Pakistan is losing its battle against polio despite putting up a full-scale army of volunteers and security apparatus in its bid to save the country from being labelled as a crippling nation abroad. It is losing because it has no physical control in its northwestern tribal badlands — the key source of polio spread — and because it has no political influence on an evasive Pashtun community living elsewhere, which records most polio cases in its children.

Only three countries remain polio endemic, Pakistan, Afghanistan and Nigeria. India recently managed to remove itself from the list with Afghanistan seemingly close to achieving a similar status reporting just 11 cases so far this year (as of Dec 18 according to The Global Polio Eradication Initiative).

Worst still, Pakistan is now informally labelled as an ‘exporter of polio’. The term was slapped on following recent developments of the virus strain originating from Pakistan being found in China, Egypt, Syria, Palestine and Israel.

These findings resulted in serious talk of restrictions being imposed on Pakistanis wanting to travel abroad. In fact, some restrictions are already being put in place.

Following Saudia Arabia’s lead, New Delhi now requires Pakistanis wanting to travel to India post January 2014 to be immunised. According to the new rules, all Pakistanis must provide proof that they were vaccinated at least six weeks before travelling to the neighbouring country. Similar rules apply to Indians travelling back from Pakistan. Since the last few years as per Saudi Arabia’s requirements, Pakistanis performing Hajj or Umrah need to get vaccinated, regardless of age.

Emergency coordinator for polio eradication in Pakistan Dr Elias Durry understands the financial and administrative implications for countries such as Bangladesh and India, who are no longer polio endemic, to impose restrictions in order to protect their population. With due recognition of the Arab kingdom’s success in zero polio spread associated with Hajj, Durry admits travel restrictions are not a permanent solution. “The only way to eradicate polio (in Pakistan) is through immunisations of children here,” he told Dawn.com.

With the WHO convention coming up in Geneva in a couple of weeks, officials expect further recommendations to curb the crippling virus from spreading out of Pakistan will be made. Suggestions from experts within the country are also pouring in.

Recognising Fata as among the most high-risk areas contributing a major chunk of total reported cases, former Director General for Health Dr Rashid Jooma proposes two measures which can be implemented. “First, bring the influential leaders to the table and switch the mood from ‘combative to cooperative’ through dialogue.” However, if this fails, Jooma doesn’t hold back from suggesting more aggressive methods.

“Fata needs to be completely isolated with a firm immune barrier built on its borders. All entry and exit points need to be covered by vaccinators and any one going in or out must be administered the polio vaccine,” he said.

The prime minister’s focal person on polio eradication Ayesha Raza Farooq confirms similar plans are in the pipeline. “We already have vaccination check points at areas bordering with other countries as well as one at each of the entry and exit points of Khyber Pakhtunkwa,” she told Dawn.com, adding, “but we plan to set up some new ones specifically focusing on Fata.”

According to Farooq, who was recently assigned the position, the government no longer plans to apply a uniform national strategy across the board and rather adopt area sensitive approaches.

That, however, is easier said than done. Unstable security situation, illiteracy and geographical inaccessibility remain major obstacles. In an effort to address some of these concerns, officials have brought religious leaders on board to promote immunisation drives. But Jooma says he is “not at all impressed” with these efforts.

Explaining his stance he says: “There is a huge difference between those who head madrassahs and style themselves as religious leaders and the actual warriors on the ground. The influence of such leaders is very limited and does not extend to the hard core militants who oppose immunisation. I don’t think these leaders will be able to deliver.”

Figures obtained from Unicef report a 0.14 per cent refusal rate of the 34.6 million targeted for the polio drive. This means at least 48,000 children face a likely risk of being infected. “Most families refuse on the pretext of their religious beliefs being against preventative medicine,” says Azmat Abbas, Unicef’s spokesperson for polio. Some families refuse immunisation, accusing health workers of masquerading contraception as vaccines.

Other issues include cold chain management as Muhammad Tariq, country director for USAid’s Deliver Project points out. “Considering that we are spending Rs60 billion on procuring vaccines, 70 per cent of which is for polio, it doesn’t make sense that we don’t allocate just five per cent of that on cold chain management which is essential for the efficacy of the vaccine.”

Pakistan’s polio case chart depicts a roller coaster ride with sharp highs and lows. Health officials say while the number of children infected has increased from the previous year the number of infected districts has declined.

The fact of the matter remains that Pakistan is still consistently recording cases and the last time it got remotely close to eradicating polio was in 2005 when it reported 28 cases. According to Expanded Programme on Immunisation (EPI) records, the highest number of polio cases was reported in 1997 when 274 children were infected with the virus. The government must take decisive action against refusal and those targeting healthcare officials out on polio campaigns. The safety and security of healthcare workers must be treated as seriously as the health and wellbeing of the children of our nation.

