Featuring over 100 beautiful and engaging images by humanitarian photographer Robin Wyatt, Eradicating Polio tells the story of CORE Group and Project Concern International (CORE-PCI)’s efforts to make polio history. Through these pages, journey to the Indian state of Uttar Pradesh and see for yourself how this dynamic partnership has used a highly successful community-oriented approach to help bring India to the brink of being declared ‘polio free’ by the World Health Organization (WHO). CORE-PCI’s success story is told through vivid and compelling photographs, complemented by words drawn from around 70 interviews from across the breadth of their field sites. This is essential reading for all those working to combat the scourge of polio in the few remaining countries that are still recording new cases of this crippling disease.
C ORE-PCI’s Experiences in I ndi a
Robin Wyatt (PhD) is a humanitarian photographer and visual communications specialist. He serves organisations working in the development sector as well as corporate social responsibility (CSR) initiatives. Holding a doctorate in Indian Sociolegal Studies from the University of London’s School of Oriental and African Studies (SOAS), he merges an advanced understanding of development issues and field research and interviewing skills with his image capturing and storytelling abilities. He works worldwide, and has experience of around 70 countries to date.
CORE-PCI’s Experiences in India
E ra d icat i ng
About the AuthorPhotographer
About Project Concern International (PCI)
CORE-PCI’s Experiences in India Headquartered in San Diego in the USA, PCI Global is a leading NGO that is dedicated to preventing disease, improving community health and promoting sustainable development in Asia, Africa and the Americas. PCI India has been registered as an Indian Charitable Society since 1998, and works on a diverse range of social development issues across ten states. Since 2000, the organisation has been engaged in five districts of Western Uttar Pradesh in efforts supported by CORE Group to eradicate polio and increase utilisation of immunisation services by targeted communities. www.pciglobal.org | www.pciindia.org
Eradicating Polio CORE-PCIâ€™s Experiences in India
CONTENTS Introduction Living with Polio Our People Working Through Children Children's Rallies Polio Booth Days Religious Leaders' Pivotal Role Influencers Knowing our Communities Health and Immunisation Camps Sanitation Reaching the Hard-to-Reach
4 18 28 50 76 94 116 130 140 164 180 190
I N T R O D U C T I O N Siblings Faizan (5), Shahin (7), Faz Muhammad (1) and Faru (6) play by the sugar cane adjoining their home, a crop that seems omnipresent in the district of Meerut, India’s ‘sugar bowl’. 5
VS Gurumani, PCI Indiaâ€™s Country Director, 2008-2013.
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PCI India’s Country Director is under no illusions about the difficulty of the task his team took up in polio eradication. The intention was to help the Indian public health system ensure that the children of the hardest to reach people in Uttar Pradesh’s highest risk areas would get immunised. “It’s a challenge to any public health system to hit 100% of its targets”, he points out. “With polio, the risks of not getting there were very high, and if we didn’t get there then downstream effects would take hold in the form of further infections”. Looking back on what was envisaged at the outset, Mr Gurumani feels that CORE-PCI is pretty much on target. “Some years ago, there was a sense of apprehension that success wouldn’t come”, he recalls with a smile. “In a programme like this, there’s much that’s outside one’s control”, he explains, pointing particularly to high levels of in- and out-migration and the ease with which the virus could be brought in from neighbouring Pakistan. “Nevertheless, we resolved to develop a quiet belief in ourselves: that we had what it would take to get there”. One of CORE-PCI’s key strengths is, Mr Gurumani explains, the way it operates as a giant family. The organisation tries to be as non-hierarchical as possible, and across the board, all the way to the senior management of PCI Global, staff have the space to exhibit their talents. As this family grew through the launch of the polio programme, it retained this ‘family feel’ by sourcing most of its people – both its grassroots workers and those further up the ladder – from the target communities themselves. These people knew the local challenges and had good ideas about how to overcome them. Mr Gurumani explains that the family has further benefited from the way in which CORE-PCI’s leadership has worked together, in spite of being part of different organisations with different priorities.
Children in Nangla Tashi, Meerut District.
VS Gurumani’s tenure was from 1st October 2008 to 15th April 2013.
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“We’ve engaged in frequent communication, sought synchronicity of views, developed mutual respect and resolved differences through open conversations rather than allowing things to escalate”, he says. During the early days, he recalls that the programme went through some very severe stresses. Communities argued that vaccinating their children was against their beliefs because the vaccine contained a haraam ingredient (forbidden under Islam), and this resistance manifested in doors being closed in grassroots workers’ faces. “When members of a team go through such experiences together, it helps them bond. They develop the notion that ‘we’re in this together’”. He also points out that CORE-PCI have invested heavily in building their team from the grassroots up. Many workshops have been organised to strengthen aspects of the programme, and utsavs (celebrations) are regularly held with great fanfare to congratulate team members for what they’ve accomplished. Indeed, Mr Gurumani personally signed nearly 800 appreciation certificates for fieldworkers recently. Finally, he stresses that the local government administrations have been extraordinarily supportive. “There has been a certain alignment of goals”, he asserts. “We’re agreed that we must get rid of this monster”. In spite of all this, Mr Gurumani cautions that “complacency is a human failing”. He recognises that people will certainly query the need to work so hard to get every under-five vaccinated, saying that “there’s no more polio in India” now that no new case has been recorded since early 2011. “We must constantly remind ourselves that the battle is not yet won, and that we must keep working hard for at least another three to four years”, he says, adding that “we may have won a battle, but we’ve not yet won the war”. Mr Gurumani stresses that continued oversight is necessary to see whether complacency is developing in certain pockets. This, he says, makes human resource management a critical part of the remaining job.
Roma Solomon “There were cases everywhere”, recalls Dr Roma Solomon, as she thinks back to when she first started working on polio in India. A medical doctor by profession, the Executive Director of the CORE Group Polio Project (CGPP) says that in 1999, she nevertheless came into the role “full of optimism”. “We quickly realised that a large part of the problem lay in surveillance,” she explains. “There was a fear that reporting a case would lead to action being taken against you on the grounds that you weren’t doing your job properly”. She argues that this was tantamount to shooting the messenger; if it stopped then more and more trouble spots could be identified. “When the government decided to start working door to door, that’s when the suspicion began”, Dr Solomon recounts. “People would ask, ‘why all this just for polio when we need so much more and you neglect us?’. They thought it was covert sterilisation of Muslims, and resisted”. This was where CORE really came into its own: in 2003, the Social Mobilisation Network (SMNet) was born, drawing on school children, mothers, religious leaders and other influential people, essentially anyone who could help break down the barriers with the community. “Another of our key early learnings was that a negotiated approach was better than simply telling mothers, ‘this is good for your child’”, Dr Solomon adds. “It’s too easy to think that we’re the educated elite and the community is uneducated, stupid and without wisdom. I believe that every woman who matures to become a mother gains a certain kind of wisdom: no mother wants to see her child sick”. Reflecting on the experience of working with PCI, Dr Solomon says that “we’ve been together on this since the beginning, and we’ve learned and grown in this together”. The partnership has succeeded, she contends, because they are both more amenable than many larger organisations to making changes. “Indeed, the whole programme has been about responding to a changing environment”. “We have much to share with the other countries that have polio”, Dr Solomon concludes. “Take Nigeria: it may be far away, but it too is grappling with resistance among Muslims, again an underserved minority community that doesn’t trust the government”.
CGPP Executive Director Dr Roma Solomon catches up on the latest public health news and views.
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The Jama Masjid Bridge, leading directly to Moradabadâ€™s main mosque. The city, one of Indiaâ€™s highest risk areas for polio, sprawls outwards on either side.
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Dr Vikas Aggarwal, Director of Programmes, PCI India
In his role as PCI India’s Director of Programmes, Dr Aggarwal reviews the quality of the polio programme, provides technical inputs, assists with resolving bottlenecks, helps in applying linkages with broader health issues, ensures that key learnings are applied to other programmes and assists with making plans for the future of the programme. He stresses that though much has been achieved to date, this has not been the work of CORE-PCI alone. Rather, the organisation has served as part of a large system consisting of multiple agencies and other entities. As with any system, he explains, every individual process must be performed as flawlessly as possible in order for the desired results to be achieved, and it’s taken great feats of coordination between these various players to achieve this. To his mind, this ability to work so effectively in partnership has been a large part of the polio programme’s success story. Though no new case of polio has been recorded in India since January 2011, Dr Aggarwal recognises that there is still time left to run before it can truly be said that the disease has been stamped out in this country. Moreover, there remains the danger of re-infection from other countries in the region while they still have the disease. CORE-PCI and its partners have been able to build considerable awareness, but he stresses that they need to ensure that local communities are able to hold the fort by themselves before they withdraw. He argues that this ought to be the case not only where the organisation has worked but also in those areas that are linked to them through the movement of migrants. He points out that the last new case in India was in a part of West Bengal where there had been no concentrated efforts to eradicate polio because it was not deemed ‘high risk’. Moving forwards, as CORE-PCI and its partners continue to work with communities to build strong systems, he feels that it’s essential to strengthen focus
Moradabad is known throughout the handicrafts world as a hub for brass workers.
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in these areas, and also on improving basic sanitation conditions to make the spread of polio through the oral-faecal route far more difficult. Reflecting on what CORE-PCI has learned, Dr Aggarwal has some clear advice for those working in the few countries that are still experiencing new polio cases. Firstly, he stresses that “any public health initiative that’s at scale will not be able to achieve its objectives unless the government is wholeheartedly working as a partner”. Secondly, he feels that India ought to share its reflections on why polio infection persisted predominantly in just a few ‘high-risk’ areas, some time after it was anticipated that the whole country would be declared ‘polio free’. To his mind, this can be explained with reference to basic issues to do with awareness and the health systems in place. There are also learnings that Dr Aggarwal feels can be used in other areas of PCI’s programming. Different levels of need were identified in the programme. One was the project need: to give the polio vaccine to under-fives. Then, the government had its needs, and communities had other needs, too (for example, many said they were keen to secure an improved level of health service provision in general before they’d accept polio drops). It was a difficult challenge for CORE-PCI to achieve sufficient overlaps to satisfy all three while ensuring each understood the others’ needs; that this was essential was a significant learning that he says should now be considered elsewhere. “Another learning concerns the phenomenon of inertia in communities”, Dr Aggarwal adds. “They take time to reach a critical threshold, but once that point is reached, it becomes easy for them to move on their own”. It’s important to research further on where that critical point lies, he explains, because this is the point that CORE-PCI is most keen to help communities reach. Looking back on the last ten years, Dr Aggarwal is particularly proud of CORE-PCI’s contribution to a situation in which no new polio cases have arisen for almost two years. He’s also proud of how they’ve positively touched so many lives in other ways too, particularly in capacity building for female community mobilisers.
Akash L I V I N G W I T H P O L I O
Contracting polio can turn a young child’s life upside down, even before s/he has had a chance to get going. Akash is 18 now. All he’s known has been a life beset by disability, as he caught the disease when he was just one month old. He was told that he got it from a doctor’s injection. Akash finds walking difficult, and relies on a long stick in order to get around. He says that his parents and wider family have always been very supportive, helping him in whatever ways they can. They’ve never treated him any differently to how they treat his other siblings. His teachers have not discriminated against him, either. However, the young people Akash knows tease him. This makes him angry. Although he asks them to stop, they often won’t. The solution he’s resolved to strive for is to study to an advanced level. Doing so, he says, will ensure he can get a good job and compensate for the setbacks his deformity have caused him. This will give him more credibility and help ensure people will not tease him in the way that they do now.
Akash visiting his local temple in Mundali, Meerut District 19
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Danishta, at home with her mother
At the age of three, Danishta fell terribly ill. Following a high fever, her legs and hands suddenly started shaking. When her foot spontaneously twisted, it was clear she had polio. The disease has affected Danishta’s life gravely. She’s 13 now, and for the past ten years she’s had to put up with her friends, neighbours and even cousins teasing her a lot, calling her names and saying nasty things about how her foot is and the way she walks. She feels bad, and sometimes it becomes too much for her and she breaks down and cries. While Danishta’s parents try to console her, they too feel burdened by their daughter’s condition. They avoid taking her to family functions because they meet with so many embarrassing questions that get under their skin and upset Danishta, too. Relatives frequently accuse her parents of not doing the things they believe she needs, like trying getting her treated. Danishta says these accusations make her feel bad. Though Danishta smiles so beautifully, her smile masks considerable pain. She talks of how she wishes she could run around and play with the other kids. Though she’s entitled to physiotherapy and braces, she says her parents haven’t taken her to the doctor. Neither have they applied for the physical handicap certificate that she’s entitled to, and hence they don’t get any assistance from the government. It seems to Danishta that her parents have lost hope. They don’t want to spend their money on seeking treatment for her because they’re sure it’ll come to nothing. They tell her that her condition isn’t curable now, so there’s no use in going to the doctor.
