BioMed Central Blog

White Rhino - a guest post from Writers Without Borders

This post is from Omar Khan and Tim Brookes of Writers Without Borders:

The following reflects Tim and my experiences while working with the World Health Organization in northwest Pakistan. Tim, a science writer and NPR commentator, was there to write about one of the most massive global health undertakings: the eradication of polio. I was there as a physician and global health guy; I clearly knew less about Tim’s field than he knew about mine. 

Tim and I had played cricket with the same team for nearly a decade, and had worked together previously on telling the story of SARS, from the index case to the Toronto quarantine.  Shortly after the polio assignment, we formed Writers Without Borders (www.writerswithoutborders.org).  WWB was our response to the realization that scientists of the developing world need to tell their compelling science and health stories. It also reflected a growing realization, which applies the world over, that scientists must learn how to write, not just for their own narrow professional interests but also to convey their work in compelling ways to the general public. In that sense, WWB mirrors the same set of beliefs that propel the OpenAccess movement: information is made more valuable if it is accessible to the maximum number of people. Just as Open Access reduces barriers to the dissemination of scientific knowledge, WWB is an attempt to break down the barriers which separate developing country scientists from achieving recognition - both within their own settings and beyond.

WWB  embraces open access principles but aims to expand accessibility to the general public by encouraging and teaching effective science writing. Tim’s piece is an example of this, conveying in narrative format a snapshot of a public health initiative involving more than 50 years of polio vaccine research; advanced disease epidemiology; microbiological complexity; and the challenges of international development, with a helping of geopolitics.

-Omar Khan, MD

White Rhino

When my colleague Dr Omar Khan and I arrived in Peshawar to observe and write about the polio eradication campaign in Pakistan, we were met at the airport by a white rhino.

Or so it seemed. Less fancifully, it was a huge white Toyota Land Cruiser with an enormous antenna, looking like a horn, mounted on the front bumper. It was the standard vehicle for international agencies working in the developing world, and no single initiative has ever led to more international agencies working in the developing world than the polio eradication campaign, arguably the most extensive effort ever undertaken in the public good. This particular vehicle was part of the effort to find and vaccinate every single child under the age of five in Pakistan every eight weeks, an undeniably epic endeavor; but from that moment at Peshawar airport I couldn’t stop thinking of it as the white rhino, and the more time we spent in and around it, the more it seemed to symbolize a great deal about the relationship between the donor countries and those in need of their help.

For one thing, it stood out like—well, like me, a 6’3" white guy of British origins, now resident in the U.S. who, by the way, spoke no Urdu or Pashto and, for all my good intentions, blundered around the back streets of Karachi and Peshawar and Abbotabad relying on the kindness and patience of strangers.

The white rhino was no more suited to its surroundings than I was. Its natural habitat was the broadest and most Westernized of streets; in order to get us to the heart of Zargarabad, one of the oldest districts of Peshawar, our driver had to approach by a circuitous route, a narrowing spiral, brushing stalls and carts on both sides until he finally halted, taking up most of a small piazza, and waited while we accompanied the vaccination teams down the intimate, bustling streets and alleys of the quarter.

Needless to say, not everyone saw this intrusion as welcome. The white rhino came with the standard UN insignia on the hood, but since the invasion of Afghanistan, "UN" had become more or less equated with "US," and the rhino, we were told, had started attracting stares, jeers and even stones. The polio team had then tried painting WHO on the front doors, but that had done little good. It was only when the familiar No Polio sign had been added to the rear doors, along with a sticker—recognizable from the polio eradication campaign posters—of a small boy, that the vehicle was in effect vaccinated against its other associations.

 For those of a more extreme cast of mind, of course, the rhino was still just a big, fat, white target. One of the dangers of operating a sizeable vehicle in decent repair with a full tank of gas in an unstable region is that the vehicle is easily seen as either an asset or a weapon or both. 

"When you work in an area that has almost no vehicles, and even the military and the police have no vehicles, or only vehicles that are very old, and you go in with your nice white 4x4, it is very tempting," the WHO security consultant explained. "One problem is carjacking. Another situation that we encounter in the field is the request, and sometimes the demand, for lifts for armed military or armed individuals. When you are in the middle of fighting, it doesn’t matter if you are working for WHO or UNHCR or whoever, they will requisition your vehicle to take their guy to the hospital--or the so-called hospital. That’s the kind of situation that can turn very, very dangerous if you don’t know how to handle it."

