Immunizing the children of poverty / by John Clements and Diana Silimperi

Immunizing the children of poverty by Dr John Clements and Dr Diana Silimperi respectively Medical Officer and Consultant with WHO 's Expanded Programme on Immunization 183 y the year 2000, about half the world's children will be living in cities. Ensuring their immuni-zation against the common childhood diseases is a major health challenge for the decade of the 1990s. If the children of the world are to be immunized properly, we must not neglect the millions of youngsters living in the poor areas of the world's cities. The growth of cities is unfortunately more than matched by a dispropor- tionate growth of the urban poor sector. Today as many as 100 million children live on the streets of large cities. Yet active search for them and immunizing them have often been given a low priority. Systems for data collection or service delivery to this group are not well developed, so there is little available information about their immunization coverage and the incidence of disease. As a result the problem has rarely been fully under- stood by the health authorities. Uteracy programmes Experience has shown that it is a good investment to allocate resources which assist the urban poor to help themselves. Literacy programmes are relatively inexpensive and enable the urban poor to participate at all levels of planning. Nonetheless, special communications materials need to be developed for illiterate or poorly edu- cated individuals. Such specially created materials help to overcome the barriers that these people often face. Managers of Expanded Program- mes on Immunization (EPI) know that the deprived sections in the cities are often poorly served and remain a reservoir for the circulation of such diseases as measles and poliomyelitis. In these crowded conditions, proper immunization coverage is therefore very important. Some major cities in developing countries (such as Dhaka and Karachi) have been highly innovative in attempting to solve these problems and are setting an example to others. Increasing urbanization makes it vital 18 that plans are made now which will involve realistic solutions to the prob- lems of immunizing the urban poor. The alternative is to see hard-won gains in coverage levels over the last decade eroded by the global trend towards city growth. Uncontrolled urban population explosions pose a threat to the health of millions of people, but especially to children. Local authorities may not willingly provide immunization services to politi- cally powerless groups such as the urban poor, and may leave the task to voluntary organizations. Ideally these underprivileged groups should choose their own representatives to act as the voice of the silent masses, transmitting their needs to the decision-makers. Efforts to reach urban poor mothers Literacy programmes, like those in Sudan, are relatively inexpensive, and essential if the urban poor are to participate in planning their own future. Left: A child receives life-saving polio vaccine in Singapore. and children can only be successful and sustained if immunization pro- grammes are integrated into com- munity health programmes with full community participation. At the same time, national, regional and local government staff and resources, as well as nongovemmental organizations, also need to be inte- grated. Regular channels of communi- cation are essential for information exchange and planning between the different sectors, and among the various parties within these sectors. In order to ensure that solutions are appropriate and will be well received by the urban poor, more information needs to be obtained about their attitudes, knowledge, fears and obsta- cles to their use of the services. This will call for well-targeted surveys to collect data about health status and attitudes, as well as up-to-date - preferably computerized - methods of analysing such information. This may not be easy in such highly mobile and W ORLD HEALTH, March -April 1991 unstructured environments. Because the roots of poverty are manifold, the barriers to using such health services as childhood immuni- zation cannot be overcome or sus- tained by taking too narrow a view. Furthermore, solutions and long-term success can only be achieved through well-integrated immunization program- mes which take into account all the Poor people in the cities are usually grossly underserved with immunization and other health services. The gap between rich and poor shows no sign yet of narrowing. WHO cartoon by Claude Krebs ' . WHO's Expanded Programme on Immunization urges national and municipal programme managers to develop action plans to reach urban populations which: - define the target high-risk populations; - provide for coordination of the many agencies (governmental and nongovernmental) which are frequently engaged in providing health services; - provide outreach services. planned in collaboration with individuals from the target groups; - encourage the development of training materials adapted to urban realities; - allow for monitoring systems to assess coverage of health services and the incidence of disease among the urban poor; - ensure that existing health facilities provide immunization services; - promote the formation of urban immunization committees to guarantee the necessary political support for improving services; - enlist the active participation of private physicians. who are an important but neglected resource in urban areas. 