In spite of the poor lot that life seems to have dealt her, Danishta is by nature a very giving child. Unfortunately, her efforts frequently come to nothing. She does her best to help with the housework, but when she tries to fetch water from the hand pump that’s three to four minutes by foot from her home, she invariably drops the bucket. Lifting it and walking properly is beyond her, and yet she still tries. So her parents scold her, asking why she stubbornly persists when she knows she’s not capable of it. She’s not even able to offer namaaz (pray) by bowing down like others do. Danishta gets a madrasa education (Islamic studies), and she says that she finds her studies interesting. People don’t discriminate against her at the madrasa. Her aspirations are that she should to study to the level where she can become a doctor, and she talks of how she’d like to be able to treat sick people. She hopes she’ll one day become known for this, rather than for her polio. She already seems to be making strides in this direction, as she helps with routine immunisation drives by asking her neighbours to get their children vaccinated. This isn’t always easy. They often scold her when she tries, saying that they don’t want to do so because it will give them fever and pain. Sometimes, Danishta feels that it’s her parents’ fault that she got polio, as they didn’t ensure that she got the vaccine at the right time. She still holds out a small hope that it will one day be possible to avail of some kind of treatment that will somehow resolve her condition. But if a cure never comes, she hopes that the family she marries into will take good care of her and allow her to pursue the job she’s looking forward to. Her parents have not suggested that her polio will cause her any trouble when it comes to looking for a suitable boy.
L I V I N G W I T H P O L I O Danishta, the girl with a million dollar smile 23
Ashi L I V I N G W I T H P O L I O
This little girl is six-year-old Ashi Sharma. As she sits on her grandmother’s lap on the charpoi (bed of taught ropes) outside her home while evening descends, she could be any ordinary young child in rural North India. But her dress disguises the fact that she’s a polio survivor. Ashi was six months old when she contracted the disease. Her parents recall how they were visiting relatives at the time. She suddenly came down with fever, and her left leg was stiff and painful. Then her leg seemed to go flaccid. They approached an ayurvedic doctor, who initially told them to massage the leg with oil. This doctor was also a member of the World Health Organization (WHO)’s network of informers. When he suspected that Ashi had polio, he told a WHO representative about her case. A stool test ultimately confirmed that she’d contracted Type 3 polio (PV3). When the local Community Mobilisation Coordinator (CMC) heard about this, she implored the family to cease with the massage regime immediately. Ashi’s case is not severe as those of many, and she is able to avoid some of the stigma with the clothes that she wears. She says that the biggest difficulty she faces is that when she tries to walk a little fast, she easily falls over. She wishes she could run around, like the other children do.
Ashi, with her doting grandmother, Dayawati 25
Monish Four-year-old Muhammad Monish is one of three brothers. He has the dubious distinction of being the last child in the state of Uttar Pradesh to have contracted wild polio virus (PV1). This happened almost three years ago. Monish’s father, a brass artisan named Jile Hassan, describes how his son came down with a high fever all of a sudden. His grandmother took him to the doctor, but the medicines he was prescribed didn’t help. The very next day, he was unable to walk or even stand. Monish had in fact received his first vaccination against polio when he was just three days old (‘zero dose’) and at every successive round, in addition to all the other required inoculations. Nevertheless, his father doesn’t think that vaccinations are useless. Based on what they have learned about the causes of certain diseases from their CMC, the family suspect that Monish could have contracted polio in spite of his immunisations because their area has especially poor sanitation. Jile fears that in the future, it will be hard for Monish to get a good education and a decent job. The CMC has urged the family to try to secure a good quality education for Monish. But his father says he’d have to send him away for this, as there are insufficient facilities in their village. He feels very bad that his son has been affected by this disease, but insists he doesn’t dwell on the fact that his is the last case in UP and ask, “why him?”. He’d be very happy if nobody else contracts it, adding that he is the father of this child, so he knows how it feels and would hate for anybody else to suffer like this. Sometimes, he watches other children running around, playing, and wishes that his son could be cured so that he could join them.
Monish (centre) with his brothers Warish Ali (7, left) and Mohsin Ali (3, right)
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Though Delhi-based, CGPP SRC Ataur Rab says that it’s possible to keep city and field on the same page because “we all regard ourselves as field people”.
PCI Programme Manager and CGPP Sub-Regional Coordinator (SRC) Muhammad Ataur Rab serves as a linchpin in the polio programme, as his role spans both operational and programmatic matters. He manages the likes of sub-grants and auditing on the one hand while reviewing programme progress towards targets and taking corrective action on the other. Perhaps most importantly, he has to keep a diverse range of people and interests together on the same page. “Though we senior staff are working from Delhi, we all regard ourselves as field people”, he explains, “because we travel there so often and keep meeting our frontline workers in person, ensuring that they remain in the communications loop”. This is what he says ensures there’s no difference in perspective between those sitting in their city offices and those working at the grassroots. Reflecting on what’s proven most rewarding about his work, Ataur recalls how Moradabad - once regarded as the world’s polio epicentre - ceased experiencing new cases. “Nobody even imagined that we would get rid of polio, but we have done it!”, he remarks, triumphantly. “Knowing that India will shortly be declared polio free really gives me a ‘wow!’ feeling”. Being part of a strong, committed team has been rewarding and a privilege, he says. But this team and the wider partnership would have been severely hampered if it hadn’t been for the strong will of the government. “This really turned the tables”, he asserts. “While senior government officials are always overburdened with work, they will always make time for polio”. And on the other side of the spectrum, he feels particular homage must be paid to those at the grassroots level. “Our frontline workers have proven amazing in the field, visiting families early in the morning and late in the evening and doing everything in their power to make polio history”.
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CGPP Deputy Director Jitendra Awale paints an inspiring picture on partnership and hope for the future.
“The success of the polio programme in India boils down to partnership”, asserts CGPP Deputy Director Jitendra Awale. “Each one has brought its particular capacities. WHO is good at surveillance, Rotary is good at advocacy and CORE Group and UNICEF are both good at social mobilisation. These all complement each other”. Jitendra himself works very closely with the CGPP Executive Director on partnership and networking issues, and he explains that the CORE Secretariat plays an important role in bringing uniformity, ensuring that the various partners learn from best practices established by other partners that initially take the lead in particular areas. He goes on to explain that while PCI implements the programme in the field, the CORE Secretariat provides technical, management and coordination support. CORE also represents the partnership to the government and UN bodies, and they work very closely together. Jitendra concedes that the government has a reputation for moving like a big elephant: very slowly. “But for the polio programme, the same machinery works day and night, with a strong system of accountability all the way from the Secretary for Health and Family Welfare down to the field person”. He adds that it’s not only the Health Department: “the Education Department, the Panchayati Raj Department, all departments are working for polio”. Why? “Everything is at stake, including our national reputation. India is off the endemic list, so a single case will be like an emergency. Nobody wants that. Since India is going to become a global power, we can’t afford to lose our credentials and our achievements”. Jitendra sees the future as very bright. “We’ve learned how to eradicate this disease. If we build on this infrastructure, highly trained manpower and partnership mechanisms, India will be able to deal with so many public health issues, such as sanitation, routine immunisation and so on. The hardest part has already been done”. Looking elsewhere, he observes that even the Taliban are willing to be cooperative on polio. “We just need to keep negotiating with people on this. If it can be done in Afghanistan, it can definitely be done in Nigeria, which also faces security challenges”.
Rina Dey Rina Dey is a behaviour change communication (BCC) expert, and as such her role is crucial to the polio programme. One of the key reasons why the programme has been such a success is that it has overcome mammoth communication hurdles, and many of the innovative techniques for achieving this have originated at Rina’s desk. “There have been many myths to dispel”, she explains, “so I have put a lot of effort into developing materials and methods that will help people believe in the vaccination programme”. Much of her time has gone into building the capacity of people identified as influencers within the communities. “If they’re not technically sound, they won’t be able to answer people’s queries”, she points out. “After thorough training, they can talk to mothers and convince them. Moreover, we’ve needed people to understand that it’s not government versus community”. Rina says that she takes an especially participatory approach to such training. “It’s very simple, local-based development. Nothing hi-tech”. This means things like playing games that help people understand why the virus spreads and why it’s so important to stop its transmission. Rina feels she’s learned a lot from the opportunity to experiment and innovate so much. “We have tried everything here”, she exclaims, “any idea that comes to our team members’ minds”. And they’re not afraid to think big; they’ve even engaged Bollywood icon Amitabh Bachchan as the brand ambassador for polio eradication. She adds, “sometimes our ideas have failed, but there have been some very big successes”. According to her, biggest among these has been the power of working with both influencers and children. “They are the ones who spread messages much faster than anybody else,” she reasons. She admits that these days, 13 years is a long time to be working on any one issue, just as seven years is a long time to have been with a single organisation. What’s kept her engaged? “I love my job”, she replies. “That’s number one. And also the team we have here. This team is amazing”.
Full of inspired ideas, Rina Dey serves as CORE’s Behaviour Change Communication (BCC) Advisor.
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CGPP M&E Specialist Manojkumar Choudhury walks a colleague through the operation of mHealth on a tablet.
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Monitoring and evaluation (M&E) specialist Manojkumar Choudhury is the polio programme’s data guru. Put simply, his task is to design and implement systems for gathering information from the field and then analyse and share what can be gleaned from this with field teams, partners and donors, as well as the government and even organisations working at the international level. “There is a massive amount of data involved in all this”, he points out. “The main challenge is to reduce the drudgery for all the database managers”. One way he’s doing this is through developing what CGPP call mHealth (short for Mobile Health). “By gathering information via mobile phones and tablets, we’re increasingly able to tabulate our data in real time”, he says, proudly. “We’ve so far found that we can gather all the types of information we need from the field through mHealth, disaggregated right down to the level of individual households”. Manoj has shown how keen he is to innovate, and he stresses that M&E should not just be about recording how many activities are conducted; “knowing the quality of these activities is far more important”, he stresses. This is why he has started using lot quality assurance sampling (LQAS), which assesses the quality of interventions through observation. Something else that he says sets CGPP’s M&E strategy apart from those of other organisations is that it doesn’t just assess the knowledge, attitudes and practices (KAP) of its clients; it even conducts such formative research among its CMCs. Manoj insists that the frontline workers don’t see all this data collection as a burden, something that’s of no real benefit to them in their work. “On the contrary, they use it for their own planning”, he retorts. “They don’t plan without evidence! It’s as much for their benefit as it is for ours”.
Shalini Salwan Though one of the polio programme’s newest recruits, having joined PCI in January 2012, Programme Associate Dr Shalini Salwan has wasted no time in getting her hands dirty. “Sitting in an AC room, one can never truly know what challenges India’s rural communities face”, she argues. “It’s all very well reading that facilities and opportunities have been provided; we need to know what difference they’re actually making”. It was her desire to find such things out for herself that prompted her to work in public health in India’s rural areas. “I really appreciate how this programme invests in its people”, Shalini says. She perhaps more than anyone else would know about this, working week in and week out with frontline staff and having anchored the most recent utsav that celebrated the achievements of 800 of these incredible individuals. “Most women living in the rural locales where we’re focused are not allowed to go out and work”, Shalini points out, adding that she has interacted with most of the programme’s CMCs and found that pretty much all of them have their own stories of triumph over adversity just taking up this role. And it doesn’t stop there. “What’s most inspiring is how these women are working in the field in the scorching sun, the driving rain and the bitter cold of winter. Nobody sitting in a temperature-controlled office can really appreciate what they’re doing and how tough it is unless s/he sees it with his or her own eyes. These women are doing this important work to make a success story in India. We may be getting paid better and receiving more benefits, but what they are doing is the actual work”. Turning her attention back to herself, Shalini says she feels that one of her greatest strengths is her communication skills. “In spite of how I’m from the city”, she explains, “people in the field feel they can easily open up to me and share what’s on their minds”. She adds that it’s important that she makes them feel comfortable, and it’s also important for her to feel that she’s one of them”.
PCI Programme Associate Dr Shalini Salwan talks with passion of her experiences working with the polio programmeâ€™s frontline staff.
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Ranpal Singh Ranpal Singh serves as Moradabad’s District Team Leader, a unique senior position in the field. He has responsibility for a team of around 400 people. Ranpal feels that part of what’s great about COREPCI is that each of these people works as if part of a family; they don’t see their work as ‘just a job’. “Only when one cares for one’s staff and motivates them to work as part of a family will they feel they should give their best for the cause”, he explains. Ranpal feels that what this programme has achieved is marvellous: a polio-free India, and soon a polio-free world. But one should also consider the side-benefits, he says, pointing particularly to the empowerment of women at the local level through the deployment of female CMCs. In Moradabad, the majority of these are Muslims, who tend otherwise to stay at home. These women have been thoroughly trained, and are also receiving their wages directly into bank accounts that they largely control themselves. He believes that these women will impart the importance of female empowerment to their own children, leading to systemic change in society. Ranpal has a few pieces of advice for those fighting polio in the few remaining countries where it persists. The first concerns micro-planning. “Everything should be mapped: where teams are moving, where the children who need vaccinating are located, etc.”. Second, the screening and selection of vaccinators must be scrupulous. Third, communication strategies must be tailored to areas’ particular needs. Fourth, surveillance must be very strong in order to keep proper track of the disease. “If these things can be covered effectively, I can say with 100% certainty that polio can be eradicated from the remaining countries as well”, he asserts.
Ranpal Singh, CORE Group Polio Project (CGPP) District Team Leader, Moradabad, talks of the projectâ€™s successes and his advice for other countries.
