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Violent resistance not the only hurdle

by Mahnoor Sherazee

Despite a national emergency being declared, Pakistan is failing miserably in its battle against polio. A total of 184 cases have been reported as of September 29 and with the Independent Monitoring Board review currently taking place in London, matters may get worse.

The government says their success, with the dozens of annual immunisation campaigns run across the country, crucially hinges on the security situation. The Minister of State for National Health Services Saira Afzal Tarar in her statement to the board said, “…64 polio teams and police officials guarding them have been killed whereas 47 have suffered serious injuries.”

But violent resistance to the polio campaign is not the only hurdle in Pakistan’s way.

When Operation Zarb-e-Azb was launched, many saw this as an opportunity to access children and families from North Waziristan who had not been immunised since June 2012. But the subsequent developments have highlighted what maybe an even greater stumbling block in the way of the campaign: accountability and the quality of immunisation.

At the same stage last year, Pakistan reported 52 of the total 93 reported overall cases in 2013. Could this mean then that the spike this year is a result of the mass migration from North Waziristan into other parts of the country? The answer sadly yet unequivocally is yes and a large part of this has been due to the declining quality of the campaign.

“The government needs to impose strict accountability for good quality campaigns and as far as the issue of cold chain management goes, it is still not being taken seriously,” World Health Organisation’s (WHO) emergency coordinator for polio in Pakistan Dr Elias Durry told Dawn.com from London.

Among the districts of critical concern are Khyber Agency, Bara Tehsil and Karachi, Durry says. But it is North Waziristan, South Waziristan and Khyber Agency which comprise almost 70 per cent of all cases this year.

A few months ago restrictions were imposed on air travellers, regardless of age, making their way in and out of Pakistan. No one was permitted to board an international flight without a polio certificate proving they had been vaccinated with a year-long validity.

The restrictions were meant to contain the virus within Pakistan, which was labelled an ‘exporter of polio’. Strains of the virus found in China, Syria and Tel Aviv originated back to Pakistan and world health bodies became concerned of the virus, eradicated decades ago in most of the developed world, resurfacing globally.

It took some time but finally a mechanism was put in place to facilitate those wishing to secure a polio certificate. There are reports, however, that many travellers were given a certificate without being administered the drops.

But even if Pakistan manages to successfully contain the virus through air travel, experts argue the main threat has always been from land routes. And that is currently the biggest challenge.

“The polio virus managed to travel internationally so it was immature for anyone to assume it would not spread nationally once families moved out from Fata and moved around the country, especially to Karachi which houses the largest Pakhtun population,” said a Unicef official who requested not to be named.

The provincial breakdown of number indicates a total of 22 districts are infected compared to 20 at the end of last year. However, prior to the operation in North Waziristan about 10 districts were reported being infected.

According to Dr Bilal Ahmed, who is Unicef’s team leader for the polio campaign in Khyber Pakhtunkhwa and Fata, the government had planned vaccination campaigns at three levels. These include the intra-district/agency followed by the inter-district/agency and finally the inter-provincial transit points.

With 203 transit points in KP, 218 in Sindh, 180 in Punjab and 53 each in Fata and Balochistan this is not an easy task. Teams are positioned at these points to vaccinate children under five, children between five and 10 years and all above 10 years to raise community immunity against the virus.

Despite these efforts Unicef’s communication specialist for Balochistan, Dr Javahir Habib, says Killa Abdullah reported cases after a 20 month polio-free spell.

“With immunity in Balochistan still low, the province is being attacked by the virus from all sides,” she said adding, “The Quetta Block (which includes Quetta, Pishin and Killa Abdullah) was labelled a reservoir but after managing to contain the virus WHO took the province off the reservoir list. But now the virus is making its way from Karachi, Kandahar and a sample tested last month showed the strain originating from Peshawar also found here.”

Confronting the issues of refusals is another ordeal all together especially in Killa Abdullah and Pishin.

Of the five reported cases in Balochistan, Habib said three were marked as refusals. Polio teams in these districts comprise of just about 20 per cent female staff which proves an obstacle when teams visit and the men of the house are not present.

“In such situations sometimes the women of the household may lie and say they do not have children to avoid speaking to male staff members or that the children are at their grandparents. This greatly limits our access to the children,” Habib explained.

Speaking on condition of anonymity as they are not authorised to speak on the issue, a government official in Punjab says about 2,500 families have migrated from northern areas to the province which is “a cause of major concern for the administration.”

“We have started thinking more strategically. It is difficult to track the migrating families so we strictly enforce administering of vaccine doses at all transit points but more needs to be done to map out a solution,” the official added.

On the other hand Ahmed is more optimistic about the situation in KP and Fata.

“Two to three years ago when Bajaur and Mohmand were cleared for the army operation against militants we recorded an influx of cases but now we have no cases being reported from there. The same will be for North Waziristan now that we can access the children from the area to vaccinate.”

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Pakistan fast losing window of opportunity

By Zofeen T. Ebrahim

With an abysmal report card, it will certainly be tough for Ayesha Raza Farooq, the focal person for the Prime Minister's polio cell, to defend Pakistan’s case at the Global Polio Eradication Initiative's Independent Board Meeting.

The IBM, assesses progress of anti-polio campaigns and reports to partners including the World Health Organization (WHO), Rotary International, the US Centers for Disease Control and Prevention (CDC), the UNICEF and the Bill and Melinda Gates Foundation.