With the health ministry devolved to provinces, each government must take ownership of the struggle to eradicate polio if they want to achieve success. Let’s take a briefly glance at each province.

Sindh

Sindh is facing an influx of families from other provinces seeking shelter due to the security situation as well as hope for better prospects of employment by living near the country’s financial hub. However, while many families come with the hope of a better life, they cling to their age old notions towards basic healthcare. The recent death of a four-month-old baby due to polio in Karachi is yet another stark reminder for the city officials to deal with matters more effectively.

Families of Pashtun ethnicity record the most refusals consequently contributing to the highest number of polio cases. It is Pashtun-centric pockets of Karachi where polio is most often recorded yet officials have not managed to make headway. When asked if more aggressive methods of immunisation were an option, deputy director for EPI Dr Durenaz Kazi said they were still seeking to deal with the issue ‘gently’.

Meanwhile, security of polio workers and staff has been a major concern since last December especially in Karachi where polio workers were targeted or killed in the city’s Gadap, Orangi and Landhi areas.

Punjab

While a stable security situation is a key factor in Punjab’s comparative success in controlling the spread of polio, another reason is that the government doesn’t hold back imposing its writ to achieve desired results.

“We have zero tolerance towards refusal of polio vaccine administration,” says Khwaja Salman Rafique, advisor on health to Punjab Chief Minister Shahbaz Sharif.

In case of refusal, the focus shifts to counselling of the family through involvement of influential community members. “If that fails, FIRs are registered against responsible person(s) and arrests are made.”

Leaving no stone unturned, officials strictly monitor inter-provincial borders and administer doses to those entering and leaving the province, says DG Health Punjab Dr Zahid Pervaiz. The efforts for immunisation against a number of viral diseases are also specifically targeted at families migrating from the high-risk districts of KP, Balochistan and Sindh.

Balochistan

Despite its difficult terrain and political uncertainty, this year Balochistan has been polio free so far. The development is a much-needed relief from a couple of years ago when the province had 73 children infected with polio out of Pakistan’s total 198 cases that year. Last year, there were only four cases from the province; in fact, the last reported case in Balochistan was in Oct 2012 from Hudda, on the outskirts of Quetta.

A factor in the province’s success can also be attributed to Afghanistan stepping up efforts to eradicate polio with immunisation camps at the border for people crossing into the country. Improvement is visible from high-risk districts such as Killa Abdullah and Pishin, which border Afghanistan.

In addition, the provincial government has beefed up security in Quetta and other troubled areas following attacks on polio workers. In October, armed militants attacked health workers in Pishin district resulting in the death of a policeman who was guarding the team.

Other high-risk districts include Naseerabad and Jaffarabad where seasonal migration in the summer increases chances of the virus spreading out. Balochistan has also struggled with refusals, the reasons for most of which stem from a deficiency of trust.

Khyber Pakhtunkhwa and Fata

Most Pashtun families continue to resist vaccinating their children. Their resistance has resulted in numerous children being paralysed and in some extreme cases dying. Mistrust and suspicion behind the ‘real agenda’ of the immunisation campaigns is the driving force behind their refusal.

Their mistrust in immunisation drives stems from multiple roots. Taliban leaders exerting influence on locals is certainly among the major reasons. Lack of understanding of the implications on their child’s well-being is another.

High-risk districts of KP are identified as Charsadda, Peshawar, Mardan and Swabi. Peshawar consistently reports the highest number of children infected with polio except for in 2009 when Swat recorded the most cases due to the militants’ sway in the region at the time.

In Peshawar, Shaheen Muslim Town is considered a reservoir for the polio virus and needs to be aggressively dealt with. However, for polio statistics to decline in the province, curbing the violence against health workers must be given priority.

With the PTI government taking initiative in the province now and Imran Khan vowing to spearhead the campaign, one can only hope that KP has a fighting chance at finally ridding itself of the crippling virus before it ruins the lives of any more innocent children.

—By Mahnoor Sherazee

Tribute

Many health care workers, officials and security staff have lost their lives in a bid to save our children. Their efforts and courage is commendable. Our thoughts and prayers go out to the families of those who lost their lives and the healthcare workers who continue to fight this crippling disease. All officials and experts interviewed for this report requested a special tribute be offered to these brave men and women and we dedicate this piece in honour of the countless lives they have saved.

Mahnoor Sherazee with additional reporting from Sana Saif in Lahore, Hammad Abbasi in Karachi, Ali Shah in Quetta and Zahir Shah Sherazi in Peshawar.