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Muhammad anas Anas has held the position of District Mobilisation Coordinator (DMC) for Moradabad since 2007. Though he started his career as a teacher, he says he always held an interest in the social betterment of his community. Observing what happened with smallpox, he saw that it was possible to eradicate major diseases, and realised that there was a real chance to do the same with polio. Ten years ago, when he first entered this field, beating polio still looked like a major challenge because there was insufficient unity among those who could have an impact. Today, Anas sees all the religions and other groups of society working together on a single platform with common purpose. This has made CORE-PCI’s job far easier, he says. “Working as a team, anything is possible”, he adds. The massive feat of coordination between organisations and government departments that India has witnessed in recent years is what Anas would most like to see the remaining countries with polio learn from. As a DMC, Anas handles the community mobilisation network of Block Mobilisation Coordinators (BMCs) and Community Mobilisation Coordinators (CMCs), and liaises with influencers and government officials on how to tackle key issues. A typical month involves 20 to 25 visits to the field, and he’s especially keen to give supportive supervision to his people at every level, making constructive suggestions wherever possible. His job is demanding, but no matter how tired he feels, he insists that it’s extremely important to him to be able to offer his support to his people in making his community, country and ultimately the wider world a better place. “My work is my prime duty on this Earth”, he stresses.
CORE-PCIâ€™s District Mobilisation Coordinator (DMC) for Moradabad is former teacher Muhammad Anas, whoâ€™s as much at home in the field as he is in the office.
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Khalid & Samreen Khalid Hussain is a BMC. He’s responsible for selecting, training and deploying CMCs. After this, he supervises and supports them as they work in the field. Every BMC faces challenges specific to his or her block. 99% of the families in Khalid’s block are Muslim, a community in which myths to do with the polio vaccine have frequently prevailed. A large proportion work in meat, bone and horn trading professions, and allied jobs such as bone and horn artisans. The main challenge he says he faces is that many of these families keep travelling in and out of the area. This makes the job of his CMCs to keep track of the population very difficult. It is a tribute to CORE-PCI’s methods and the dedication of its teams at block and community level that they have prevailed in spite of this formidable obstacle. In one of his areas, his CMC found that out of around 500 houses, more than 300 were resistant to polio vaccinations. Yet today, none of them still are. CMCs share what they’ve learned with local influencers, and between them they spread this knowledge as widely as possible. Khalid finds the methodology of using CMCs in partnership with influencers to be especially smart, and asserts that this has had a very great role to play in securing success. He also views the information, education and communication (IEC) material that CORE-PCI provides for teaching as very engaging, and thus helpful for knowledge dissemination. While a lot of hard work has been done very successfully, Khalid stresses that the battle hasn’t yet been won. Two countries where polio persists lie very close by, and there are population movements between these countries and India, including his
BMC Khalid (right) trains CMC Samreen (left) on the use of soap paper.
O U R P E O P L E 43
block. So he reasons that the team must remain vigilant. In his opinion, those countries that are still experiencing fresh polio cases would do well to observe and learn from the strong and mutually supportive team structure and networks that COREPCI have formed as they too seek to become ‘polio free’. Samreen is one of the CMCs who report to Khalid. She confirms that population fluidity is a big challenge here, as it makes keeping accurate records very tricky. In her area, there are a lot of people living and working in very poor sanitary conditions. Though she continues to explain the importance of hygienic practices, the message is particularly hard to get across where the people she’s talking to depend on other people’s garbage to make a living. The problem is compounded during the monsoon, when the rains quickly turn the narrow alleys into rivers of germ-riddled mud. Samreen finds the women she meets to be more receptive to her message on hygiene and sanitation, so she asks them to persuade their menfolk in turn. These men’s main argument against change is that their professions will always militate against it, though she is now finding that they tend to wash their hands with soap before eating far more than they used to. This feels to her like a significant success. When she first started as a CMC, Samreen says she took one look at the area she’d be responsible for and wondered how she’d ever manage to change anything. Less than a year later, it’s clear that she’s making significant inroads. She is especially proud of her success rate for persuading refusal families to accept vaccinations. There’s only one family that persists in refusing in her area (who we’ll meet later in this book). Her advice to those countries that are still getting new polio cases is that regular contact should be maintained with all such resistant families. Doing so, she is sure, will guarantee that they’ll ultimately succeed.
O U R P E O P L E
CMC Reshma on her rounds in Budhana, Muzaffarnagar District.
Reshma Ali Siddique is also a CMC. She has been working in the town of Budhana, near Muzaffarnagar since 2005. She says that when she first started, around 40 to 50% of families in this area were resistant to the polio vaccine, and many were even unwilling to embrace routine immunisation against other diseases. Gradually, she worked through inter-personal communication (IPC) methods in both households and mothers’ meetings in order to change this. Today, although roughly 100 families remain resistant to routine immunisation in her area of 500 households, only around one percent of them are still resisting the polio vaccine. Talking about what she does, Reshma explains that CMCs regularly visit the houses of those people in their areas who have children aged zero to five. They focus most diligently on those households where children were missed for whatever reason during the previous immunisation round. When a CMC first starts, she will focus first on building rapport with the mothers they meet. They tend to refrain from launching straight into health-related topics. Only after they feel they’ve built sufficient rapport will they ask about children’s welfare, and they feel their way from there. Wherever there’s a problem, CMCs try to help out. Reshma says this can mean teaching how to ensure a child who has a cold remains warm or explaining how to prepare homemade oral rehydration solution (ORS) to treat diarrhoea. If they notice that there’s a problem with home sanitation and hygiene, they’ll explain the importance of maintaining proper cleanliness. It’s all very situation-specific.
O U R P E O P L E
Surrounded by her children, Anas, Rukhsar, Akshara and Goori, Khurshida listens intently as CMC Reshma talks her through certain aspects of child health and hygiene.
Khurshida and her children, pictured here, live on CMC Reshmaâ€™s turf in Budhana, Muzaffarnagar District. To begin with, this family would not allow her to enter their home, so Reshma logged them as a resistant family in her records. It didnâ€™t stop her coming back, but when she did, she focussed squarely on building rapport, not on polio and vaccinations. She would ask about their general well-being and about their wider lives. Slowly, she made inroads, and this process paid dividends. It took five years of visiting with five to six visits every month before she could talk the family round. When she was finally invited into their home, she saw immediately that there was a sanitation issue as many parts of the house were waterlogged. So she told them about techniques to make the water drain away properly. She then explained the importance of maintaining hygiene and asked them to wash their hands after using the toilet and before eating. Doing this would not always go down well. Sometimes, they would get annoyed and demand to know why she felt she had to keep nagging them about such things. They would say that they had so many children at home, it was impossible to maintain control of every small detail. Over time, as Khurshida got to know Reshma better, she says she began to understand what polio could do to a child: how it can cause paralysis. Ultimately, she conceded that vaccination was necessary. But her husband and in-laws, the family decision-makers, remained against it. Reshma therefore enlisted the assistance of local doctors to help persuade her husband. With this, and also after hearing the imams every Friday, urging people to get their children vaccinated, he too finally agreed.
CMCs Reenu and Reena go over their plans.
Reenu & Reena
O U R P E O P L E
Similarly named but unrelated, Reenu Yadav and Reena Yadav both serve as CMCs in the village of Asmoli, Moradabad District. Reenu has been in this position for a little over three years, and she says she loves her job because she really enjoys the company of children and the activities - playing, drawing, etc. - that she does with them. It allows her to indulge her creative side, which as can be made out from the map she drew that’s pictured here, is strong. To be more precise, what Reenu has drawn is a ‘social map’. The CMCs use these to plan teams’ movements during door-to-door work. For ease of reference, key landmarks are depicted, such as places of worship, notable trees, etc. Each house in an area is clearly drawn, and annotated to show where pregnant women, newborns and young children live. These maps make door-todoor work considerably easier as compared to constant reference to the CMCs’ detailed but bulky registers (also pictured). Reena was only 11 when her father died due to tuberculosis (TB). Distraught at her loss, she resolved to learn all she could about TB and other contagious diseases, and to work for the health and welfare of her community. She commenced work as a CMC in Asmoli about a year ago, having already served in another village for over five years in spite of initial resistance from the male members of her family. Reena says that for her, hand washing with soap before meals is one of the areas where it’s hardest to achieve behaviour change. This is because people can’t actually see the germs on their hands. She counters this by handling garbage in front of them and then asking whether she can now eat. Having seen where her hands have been, they say she can’t.
W O R K I N G T H R O U G H
CORE-PCI has had tremendous success in using children as agents of change in its efforts to combat polio.
C H I L D R E N
‘PT’ (physical training) session at the village of Nangla Tashi’s primary school, Meerut District.
Neesha (11) and Mushrina (9) colour in the pictures in a colouring book that teaches them what they can do to protect themselves against germs.
Masti ke Doot ‘Masti ki Kakshayein’ (meaning ‘Classes of Fun’) are organised by CORE-PCI’s CMCs in schools, and are designed to help children learn the importance of personal hygiene – particularly hand washing after using the toilet and before meals – in preventing germs from spreading and potentially causing diseases such as polio. In Masti ki Kaksha sessions, the children enter not as pupils but as ‘Masti ke Doot’. This literally means ‘Ambassadors of Fun’; the idea is that they should serve as agents of change, going back to their homes and passing on their learnings and good habits to their families and the wider community.
W O R K I N G
T H R O U G H
C H I L D R E N 53
Dharampal Sharma Dharampal Sharma’s job is to ensure his school lends whatever support CORE-PCI’s CMCs require in order to do their work with the children effectively. Masti ki Kaksha classes have been run at the primary school in the village of Nangla Tashi in Meerut District for two years now. Mr Sharma has observed how the school’s Masti ke Doot have been extremely effective in conveying their learnings to the other children. “The younger children have been learning from the elder ones”, he explains. “They’re now far more aware about matters of personal hygiene”. He goes on to describe how they also convey this information to the other members of their households and friends outside the school, resulting in behaviour change. “I’ve seen that the CMCs work very hard to convey their messages, using drawings, poems, games and skits”, Mr Sharma says. “And because they get the children to learn through having fun, they seem to enjoy these classes far more than their regular subjects!” Observing this, the school has decided to make an effort to learn from what the CMCs do, and use similar methods for academic sessions in the expectation that this will make the children more interested in their studies.
W O R K I N G T H R O U G H C H I L D R E N Masti ki Kaksha nodal teacher Dharampal Sharma. 55
Yogita Rawat Yogita has been working as a CMC and coming to the primary school in Nangla Tashi for two years now. Before this, she worked as a vaccinator, so she brought considerable knowledge of health and hygiene to her new role. She starts today’s Masti ki Kaksha session by talking about personal hygiene, cleanliness and hand washing. She tells the children about the five main diseases that are communicable as a direct result of poor hygiene, namely tuberculosis (TB), diarrhoea, whooping cough, diphtheria and polio. She then explains how important routine immunisation is for children aged less than five. She also talks about the importance of daily bathing, keeping one’s nails clean and regular brushing of one’s teeth. She asks the children to pass on all of these messages to their relatives and neighbours. Yogita often teaches through drawing, and
the children love making posters to teach others about good hygiene and sanitation. In these, they depict people using dustbins, cleaning their streets and so on. She says the children clearly enjoy their Masti ki Kaksha sessions more than they enjoy their regular classes, as they get to participate much more actively in them. This is no surprise to her; after all, they are ‘classes of fun’ by design! While her supervisors ask her to do certain things in the sessions, Yogita also likes to bring her own ideas into the mix – organising plays and skits, for example. Laughing and smiling widely, she says that she enjoys her work a lot. Her time with the children is very special to her, and she especially loves how much they in turn adore her. “The moment I walk in through the school gate, so many children run up to me and give me a hug!”, she says, beaming from ear to ear.
W O R K I N G T H R O U G H C H I L D R E N CMC Yogita loves to keep her Masti ke Doot as active as possible. 57
Mushrina Today, Mushrina and her classmates have been given a colouring book to work on. Their CMC has told them that through colouring, she’ll help them understand what she wants to teach them better. In this book, the poem ‘Aakkad Bakkad Bambe Bo’ is narrated, and the accompanying pictures depict how important it is to keep oneself clean.
W O R K I N G T H R O U G H C H I L D R E N Masti ki Doot Mushrina (9), avidly colouring. 59
Masti ki Doot Asmeen (8), learning through fun.
T H R O U G H C H I L D R E N
Here’s Asmeen, deep in concentration, colouring in the scenes from the same story. According to the poem, those who wash their hands are the smartest of all, while the one who doesn’t wash them gets labelled ‘the culprit’. When the others dance around him or her in a circle, this makes the culprit feel bad and s/he learns the lesson the hard way. The book also teaches the children how important it is for them and their families to cease open defecation, and that when they then wash their hands, they should always do so using soap and water. It suggests that only if the children wash them properly may they then get their full meals. As Asmeen colours and reads the accompanying text, she learns that if she doesn’t follow these rules then viruses can follow her everywhere and will eventually enter her mouth and work their way down into her intestines, causing terrible things to happen, even paralysis. The other thing it tells her is essential to stop this happening is taking two drops of the polio vaccine whenever vaccination time comes.
W O R K I N G
Neha (10) and Sana (10) chant ‘Aakkad Bakkad Bambe Bo’.
Neha & Sana
Akkad bakkad bambe bo, Masti ke doot, ho ho ho. Smart wahi haath dhoye jo, Naa dhoye wo ganda. Dalo haath mei phanda, Aab toh ghere mei anna padega, Aachi baato ko aapnana padega. Sabun se haath dhona padega, Tabhi khana pura milega. Warna vishanu peechha karega, Aaton mei panapata rahega, Aapang hume banata rahega. Isse bachne ka ek upaye:
C H I L D R E N
Khule mei shauch band karna padega,
T H R O U G H
Aao, khele aakkad bakkad bambe bo,
W O R K I N G
After theyâ€™ve finished colouring, the CMC leads the children in chanting the words of the poem in the book. For Neha and Sana, itâ€™s one of their favourite Masti ki Kaksha activities, and they know the words by heart. With all its colloquialisms, the poem is a little difficult to translate meaningfully into English. For the benefit of Hindi-speaking readers, however, the original words are as follows:
Do boond har baar pilaye, Puri takat mile tabhi, Tike jab lag jaye sabhi. Akkad bakkad bambe bo, Smart wahi haath dhoye jo. 63
Shalu (14) finds that a few things need to be set straight in the Kingdom of Fun!