Hence the rhino’s horn: the massive antenna is installed so the driver can pick up shortwave signals from UN Security and transmit its GPS coordinates so the UN knows where it is at all times. Even so, the Land Cruisers in the North West Frontier Province had come under fire.

"There have actually been three attacks," said Dr Abraham Debesay, at the time the provincial polio team leader. "One time we were shot at, one time the vehicle was kidnapped and not recovered for five days, and one time the vehicle was kidnapped and we never got it back."

Those attacks were relatively uncommon, of course; yet there was a sense in which even the day-to-day activities of the polio program, and by extension many of the other projects being carried out by international aid agencies, uncomfortably resembled the rhino and its thick-skinned momentum.

From the safe distance of the United States or Western Europe, such interventions seem indisputably sensible and altruistic: if we can eradicate a disease by throwing almost infinite amounts of money and energy at it, surely the disease will succumb, and surely our actions are a de facto good?

On the ground, though, this attitude seems all too much like the lumbering charge of the rhino. On our first day in Pakistan we met with a council of town elders, some of whom energetically questioned the value of the polio eradication program, or at least its priorities. One said, not unreasonably, "Our main problems are unclean air and unclean water. Why aren’t you helping us with those?" Another pointed out that only one or two children a year died of polio, whereas dozens died every month from diarrheal diseases. Why would the community want to direct, say, 80% of its energy addressing its (at best) tenth gravest health risk—and why wasn’t the international community doing anything to help with the nine risks above it on the list?

Most poignantly of all, in the tribal regions near the Afghan border, some of the poorest and most under-served communities on Earth, some villages had decided to hold their own children as hostages, in effect: they said they wouldn’t allow the vaccination teams in until the government built a road, or a water line, to the village. In the face of these urgent and complex problems, the rhino seemed impossibly heavy-footed, hard to steer. Everyone involved in such programs must at times feel the urge to blow on the horn, to lean out of the window and try to wave people out of the way.

Ironically, the rhino’s limitations are best exposed if and when the polio campaign (or whichever intervention is being driven by those in the air-conditioned interior) succeeds.

International aid campaigns are essentially an aberration, financed and sustained from outside, and much better funded than routine healthcare. If polio is ever eradicated in Pakistan, one health officer suggested to us, it could be one of the worst outcomes for the country. Polio program money is a major source of funds for routine childhood immunizations, and if the polio funding ends and the foreigners (such as himself) leave, the level of routine vaccination of measles, diphtheria, pertussis, tetanus and tuberculosis will fall to nothing. The success of one vaccination campaign will be the death of the others.

Even the white rhino, that hardworking and profoundly useful vehicle, would cease to be an asset, too expensive for the people and too big for the streets it needs to serve.

"Smallpox eradication left very little behind," a senior WHO officer explained, looking back to the world’s previous major eradication program. "It was pretty much run, in the end stages, by internationals who worked as supervisors in developing countries, and worked to get the job done. Those internationals had their own vehicles, their own funding. They could move things ahead very rapidly, [but] that’s not the way to develop a country’s capacity."

When the smallpox program pulled out, it left behind what might be thought of as well-intentioned Western junk. The smallpox campaign’s vehicles were just an added burden to an already extended local government budget, and spare parts and even gasoline were a luxury that could no longer be afforded.

"In many parts of Africa and some parts of Asia," he went on, "there were actually graveyards of smallpox eradication vehicles."

Tim Brookes is co-founder, with Omar Khan, of Writers Without Borders (www.writerswithoutborders.org) and the author of Behind the Mask: How the World Survived SARS, A Warning Shot: Influenza and the 2004 Flu Vaccine Shortage and The End of Polio?, all published by the American Public Health Association Press.

 

Dr. Omar Khan, Nazeer, Dr.Mulugeta Abraham Debesay and the white rhino in Pashawar, Pakistan.
Photo credit: Tim Brookes

Posted by Matthew Cockerill at 16:05    Comments (0)