly on the move.”

Overall, missing a single person would result in the whole campaign being set back by years:

The philosophy for the polio campaign was, Dr. Bahl says, “Who have we missed? Why have we missed them? Why did they not take the vaccine? And we constantly looked at the data to help us.”

In a country the size of India, just getting the message across to everybody, without it getting twisted in the process, was a big job with unique challenges. Here is one example:

Communication — Unicef’s job — is the last key pillar of the polio campaign. It goes beyond just fliers, banners and announcements. Previously, when Muslim communities refused the vaccine — on the grounds that the vaccine was designed to make their children sterile — communication became critical. “At the local level, we had to work with the ulema [Muslim clerics], to correct this message,” said Dr. Bahl. By collaborating with local leaders, Unicef found a new venue to preach the message of good health: the mosque. And it was the health workers who took that message further, by carrying letters, written and signed by local Muslim clerics, urging families to have their children inoculated.

Where do we go from here? India is getting ready to use this success and go after the next big challenge – routine child immunizations.

India’s routine immunization rates — for measles, rubella hepatitis B, TB and the like — were last recorded in 2009 at 61 percent nationally. India accounts for a third of the world’s measles deaths. Public health is dismal, and India’s per-capita spending on health care is among the lowest in the world. Yet with polio, India achieved 95 percent coverage.
The success of India’s polio effort has turned it into a blueprint for large-scale health campaigns. Now India is using what it did with polio to boost rates of routine vaccinations.

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Data about birth-control in India: Myths and Realities

The Asian Age has an interesting article with data on India’s birth-rates and efficacy of our birth-control programs

Here are some interesting excerpts:

good news is that the increase in contraceptive prevalence has been larger and faster among illiterate and uneducated women than those with schooling.

According to the International Institute of Population Sciences (EPW Arokiasamy 2009), more than two fifths of the reduction in Total Fertility Rate country-wide is attributable to illiterate women. The study calls it “remarkable demographic behaviour which has given significant direct health benefits to women and children — almost equal to what educational improvement has done for progress in human development.”

But all is not good:

Now some disappointments: States which continue to lag behind are the same — Bihar, Uttar Pradesh, Madhya Pradesh, Jharkhand, Chattisgarh and Rajasthan — some 284 problem districts account for nearly half India’s population and 60 per cent of the yearly births countrywide.

and:

Among 18 to 24-year-old couples the contraceptive prevalence rate is not even 19 per cent. In many districts it is as low as 10 per cent. According to NFHS -3 and the latest Annual Health Survey, in Bihar more than half the women in the child bearing group are not using any family planning method.

and the worst part is:

In India, female sterilization continues to be the most dominant method of birth control even though women overwhelmingly favour non-invasive options.

because:

In the absence of tools that do not depend on partner-co-operation (condoms) or adherence to rigid regimens (pills), a poor woman confronts the prospect of an unwanted pregnancies every month, until somebody agrees to escort her for an operation.

Do Muslims procreate much more than Hindus? Apparently, Muslims are a little worse off in this aspect, but not as bad as is widely believed. Here is the data:

That brings one to a widespread myth relating to the practice of contraception by religion. Professor P.M. Kulkarni at JNU who has researched differentials in population growth among Hindus and Muslims (using NFHS data) says that all religious communities have experienced substantial fertility decline and contraceptive practice has been well accepted by all. Within religious faiths, 85 per cent of Hindu women would like to limit the family to two children whereas in the case of Muslim women, the figure is 66 per cent.

and:

The belief that religion and religious fiats discourage contraception among Muslims is not borne out by statistics.

An even more significant aspect of his analysis of NFHS data shows that the unmet need for family planning is one and a half times more among Muslim women than Hindu women.

Another interesting aspect is that the kinds of contraceptives preferred by Muslim women is different from that of Hindus:

In terms of contraceptive use, Muslim women’s use of the pill is almost twice that of Hindu women and the use of IUD is also higher compared to Hindu women. Two things can be concluded: First that among the rural poor, the difference in fertility between Hindus and Muslims is not as marked as is usually supposed.

Second: there is a perceptible difference in the preferred method of contraception: Muslim women seem to be more open to the use of it.

Read the full article for more details.

The connection between nutrition and social status

Did you know that younger daughters-in-law in rural India have shorter children on an average? And that there is a perfectly good explanation for it?

A very interesting article in the The Hindu points to new evidence that the unequal social status of women plays a significant role in the fact that they’re undernourished.

Apparently, India has “inexplicably” high levels of under-nutrition.

For its per capita income, India has stubbornly higher than expected levels of stunting and under-weight among children and adults — the so-called “Asian enigma”

and

there has been a growing acknowledgement, including by Dr. Sen himself, that food consumption alone does not explain the scale of India’s under-nutrition.

The explanation is this:

A growing body of evidence is also now showing that the low social status of women — something difficult to capture statistically — could be a big part of the explanation. A new working paper by economists Diane Coffey, a PhD candidate at the Office of Population Research at Princeton University; Reetika Khera of the Indian Institute of Technology-Delhi; and Mr. Spears has shown that the younger daughters-in-law in a rural joint family have shorter children on average.

While this is no longer the typical Indian family, it provides a rare econometric measure of “social status.” Sure enough, the younger daughters-in-law “report having less say in a range of household decisions; they spend less time outside the home on a normal day than [the older] daughters-in-law; and, they have lower body mass index [BMI] scores than their [older] counterparts,” the researchers find, using official National Family Health Survey data.

This is a serious concern.

Recent research by Angus Deaton, Professor of Economics at Princeton University and the Woodrow Wilson School of Public and International affairs and leading global expert on poverty and nutrition in the developing world, has shown that Indian women’s nutrition is undeniably not improving at the same pace as men’s. Mr. Deaton has found that Indian men’s heights are growing at nearly three times the rates of women and the gap is widening

Read the full article