Muhammad Abid W O R K I N G T H R O U G H C H I L D R E N
Next on the programme for the children is a special treat. Muhammad Abid, a drama teacher at New Horizon Public School, has come to give his time on a voluntary basis; they’re going to put on a play together. The theme of this play is hygiene and sanitation. It is set in an imaginary kingdom, ruled by the ‘King of Fun’. The king is worried about his people, and is wondering how many of them are following good hygiene and cleanliness procedures. So he asks his subordinate to tell him about the situation on the ground. The reply comes that there are a few people who aren’t following his instructions on cleanliness. So the king calls for some of these people to be brought to his palace, where he asks them what they think should be done with them. Should he punish them? At this, they apologise profusely and assure him that they’ll follow his instructions scrupulously from now on. Abid says that through this play, he intended to teach the children something that they’d then go home and tell their families about, probably by narrating the storyline to them. In turn, their family members would get to understand how important these things are. With the CMCs’ help, Abid devises plots for plays like this drawing on concepts and ideas that he knows the children can relate to. He also helps schools put on magic shows, and he stars in these as the magician. These help teach the wider community about the importance of polio vaccinations and routine immunisation. Abid enjoys entertaining the children a lot. After all, he points out, this is what his profession is all about!
CMC Reena teaches Rashmi (9), Suraj (7), Abhishek (8) and Rohit (11) the method for effective hand washing.
W O R K I N G T H R O U G H
There are five steps to effective hand washing, as any Masti ke Doot will tell you.
C H I L D R E N 67
Priti (10) helps classmates Shusheel (10), Sangeeta (13), Saiba (8) and Khushnuma (9) practise what theyâ€™ve learned.
T H R O U G H C H I L D R E N
10-year-old Priti, who you see pouring water here, is studying in the 5th Standard at Asmoli Primary School, near Moradabad. Priti says that CMC Reena taught her and her classmates that it’s important to wash their hands thoroughly both before eating their meals and after using the toilet. If they don’t, she explained, germs can get into their mouths and will then travel down into their stomachs and make them ill. Priti says that in addition to following these instructions, she also takes a bath every day before going to school, and washes her hands after doing any kind of work that makes her hands dirty. She has taught the importance of such cleanliness to her family as well, and they’re now much more regular with their hand washing than they used to be. For Priti, the Masti ki Kaksha sessions are a lot of fun, and she enjoys finding out about such things through games and poems. They only happen once or twice a month, so in between times she looks forward to them eagerly.
W O R K I N G
Shalu 14-year-old Shalu is the School Monitor at the Nangla Tashi Primary School. She’s an especially active Masti ki Doot, often taking the lead in activities and helping those who are less quick to learn. She takes very seriously her job of passing on her knowledge of the importance of maintaining good hygiene and sanitation to family and neighbours. Like many other Masti ke Doot children, she’s come a long way. Shalu says that before she started attending the Masti ki Kaksha classes, she didn’t know much about cleanliness. She used to eat with dirty hands, and when flies settled on her food, she had no idea that this could pose a risk to her. At home, she has been successful in persuading her mother to take washing her hands prior to cooking more seriously. At first, her mother got irritated at being nagged about this, but Shalu persisted and after a week or so of trying to convince her that her dirty hands could spread germs to other members of the household, her mother relented. Shalu then shifted her efforts up a gear and started to throw away milk if a fly landed in it; if her mother scolded her, she’d say that if she were to give that milk to the babies, they’d probably fall sick. Treating them would be far more costly than the money lost through the wasted milk. Then, Shalu says, her mother would understand. Her parents now feel proud of what she’s accomplishing as a Masti ki Doot.
School Monitor and Masti ki Doot Shalu (14) helps pupils wash their hands before lunch.
W O R K I N G
T H R O U G H
C H I L D R E N 71
Nisha Masti ke Doot children’s most important job is to share their learnings at home and in their communities. Here’s Nisha, doing just that. She found her parents knew that they ought to wash their hands after using the toilet and before eating, but she noticed that her younger sister, brother and grandparents weren’t doing it. So she took it upon herself to tell them how important it is. After showing everybody at home how to do it properly, and reinforcing the importance repeatedly for a week or so, Nisha says they all started washing their hands the way she’d showed them and have continued to since. She has since gone further, telling her siblings how important it is to take regular baths, wear clean clothes whenever possible, and that they should brush their teeth regularly. Another thing that Nisha pointed out to her parents was that the dirty drainage system their house was connected to could pose a potential hazard. While this was primarily the government’s responsibility, she felt that they could at least maintain the part connected to their home better. Now, Nisha’s younger sister Shana is also learning about immunising against polio and other diseases at school, and she has been sharing what she’s been learning about this and about hygiene both at home and with the neighbours. Nisha has noticed that their neighbours have started keeping their homes cleaner than they used to, thanks to these interventions.
W O R K I N G T H R O U G H C H I L D R E N Nisha (12, wearing her blue school uniform) and sister Shana (10) show their grandparents how to wash their hands most effectively. 73
IRFAN & RAVANAK Irfan is a Masti ka Doot who’s earned a reputation for himself as an especially effective agent of change. Before he started his Masti ki Kaksha sessions two years ago, he used to wash his hands using only water, or else ash or soil, as is traditional here. After he found out that it should be done using soap, he asked his father for some money and bought Dettol soap for the whole family, and explained to them the importance of using this. Irfan’s family members now wash their hands not only after using the toilet and before eating, but also when they return home. He has been very insistent about the dangers of diseases spreading through poor cleanliness. He’s also taught his family that it’s important to use a toothbrush and toothpaste when brushing one’s teeth, rather than using only water or else one’s finger and tooth powder. Now, the family keep separate soaps for hand washing and for bathing, and every individual has his or her own toothbrush. Since he converted his family to hand washing using soap, Irfan estimates that there’s been a reduction in instances of sickness at home by around half. When diarrhoea occasionally occurs, he knows how to treat this using homemade ORS. Irfan’s mother Ravanak recalls that when her son came to tell her about the importance of personal hygiene, she felt pleased that he was gaining worthwhile knowledge at school; all the more so because he was passing it on to his family. After learning from him, she does many things differently. Ravanak feels great pride in Irfan. He’s managed to bring fundamental changes both at home and in their neighbours’ homes. In addition to pressing the case for vaccinations, he takes the under-fives in the area to be immunised on Booth Day.
After a meal, Irfan (14) shows his mother Ravanak how to brush her teeth properly.
W O R K I N G T H R O U G H C H I L D R E N 75
A man comes to see what all the noise is about as children rally through the streets of Asmoli, Moradabad District.
C H I L D R E Nâ€™ S R A L L I E S
Childrenâ€™s rallies have proven a highly effective way for CORE-PCI to get certain messages out to the communities in which they work.
C H I L D R E Nâ€™ S R A L L I E S
CORE-PCIâ€™s CMCs coordinate closely with school staff to ensure their constant support for the rallies they want to hold. This section introduces two of the three different types, the polio rally and the kukro koo rally, while the bulawa tolli is covered in the next section.
CMC Reena Yadav meets Headmaster Rakesh Kumar Sharma to ask his permission to take children out of school for a rally. 79
CMC Kalpana Yadav teaches a pre-rally polio class in Asmoli, near Moradabad.
R A L L I E S
“There used to be a lot of polio cases in Asmoli and its surrounding area”, says CMC Kalpana. “I can remember seeing 11 or 12 since she I was a child”. While many other diseases can be cured, the paralysis that polio causes will remain with a survivor for life. “This is why I decided that this was the health problem I wanted to work towards eliminating”, she explains, adding that she gets inner satisfaction in doing this work because she knows she’s working for children, and that ultimately this crippling disease will be eradicated. Today, Kalpana is preparing the children to rally through the streets of their village as part of the drive against polio.
C H I L D R E N’ S
Polio rally Kalpana begins by talking to the school pupils about what polio does to children, and tests their knowledge about what can be done to prevent the disease. She explains to them that they have a really crucial part to play in helping to wipe polio out completely, which makes the children feel important and excited. Through the rally, Kalpana says, they can help ensure that the adults in the village will bring their children to the polio booth for vaccination the following day. Kalpana then teaches the children the slogans theyâ€™ll be chanting, and works out who will walk where in the group and who will hold which banners.
Anshu (11) enthusiastically raises her hand to answer a question.
C H I L D R E N’ S
R A L L I E S 83
Himanshu (12) and Zeeshan (10) lead a polio rally through Asmoli.
formation and do a transect walk around their area, carrying banners and handing out leaflets. These inform the community about the time and venue for the immunisations the next day. Not only do people see and hear the kids as they process through the streets, as the two boys who have come out of their home to see what all the fuss is about in this image, but the children also go home and excitedly tell their parents about what they did that day. This further reminds them that vaccination needs to be done.
R A L L I E S
Himanshu and his friend Zeeshan have been chosen by CMC Kalpana to lead the way in today’s polio rally. They have the important responsibility of carrying the main banner announcing that the following day will be ‘Polio Sunday’ and that every child should be immunised. The polio rally is always held the day before Booth Day, the day on which a new polio round begins. Schoolchildren dress up in special aprons and head shades and wear badges with slogans on them. They are then organised into
C H I L D R E N’ S
Himanshu & Zeeshan
Sabeena & Swadikeen
C H I L D R E N’ S R A L L I E S
Best friends Sabeena and Swadikeen study together in the 5th Standard at Asmoli Government Primary School. Today, they too are participating in the polio rally to tell the local people that the polio booth will be operating tomorrow so they need to bring their under-fives for vaccination. According to CMC Kalpana, Sabeena is one of the top contributors in the classes she takes. She loves to be there at the front when the rallies are held! And Swadikeen is always right there behind her. She shows she knows that they’re more than about making a big noise, explaining that if children are given polio drops, they will keep them safe from polio. For Sabeena, the best thing about these rallies is their festive feel. She simply loves reciting the slogans they’ve been taught, and enthusiastically chants them at the top of her lungs. One of them, she recounts, goes “we will march through every street to eradicate polio”. Another proclaims that “with two drops of the vaccine, polio will be prevented”. And a third says, “if just one child is left out, the chain will be broken”. Of course, it all sounds much catchier in Hindi! The girls also like the fact that they get to wear colourful aprons, head shades and badges, which themselves have slogans written on them. One of these, for instance, reads “the gangs of children are going to eradicate polio!”. Another puts its message across very succinctly: “two drops of life”.
Sabeena (10) and Swadikeen (11, behind her) give it all they’ve got during the polio rally. 87
R A L L I E S
Poor sanitation is known to be one of the primary causes of polio spreading in India’s high-risk blocks. The Kukro Koo Rally (or ‘Rooster Rally’) was designed to address this. The aim is to increase local populations’ awareness that open defecation causes disease, and to prompt them to switch to toilet use. Toilets judged to be ‘sanitary’ do exist in some of the houses in these areas, and the numbers are increasing. But male householders in particular often still prefer open defecation; in the case of rural households, this is done in the fields, owing to the belief that it will make the soil more fertile.
C H I L D R E N’ S
Kukro koo Rally
Boys and girls line up excitedly for a Kukro Koo Rally in Asmoli, near Moradabad. 89
R A L L I E S
One day before the Kukro Koo Rally, the CMC conducts a class with the children to explain its purpose. She tells them how germs spread following defecation in the open, and explains how this can make people fall sick with diseases. She then teaches them the lines they’ll need to chant the next day. And she chooses the one pupil who’ll lead the chants, using a megaphone. This time, it’ll be Sachin’s responsibility. Kukro koo rallies have been quite successful in persuading people that open defecation is far from sensible. They also point out to bystanders that if they don’t have the resources to get their own toilets constructed, then there are government schemes to help with this.
C H I L D R E N’ S
Sachin (8) leads the Kukro Koo Rally, bellowing into his microphone. 91
C H I L D R E Nâ€™ S R A L L I E S Kukro Koo Rally in full swing. 93
Bullawa Tolli The CMC selects certain Masti ke Doot pupils to be in the Bulawa Tolli, or ‘Children’s Calling Group’. These are generally the children whom she judges to be the most enthusiastically involved with the polio-related activities that she runs. They then gather at the polio booth on the morning of Booth Day, and process through the lanes of their area, calling for the local people to bring their children to be vaccinated.
Muhammad Shahbaz “I’m in the 6th Standard now, and have been in the Bulawa Tolli since I was in the 4th Standard. One day before Booth Day, the CMC comes to our class to tell us that the Polio Round will be starting the next day, so we’ll be needed for calling the children from the houses. “I enjoy shouting into the microphone when we march through the streets!”
P O L I O B O O T H D A Y S From left to right, Shagufta (12), Azma (9), Shahbaz (11) and Mahek (11) make their final preparations for the Bulawa Tolli on Booth Day. 95
Azma “I’ve been doing this for the last three years, since I was in the 3rd Standard. It’s a lot of fun! We enjoy shouting slogans in the streets. We keep reciting that “today the polio booth is open, please bring your children for their vaccines. Whosoever does not send them, we’ll come and take your children!”. We make a special effort to get the families whose children were missed in the last round to bring their kids for vaccination.”
