Pakistan's POLIO: A problem of perception

By Zeeshan Salahuddin

Despite incredible progress in the two decade long fight against the disease, Pakistan stands at risk of becoming the last active reservoir of the poliomyelitis virus in the world

Maasi Askari, the eldest member of my family was in her late 60’s when she passed away nearly two decades ago. She was afflicted with polio as a child, all of her limbs misshapen and twisted at unnatural angles by the time she reached puberty. She never married, she never held a job. Even the simplest tasks, such as a trip to the washroom took nearly an hour. She suffered from severe depression during most of her life, watching her brothers and sisters get married, employed, and have children, grandchildren, and great grandchildren. Her last few years were an excruciating cocktail of immobility, debilitating pain and embarrassment at not being able to take care of herself. The most dignified member of our family died a most undignified death, completely cognizant of her situation, and utterly unable to do anything about it. This is the likely fate that awaits children crippled by poliomyelitis in Pakistan, which is now arguably the last refuge in the world for the polio virus. Despite the incredible progress made against this incapacitating disease worldwide and most of Pakistan, it continues as an endemic, with 91 confirmed cases of polio reported in 2013 alone.

A TALE OF TWO BARRIERS

Poliomyelitis may only be prevented, and it mostly affects children under the age of five. One in 200 infections results in the virus attacking the nervous system, causing paralysis in literally a matter of hours. During a national vaccination campaign, even a single child missed can put the entire campaign at rish.

Fortunately, we have a vaccine that can categorically prevent polio, effectively creating a barrier between the virus and the child. In Pakistan, this barrier unfortunately exists between the vaccine and the child. Imagine the polio virus as an invading force. The vaccine acts as an armor between the virus and the child population in the target location. If even a single child, or set of children, or community is missed, this creates chinks in the armor, allowing the virus to seep through, and potentially infect unwitting children. Nearly every country in the world has devised a strategy that created an impermeable barrier for polio, effectively eliminating it from its soil, thereby providing a plethora of examples to learn from. It all started with Cuba. A campaign began in which vaccination posts were set up in civic locations such as community centers, schools, churches and synagogues, hospitals and the like, and people were encouraged to bring their children to get vaccinated. The technique worked, and was very successfully replicated in multiple countries. However, the efficacy of this solution was hampered by high-density populations. To mitigate this, door-to-door campaigns were constituted, an evolved and highly complex form of which is now in full effect in nearly every part of Pakistan.

UNDERSTANDING POLIO

There are three countries in the world that still considered polio endemic: Nigeria, Afghanistan and Pakistan. In 2013, Nigeria reported 53 cases, a 57% decrease over 2012, Afghanistan reported 13 cases, a 65% decrease, whereas Pakistan reported 91, a 156% increase over the prior year. Cases were also reported in Somalia, Chad, Cameroon, Syrian African Republic, Ethiopia, Kenya and Niger. However, these were isolated incidents or outbreaks that are easily contained and not a cause for alarm for Dr. Elias Durry, the World Health Organization’s pointman for the eradication of polio in Pakistan. The endemic countries, on the other hand, are cause for concern.

“Pakistan stands at the risk of being the only polio endemic country in the world,” says Dr. Durry. Of the 13 cases reported in Afghanistan in 2013, 12 can be traced back to Pakistan. In Nigeria, the last reported case was on October 8th, 2013. So in the last four months or so, every polio case in endemic countries can be traced back to Pakistan, with the exception of the solitary case in Nigeria. Most recently, the WHO has labeled Peshawar in the Khyber Pukhtunkhwa province as the largest polio reservoir in the world, with nearly 90% of the cases genetically linked to the virus circulating in the city. While India was formally declared polio-free in early 2014, Bill Gates, a man who’s foundation has been fighting against polio around the world, claims that Pakistan may not enjoy the same status, as far down the line as 2018.

This is a very alarming state of affairs for the country, which stands the risk of being branded the last refuge for the poliomyelitis virus. This is a shame that Dr. Durry understands all too well, having grown up reading about how his part of the world was the last refuge for the smallpox virus. He has spent the better part of the last two decades eliminating polio from several locations across the globe, including the Horn of Africa, Yemen, and Nigeria. His most challenging task now is the situation in Pakistan. It is important to distinguish that there are three categories that signify the seriousness of polio virus’ spread. The first category is known as reservoirs. These are pinpointed, specific locations where the virus circulates, and continues to thrive. The most significant polio reservoirs exist in Karachi and Peshawar, and one was most recently eliminated in Quetta. The second type occurs when a district reports multiple infections. This is still alarming, but not a cause for huge concern as it is a highly local phenomenon and can be easily contained and fixed. The third is an outbreak, where a string of cases are reported, and this too is containable.

