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Health workers carrying polio vaccine, as part of a vaccination campaign organized by the opposition Assistance Coordination Unit, Aleppo, Syria, May 5, 2014
Article initially published in The New York Review on August 27, 2014 and written by Save The Children in response to Annie Sparrow’s article on the public health crisis in Syria and in particular the threat of polio.
In response to Annie Sparrow’s recent article on the public health crisis in Syria and in particular the threat of polio, The New York Review has received the following statement from Save the Children-UK. A reply by Sparrow is posted beneath the statement.
There was never a shortage of vaccines for the campaign as alleged by Dr. Sparrow, but there was a shortage of funding to allow these vaccines to be delivered in northern Syria. In response to this identified need, Save the Children stepped in to provide funding to allow the second round of vaccinations to take place in our area of operation.
We categorically deny that at any point did Save the Children claim that any vaccines we were storing had been destroyed, or indeed that they had been destroyed as a result of our warehouse being shelled. At no point did Save the Children refuse to use the vaccines we were in possession of, and in fact we were in steady contact, coordination and collaboration with WHO to assess how it would be appropriate for the vaccines to be used.
Since the start of 2014, Save the Children had been storing these vaccines in cold chain facilities in Syria, to ensure they could be used when needed. While these particular vaccines were not used during the polio vaccination campaign, this was ultimately because sufficient supplies of vaccines from other sources were made available to allow the campaign to be successfully undertaken and to reach vast numbers of children. No child has gone, or will go, without being vaccinated against polio because these vaccines have not been used.
Even when our office in Syria was temporarily closed due to insecurity, our committed staff came in to check on the cold chain twice a day and to ensure that at no point were the vaccines compromised, and that they remained viable. The decision to dispose of the vaccines as per best practice was taken by WHO following concerns that after being stored for several months they may become compromised once removed from the static cold chain storage given the hot weather and challenging operating circumstances.
Put simply and clearly, at no point did Save the Children hide or deny the existence of these vaccines, and at no point did it block their use in the Polio Vaccination Campaign. Given the highly complex operating environment inside Syria and the special difficulties of implementing a mass vaccination campaign there, it was vital that all humanitarian actors involved in the campaign worked in partnership. Therefore, we repeatedly and consistently encouraged organizations tasked with coordinating and implementing of the polio vaccination campaign to use these vaccines as part of the campaign as they deemed necessary. It would not, however, have been appropriate to use the vaccines without the authorisation of these coordinating authorities.
Approximately 1.4 million children have been consistently reached over the seven rounds of the polio vaccination campaign, including more than 253,000 children in the areas that Save the Children has been supporting. Save the Children has been providing technical assistance to those actors delivering the vaccines to help ensure the campaign reached as many children as possible. The polio campaign was undertaken in incredibly challenging circumstances, with active conflict regularly disrupting access to communities. The ability of the humanitarian community to reach so many children is testament to the bravery of the health workers who have been prepared to risk their own lives to deliver these vaccines.
Annie Sparrow replies:
My recent article “Syria: The Other Threat” mentions that 250,000 doses of polio vaccine that were entrusted to Save the Children-UK specifically to protect children from the polio epidemic spreading across northern Syria came to expire in a time and an area of critical need. Save has now challenged the accuracy of my report, claiming it is “entirely wrong.” Part of its denial is in the response printed above, and part is in a separate, more detailed statement sent to The New York Review of Books and others. I welcome the opportunity to detail the evidence and underscore the points made in my article.
There is clear documentation showing that on December 24, 2013, Save received 124 boxes containing 12,400 vials of polio (OPV) vaccine1, twenty doses each, or 248,000 total doses, with an expiration date of April 2015. Acquisition of these vaccines was facilitated by the extraordinary efforts of the two responsible UN agencies, WHO and UNICEF, to address the epicenter of the polio epidemic in opposition-held parts of northern Syria despite the limitations of their UN mandate. At the time, that mandate prohibited them from directly aiding this region without the consent of the Syrian government, which it refused to provide.
The vaccines given to Save were taken to the town of Hazano in Syria’s Idlib governorate. The vaccines were stored in refrigerators that required eight hours of continuous power supply per day to keep the vaccines viable—preserving them in the temperature range between 2 and 8 degrees Celsius that international standards require. Wartime Hazano is a town with inconsistent electricity supply, so backup generators are imperative.
Save claims that its cold chain was maintained—that the vaccines were continuously kept in facilities with adequate refrigeration—and that the vaccines remained viable. Yet it is documented, and Save admits, that for a period of twenty-six days in January 2014, backup generators were not available at all. It is clear that the vaccine viability was indeed compromised because by May 23, WHO determined that they had become unusable. As I wrote in my article, “After reviewing the viability seals on the vials, Dr. Raul Bonifacio, a WHO official, concluded that ‘these vaccines cannot be used for any polio vaccination activity.’”
Save disputes this. In its response, Save insists that the vaccine entrusted with it “remained viable.” It explains the decision nonetheless to destroy these supposedly viable vaccines by pointing to WHO’s “concerns that after being stored for several months they may become compromised once removed from the static cold chain storage given the hot weather and challenging operating circumstances.” Yet as noted, the vaccines in Save’s care, if properly stored, were not meant to expire until April 2015—a year later—and the polio vaccination campaign conducted by the Syrian opposition-organized Polio Task Force continued with other vaccines in northern Syria throughout the hot summer months. Indeed, the Polio Task Force completed the most recent round of vaccinations on August 7.