P O L I O B O O T H D A Y S Azma leads as the Bullawa Tolli gets underway. 97
Shagufta P O L I O
“We first call for families to bring their underones for inoculation against polio. Later, after the under-ones have been covered, we call on them to bring their under-fives.”
B O O T H D A Y S
Mahek “It’s nice that we get a packet of biscuits at the end of the day. That’s our reward for working hard!”
The Bullawa Tolli hits the streets of Budhana. 99
Arshi Ilahi Khan While the Bullawa Tolli roams the streets of Budhana, Arshi – one of the town’s CMCs – is helping to get her local polio booth ready. “We start getting prepared for Booth Day one day before”, she explains. “We make the banners and get ribbons and other decorative items. We then hang all these in place on the morning of Booth Day itself. We also make rangoli (decorative designs on the ground) for the entrance, and write ‘Welcome, CORE-PCI’ on the ground as well”. Arshi adds that she really enjoys these tasks, like the rest of the work she does as a CMC. This is not just because she has a creative streak. She says that what she especially values is that she gets to talk with a lot of influential people in her area, which has helped her to build her confidence for speaking up in the community.
CMC Arshi puts the finishing touches to her local polio booth on the morning of Booth Day.
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Atul Bansal After the CMCs and other grassroots workers have done the hard work behind the scenes, the polio booth is then inaugurated by an influential person from the area – such as a Medical Officerin-Charge, an imam or another well-respected local figure – in order to show the activity’s importance. This person cuts the ribbon that’s been strung across the entrance, and then gives the first drops of the day to the first child in line. Today, this booth is being inaugurated by Dr Atul Bansal, Medical Officer-in-Charge at Budhana’s Primary Health Centre (PHC). Dr Bansal describes his role among the grassroots workers as akin to that of the head of the family. “When there is a difficulty in the field”, he explains, “I receive a call”. This might, for example, be when local influencers are unable to change the minds of refusal families. In such instances, he is asked to visit, sometimes alongside a BMC or WHO monitor, in order to provide additional motivation. Dr Bansal stresses just how much he hopes that there will continue to be no more new cases of polio in India for at least another two years, so that it can be truly certified that the country is ‘polio-free’. “That achievement would make me feel out of the world!”, he says with a wide smile. “I’ve seen how the children who’ve caught polio are forced to grow up, and I know how their parents feel. So it would be a great accomplishment for India to wipe this disease out”.
P O L I O B O O T H D A Y S Dr Atul Bansal declares a polio booth officially open in Budhana, Muzaffarnagar District. 103
STEP 1 At the booth, the vaccinator must first position the vaccine over the childâ€™s open mouth. These little ones often seem to have other plans, and wriggle around and fight all efforts to squeeze their cheeks together in order to open their mouths. This particular baby seems to be winning! Only once the vaccinator has managed to get her index finger across to the other cheek will she be able to open the mouth properly and administer the two required drops of the vaccine.
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Once the drops have been given, the childâ€™s index finger is marked with a marker pen. This will help the CMCs verify that s/he has been vaccinated during the coming days when theyâ€™ll go from house to house, looking for those children who missed out on Booth Day.
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The black mark is not all the child gets as a going away present. Here, baby Rijwan is helped into a trendy â€˜eradicating polioâ€™ head shade for his troubles.
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Lastly, a record is made of the childâ€™s inoculation on the tally sheet, before the next parent steps up to the mark. These records will be very important over the following days of the polio round, guiding the fieldworkers in their efforts to mop up those children who did not receive their doses of the vaccine today.
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Afsana Safi It’s always a moment of pride for CORE-PCI’s CMCs when they welcome members of previously resistant families for their children’s vaccinations on Booth Day. Afsana is from one such family. “The elders, both in my family and from the wider community, told us that we shouldn’t allow polio drops to be given to our children because they cause impotence”, Afsana explains. “When the CMC visited our house, she explained to us that the vaccine is very important for children. But my husband and in-laws stood their ground because they believed the elders, and they’re the ones who take the household’s decisions”. The CMC therefore invited these three people to one of her parents’ meetings. They attended not once but several times. With these, alongside her repeated visits to the house, and also because mothers in their area told them how important the vaccine was, they gradually became convinced of what she was telling them. Today, Afsana has come willingly to get polio drops for her son Aayan. She didn’t wait for the team to come to her house to tell her that he needed them.
P O L I O B O O T H D A Y S ANM Parineeta Milke administers polio drops to Afsanaâ€™s son Aayan (2), as CMC Farzana Tyagi (in orange) and ANM Seema Rani observe the procedure. 113
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Dr VK Jhori, Muzaffarnagar District’s Chief Medical Officer, presides over the district’s postBooth Day evaluation meeting of stakeholders.
Sitting immediately to Dr Jhori’s left is Dr Gyanendra Kumar, Muzaffarnagar District’s Immunisation Officer. He adds context to the CMO’s message, noting that China was thought to be off the polio list, having seen no cases for several years. But then, in 2011, a case emerged. “I continuously demand that we shouldn’t become complacent”, he asserts. “We’re used to overcoming challenges. Temperatures can approach 50°C in May, and then the monsoon rains can be severe. Yet our staff keep working”. However, Dr Kumar identifies the greatest challenge as the population movements to and from Pakistan. “This means it’s crucial to improve on our surveillance reach. No case of acute flaccid paralysis (AFP) in under-15s should be missed, not even palatal paralysis”. He adds, “we’re confident that we’ll achieve our goal!”.
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Dr VK Jhori is Muzaffarnagar District’s Chief Medical Officer (CMO). This evening, he has convened a meeting to evaluate the Booth Day activities. In attendance are the District Immunisation Officer, six Additional CMOs and various partner agencies’ representatives. “Uttar Pradesh’s West was previously one of India’s worst areas for polio”, Dr Jhori points out. “Now, we’ve not seen a new case here since 2010”. To maintain this record, he says, meetings like this must be held regularly in order to examine what’s working well and where areas for improvement lie. Among the latter, it’s been agreed this time that newborn vaccinations should be increased from 91.35% to 95%. “Fatigue should not take hold if polio is to be completely eradicated from the world”, he adds. “We need to keep pouring more and more energy into this programme”.
The Jama Masjid is the largest and most important mosque in Moradabad. CORE-PCIâ€™s polio programme has focussed on Muslim-dominated areas, and has relied heavily on the support of religious leaders.
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The Qureshi Family CMC Samreen has 491 households on her beat. Of these, this is the last remaining one that continues to reject polio vaccinations. Samreen has been visiting this 15-person household, whose members work in the scrap and meat trades (like many in this part of the state), since she started working for COREPCI. Ashad, the eldest son, explains that his mother, the head of the household, refuses vaccinations because she believe they cause impotence. In fact, Samreen’s records show that no child in this house has been vaccinated against any disease at any point. Ashad simply says, “our hearts are not in agreement with vaccinating”. The family members know that all the other families in the area willingly allow their children to be vaccinated, yet they insist that they won’t bow to popular pressure. “We simply don’t have faith in it”, repeats Ashad. He adds, “what we do have faith in is that God will protect us”. Such statements, for long common in the areas in which CORE-PCI works, highlight the important role that religious leaders have to play. Indeed, Ashad says that till now, his family has not been in contact with any religious person on this subject. As this section will show, those that have had such contact have frequently ceased resistance. The following section will then examine the role of influencers, of which religious leaders are perhaps the highest order. We can get an idea of the effect that influencers can have, as Ashad’s father Azim says that now that someone (namely the photographer and researcher for this book) has come from London and is asking why his family has not yet accepted the polio vaccine, he will tell his wife about his visit and perhaps she will finally change her mind.
CMC Samreen meets Rahemeen on the doorstep of the home of the Qureshi family, the last refusal family in her part of Moradabad City.
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SyedMasoomAliAzad The ancestors of Syed Masoom Ali Azad have held the position of Moradabadâ€™s Shaher Imam (City Imam) for the past 200 years; he himself is the ninth imam in the history of the Jama Masjid (pictured at the start of this section), and has occupied the seat of Shaher Imam since 1987. He explains that his role includes a leadership position in social work for the city. Very soon after the polio immunisation campaign was first launched, he led the way in conveying the message that the vaccine was both safe and essential, just as soon as heâ€™d consulted with various Muslim medical colleges after hearing the rumour that it contained an ingredient regarded as haraam under Islam. Once he had verified that this was no longer so, he began making regular announcements at Friday prayers at the Jama Masjid that this vaccine ought to be accepted if polio was to be eradicated in India. Indeed, CORE-PCI has found that a quick, easy and effective way of getting its message out is to ask religious leaders to make announcements in this way at mosques and temples. Frequently, the use of loudspeakers ensures that these messages reach much of the community, not just those within the building at the time.
Moradabadâ€™s Shaher Imam, Syed Masoom Ali Azad.
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Haji Idrish announces from Mundaliâ€™s mosque that Booth Day is approaching.
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that command that the Prophet be followed. The Shaher Imam says he refers to these statements during his addresses at Friday prayers, as well as other such statements related to the importance of maintaining hygienic and sanitary conditions. “Islamic guidelines state that all people must strive to be pak, or ‘clean’”, he points out, adding that “while it’s not absolutely essential to pray five times a day, it is certainly essential for one to be aware of certain important issues, including the need to foster a healthy environment around ourselves”.
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Poor education plays a big role in people’s lack of understanding about health issues like this one, according to Moradabad’s Shaher Imam. When asked about the last remaining refusal family in CMC Samreen’s area, who stated that if their child gets polio then it must be God’s will, he replies that these people ought to be told – with reference to the Qur’an and the Hadees (collection of sayings and deeds of Prophet Muhammad) – that while diseases are sent by God, so too are medicines. It is, he says, Sunnah, which comes from those passages in the Qur’an
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Qari Maqsood Ahmed privately studies the Qurâ€™an.
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Qari Maqsood Ahmed is the Imam and head of the madrasa at Bari Mosque in the city of Moradabad. He has held this position since 20 years ago, a time when there were many people living with polio in Moradabad. Owing to a widespread lack of education in the area, he says that many used to believe that the polio vaccine would cause impotence, thought to be a government conspiracy to reduce population growth. Many others argued that the vaccine contained an ingredient considered haraam according to Islam, created in a culturing process that used particles from pig fat. (This indeed used to be the case, but the present day vaccine no longer uses this ingredient). Maqsood Ahmed recalls a time not long after he first came to the city when, while walking at night, he thought he saw a dog on the road. When he shined his torch at the creature, he found that it was actually a man who had been gravely crippled by polio. He was already used to seeing such people coming to his mosque to offer namaaz (say their prayers), sometimes wearing sandals on their hands so that they could move about. He found this tough to observe, but it was his thought that night that the polio-affected man was a dog that prompted him to act more decisively.
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Qari Maqsood Ahmed
The imam was then sensitised further during a meeting convened by the WHO and its partners. This meeting was addressed by a paediatrician, who gave his assurance that the vaccine would cause no harm to anyone. After this, he began making announcements at his mosque to encourage people to get their children vaccinated. In order to bolster the case he was making, he also procured literature from Muslim medical colleges that spoke of how the vaccine was safe. Bari Mosque is the most important mosque in its locality. Consequently, those who live in the area place great faith in Maqsood Ahmed. During the gatherings in the mosque before Friday prayers, he addresses the faithful and frequently speaks on this subject. Slowly but surely, he says the mindsets of his devotees have changed. With the help of other influential people in the area, he has turned a situation in which 75% of families were refusers on its head.
Qari Maqsood Ahmed discusses polio awareness raising with Shanim of CORE-PCI at Bari Mosque.
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Kirshanpal SingH While the blocks in which CORE-PCI has been working in Uttar Pradesh are largely Muslim-dominated, there are significant pockets of Hindu populations. The proportion of Hindus in the village of Mundali in Meerut District, for example, is approximately 35%. Kirshanpal has been the caretaker-cum-pandit of the Hindu temple here for the past 12 years. When CORE-PCIâ€™s team first approached him to ask if he could make announcements from the temple, he says he was very happy to know that they were arranging such activities in the village. He could see that they would contribute to the health of its children in a big way. While vaccinations among Muslims have been restricted owing particularly to certain myths, Kirshanpal says that such myths have never existed among Hindus, at least in his area. Indeed, he says that very few Hindus were ever against the vaccine here, and that if a child is missed then the parents will sometimes be very insistent that the team should give him or her the vaccine later. His announcements are nevertheless important because they contribute to awareness. In addition to making announcements, Kirshanpal says he sometimes also goes from door to door to encourage families to get their children vaccinated. Where he does meet resistance, he points out that since the polio rounds started in this area, the numbers that caught the disease fell rapidly, and now itâ€™s almost possible to declare the disease wiped out.
Pandit Kirshanpal Singh announces the upcoming polio round over Mundaliâ€™s temple loudspeaker.
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In Muslim areas such as Mundali, madrasas frequently play host to influencer meetings.
