In 2014, one-and-a-half year old Rukhsar Khatoon unwittingly became a symbol of India’s arduous fight against—and eventual victory over—polio. The little girl, a resident of Howrah district in West Bengal, was the last-ever reported case of the deadly virus, and three years after her diagnosis, India was declared polio-free.
Up until a few years before, the country was contributing to more than half of the worldwide cases of polio. The road to success was to be an 18-year-long rollercoaster with many ups and downs.
“The global community had lost faith in India’s ability to eliminate polio,” recalls Anuradha Gupta, then additional secretary in the Ministry of Health and Family Welfare, and director of India’s National Health Mission. “There was a great sense of despondency globally, because transmission here was very intense, particularly in UP and Bihar. Everyone thought we would not be able to get rid of polio.”
She adds, “Within the country, there was immense fatigue. The programme [to tackle polio] had been going on for years, but we were still unable to get rid of the virus. People were getting tired. Communities started to push back. They felt like all that the government’s health department cared about was polio vaccination, whereas they had many grievances that needed addressing — water, sanitation, and the like. There was massive hesitancy and confusion.”
At the time, Anuradha, now deputy CEO of Gavi, The Vaccine Alliance, had just been asked to join the Health Ministry after a long stint in the Indian Administrative Services, working for a range of issues including urban development, health, poverty alleviation, and women and child welfare, among others.
She joined the 1981-batch of the Haryana cadre, and began her career as a sub-divisional magistrate in Mahendragarh. “Working in Haryana, which performs well in terms of economic indicators, but lags far behind when it comes to social indicators, was an educational and thrilling experience,” she says in conversation with The Better India.
Anuradha, who helmed India’s battle against the virus as the mission director, explains what it took to help the nation eradicate polio, despite a rocky start.
A lifelong dream
Going back to what set her on this career trajectory, she recalls, “When I was a kid, I’d always wanted to be a doctor — I thought I would heal people, bring them out of their misery…My father, who was a professor of Math, had his own vision of what his children should grow up to be. My oldest sister became a doctor, so he pushed me for IAS. I sat for the exams with much reluctance, but I was happy when I began working. I have always been driven by the idea of helping people who are not as fortunate as me.”
As an IAS officer, Anuradha made this very drive her mission. “I used whatever power I had to veer towards the social sector. I worked in many sectors, including education and women and child development, but it was in health that I found my true calling,” she smiles. “I’d always wanted to be a doctor, and my work experience in the sector brought it all together.”
Shortly after Anuradha began working as the health secretary in Haryana, there was a polio case in Mewat. “That’s the time I began to understand just what polio is, and how poor the immunisation rates in Mewat were. I went by the book — I tried to understand the protocol, how to convene meetings, what a mop up involves, etc. It all happened at a rapid rate. In the end, that was the very last case in Haryana.”
It was then that Anuradha received a call from Sujatha Rao, former secretary at the Ministry of Health, Government of India, who invited her to join the ministry as the secretary. “When I joined the GOI in early 2010, I was put in charge of women and child health, including polio. It was here that I truly realised how much India was contributing to the global polio burden.”
Anuradha realised that the way to tackle the nation’s polio crisis was not by looking at how many children were being covered in every round of immunisation. Instead, it was to factor in how many children the government was missing. “I think that was a radical shift. We were able to carefully monitor how many households had refused the vaccine, and how many kids were missing out. Otherwise, the programme was repetitively going back to the children we had covered, but constantly excluding the kids we had missed,” she says. “We completely repositioned the programme.”
A courageous step for the nation
At the time, there was a bivalent (stimulates an immune response against two different antigens, such as two different viruses or other microorganisms) polio vaccine that had been developed in India, Anuradha explains. “But globally, a monovalent vaccine was being used. There are three different strains of the virus — P1, P2, and P3. P2 was under control, but we were struggling with the other two. There was one vaccine to address P1, but when that was administered, the P3 variant would go out of control, and vice versa. There was nothing to address both.”
At the time, India was receiving funding from the World Bank for procuring vaccines, with the condition that the manufacturer should be WHO-qualified. The bivalent vaccine seemed to be working, but a massive roadblock came when India’s global tender for it failed. “WHO delisted all global manufacturers of the vaccine after a quality audit. So we suddenly had no manufacturer that was WHO-qualified. That’s where the big question of ‘What do we do?’ came in,” she recalls.
