Neeraj Jain is Chief Executive Officer of WaterAid in India.
India's polio-free declaration is good news by any measure, a public health victory at a time when polio is grabbing headlines with its terrible resurgence among Syrian refugees, and its stubborn tenacity in Afghanistan, Pakistan, and Nigeria. The head of WHO’s polio eradication programme, Bruce Aylward, called it the one thing that everyone said could never be done.
As recently as 2009, India reported 762 cases of polio, more than any other country in the world. To combat this, an army of 2.3 million health-care workers reached out to some 170 million children with polio vaccine – including children in flooded regions and remote villages who might not have ever seen a nurse.
This massive immunisation drive takes most of the credit. But there is another factor at play, one which makes immunisation more effective, and which threatens future successes without further progress and development. Clean, safe drinking water and good sanitation are key to fighting the spread of polio. Poliomyelitis is transmitted through human waste. Where sanitation and hygiene are good, the disease can be more easily kept in check. But it can flourish in crowded and dirty conditions like urban slums or refugee camps.
Out of India’s population of 1.2 billion, 780 million people do not have a proper toilet, and another 96 million do not have access to safe drinking water. In rural areas, nearly 7 in 10 people still practised open defecation in 2010. Multiple studies have shown that oral polio vaccines are much less effective when a child is suffering from infection and diarrhoea. Studies led by Imperial College, London, UK in 2006 and 2007 in Uttar Pradesh and Bihar found that it was difficult to eliminate polio in crowded areas with poor sanitation. In the absence of toilets, live polio virus – which is excreted in faeces – continued to spread despite attempts to stamp it out with immunisation. Researchers also found children in these areas struggled to respond properly to the oral vaccine.
The effort to wipe out polio meant that children in some parts of India have received as many as 30 doses of oral vaccine before their fifth birthday. “This is an incredible achievement and they should rightly be celebrated. But it took a lot of doses of vaccine to get there,” said Nicholas Grassly, the Imperial College epidemiologist who co-authored the study. “It’s also important to create an environment where the vaccines will work better.” Water and sanitation improvements are vital components. In 2012, WaterAid India helped more than 450,000 people get safe drinking water and nearly 300,000 get toilets, but there is a long way still to go. India’s prime minister, Manmohan Singh, acknowledged this 2 years ago in calling for safe drinking water and proper sanitation for India’s children, to prevent and control the spread of disease.
Despite India’s incredible progress in eradicating polio, we know that the elimination of this transmissible disease is fragile as long as children and adults must relieve themselves in slum streets and on railway tracks. We can help ensure that this terrible disease does not return by tackling the insidious way it spreads – by addressing poor handwashing, bad sanitation, and an unsafe water supply. Only by putting this basic but vital infrastructure in place can we make sure that Ruksha remains India’s last victim of this deadly disease.