India Worked With Muslims to Build Trust and Beat Polio

LUCKNOW, India—Global health experts long believed that India, with its massive population, poor sanitation and widespread poverty, would be the last country in the world to eradicate polio.

On Thursday, however, public-health officials are expected to certify that the South Asian nation is free of the infectious scourge, which has afflicted more than 8,500 Indians since 1998.

A critical ingredient in reaching this major public-health milestone: Building trust in Muslim communities. It is a lesson that has been applied to vaccination campaigns in Pakistan, Afghanistan and Nigeria, where polio remains endemic.

"It's always important to find out who people trust," said Heidi Larson, an anthropologist at the London School of Hygiene and Tropical Medicine, who tracks immunization programs. "The more health workers listen to and engage with locals, the more successful they are."

As India pushed ahead with a mammoth $1.6 billion government-led campaign that relied on about two million volunteer vaccinators, it realized Muslims were being disproportionately left behind.

In 2002, about 57% of polio cases countrywide were Muslim children; by 2004, that had risen to 62%. Muslims account for about 13% of India's 1.2 billion people.

Many of India's polio cases were being recorded in its most populous state, Uttar Pradesh, which experienced an alarming outbreak in 2006. Of the 676 polio cases that year, 548 were in Uttar Pradesh. Nearly 60% of the sick were Muslims.

To defuse this epidemiological bomb, health workers tried something new. In Uttar Pradesh, they created a 10-person group, known as an Ulama Committee, to bring health workers and local Muslim religious leaders together to promote vaccination.

Among India's Muslims, rumors were rampant.

Some believed the polio vaccine—which is delivered orally—contained pork, which Muslim religious rules say can't be consumed. Others suspected a plot to sterilize or infect Muslim children.

The war in Iraq also made many poor Muslims deeply suspicious of the U.S. and health workers were sometimes seen as agents of Western drug companies or intelligence agencies.

Vaccination efforts in Pakistan and elsewhere remain hindered by this kind of distrust. But, unlike in India, health workers elsewhere also face violent opposition from militant groups and others.

On Monday, the bullet-riddled body of a female polio worker was found by a river in Peshawar in northwestern Pakistan.

India's outreach to Muslims began in earnest with a 2006 meeting in New Delhi called by Rotary International, a major sponsor of India's antipolio campaign. Ashok Mahajan, a Hindu Rotary member from Maharashtra, addressed a crowd of imams, scholars and doctors.

"I began with a speech citing the Quran," Mr. Mahajan said. "The Quran says that the health and happiness of a child is the most important thing. I said, 'These are not my views; they are the views of the Holy Book.'"

Mr. Mahajan and Ajay Saxena, a n experienced Rotary volunteer in Uttar Pradesh, set out to recruit members from each Muslim sect as well as at least one Muslim doctor for the Ulama Committee. Ulama means scholar.

A physician was necessary, Mr. Saxon said, because religious leaders refused to promote the vaccine until a doctor certified its safety. The men turned to Tabassum Shahab, chairman of the pediatrics department at the Jawaharlal Nehru Medical College at Aligarh Muslim University.

"It was not easy to involve him at first," said Mr. Saxena, a bespectacled man with a shock of gray hair. "But once he was convinced the vaccine was safe, he asked why we hadn't involved him sooner."

Dr. Shahab agreed to sign a certificate verifying the vaccine's safety. Copies of the certificate, which included his cellphone number, were distributed to health workers and Muslim families across Uttar Pradesh. Soon Dr. Shahab was fielding as many as 40 calls a day from Muslim parents.

"They would call and ask me if the vaccine was safe, and I'd say yes," Dr. Shahab said. "They'd ask if it was absolutely safe, if it was okay for their children, and I'd say, 'yes' again. They'd ask if it would make their children impotent, and I'd say 'no, that's just a rumor.'"

Khalid Rasheed Farangi Mahli, chairman of the Islamic Centre of India, an influential religious leader, also joined the group. Mr. Farangi Mahli said he had been suspicious of health workers who came to Muslim villages. "We wondered if they had an ulterior motive," he said.

He said his concerns were allayed when Mr. Saxena informed him that the same vaccine was administered to children of various religions world-wide. Mr. Farangi Mahli would later be photographed giving administering the vaccine to his own son.

Similar committees were set up across Uttar Pradesh. Mosques began to broadcast vaccination reminders alongside prayers. By 2008, Muslim children accounted for just 37% of polio cases statewide, down from 70% a year earlier. In 2010, Muslim children accounted for just 31 polio cases across the country.

The Ulama Committee was one part of the broader campaign to build trust for health workers among locals, and not just Muslims, said Ms. Larson, of the London School of Hygiene and Tropical Medicine.

"The reality is that a lot of families had concerns about vaccination for reasons beyond the religious," said Ms. Larson. "Many people wanted women, instead of men, vaccinating their children. Others distrusted health workers who came from Delhi; they wanted to be vaccinated by people they knew."

But the strategy that worked in Uttar Pradesh is only an aspect of eliminating polio in places like Pakistan and Nigeria, where increased militancy threatens vaccination efforts, Ms. Larson said.

"The kinds of issues we face today were not part of the challenge in India," Ms. Larson said. "It's no longer enough to convince parents to accept the vaccine. Now we must convince multiple levels of actors, like the Taliban or a governor in northern Nigeria."