As per the agreement with the World Bank, if India decided to tie up with manufacturers not listed by WHO, they would stand to lose their funding.
“In the usual scheme of things, we might have just given up, because what else was there to do?” she says, smiles and pauses, and then adds, “But I was made of different stuff.”
At this time, Bharat Biotech had also bid for the global tender, and was manufacturing the bivalent vaccine in India. “I took the time to study how the process takes place, and I realised that this Indian company had received approval from the National Regulatory Agency, which was WHO-prequalified. So if the company was prequalified by our own agency, it meant that they were meeting the required standards of WHO as well,” she explains.
This realisation invited a lot of pushback, she notes. “But I asked the authorities to give me one good reason. In our routine immunisation programmes, we were using vaccines produced by our own manufactures. Our NRA is WHO-approved. So why should this be any different? It was the first time that a spotlight was thrown on how illogical it is to have two sources of procurement, different pricing, etc. It also highlighted how global institutions can have unreasonable insistence, and how that does not account for the country’s voice. There’s a massive disconnect between the thinking of global institutions and a country’s reality.”
With this thought in mind, Anuradha approached Dr Naved Masood, then financial advisor in the Ministry of Health. “Naved and I had worked together in the past, when I was working in education. I said to him, ‘We definitely need [the World Bank’s] money, but here is a choice to be made. Either we get rid of polio—and we are very hopeful that this vaccine will give us the required results—or we just wait it out and children continue to suffer.’ We were already putting in close to Rs 1,000 crore annually to fight polio. It was like we were being held hostage.”
Dr Masood scrutinised the overall budget of the ministry, and realised there was unspent balance from another project that year. “We received the go ahead, and you know, the rest is history,” Anuradha says.
A quest to find ‘missed children’
Despite losing the World Bank funding, India strengthened its immunisation programme. The bivalent vaccine, combined with increased focus on “missed children”, got India over the hump.
Wasn’t it a massive risk to stick their necks out in such a manner? “Yes,” Anuradha nods. “But it was also the ability to grapple with detail. Sometimes, we bureaucrats and civil servants don’t pay attention to detail, we don’t find the time to dissect issues and get to the core of the problem. But we had to ask ourselves, ‘Why are we procuring immunisation from two sources for our children? Especially if this vaccine is good for them under routine immunisation?’ Of course, it did involve a lot of courage and thinking out of the box.”
“I used to joke, if the World Bank had its way, we would never be able to get rid of polio,” she laughs.
Recalling Rukhsar’s case in Howrah, Anuradha says, “Howrah was not even a hotspot. Everyone was taken aback. When we probed the matter, we realised there was a cluster of unvaccinated children we had missed. So that was my learning — you have to be much more targeted, and you cannot have a macro-statistics approach, which masks the realities of the neglected population.”
A rapid emergency mop up was conducted and was completed within a record six days, despite the fact that these sort of procedures can take weeks due to the sheer number of population that needs to be vaccinated.
In 2011, Anuradha asked the Union Health Minister to declare Polio as a Public Health Emergency, which put all states and UTs on high alert. Rukhsar’s case became the last polio case reported, and on 27 March 2014, the WHO declared India polio free.
In 2015, Anuradha joined Gavi. Since then, she says, “India is the world’s largest and most precious lab. It’s a combination of the best and the worst and most challenging. When I joined Gavi, I brought my learnings of how to use data to identify marginalised populations that need to be prioritised, and how to bring in equity in immunisation.”
Under Anuradha’s leadership, Gavi had developed a programme to identify ‘Zero Dose Children’, wherein they analysed data to find that one-in-ten children in Gavi-supported countries have not received even a single dose of routine immunisation.
As far as vaccination programmes in India are concerned, Anuradha opines, “India has many gaps in terms of vaccination. We’ve made progress in coverage, but inequity is a huge challenge. The country has the largest number of zero dose children at 3 million, a number that increased last year. The pandemic has hit routine immunisation services, especially for marginalised communities. That means that India needs to focus more on these children, lest they begin seeing outbreaks of diseases like measles, or the return of polio — a vaccine-derived virus, not the wild polio. Gavi is working to introduce new vaccination and immunisation programmes with India. There are a lot of gaps to be covered.”
Edited by Yoshita Rao