Q. Dr. Jacob John in his recent thought provoking editorial(1) raised some important issues regarding polio eradication in the context of Acute Flaccid Paralysis (AFP) Surveillance. AFP Surveillance undoubtedly needs adequate virological investigation
besides adequate immunization. He has also rightly inferred the Indian
Polio Vaccination fiasco(2). A careful review of both articles indicates
the basic problem of accepting the responsibility (which is the hallmark
of intellectual independence). It is at this point the policies of
bureaucrats and "Ministry regularly fails; the fundamental fault with
government policies is their tar- get oriented approach. Such approach
descends down from top beuroucrats to the ultimate government servants who are supposed to implement the measures. These employees are now given a fixed target to achieve annually. The priority then is to achieve these targets on paper rather than actually providing correct data including shortcomings. of any programme or approach.
Such target oriented approach which has previously destroyed the Maternal and Child Health (MCH) component and the Family Planning Program was appropriately diagnosed to have
"Targetitis"(3). On the other hand pulse polio is and will continue to be h major success because it incorporates private sector skills put in by honest, dedicated and naive volunteers who are not bothered to achieve a particular target so as to glamourise their annual confidential report or so as to gain something in terms of promotion, transfer, etc.
A similar situation occurred" with routine polio immunization where targets were
achieved on paper but the situation remained dusky as proper cold chain
maintenance cannot be measured by the number of OPV doses.
So if the dream of an India free from polio virus and from the many viruses of apathy, corruption and
diffidence(1) is to be turned into reality, we all should try our best so that polio eradication programme is not transformed into "Targetoma".
I also kindly request Prof. Dr. Jacob John to explain the salient features which had made the. small pox surveillance pro- gram a success and why such measures can't be applied to AFP Surveillance?
Consultant Child Specialist,
Kota 324 005,
John TJ. India's polio eradication efforts at cross road. Indian Pediatr 1998; 35: 307- 310.
John TJ. Reply. hrimunogenic response to Hepatitis B vaccine in Indian infants.
Indian Pediatr 1998; 35:376-377.
Ghosh S. A paradigm shift-A new approach to National Family Welfare Program. "Indian Pediatr 1997; 34: 41-46.
Dr. Goyal has raised some very important issues regarding the health status of the surveillance component of India's polio eradication efforts. He is apprehensive about the modus operandi of AFP surveillance, particularly in its target oriented design. He
suggests that a target fixation by the staff play lead to a situation in
which the achievement of target becomes the objective of a program and not the envisioned "end result of the. program itself. The term 'targetitis' was coined by Prof. Shanti Ghosh to draw
attention to this aberration. Dr. Goyal wants the polio eradication efforts to succeed, and not to suffer from failure on account of faulty surveillance. He makes a subtle difference between the target fixation and the ultimate failure of the program on account of this design problem. The failed outcome is denoted by the diagnosis of targetitis. The target fixation itself is called 'targetoma'
by him. Personally I do not see much value in using either term, but the caution that we must not fail, on account of inadequate surveillance, to eradicate polio and convincingly document its success, must be taken extremely seriously.
Dr. Goyal states that in the program of 'routine' polio immunization,
targets had been reached but the problem of polio remained. He thinks that the targets were reached only on paper (meaning records
and reports). He also says that the quality of vaccine cannot be assessed by the immunization coverage targets. Goyal is articulating the perception of innumerable health care workers that something had gone awfully wrong with polio control by immunization and he is cautioning us to carefully examine targets, target orientation, target fixation and achievement of targets in truth and on paper. This is very important in view of our commitment to eradicate polio
by the year
for which the time left is
short and also in view of the huge investments we and our donors are
committing. Let me declare that his cry and my response are not to be taken .as adverse criticism of anyone or any method. In truth they must be taken as a friendly but anxious request, from members of lAP who have pledged our unstinting support for polio eradication, to the leaders of this truly greatest public health program ever, not to let us down in the eyes of the world and in our own self esteem.