19 Population projections (in millions) for the year 2000 of the world 's 49 largest cities, ranked according to their size in 1985. Tokyo/Yokohama (Japan) Mexico City (Mexico) New York (U SA) Sao Paulo (Brazi l) Shanghai (Ch ina) Buenos Ai res (Argenti na) London (United Kingdom) Ca lcutta (India) Rio de Janeiro (Brazil) Seoul (Korea, Rep. of) Los Ange les (USA) Osaka/ Kobe (Japan) Greater Bombay ( India) Beijing (China) Moscow (USS R) Paris (France) Tianjin (China) Ca iro/ Giza (Egypt) Jakarta ( Indonesia) Milan (Italy) Teheran ( Iran. Islamic Rep) Metro Manila/ Ouezon City (Philippines) Delhi (India) Chicago (USA) Karachi (Pakistan) Bangkok (Thai land) Lagos (Nigeria) Lima/ Callo (Peru ) Hong Kong (Hong Kong) Leningrad (USS R) M adras ( India) Madrid (Spa in) Dhaka (Bangladesh) Bogota (Colombia) Baghdad ( Iraq) Naples (Italy) Santiago (Chile) Phil adelph ia (USA) Shenyang (Ch ina) Pusan (Korea. Rep of) Detroit (USA) Bangalore (I ndia) Rome (Italy) Sydney (Austra lia) Caracas (Venezuela) Wuhan (C hina) Lahore (Pakistan) Katowice (Poland) Guangzhou (C hina) 21.32 24.44 16.1 0 23.60 14.69 1305 10.79 15.94 13.00 12.97 10.91 11 .1 8 15.43 11.47 10.11 8.76 9.96 11.77 13.23 8.74 13.73 1148 12.77 6.98 11.57 10.26 12.45 8.78 6 09 5.84 7.85 5.42 11 .26 6.94 7.66 4.46 5.58 4.33 5.50 5.82 3.92 7.67 3.82 4 06 4.79 4.47 5.93 3.88 449 * Based on data presented in "The Prospects of World Urbanization ." Revised as of 1988. Popu lat ion Studies. No 112, ST/ ESA/ SER A/ 11 2, New York, 1989 . 20 lining up to register children for immunization in a slum area of Bucaramanga, Colombia. factors that contribute to the poor health of the urban poor. So it is important to have an input from a wide range of personnel includ- ing health providers, urban planners and engineers, from the planning stages through implementation to evaluation. These individuals often have to make critical decisions about the location of a particular facility or its design. They may be responsible for creating road systems, for instance, which will be vital for improving access to a health facility, or for installing water and sanitation facilities which may improve the overall health environment. Women volunteers We have found that the best repre- sentatives from among the urban poor to be involved in planning and carrying out immunization projects are local women who volunteer their services. Since, by definition, these women come from the recipient communities, they can provide critical mtssmg information about attitudes, perspec- tives, and responses to the immuni- zation messsage. They know their communities' limitations and what is reasonable or feasible within the con- straints of their home environments. They can be more effective motiva- tors because they speak the language of the people. And they can transmit basic information more successfully because they are trusted members of the community and can easily over- come social barriers that might other- wise block communication. They are also adept at chasing up defaulters - parents who fail to bring their children for the next round of immunizations. However, it is important to generate considerable enthusiasm from the start if the number of volunteers is not to dwindle after the first excitement of a nei.Al programme dies down. Women are often very flexible and receptive to nei.Al ideas, and very willing to provide the service to their communities on a voluntary basis. They consider it suffi- cient re~Nard simply to have improved access to knowledge, or to enjoy the increased self-esteem and status which stems from their participation in such a programme. Problems sometimes arise because national, regional and local authorities, nongovemmental bodies and private practitioners may all be providing EPI services to urban populations. Such a diversity of responsibility often results in independent planning and carrying out of EPI projects with little cross- communication. Inconsistency and duplication can be avoided by creating an urban EPI steering committee with representation from all parties. Politics are interwoven into the fabric of urban society, whether muni- cipal, regional or national, and cannot be ignored. Even the setting up of routine immunization services can become bogged down in local politics, especially if the support of politicians has not been obtained beforehand. Conversely, the active support and involvement of urban leaders can help to provide the political will necessary to mobilize communities into action. • W ORLD HEALTH. March -Apri l 1991