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  3. Thursday, 03 February 2000
Post0225 OPINION III 3 February 2000 CONTENTS 1. NIDS AND ROUTINE EPI: RESPONSE TO COMMENTS IN POST0220 OPINION PART II 2. PROGRAM INTEGRATION: A RESPONSE TO COMMENTS IN POST0220 OPINION PART II 1. NIDS AND ROUTINE EPI: RESPONSE TO COMMENTS IN POST0220 OPINION PART II In TECHNET Post0191, Robert Steinglass, BASICS, in an opinion piece, discussed the relationship between the accelerated polio eradication effort and the routine expanded program on immunization (EPI). Robert originally presented his views at the Global Consultation on Progress towards the Eradication of Poliomyelitis, WHO/Geneva, 2 - 3 June 1999. Anthony Battersby, FBA Analysts, agreeing with Robert's concerns, responded in TECHNET Post0220, 24 January 2000. This response generated some heated messages from Michel Zaffran and Hans Everts at WHO/V&B. The moderator offered all participants the opportunity to consider their messages. The 3 messages that follow have been revised. * Email your own comments and field experiences in this important area to the TECHNET Forum. Action, comments and additions please: [][/email] or use your reply button ___________________________________________________________________________ Date: Mon, 31 Jan 2000 12:19:16 -0500 From: "Robert Steinglass" To: [][/email], [][/email] Subject: NIDs and routine Dear Allan: My intention was to encourage some reflection and constructive debate. The rhetoric on all "sides" needs to be turned way down; and, yes, polio of course needs to be eradicated as soon as possible. I do hope that people will be encouraged to express their views in a constructive manner and that TECHNET can be a venue for that to happen with openness but also with civility. There are serious issues out there which warrant serious discussion. I believe that it is essential that TECHNET Forum readers remain engaged in these discussions, as TECHNET members and the wider readership of the Forum represent a unique body of expertise. Polio eradication presents many opportunities (but which are not always realized) from which we must learn. However, I think we must also guard against missed opportunities - - areas which need attention in addition to polio (which I mentioned in the earlier piece). And in addition to polio eradication which absorbs so much energy, there are now important new opportunities and alliances taking shape. One such new opportunity - - GAVI and the Global Fund for Childen's Vaccine - - is not likely to come again. I hope we can seize it to attend to the full array of financial, technical and supply needs. Not only new vaccines, but also some hardware needs, and even more importantly some of the "software" needs (i.e., training, management, IEC, active monitoring, etc.) which have received insufficient attention during the 1990's.. Robert ___________________________________________________________________________ From: [][/email] Date: Tue, 25 Jan 2000 07:21:16 +0100 To: Cc: , Subject: Re: Post0220 OPINION PART II Anthony, I was disturbed and offended by your comments in TECHNET Forum Post0220 on 24 January 2000. This time I thought that I had to respond. You said that " The malaise for EPI seems to start at WHO HQ where the systematic dismemberment of the service appears to continue. " There has been no dismemberment of EPI to my knowledge, and I still work in the department. Time are changing and WHO is changing, EPI is changing and people are changing. Some have decided to move along. Structures are being changed and not just for the fun of changing but because there was a need to be streamlined to facilitate the work of the EPI and to address new challenges. We may not have explained these changes well enough to you and others outside the building, and some of the people who have had to change from within may not have been very good advocates. This is granted! Please grant us also the benefit of the doubt that we are not fools playing around with ideas and people. Our new structure and strategic plan however complex it may seem is trying to address the challenges of the new decade in Innovation, Immunization Systems and Accelerated Disease Control. After a careful review and consultation with a broad range of partners outside of the EPI, we have set three priority projects out of our 9 focused targets: Accelerated vaccine introduction, Immunization Safety and Polio eradication. We have put these to the top of our Agenda. The weakness of immunization systems in many countries is of great concern to us and, although some key staff have chosen to move to other areas, we are putting the necessary resources in to strengthen this field. But good people, as you know, are not easy to find.... The establishment of the Global Alliance for Vaccines and Immunization (GAVI) is another major challenge for us but it is also the potential rebirth of the EPI. A new sustainable EPI built on the framework established in the past and supported through the GAVI.. Times change! This is where we will have a chance to see the unambiguous support for routine immunization that we have been calling for all these years. While the frustrations expressed in the un-attributed quotation "Polio is driving us crazy and everything else is neglected." have some reality, even the most forceful opponents (and the proponents) of Polio eradication now agree that, at this point of time, having come so close, we must get the job done, do it fast, and get on with something else. While Robert's comments in Post0191 are substantial and serious, and are taken as such by all of us, they were not destructive and derogatory, they call upon us to think more and further. Your comments about polio eradication are not helpful and are derogatory to the all the people across the world who spend long hours and put all