Stumbling Blocks to Ending Polio in Indonesia

Successful health projects in developing countries require the support of local and national governments. That's especially true for vaccination campaigns. And getting government support has been particularly difficult in Indonesia, for several reasons.

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One is the uneasy relationship between the central government in Jakarta and the provinces. For most of the last century, the central government ran everything. It issued orders that everyone followed. Vaccination rates were high.

But recently, facing pressure from the provinces and several insurgencies, the central government has embarked on a campaign to give more power and money to the provinces. Now the central government can't command the provinces to vaccinate. It has to ask and convince the provinces to do it.

So picture this: You're a provincial authority. You've got a farming village desperate to get its product to market. Everything has to be ferried across a river. You'd love to build a bridge. Meanwhile, you've been vaccinating children against polio — and you've seen no cases for 10 years. What are you going to spend your money on? The central government can ask the provinces to spend money on vaccination. But it can't force them.

It would be much easier to get the government interested if the situation were worse — if there were thousands or tens of thousands of sick or dying children. The waning days of a disease are much more challenging than when there are so many sick people around that everyone can see that vaccination is necessary. One of the reasons some religious leaders in Nigeria were able to create a movement against polio vaccination is because no one had seen polio in a long time.

Another problem for the Indonesian government and polio eradication: There's avian flu in people and poultry. Avian flu is preoccupying top government health officials. When we went to interview the head of the country's Center for Disease Control, we had to wait while he met with other officials to discuss the country's response to bird flu. He couldn't remember the last time he'd had a day off. And as soon as we left, he had another bird flu meeting.

Government health officials also face the challenge of getting people to trust them. Following decades of dictatorship, Indonesia now has an elected government. But many people remain distrustful of the national government, which they believe to be corrupt and non-responsive. Many of the people we met didn't trust their provincial officials. They only trusted the people they knew — the local health workers — even though many of the local health workers had not been fully trained to deliver the polio vaccine.

But with all these challenges — insufficient funds to train health workers, public distrust, the distraction of bird flu, competing needs — the Indonesian government has managed to work with the various agencies and groups from the international Polio Eradication Project. Rotary International is there, training local volunteers to help with vaccinations. The World Health Organization is there, advising the government and UNICEF on what's needed in the vaccination campaigns, and coordinating an outreach to local media. The U.S. Centers for Disease Control and Prevention is helping as well. The vaccination numbers for the September round were better than the August round. And Indonesian and international officials have great hope that another round at the end of this month will go even better.

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