Pakistan has seen an alarming rise in polio cases this year, at times as high as five have been reported in a single day. Dr Margaret Chan, director general of the World Health Organisation, in a high-level meeting at the United Nations General Assembly recently reproached saying: “Pakistan is the single most important stumbling block along the road to ending polio, once and for all.”

Farooq has urged the international community to not overlook the complications the country faces in effectively dealing with the issue.

“We have not been negligent, nor can the increase in polio cases be attributed to failure of our programme,” Farooq said in an interview with Dawn.com.

“Our international partners should have realistic expectations from us; polio virus that had remained in certain areas of Pakistan cannot be eradicated overnight,” she said.

Farooq said that 80 per cent of the cases this year are from the security compromised areas of the Federally Administered Tribal Areas and Karachi and reminded the global bodies of the damage caused by the Shakil Afridi fake vaccination drive in 2011.

"Prior to that there was no ban and Pakistan was progressing well in its target of ridding the virus," said Farooq.

Farooq's predecessor Shehnaz Wazir Ali, now the technical advisor to Sindh government on primary healthcare including polio, acknowledged the meeting would be difficult but said if she were to plead Pakistan's case, she would be “very candid” and narrate the ground reality at the meeting.

“It's not an easy issue and a battle every day,” Wazir Ali pointed out.

“There is a vast swathe of population that needs to be vaccinated and many of these live in areas difficult to access. Often terrain is such that it can take up to two days to reach and where maintaining cold chains is a gargantuan task.”

“Entrenched views” opposing administration of polio drops specially “among the Pakhtun population” is a big challenge polio teams face, Wazir Ali added.

But she put the blame squarely on the shoulders of the interim government (before the PML-N formed its government in June 2013) for the losses.

“We had warned the interim prime minister of the slippages that could occur since the issue requires continuous attention, but no heed was paid.”

“We hold the interim prime minister responsible for the gross and criminal negligence for disbanding the polio eradication cell,” she said adding the new PML-N government took its time, and lost ground which they now find difficult to recoup.

“That is because you cannot tackle polio on a part-time basis; you have to have your nose to the ground and pursue it relentlessly. It requires close and rigorous coordination down to the union council level -- from seeing that procurement is done on time to ensuring the quality of campaign.”

Speaking to Dawn.com, on condition of anonymity, a United Nations public health expert, who has long been working with the Pakistan government said candidly that he had never found the top leadership serious.

“And this I found across the board. I don't think polio is their priority,” he said adding that he found that “dengue mustered a more cohesive approach by the leadership. It's a national security issue and the country may find itself further isolated."

He found it hard to believe that for two years the government could not enter the region where the Taliban had put a ban on the vaccine.

"We need a leadership that refuses to accept such a defeatist attitude; we need someone at the top who takes the lead and finds solutions."

According to him, the government was fast losing the window of opportunity it had when the army evacuated North Waziristan.

The same was corroborated by Dr Elias Durry.

“The virus has been cornered; all that is needed is relentless pursuit and concentration on a smaller area before the virus spreads like wild fire. The opportunity is still there to bring the programme back on track, but if missed all of the 25 years of work will be undone,” Durry warned.

Wazir Ali, however, was hopeful and pointed out that now that the ban on polio vaccine is no more effective, in the months to come, the government would be in a far better position to control the circulation of virus. She said the Khyber Pakhtunkhwa administration proved that polio eradication campaigns can be run successfully despite security threats.

No more excuses

With Pakistan fast losing all valid excuses it had so far been giving the international community, what then is the real reason behind the failure? Has this three-decade-old programme become redundant? Does it need tweaking to suit the country's present needs?

The May 2014 IMB report had certainly found the programme “years behind those of other endemic countries in its sophistication”.

Is the problem then at the field level or the policy level? Is there a problem at the management level where responsibility stands divided between the United Nations agencies, non-governmental organisations and the government? Has the programme been devolved down to the union council level now that health has become a provincial subject?

According to Wazir Ali, the programme still has "all the necessary components, is suited to and responds to local context, involves religious and political leadership".

“I think the campaign is just fine," she says.

Dr Zulfiqar Bhutta, founding director of the Centre for Excellence in Women and Child Health at Aga Khan University, in Karachi, and co-director of the Centre for Global Child Health at The Hospital for Sick Children, in Toronto, finds no fault with the with the blueprint for polio eradication and the emergency action plan either.

“The programme is flexible and has evolved and improved over time based on the advice of the technical group's assessments,” pointed out Farooq.

But Bhutta said, perhaps what needs to be looked into is devolving and strengthening it at the local level.

“The data needs to be hundred per cent accurate, the capacity of the local polio workers built, the leakages need to be plugged and sloppy performance done away with,” he suggested.

At the same time, he said unless the programme won the hearts and minds of the people, it would remain ineffective.

“Community mobilisation is critically important,” he emphasised and pointed out that the agencies concerned have consistently failed to come up with an effective sales pitch to promote the vaccine and inform the population at-risk in a manner they understood best.

According to Farooq, the government would now be taking all those sensitivities into account.

“You will see the difference. Our focus is now on engaging with the community in the high risk areas and spreading the message in their language. We are seeking the help of local clerics and trying to win over other clerics.”

While the bleak coverage of routine immunisation was a huge challenge in the fight against polio, it was about time Pakistan stopped looking at polio myopically, Bhutta said in response to Farooq's comments.

"Unless routine scale up becomes a priority and we link this with polio immunisation, unless we begin a massive hygiene and sanitation campaign, the disease will not go.”

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