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In each community, many local people have been associated with CORE-PCI’s programme in one way or another, whether directly or indirectly. In particular, a large number have worked since the beginning to try to convince others of the necessity of taking the polio vaccine. This section draws on images and discussion from a meeting of these ‘influencers’ held at the madrasa in the village of Mundali, near Meerut. The madrasa is the location of choice for these meetings in Mundali because it is considered a neutral space where all are welcome on an equal footing. Influencers come from a variety of professions, including imams, mohotamins (mosque caretakers), quotedars (ration shop administrators), local doctors, dhais (midwives), ex-pradhans (village leaders), parshads (members of local government bodies), teachers and other influential people. Influencer meetings are conducted once a month at the village level. Influencers engage in experience sharing in order to motivate their fellow influencers, and efforts are made to enlist the help of further influential people in converting resistant families. Another type of meeting, the ‘interface meeting’, is held once every three months. At these, discussion covers immunisation, the names of resistant and missed families, mosque and temple announcements, religious leaders’ participation and students’ involvement. Meetings are also convened at block and district levels in order to give mementos and appreciation letters to influencers, thanking them for playing an important role. These may be addressed by
Chief Medical Officers (CMOs), Sub-Divisional Magistrates (SDMs), District Magistrates (DMs), tehsildars (tax collection officers) and block development officers (BDOs), who will use inspiring words to further motivate those invited. One of the main methods used by influencers is the invocation of religious teachings. For example, they explain to Muslim people that Islam teaches that a child’s welfare is the duty of his or her parents. If they don’t give the polio vaccine to their child, they say that the parents will be liable to God’s punishment for not fulfilling their responsibilities. And, as was shown in the previous section, Muslim religious leaders’ help has been especially invaluable in dispelling the myth that the vaccine causes impotence in boys. Influencers who work as local doctors often organise polio vaccination activities at their own clinics, so that people can see that the doctors themselves give the vaccine their seals of approval, making it clear that it must be for the good of the community and not for its harm. Doctors are also well-placed to explain how important the vaccine is and how it works. Frequently, influencers have to problem-solve, based on situations they’re confronted with. Influencer meetings are a key place for doing this in the round. They also contribute to a useful feedback mechanism. For example, community members have been known to complain to influencers that people keep coming to talk about the polio vaccine, but never gave any other kind of medicine when they need it. Hearing these implied demands, CORE-PCI organised community health camps in collaboration with the Department of Health of the Government of India. These have since become a crucial part of CORE-PCI’s methodology, as will be seen in a later section. They ensure that people can get check-ups and access to free medicines, and have won objecting communities over.
Dr Rashid Hasan shares his experiences with other influencers during the influencer meeting.
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“We have so much to thank CORE-PCI’s DMCs, BMCs and CMCs for. They are working day and night for the welfare of our community. I feel I owe it to them to assist in whatever way I can. So I ask people again and again to please give the polio vaccine to their children. As a rural medical practitioner, I can assure them that it’s in no way harmful. “I tell them about the earlier days in our village, when so many people suffered from this disease. Even after the vaccine became available, so many families refused it and a large number of their children ultimately contracted polio. These cases could so easily have been avoided, and I just have to keep spreading this message so that our next generation won’t go through what the previous ones did”.
Mundali community elder Munshi Ali Hasan speaks animatedly on what he finds works as an influencer.
Munshi Ali Hasan
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In the same way that the government was successful in eradicating smallpox from India, Munshi Ali Hasan feels sure that it is on the brink of ending the scourge of polio for good. “I tell people that they should not see its efforts as some kind of covert, sinister family planning initiative”, he shares with his fellow influencers. “Rather, they are simply trying to banish a very dangerous disease”. And he calls upon all assembled to keep working together as a team to ensure this is a success. The polio team used to find many refusers in Mundali and its surrounding area, both for polio and for routine immunisations. When vaccination days came, Ali says his method for convincing such people was to bring a child from his own house and ask for drops to be given to that child first. “When people saw this, in the light of the trust they had in me, they understood that the vaccine must be safe”. Ali also shares the logic his own elders imparted to him when the vaccine first came. “I understood from them that the government would not initiate any covert family planning programme because it already had an open and respectable family planning programme in place. If it really wanted to push such a covert programme then why would it also waste its resources on that open programme?” And in case logic isn’t enough on its own, Ali also points out that Darul Uloom Deoband, the Islamic school where the Deobandi Islamic movement was started, at one point announced a fatwa (Islamic ruling) that declared that the polio vaccine would bring no harm. “Given that this fatwa came from such a highly respected religious institution in our state”, he asserts, “Muslim people should respect it”.
Abdul Kalam Dr Abdul Kalam is a medical practitioner in the village of Mundali. He says that many polio cases used to come to his clinic, and notes that these people’s pain was far more than just physical. “They used to see themselves as a burden to everybody else on Earth”. Dr Kalam therefore welcomed CORE-PCI’s arrival wholeheartedly. “Initially, CMCs would find doors shut in their faces”, he recollects. This was where he and his fellow influencers came in. “As a doctor, I knew that the myths associated with this vaccine were untrue and was ready to work hard to discredit them”. Far from being a threat, he assured people that the vaccine would keep their children safe from this crippling disease. While Dr Kalam is keen to thank the village madrasa and schools for the way they’ve contributed to beating polio through their children, he adds sternly that “this is not the time to rest upon our laurels”. He accepts that a year has passed without a new polio case in all of India, but insists that “we must secure many more such years. With two nearby countries still having the virus, we’re still in the danger zone. So we should maintain our current proven strategies, but work even harder to make sure this virus never returns”.
Shafaqat AlI Talking with rural medical practitioner Dr Shafaqat Ali, it becomes clear how charged the issue of polio vaccination can be. “Sometimes, in the past”, he admits, “I’ve felt nervous that if something should go wrong for a family that allowed polio drops to be given after I offered my influence, then I would have to bear responsibility”. But he stresses that he’s managed to move on from this. “I tell myself that I should remain strong and keep convincing families, because this is about more than me or my family, it’s about our whole country”.
I N F L U E N C E R S After the influencer meeting, Dr Shafaqat Ali (far left), Dr Abdul Kalam (second from left) Chawdhary Shalim (second from right) and Munshi Ali Hasan (far right) continue their conversation outside. 137
Mufti Muhammad Sahazad (centre) chairs a meeting of senior religious figures from Mundali.
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Mufti Muhammad Sahazad is the most senior Muslim religious figure in Mundali, and a focal point among the influencers here. According to him, when the polio-related work began in this area, there was very little public understanding about it, especially among women. “They strongly believed that the vaccine had no benefit”, he recalls. “They thought that it only had ill effects, particularly that it would cause impotence as boy children matured”. He adds, “it was thought that the government was doing exactly what it did long ago to papayas, when a spraying programme led to the fruits’ seeds drastically reducing in number. It was basically seen as a method for reducing population growth among Muslims”. Mufti Sahazad found that bringing an end to this misconception was the biggest challenge that he and his fellow influencers faced. “We imams would work with the CORE-PCI team to organise meetings, where we would try to convince these women that their beliefs about the vaccine were wrong. We also announced a community level fatwa, declaring that there are no ill effects associated with this vaccine, not even weakness”. As it became clear how effective the strategy was, Mufti Sahazad says the shape of the influencer system gradually evolved. “Initially, the Hindu priests were enlisted to convince Hindu families, and imams were enlisted in the Muslim communities. Today, however, influencers are drawn from many different respected roles”. There is apparently no difficulty in recruiting them. “So many people are keen to take up this responsibility, simply because they want to see a healthy India”, he explains.
To most people, a nameless street in small town India; to its local CMC, a street full of names.
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PCIâ€™s CMCs must know who lives behind every door along every lane of their areas. They work hard to build strong human relationships wherever a family has a pregnant female or children aged under five.
CMC Roshina (far right) leads Team A (from left to right: Shamim, Gulshan and Poonam) through the streets of Jansath, near Muzaffarnagar.
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After Booth Day (generally a Sunday), the next stage in the Polio Round involves going door to door in the targeted communities. For the first five days, ‘Team A’ visits each and every household where an under-five lives. The team is led by the local area’s CMC, because she has taken the time to get to know the area’s residents personally. At each house, Team A checks whether the children there have received their doses of the vaccine or not, which they can easily tell owing to the presence or absence of finger markings. Where children have taken up the vaccine, these houses are recorded as ‘P’ category (for ‘polio’) in the CMC’s register and on the outside door to the house (as shown on the next page). Where any child has not taken up the vaccine for any reason (e.g. family refusal or inability to get to the booth that day) or it’s not possible to verify his or her status (e.g. the child is sleeping, sick or otherwise unavailable, or the house is found locked) then the household is placed in ‘X’ category.
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Where families are willing and it wasn’t done on Booth Day, the polio vaccine can be given on the spot. These children’s index fingers are then marked and they are moved to ‘P’ category After lunch, the team returns to those houses where there are children who are still in ‘X’ category. If they were unavailable earlier, the team has another go at reaching them; if their parents are resistant (recorded as ‘XR’ category) for some reason, they try to persuade them to change their minds with the help of an influential person from the area. If the influencer is unable to resolve the issue then the case is referred to the area’s Medical Officer-in-Charge in the hope that he will be able to assert his more senior influence. After Team A’s work has been completed, ‘Team B’ takes over, focusing for two further days on those houses that remain in ‘X’ category. Additional teams target hard-to- reach people (e.g. working on brick fields) and those who are in transit (e.g. at railway stations, melas (fairs) and so on).
Overseen by a WHO observer, vaccinator Gulshan records the polio immunisation status of the children of a Jansath household on their front door.
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CMC Roshina verifies whether Lakshmi’s newborn baby Chotu has received the ‘zero dose’ of polio vaccine.
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CMC Roshina has been working for CORE-PCI in the Jansath area of Muzaffarnagar District since 2005. After completing her Masters in Sociology, she first became a teacher. But it was her personal interest in social work that prompted her to switch professions. Seeing so many young children suffering from polio in her locality, this was the one cause that especially moved her to act. One of the things that Roshina especially likes about working with CORE-PCI is their work culture and the fact that they give regular training sessions to help enhance both their grassroots’ workers knowledge and their capacity to communicate with and convert sceptical and sometimes overtly hostile people. At first, she used to hesitate before speaking to families about immunising their children, especially as resistant householders could sometimes speak very rudely to her. She’s come a long way, as she’s now able to speak openly and with great confidence in situations where she used to be fearful. Roshina says she’s learned not to let initial setbacks weigh her down. “I know that I must keep persevering, gradually building rapport, trust and familiarity”, she says, explaining that she does this by talking about other personal topics until the point where she feels able to try again on the subject of vaccination. Sometimes, she’ll keep working on rapport building to the point where she’s treated as if she’s one of the family. “When I come to such houses, I get welcomed with a big, warm smile!”, she adds.
Poonam gives Lakshmi some further advice before the team move on to the next house.
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Muslim families make up 80% of the local population where Roshina works. She’s found that their main reason for resistance has been the myth that the polio vaccine is a government conspiracy to make young Muslim men impotent so as to stem the community’s population growth. Among those 20% who are Hindu, resistance apparently comes mostly from uneducated families. “These families tend to take their beliefs from their elders”, she explains. And, again, the notion that the vaccine causes impotence crops up here. One of the methods Roshina uses for convincing mothers she finds resistant during her doorto-door rounds is inviting them to mothers’ meetings alongside mothers of immunised children. She then asks the latter to explain the virtues of vaccination to the resistant women. “I don’t just expect them to take my word for it!”, she laughs. Sometimes, she finds that families ask for medicines for other more pressing conditions before they’ll be agreeable for vaccinations. So she takes them to see health workers, who can give them much of what they need. There are also side benefits to this work for the community, Roshina adds. “After gaining the respect of Muslim families”, she elaborates, “many of whom don’t allow their girl children to study, I often ask them to send their girls to school”. Looking at Roshina, someone they regard as an inspiration, many parents decide that they would like to see their daughters grow up to be like her.
Manju mother of Vaibhav (2), takes advantage of CMC Roshinaâ€™s visit to ask a couple of questions.
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Next on the team’s route is Manju’s house. She is mother to Vaibhav, aged two (pictured here), and also has a six-year-old daughter. She says that CMC Roshina visits her regularly and lets her know when polio booths are due to be set up; she also keeps her informed about the various other diseases that must be vaccinated against. From time to time, Manju hosts the mothers’ meetings that Roshina convenes in her house, and she actively participates in these. Here, she learns further details on how to take care of the health of her children. Though her daughter is fully immunised, Manju admits that at one point she refused to allow Vaibhav to be inoculated against diphtheria because the vaccine caused bad swelling in her daughter’s leg. It seems that Roshina has strong powers of persuasion, because she ultimately changed her mind and consented! Today, Roshina and her team have come primarily to see whether Vaibhav was given his polio drops on Booth Day. They do this by checking his hand to see whether his finger has been marked. Roshina then takes advantage of the opportunity to check on the sanitation and hygiene situation in the house. If she had noticed any problem areas, she would have explained to Manju what she needed to do. Manju concedes that she didn’t know much about caring for young children’s health before. After the CMC learned that she’d given birth to her first child, she started visiting and teaching her what to do when certain things happen, such as diarrhoea, colds, fever, etc. It was the CMC who first alerted her to the need to get her children immunised.
CMC Roshina updates the public tally of vaccinations in her area, following completion of Team Aâ€™s work.
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CMC Sushma (wearing the green and red suit), herself a polio survivor, works the streets of Budhana with her good friend CMC Garima.