In its response Save elaborates, claiming WHO officials found the vaccines, originally at a viability of stage 1, to have degraded only to stage 2—that is, compromised but still viable—not stage 3, the designation for their having become unusable. In fact, WHO’s expert review found, after checking samples from each of the 124 boxes of vaccines, that they had already deteriorated to stage 3, meaning they were no longer viable and had to be discarded. The degradation of these vaccines is illustrated in the photo below—one of 127 such photos that can be viewed here—which Save provided to WHO on May 23 at WHO’s request. Responding to Save, Dr. Bonifacio of WHO said: “[T]hanks for these collective photos of the…vaccines. Upon review of all the photos it is noted that the color of the inner squares is almost matching (dark) with that of the outer squares—which is equivalent to…stage 3 and has reached the discard point. This cannot be considered…stage 2 because under this stage the inner square is lighter (white in color) than the outer circle.”
As I explained in my article, WHO discreetly advised the Polio Task Force to ask the three NGOs to make the vaccines available to the task force. Two of the NGOs promptly made their vaccines available. However, Save did not and said in its later statement that it was “unaware” that the Polio Task Force was working to overcome a shortage of vaccines for the second vaccination round in February. This is surprising in light of the fact that Save itself is the chair of the Health Working Group in northern Syria, and as such Save’s responsibilities include information sharing and coordinating coverage of gaps in health efforts. In my opinion, these duties should have made Save aware of the extraordinary efforts being undertaken by the Polio Task Force, aided by WHO and the Turkish government, to secure polio vaccines, especially to overcome shortages for the second round. The same duties should, in my view, have led Save to circulate those needs to the other members of the HWG. Indeed, the minutes of the January 16, 2014 Health Working Group meeting, just before the launch of the second round, speak of “challenges” for the polio vaccination effort in northern Syria involving “[u]ncertainty of vaccine delivery time, then late delivery.” Save’s position as a funder of the Task Force’s polio vaccination effort should also have made it aware of the vaccine shortage.
In any event, Save suggests in its statement that there was no harm done because there was “no need” for its 250,000 vaccine doses in Idlib—that the vaccination campaign has “run smoothly.” This seems a little naive, given the extraordinary range of obstacles faced by the Polio Task Force over the last eight months, as detailed in my article. More to the point, the start of the second round had to be delayed due to a lack of vaccines. Save’s inability to make its vaccines available in Idlib meant that the task force had to shift vaccines to Idlib from eastern Syria, a difficult and dangerous process. To make matters worse, the vaccines that deteriorated in Save’s storage facility were the more effective, bivalent variety. The vaccines ultimately given to the children of Idlib in round 2 were the less effective trivalent variety because they were the only ones that the Task Force could secure.
Save also claims that “no child was denied or delayed inoculation or missed out as a result of these un-used vaccines we were storing.” But 22,569 children across northern Syria were not vaccinated during the Polio Task Force’s second round of vaccinations, including 2,395 children in Idlib. This data is publicly available on a website run by the organization Humanitarian Tracker, providing data freely to aid communication and cooperation for optimal results. Part of the reason that children were not vaccinated in Idlib was because some of the vaccines being offered, in the absence of the ones from Save, were sent from the Syrian health ministry in Damascus, which local parents didn’t trust. Again, this knowledge is in the public domain2.
Save goes on to assert in its statement: “We have vaccinated 250,000 children against polio in Idlib” (emphasis added). But in fact Save used the Polio Task Force to do it, and Save was not even part of the Polio Task Force3. The real heroes were the thousands of Syrian doctors and vaccinators of the task force who risked their lives to vaccinate children, as I describe in my article. Dr. Hosam Jaroud, the Syrian doctor pictured below, was killed during the second vaccination round in Idlib.
My point is not to embarrass international organizations like Save the Children, which in previous conflicts such as Darfur have played an important part in improving the health and well-being of civilians. And, of course, I recognize that working conditions in northern Syria are difficult and dangerous. My intention is to highlight the extraordinary success of the Polio Task Force, which despite the Syrian government’s barrel bombs and the need to negotiate access to territory controlled by jihadists such as ISIS, has managed to vaccinate 1.5 million children in northern Syria during the multiple vaccination rounds since the beginning of this year, with a 97 percent coverage rate. This is a heroic and unprecedented level of success in the extraordinarily difficult conditions of this brutal war. It should be noted that the Turkish government has been exemplary in supporting and taking responsibility for the polio campaign, enabling this massive cross-border effort.
It is important not to lose sight of the larger challenges presented by the Syrian crisis. This crisis is no longer local or even just regional. It is quickly spreading across the Middle East, and polio transmission is an international threat. Efforts to contain it must also move nimbly across borders. The Polio Task Force’s ability to meet the immense logistical challenges of crossing national boundaries and conflict lines has now led it to undertake a new cross-border vaccination effort from Syria to Iraq. UNICEF and WHO began a new campaign in Iraq on August 11, yet certain areas are too dangerous for them. But the Polio Task Force is reaching several of those areas and has already vaccinated children in ten villages in northwestern Iraq despite ISIS’s control of that region.
This is a complex reality riddled with different groups, ambitions, security concerns, and international politics. I hope my article encourages greater coordination that transcends individual and institutional ambition, in order to effectively address polio and other infectious threats to global health. International agencies, the UN, and donors must move beyond their traditional perspectives and usual implementing partners to empower national actors that are getting this incredibly difficult work done.
Read the full response on nybooks.com