Is fixing targets for projects and pro- grams inappropriate? Any management expert will tell us that targets are very important for any venture. Target to a program is the equivalent of destination to a journey. If the target had not been identified, how will the workers and program managers know how near or far they are to achievement? However, we must clearly understand what the management pundits understand by target before we apply a tar- get orientation to our programs. It takes
hours by bus to travel from Vellore to Chennai. The direction is east-north-east. If I send a messenger with the instruction to travel 3 hours by bus, he may think that the target was to do just that and end up in Tirupathy instead of Chennai. If he knew to take a bus which travelled east-north-east, and got out after 3 hours of journey, he might have reached somewhere in Chennai but he must now check it out. If the bus had travelled at an average speed lower than usual, he would not have reached the destination. The messenger should know the real target of journey as Chennai and that the vehicle is the bus and the travel time is 3 hours. He must check all three parameters to make sure that he reaches target on time. If I had not given him further instructions as to why he is being sent to Chennai, he may return from Chennai and report that the target has been reached. The job in Chennai is the objective or the outcome intended to be achieved by the travel by the messenger; the target of the bus travel was Chennai. The purpose of the journey is equivalent to the objective of the project. The travel or the target is a parameter of in- puts
to be assessed by checking arrival at destination or by achieving
coverage level of 85%. The job at the destination or the objective of the project is the parameter of output or outcome,
to be evaluated by the degree of success of the job or the degree of decline in incidence of polio. What went wrong was that only the inputs
were assessed but not the outcome.
In summary, under the DIP, OPV was routinely given according to the EPI schedule.
The Ministry of Health claims that for 5 successive years the coverage
levels among infants was over 90%. The stated target was only 85%. Thus
we exceeded the target, but polio continued to occur, more frequently in
unvaccinated children but disconcertingly often in vaccinated children also.
Goyal's point is that the immunization coverage target was achieved out the
problem of polio was not solved. Without establishing a basic surveillance system, the outcome or the actual decline of polio could not be measured; therein lies the fundamental error. The DIP managers did not realize that 85% coverage with 3 doses of OPV was not achieving the expected outcome (90 to 99% fall in incidence), because of the target fixation.
They had the responsibility to examine whether the target had been achieved in truth or only paper. If target had really been achieved then they had to re-examine the sufficiency of the target. They would have immediately realized that even 90% coverage with 3 doses was not enough to control polio. If some 30% or more of cases were in completely vaccinated (with 3 doses) children, obviously the number of doses had to be increased to the recommended 5 in first year and 2 more later. That would have been easy enough to do since the fifth contact in infancy is for measles vaccine' and there are 2 booster contacts beyond infancy and each time a dose could have been offered. In addition the quality of vaccine had to be monitored on a continuous basis and I must compliment them for doing this in several states. In short, without sufficient outcome evaluation we did not know that we were failing in controlling polio, for nearly 2 decades. The gurus of management would call this wasted resources.
The smallpox surveillance was indeed successful for it guided the smallpox vaccination tactics and also documented its de- cline unto zero. However, when the eradication efforts were wound up, the surveillance system also went with it. That was because the surveillance was part of eradication,
managed under the eradication activities and not the other way around. Had eradication been under the surveillance
program, it would have survived and grown even after smallpox was finished. In the case of polio eradication also, the surveillance
is under the eradication management. Surveillance is not guiding immunization tactics, but following pulse immunization.
For example, pulse started in December 1995, but surveillance in October
1997. The surveillance establishment is ad hoc, solely to monitor polio
eradication and outside the traditional health care management
activities. It is even outside the Department of Health. I am sure that eventually the AFP
surveillance system will become excellent enough to achieve and document polio eradication, just as the smallpox surveillance was excellent enough for its eradication, but my worry is that history might repeat and the surveillance system might disappear along with the discontinuation of polio eradication efforts once polio is really and truly eradicated and certified by the International
Commission. Obviously the. WHO wants India to eradicate polio on schedule and I than God for their insistence and persistence, for without these, we might have continued to drag our feet.
What does the Ministry of Health want? Simply polio eradication or the
building of expertise and infrastructure based on the lessons being
learned through the planning, executing, achieving and evaluating polio eradication? If the former, the current international leadership will achieve it. If the latter, we need to soul search and do it now.
T. Jacob John,
Indian Academy of Pediatrics
2/91 E-2, Kamalakshipuram,
Vellore, Tamil Nadu - 632 002,