Sushma K N O W I N G O U R C O M M U N I T I E S
CMCs’ door-to-door work in the community is of course not confined only to Polio Round time; it is constant. You may remember how it took Budhana-based CMC Reshma five to six visits every month over a five-year period to persuade Khurshida’s family to stop resisting immunisations. CORE-PCI’s CMCs are clearly a special breed. Among their ranks, there are even some CMCs who are polio survivors themselves. Sushma, also from Budhana, is one of these, and it was her own situation that inspired her to take up the role. During her childhood, it distressed her greatly that she was unable to run around and play with the other children owing to the disability that had affected her left leg. Later in life, many prospective grooms rejected her while she was looking for a marriage suitor. Ultimately, Sushma did find a man who was willing to accept her for marriage. But when she told him that she wanted to apply for the role of CMC, he initially told her she shouldn’t because she’d have to spend much time walking the back lanes of the area alone. She convinced him, however, arguing that she didn’t want to see other children becoming affected by the same condition that’s debilitated her. When she meets families during her house-tohouse work, Sushma speaks of her own condition frequently. “It’s helped me to convert XR families on numerous occasions”, she says, happy that her condition has actually given her something to be proud about. “When they realised how my polio was helping me on the doorsteps”, she adds, “other CMCs started asking me if I’d join them on their rounds”.
Monsoon rains prove no obstacle to CMCs Sushma (left) and Garima (right), as they come to meet Samima, grandmother of Hanja (2).
O U R C O M M U N I T I E S
CMC Garima Tyagi has been working with CORE-PCI for five years now. When a CMC post became available near her area, she helped arrange an introduction to her BMC for Sushma, who was a good friend of hers. When she realised how effective her friend was at converting resistant families, she asked Sushma to come with her to her area and help with interpersonal communication with XR families. She now joins her around ten to twelve times every month. “When XR families tell me that their children’s health is up to God, I introduce them to Sushma”, Garima says, “and ask her to tell them about how she suffered during her childhood and when she was looking for a groom. She then asks them whether they would be willing to risk their children suffering in this way in the future”. That often clinches it. If there are ten XR cases that she asks Sushma to help her with, Garima tends to find that at least five of these will change their minds after meeting her. “Sushma is my secret weapon!”, she jokes.
K N O W I N G
This was a turning point in Sushma’s life. Earlier, owing to her condition, she used to hide herself away at home and hesitate greatly about showing her face in public. After starting work as a CMC, she developed increasing confidence in herself. As she spoke with people more and more, gradually her communication started to flow. And as she built her self-belief, she also found that she was starting to walk faster than she ever used to. While the average person would take 30 minutes to reach the local primary health centre from her house, she would take an hour; now, she boasts, she can cover the distance in just 15 minutes! “The CORE-PCI family never looked on me as someone with a deformity; they welcomed me with open arms”, Sushma says with a smile. This has helped her to turn on its head a situation in which she used to find it difficult to walk and to tolerate the insults she used to face. “These used to be the areas of my weaknesses; now they are the terrain of my greatest strengths!”, she asserts. When she’s able to help convert XR families in her area as well as those of other CMCs, and also give other health-related assistance, Sushma says she feels very happy. She contrasts this with the days of her childhood, when she remembers that there were hardly any such people who could give such advice to the local population. But she does not dwell on the idea that had things been different then, she may not have contracted polio herself. “At least I’m able to help people in this way today,” she says.
Mothers' meeting Held in each area at least once a month, mothers’ meetings seek to sensitise communities to mother and child health issues. The main objective is to increase acceptance of the polio vaccine and routine immunisation coverage, but other topics such as personal hygiene and sanitation, managing the common cold, cough, fever and diarrhoea and the importance of breastfeeding are also covered. Information is shared through demonstrations, charts, pamphlets, flashcards, mothers’ individual experience sharing, games and personal appeals. It is primarily pregnant females and mothers of under-fives who are invited to these meetings, as these are (or will be) their children’s primary care givers. If these women understand the importance of vaccination, it is believed that they will further persuade other family members and mothers in their vicinities. Others do frequently attend, however, such as both maternal and paternal grandmothers. At times, CORE-PCI’s CMCs and BMCs also conduct fathers’ meetings for the male members of families, in order to brief them about polio vaccination and routine immunisation and persuade them to allow their children to be inoculated. Sometimes, mothers are in agreement but fathers refuse. It is therefore important to pursue each and every family member.
Unable to leave her motherhood duties for too long, Rachana still attends the mothers’ meeting, cradling her infant baby Niveeya as she sits.
K N O W I N G
O U R
C O M M U N I T I E S 159
As her son Sonu (2) plays, Nasim listens attentively to CMC Laxmi, while CMCs Sarita (left) and Usha (right) stand by to assist.
Laxmi, Usha & Sarita
K N O W I N G O U R C O M M U N I T I E S
Laxmi Tomar and the other CMCs who’ve come to lead the mothers’ meeting today work with CORE-PCI in Mundali, near Meerut. “One of the challenges we used to face in this area was that mothers-in-law used to place restrictions on their daughters-in-law for going outside their homes”, she shares. With time, however, she says they’ve managed to convince these women that the meetings are important for the welfare of their children. “Today, the biggest challenge we still face is that women are so busy that they find it difficult to allocate time to come”, Laxmi adds, explaining that not only are they wives and mothers, but many are engaged in home-based family handicraft businesses as well. For this reason, the CMCs make it clear that it’s perfectly fine to come with a child in tow if need be. According to CMC Usha Tomar, today’s meeting was principally about diarrhoea management. “We explained that diarrhoea cases increase during the monsoon season”, she says. “We then told the mothers that the first step in dealing with a case should be the home preparation of oral rehydration solution (ORS) - and we explained how to do this - followed by taking a zinc tablet”. Usha’s primary motivation in becoming a CMC was to make a contribution to her country, and she felt that she was best placed to do this through social work. Before joining, she wasn’t very confident in public speaking. This role has helped her build her confidence and capacity. “Today, I have the confidence to talk with anyone in my area about immunisation”, she asserts. “I actually don’t think there’s a single person I couldn’t convince on this subject!”. CMC Sarita Tomar assists her colleagues in convening mothers’ meetings, and finds they work especially well when they operate as a team. “I feel really proud that this team of ours has helped to create a polio-free India”, she says.
Rajni “I’ve been to seven or eight of these meetings so far”, says Rajni, who clearly likes to learn as much from them as she can. “Though I didn’t have a problem with polio drops, I didn’t like the idea of vaccinating with needles for the other diseases. In the third meeting I came to, one of the CMCs showed me a pamphlet with pictures of what children affected by these different diseases look like”. These frightened her, she admits, grimacing. “The one of a kid with bone tuberculosis affected me really badly, and I got scared that my little boy could end up like that”. Since getting him vaccinated, Rajni has told the rest of her family and also her neighbours about these diseases and how dangerous they are, and insisted that they too should vaccinate their children. “I’m happy because they all agreed”, she adds.
Rajni (wearing the orange saree) makes absolutely sure she’s understood the CMC’s point, while (from left to right) Seema, Bimla, Sunita and Nasim listen carefully.
K N O W I N G
O U R
C O M M U N I T I E S 163
A health camp draws a large, enthusiastic crowd in the village of Sambhalhera, Muzaffarnagar District.
H E A L T H A N D I M M U N I S A T I O N
Routine immunisation and general health camps form an integral part of CORE-PCIâ€™s multipronged polio eradication strategy. This section shows how this apparent diversification helps.
C A M P S 165
Anu In mid-2010, Anu became the first CMC to be appointed in Sambhalhera, a small village close to Jansath in Muzaffarnagar District. “A lot of the families in this area were resistant to vaccinations at that time”, she reports. Soon after starting work here, she arranged for health camps to be held at periodic intervals. With the arrival of these camps, Anu says that the villagers saw that doctors were coming and giving them access to medicines free of cost. “They felt that an effort was being made to make a positive difference for their health”. She adds that people would feel attracted towards the camp, owing to the big tent that would be erected and its beautiful decorations. In other words, the team was capitalising on the basic human tendency to be seduced by appearance and the belief that there was something in this for them. “In order to avail the free medicines they desired”, Anu goes on, “they would bring their children with them, as we’d requested”. She and other CMCs would then be on hand at a stall of their own to encourage participants to take up polio and routine immunisations. “Having been made happy by what they’d been given, we found that many were more amenable to accepting our explanations of the benefits of vaccination”, Anu reveals. Interestingly, she adds that when doctors and others come from places further afield, such as Delhi, to give their assistance, this often influences people further. “They assume that nobody would travel so far if it wasn’t for something important”.
H E A L T H A N D I M M U N I S A T I O N C A M P S Flanked by five of her colleagues, CMC Anu explains the importance of routine immunisation to a visitor at the health camp. 167
Charul Maurya Since completing her medical studies, Dr Charul Maurya has been working as a government general practitioner in the village of Mirapur, Muzaffarnagar District. She attends health camps like this one roughly once a month. “These camps are open to people with all kinds of medical issues”, she explains, adding that they also help to inculcate awareness about related issues, such as sanitation. Doctors like her are supported by auxiliary nurse-cum-midwives (ANMs), CMCs, Accredited Social Health Activists (ASHAs) and anganwadi workers (who serve as motivators, encouraging people to attend), pharmacists (who provide medicines), technicians (who give blood tests) and vaccinators (both for children and for ante-natal cases). Charul observes that these camps have had a significant impact in the areas in which COREPCI works. “Generally”, she says, “the people living in these areas weren’t previously very wellversed in health matters”. But over the time, the participating doctors have noticed a clear decrease in instances of diseases around where the camps have been held, in addition to related changes such as increased numbers of women choosing to deliver their babies in hospitals rather than at home.
Dr Charul Maurya writes out prescriptions at the health camp.
H E A L T H A N D I M M U N I S A T I O N C A M P S
A N D I M M U N I S A T I O N C A M P S
Saroj is an anganwadi worker. The word ‘anganwadi’ means ‘courtyard shelter’ in Hindi. First established by the Indian government in 1975, these were intended to provide basic maternal and child healthcare. In this capacity, Saroj is mostly responsible for immunising pregnant women and newborns. She also weighs babies immediately after birth and assists with home-based deliveries. Saroj confirms that there used to be many XR families in Sambhalhera. However, she states that there are no longer any such families resisting polio vaccination, though there are some who continue to refuse routine immunisation. “These health camps help a lot”, she says, “because they ensure that people in out-of-the-way areas like this are far more aware about basic health issues than they used to be”. Another change Saroj says she’s observed is that fewer people are coming to the camps simply because they want free medicines to treat existing conditions. “They’re also coming because they want their health and the health of their children to be better in general”, she asserts.
H E A L T H
Under the watchful eyes of her fellow anganwadi workers, Saroj Bala carefully weighs a newborn baby at the health camp. 171
The teachersâ€™ stall at the health camp is a hit with Sambhalheraâ€™s children.
A N D I M M U N I S A T I O N C A M P S
The health camp also includes a stall manned by teachers. Laxmisharan, a teacher at Sambhalhera’s primary school, explains that they are there to encourage visitors to send their children for schooling. “As you can see”, he says, pointing to the table, “our stall has many different textbooks that children and their parents can look through to help them understand what they could learn at school”. Once a child is admitted in a government school, these materials as well as a uniform, bag and scholarship money are provided free of cost by the government. “CORE-PCI asked us to contribute to the camp on the basis that health and education are two interlinked development areas”, Laxmisharan goes on to explain. The logic, he reveals, is that with a decent standard of education, it’s thought that people are more likely to know how to ensure high standards of health; likewise, a healthy child will be capable of attending school and studying well. Of course, CORE-PCI’s Masti ki Kaksha classes are conducted in schools, so those children who are able to attend will be far better educated on the importance of sanitation, means of ensuring good health and so on, all of which are part of the effort to eradicate polio.
H E A L T H
Local NGO director Satendar Kumar (left) and Muzaffarnagar DMC Dushyant Kumar (right) discuss progress at the Sambhalhera health camp.
A N D I M M U N I S A T I O N C A M P S
Satendar Kumar runs a local NGO based out of Muzaffarnagar named Grameen Parivartan Vikas Sansthan Samelan. The organisation works on a wide range of community welfare issues, including health, education, female foeticide / infanticide and the environment. Prior to setting up this organisation, Satendar worked with CORE-PCI as a CMC for five years. “My interest in social work dates back to when I was in the 8th Standard at school”, he recalls. After he set up his NGO, it remained unregistered for some time. Then he joined CORE-PCI, and while working with them he gained recognition for his own work. Ultimately, he felt he had the confidence to register the organisation officially, and left CORE-PCI to concentrate squarely on this. Satendar’s organisation supports CORE-PCI in raising awareness about routine immunisation, as it is doing at the health camp today, and also assists with arranging meetings of community influencers.
H E A L T H
Amir (1) proves heâ€™s a brave little boy as ANM Sudha Singh brings his vaccinations up to date.
A N D I M M U N I S A T I O N C A M P S
CORE-PCI and their partners recognise that it’s important to increase not only the numbers of children receiving polio vaccinations but also of those who’re given the broad range of childhood vaccinations. In addition to the oral polio vaccine (OPV), these include BCG (for tuberculosis), DPT (for diphtheria, pertussis (whooping cough) and tetanus), measles, hepatitis and vitamin A. The reason for promoting the uptake of all these vaccinations during ‘routine immunisation’ drives is that children’s basic immunity needs to be maximised if they’re to be expected to fight the polio virus if exposed to it; OPV may not be enough alone. If just one case of polio is detected in which the symptom of weakness in the limbs can be observed, it is likely that the virus will have entered the intestines of between 300 and 500 other children. In such a situation, those children with low basic immunity levels would be the most susceptible.
H E A L T H
Arteshyam (2) gets his ‘two drops of life’.
H E A L T H A N D I M M U N I S A T I O N
Plentiful stocks of the polio vaccine are always available at both health and routine immunisation camps.