their energy into this. We should all support all our colleagues in the field. We are all committed to the success and sustainability of the EPI. Let us eradicate Polio! Let us use the lessons learnt, the momentum, the human resources and the frustrations that Polio Eradication activity has revealed, to establish GAVI on firm grounds as the new immunization paradigm for the years to come! Best wishes, Michel ___________________________________________________________________________ From: [][/email] Date: Wed, 26 Jan 2000 13:05:08 +0100 To: Subject: Re:Post0220 OPINION PART II Allan, A quote from a cold chain technician: "Thanks to polio money we could revitalize the cold chain in my country." A quote from an EPI manager: "Through micro planning, flexible cold chains and other polio specific issues, we realise there are different, and perhaps more fruitful ways to look at implementation of the routine programme." A quote from a programme officer: "Routine coverage has increased since awareness of immunization activities was raised through polio eradication." A quote from a UNICEF officer: "The ICC for polio offered the first opportunity to sit down and plan with colleagues from WHO,MOH and other agencies. We intend to continue to use the ICC for routine." A quote from a child in Somalia: "The polio teams were the first health workers I have seen in my life." A quote from ..... A quote from ..... A quote from ..... A quote from ..... etc, etc. Quotes are pleasant anecdotes for illustration of a point, but largely insufficient to prove that point. It is like the reporter of the 8 o'clock news who strengthens his message by interviewing somebody who luckily confirms what the reporter just said. I do not think the impact of polio on EPI or generally on other health systems can be measured by quotes. More serious and in depth work needs to be done for that. This is currently being done. The statement that polio can not be a platform for the rest of EPI only because it is not an injectable vaccine, does not reflect reality. Polio heat stability has set cold chain standards for a few decades. Experience with VVM on polio opened up new visions about cold chain practices in general. Polio has planned and implemented eradication activities through Interagency Coordination Committees, that are now in many countries used for planning routine EPI. Polio laboratories are increasingly used for measles. Polio campaigns have taught about micro planning and community participation now used for campaigns with other antigens as well as with normal routine. Of course polio was not always the first in these changes, but it certainly accelerated them. It is an open door that polio activities disturb routine, and complaints on this issue should be handled with respect, but the real questions should be: 1) without wanting to generalise it, is a certain amount of disturbance not necessary in some countries, especially in decaying programmes with coverages as low as 20% 2) what is the balance between the negative and positive impact of polio on routine To justify the disturbance of many people's work for the sake of polio eradication we have to make a major effort to show why we think the eradication and its spin offs are worth the disturbance. All changes disturb something. Disturbance in itself can be positive or negative. 'Disturbance' as such should not be a value judgement, unless one is of course opposed to any kind of change. Last but not least, I think the opposition 'polio' and 'routine' is quite sterile. Routine will never be as it was before polio. Routine was stagnant, if not in decay in many countries, before and/or irrespective of polio eradication. Some may argue that polio played a role in that decay, a view that I do not support, but anyone arguing that polio activities were the only reason for stagnating EPI misses the reality of developing health systems in a changing socio economic context. Anyone can agree or disagree with the polio eradication programme, but nostalgic reflections on the pre-polio era are not constructive and miss the point of changing health programmes in a changing world, with or without polio. Hans ____________________________________*______________________________________ 2. PROGRAM INTEGRATION: A RESPONSE TO COMMENTS IN POST0220 OPINION PART II Coeli Geefhuysen, ACITHN, who works in, assesses, and teaches immunization, has contributed these comments from the perspective of the operation and delivery of routine Primary Health Care, MCH, and EPI in developing countries. Thanks, Coeli. * Email your own comments and field experiences in this important area to the TECHNET Forum. Action, comments and additions please: [][/email] or use your reply button ___________________________________________________________________________ Date: Thu, 27 Jan 2000 16:07:59 +1000 To: TECHNET MODERATOR From: "Coeli J. Geefhuysen" Subject: Re: Post0220 OPINION PART II In reply to some of the remarks by Anthony: Anyone who has had experience in the actual application of EPI in countries knows that it is only too easy to disrupt the smooth flow [of work]. Not only of EPI, of any program that has a routine and in which staff already overloaded have to perform some fairly standard tasks. It is the proverbial straw and the camel's back - there are already an excess of straws - programs that run fairly well need constant reassurance and reinforcement and praise! To 'piggy back' occasional campaigns eg for polio only, withdraws essential resources and, once withdrawn, they often do not return. Please remember sustainability - - EPI was being integrated into routines programs. As it is, the integration of maternal and child health lags behind the ideal. Coeli ____________________________________*______________________________________

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