C A M P S 179
S A N I T A T I O N
Pradhan of Matawali Vinod Kumar Sharma chairs a Village Health, Nutrition and Sanitation Committee (VHNSC) meeting. 181
Vinod Kumar Sharma
S A N I T A T I O N
Pradhan Vinod Kumar Sharma gives careful consideration during the VHNSC meeting.
Gram pradhans are elected by the local population to, among other things, oversee local development. Vinod has so far served the first two years of his five-year term as pradhan of the village of Matawali, near Moradabad. He explains that it’s his responsibility to ensure that the benefits of various different government schemes reach individual villagers. The Village Health, Nutrition and Sanitation Committee (VHNSC), pictured on the previous page, meets at least once in a month. It is chaired by the pradhan, and four of its members are elected, while up to eight may be nominated based on recognition of their socially-minded natures. ASHA and anganwadi workers, CMCs and ANMs can also serve. Discussion focuses on the current state of the village across the three focus areas of health, nutrition and sanitation, and strategies are formulated to overcome whatever challenges the village may be facing at the time. It’s able to draw on a ` 10,000 fund given annually by the government in order to address the issues it identifies, as well as strategic assistance from CORE-PCI. According to Vinod, the major recurring problem that Matawali faces is waterlogging, as there this place lacks a proper drainage system. There is no suitably sized drain outside the village capable of carrying the village’s wastewater either. One potential solution discussed by the committee is that wastewater could be directed to a pond that lies about 0.5 km outside Matawali. “I have approached the government for funds for this”, Vinod says. “If they don’t agree then we’ll take it upon ourselves to dig a channel to the pond ourselves once the monsoon’s passed”.
Murti Murti is a street cleaner in Matawali. She says the village used to be an extremely dirty place. The lanes were clogged with filth and there was severe waterlogging, making them a breeding ground for mosquitoes and germs. Today, the situation is far better than it used to be. Thanks to the training sessions convened by the Area Development Officer (ADO) and Block Development Officer (BDO) that she and her colleagues regularly attend, she understands how essential it is to maintain high standards of sanitation so as to ensure that germs and diseases have less chance of spreading. Murti stresses that itâ€™s helped that the villagers now understand the importance of keeping their surroundings clean more than they used to, thanks to CORE-PCIâ€™s sanitation drives, and are being supportive in their own ways.
S A N I T A T I O N Street cleaner Murti at work in the lanes of Matawali. 185
Working as a team, Sanjeev (left) and Ramesh (right) tackle areas of stagnant water in Matawali.
Sanjeev & Ramesh
S A N I T A T I O N
Sanjeev Kumar and his maternal uncle Ramesh live and work together as street cleaners. It’s clear to them that sanitation is directly linked with health, and that if there’s waterlogging and no proper garbage disposal – as used to be the case in Matawali – then the conditions will be ripe for many diseases to spread. In addition to what they hear at the meetings convened by the ADOs and BDOs, they say their local ASHA workers and CMCs regularly drive home this message. With health and sanitation being such topics of concern, both men know that they play an important role in their village. They feel that it is in part thanks to their hard work that polio and malaria cases have reduced in Matawali in recent times. “We’ve seen various cases of diseases that come from poor sanitation and waterlogging here in the past”, says Ramesh. “I remember polio, TB and malaria cases clearly”. But Sanjeev chimes in to say that nowadays, more people are using toilets in their homes and fewer are defecating outside. “This has helped a lot”, he stresses. “We can’t do it all alone!” Ramesh, nodding, also points out that there’s far greater awareness of the need to kill germs through hand washing before eating, and that this is surely contributing to the fact that there are fewer such health issues in the village now. Ramesh and Sanjeev also talk with their area’s BMC and CMCs at least once in a month. This gives them the opportunity to discuss the current sanitation situation and the challenges they’re grappling with as they action their Village Cleanliness Plan. They say that this plan, which was first devised four years back, helps them keep their work systematic.
CMC Reshma hammers into place a plaque honouring a Budhana householdâ€™s commitment to high sanitation standards and the use of a home toilet.
S A N I T A T I O N
These plaques are given to those households where CMCs judge that their toilets have been constructed according to good standards of sanitation, where no family member is defecating outdoors and where other hygiene rules are also being followed. The plaque mentions the name of the head of the household and his or her address. A new toilet costs upwards of ` 2,500 to construct, but CMCs make households aware that they have to pay only the first ` 500 of this, and that they can get the assistance of the Block Development Office (BDO), a government department, in obtaining the rest of the money. The idea behind displaying these plaques is that they give families prestige, showing those that live nearby that their household has passed a test of its hygiene standards. Passers-by see the plaques and feel motivated to do what it takes for plaques to be displayed on their walls, too. This scheme is being rolled out gradually across different blocks. In Budhana block, where this image was captured, 55% of the households have been judged to be using toilets that pass the good sanitation test and have no members defecating outdoors. Older members of households are often harder to convert, as outdoor defecation is the habit of a lifetime for many of them. But CORE-PCI’s fieldworkers feel confident that it won’t be long before 100% of the households in the areas in which they’re working are following sanitary procedures.
Subhash Kumar By day, Subhash Kumar is a tailor; by night, he’s one of CORE-PCI’s transit workers. He’s served as a railway station transit vaccinator for the past six years. India’s railway stations are well-known for being places where one of the worst manifestations of the scourge of polio can be seen: people who’ve resorted to begging because they can secure no other means of earning a living. In this image, Subhash is giving polio drops to twoyear-old Minakshi at Moradabad Railway Station, shortly after her family stepped off a train from Rewari in Haryana. This is part of CORE-PCI’s strategy of ensuring that no child slips through the net. Because the family was travelling, they weren’t in town during Booth Day, and consequently Minakshi missed out on her allimportant dose. Subhash knows how crucial his role is. “Without us transit vaccinators, it would be possible for the virus to spread more readily between districts”, he explains.
Baby Minakshi’s mother is called Baby. Though they’re from Moradabad, she says they spent the last year 250 km away in Rewari, where they now live. “It’s a good thing that we bumped into this man as we were leaving the station!”, she says. “I’m glad Minakshi got to have her drops”, she adds. “Immunisation is so importance”. This incident reminds Baby that Minakshi also has some other vaccinations pending, according to the card given to her by her government health worker. It gives her the opportunity to ask Subhash what she ought to do, as she’s carrying a vaccination card from Moradabad which is not accepted in Rewari. He explains that she could get a new card there and have the details of vaccinations received to date transferred across.
R E A C H I N G T H E H A R D - T O - R E A C H Transit vaccinator Subhash Kumar ensures Babyâ€™s daughter Minakshi (2) doesnâ€™t slip through the net at Moradabad Railway Station. 191
Barber Muhammad Iqbal, an invaluable influencer among Sheikhpuraâ€™s migratory population, hard at work.
Muhammad Iqbal R E A C H I N G T H E H A R D - T O - R E A C H
Muhammad Iqbal is a barber. His small shop sits right next to the field where what CORE-PCI calls ‘Sheikhpura transit camp’ (a slum, to all intents and purposes) is situated. Careful attention has to be paid to the camp’s inhabitants because they are so transitory, meaning children can easily be missed at polio round time as their families move on. Iqbal has been helping CORE-PCI’s grassroots workers as an influencer here for many years. The field staff never actually have to approach him for assistance; rather, he takes it upon himself to come to them to see if they need his help. “There used to be a lot of cases of polio over here, but the vaccine has made a huge difference”, Iqbal reports. He remembers the last case the area saw. “It was in a nomadic family that had come from Loni, on the outskirts of Delhi. The family then moved on to Lucknow, but because the polio team had been tracking them well, they caught up with them there”. Iqbal says that convincing these families used to pose quite a challenge. “People would believe either that the polio vaccine would cause impotence, or simply that it would make their children feverish and give them diarrhoea:, he explains. “Once, when a health camp was organised, these people got angry because they thought that all the health workers wanted to do was give their children polio drops, which they’d insisted they didn’t want. In their anger, they demolished the camp”. Another issue faced was that people would argue that the government ought to look after them in other ways, such as by providing them with housing, before expecting them to take the vaccine. Owing to the strength of feeling, Iqbal says he keeps a big cane in his hand as he walks around the slum, asking people to vaccinate their children. When someone refuses, he’s willing to issue a strongly-worded rebuke, waving the cane in the air menacingly. It seems to work!
CMC Asha goes through the vaccination record card of Sunitaâ€˜s baby Satish (1), while his sisters Shivani (5, left) and Khushboo (3, right) listen in with interest.
H A R D - T O - R E A C H
When CMC Asha initially came to see these families, people would ask for a share of the money they assumed the government had given her for vaccinating their children. It took time to make them understand that she didn’t have access to hard cash; to begin with, they’d insult and throw stones at her when she said she couldn’t pay. As she returned over time, she’d meet less aggression thanks to the intervention of Iqbal and the owner of the land, Intezar, but the women would hide their children under their skirts. With repeated visits over a long period, she began to convince them to be receptive. “My strategy has been to make certain friends in the camp”, she explains. “When I face resistant families, I call on them”. Now she’s built her own identity in the community and people recognise her not by the name of her parents but as ‘CMC Asha’.
T H E
R E A C H I N G
Sunita and her family are frequently on the move. Like the other inhabitants of Sheikhpura transit camp near Muzzafarnagar, they keep travelling back and forth between here and other cities, such as Meerut, Loni and Lucknow, in search of whatever work they can find. During this stay, which has lasted for two months so far, Sunita’s husband has been earning from rag picking and begging. Though she has three small children, she has also been collecting scrap iron from rubbish heaps to sell. Of the members of her nomadic group, field staff find Sunita to be the most cooperative in their work, as she’s never refused polio drops or routine immunisation for her children. Indeed, when vaccination sessions are organised, she’s often the first person waiting in line with one-year-old Satish. She lost a son at a very early age after he got an infection that could have been prevented if only he’d had a tetanus shot. She’s learned the hard way.
Kashmira Kashmira and her husband are from Calcutta. Their work involves collecting scrap, particularly polythene bags, and selling this to scrap dealers. They have four children: two boys and two girls. The family has been living in Moradabad for the past ten years, but they return to Calcutta once or twice a year for extended periods. For this reason, the local CMC has to pay close attention to ensure that no vaccinations are missed during the periods that they’re away. Kashmira says that her CMC visits her at home at least once every month or two. Often, she’s away from home from the whole day owing to her work, so the frequency depends on this. “My CMC has taught me that it’s really important for me to pay regular attention to the vaccination cards she’s given me for my children, and to keep their inoculations up to date”, Kashmira says. “I know what could happen to them if they contract any of these diseases, and it’s not nice”. She then proceeds to describe the sort of disability that polio causes vividly. “I want to look after my children well”, she adds, “so that they will never catch any of these diseases”.
Kashmira, a frequently mobile low income mother of four, attends to her cooking.
R E A C H I N G T H E H A R D - T O - R E A C H 197
Jahangir (left) and his brother Mintu (right) sort through scrap at their home in Gulshan Nagar, Moradabad.
Jahangir R E A C H I N G T H E H A R D - T O - R E A C H
Jahangir and his three brothers earn a living off scrap. They scavenge for it, separate out the useful components and sell it on. They live and work in some of the most challenging conditions for CORE-PCI as they seeks to drive up sanitation standards in their focus areas. These men’s slum home is subject to frequent flooding during the monsoon months, which creates conditions ripe for the spreading of disease-causing germs, particularly due to the fact that their area is stacked high with bags of discarded bones, horns and other items that they’ve scavenged. Every year the whole family goes back to Calcutta, where they’re from, for about a month during the Muslim festival of Muharram. This poses its own challenges, as the local CMC seeks to ensure that all children’s vaccinations are given in a timely manner. Jahangir and his wife Sharifa have six children, two sons and four daughters. They’re aged between five months and seven years. In spite of the family’s regular travel, their CMC has been successful in ensuring that most of the couple’s children have been vaccinated against polio and other diseases. The CMC also frequently suggests ways for the family to improve the sanitation and hygiene standards where they live. Jahangir protests that their work makes it very difficult for them to be hygienic all the time, though at home he feels that Sharifa maintains good standards of cleanliness.
T H E H A R D - T O - R E A C H
Nasreen Parveen comes from the town of Muzaffarpur in Bihar. Her small boy Muhammad Armish, is a year and a half old. Nasreenâ€™s husband is the accountant at these brick kilns, situated in the countryside outside Moradabad. While their family lives on site throughout the year, the labourers are much more transitory. Most come from outside the district; many even come from other states, as far afield as Punjab and West Bengal. In the district of Moradabad alone, there are around 150 sites like this, each hosting approximately 50 to 60 workers of both genders. CORE-PCIâ€™s team needs to keep a careful tab on these people and their children, owing to their frequent moves in and out of the area. During the monsoon, for example, the work at the brick kilns halts and those that work at them generally return to their native places. This poses formidable challenges, which the field teams have become well used to meeting. Every three to four days, grassroots workers return to each site to enquire as to whether any new family has come, and they provide vaccinations and update their registers accordingly. Extra concerted efforts are made at Polio Round time to ensure that all children are accounted for.
R E A C H I N G
Nasreen and her son Armish (1) at a brick kiln site, which hosts many migrant labourers. 201
This publication was made possible with the generous support of the American people through the United States Agency for International Development (USAID). The contents are the responsibility of the authors and do not necessarily reflect the views of USAID or the United States government.
All images and text in this book ÂŠ Robin Wyatt and PCI India 2013. No reproduction without permission. For more information, please visit www.robinwyatt.org/photography and www.pciindia.org.