Pakistan, unfortunately, in varying degrees, experiences all three.

CONTEXTUALIZING THE NUMBERS

There are three main issues that have had a direct impact on the rise in polio cases in 2013, and all three can be traced back to militancy. “The biggest problem is fear,” claims Dr. Durry. “Without fear, there is no problem. But as long as fear exists, for parents, for polio workers, for us, the polio eradication program will suffer.” First, the ban. The Taliban have imposed a ban on vaccination campaigns in parts of Pakistan, most notably the Federally Administered Tribal Areas (FATA). In the earlier analogy, there is a massive gaping hole in the vaccination armor here, one that causes hundreds of thousands of children to miss polio vaccinations every year. This number has fluctuated between 0.68 million to 1.3 million missed children in 2013. The FATA ban has been in effect since June 2012. Effectively, no children in the banned areas have been vaccinated against polio in nearly 20 months.

There is another, more tacit type of ban in areas that are not necessarily in Taliban control. Some attempt to indoctrinate communities by claiming that the polio campaign is a massive global conspiracy to render Muslim children impotent and that the drops accomplish this goal. As a result of this and threat of retaliation from the militants, a fraction of children, as many as 65,947, are missed because ill-informed and radicalized parents refuse to give the drops to their children. It is important to note here, that despite media’s apparent focus on refusals, the refusal cases present less than 5% of the missed children, the vast majority of which are missed because of the ban.

The Taliban oppose the polio campaigns, which they say is a cover for international espionage. While most other claims can be debased quite easily, this assertion is difficult to refute because Dr. Shakeel Afridi, in an attempt to positively identify Osama bin Laden in Abbottabad, embedded himself in the polio campaigns in the area. In a video statement released by the Taliban, they unequivocally state that they believe this campaign is a cover for spies, and while they are for Muslim health, their priority is to eliminate infiltration. Second, the military operations. There has been a prolonged military campaign in the tribal regions of Pakistan against militancy and Taliban control since as early as 2009. The necessity for this campaign notwithstanding, it also results in a logistical nightmare for polio teams as they cannot enter tightly controlled theaters of war.

In November 2013, a US drone strike took out Tehrik-e-Taliban Pakistan’s (TTP) leader Hakimullah Mehsud, and the TTP vowed bloody vengeance. After a few months of relative calm, the TTP launched a series of brazen and deadly attacks, including an attack on a paramilitary convoy on the way to Ramzak in North Waziristan, and a suicide bombing that killed at least 13 people near Pakistan’s army headquarters in Rawalpindi, 8 of them military personnel. In response, Prime Minister Nawaz Sharif cancelled his trip to the World Economic Forum in Davos, the army launched a counter-offensive, spearheaded by aerial bombardments of TTP hideouts, and the TTP reaffirmed their stance. All of this, unfortunately, renders any vaccination attempts in war-ravaged areas impossible. Furthermore, with the ban in effect for 20 months, the migrant communities relocate to urban centers, carrying the virus with them, thus propagating it.

Third, the killings. On Monday, January 21, 2014, polio workers and their protective detail came under fire again, killing three and injuring another two in Karachi, adding to the list of 29 already killed since the middle of 2012. The attacks are concentrated in Peshawar and Karachi, although no group has formally accepted the responsibility for the attacks. “It is unfair to simply say there was an increase in the number of polio cases in Pakistan in 2013, without contextualizing how and why this happened,” says Dr. Durry. “These three factors, the ban, the military operations and the killings have greatly hampered polio efforts in the country, despite remarkable progress in the last few years.” In fact, without the three factors listed above, Pakistan could have had as few as two cases in 2013, both in Sindh, which would have been 98% decrease in cases from 2012.

THE LAST ONE PERCENT

The remarkable progress Dr. Durry talks about is undeniable. Polio, by and large, has been eliminated in nearly all parts of Pakistan where there has been a consistent campaign. The numbers don’t lie. Nearly 33.4 million children and targeted for vaccinations during each campaign, and a vast majority of these, between 98-99% are actually covered by the campaign. 20 years ago, in 1994, when the campaign began, there were 25,000 reported cases of polio in Pakistan. The 91 cases last year mark a 99.9% decrease in polio cases since then. WHO data empirically establishes that wherever there has been consistent blanket coverage for vaccinations, the virus has been systematically and judiciously eliminated. Even nomadic populations, tested at random, were positive for polio virus nearly 98% of the time, is now down to single digits.

The polio reservoir in Quetta has been eradicated. We can now identify specific areas, within specific union councils, within specific districts of urban centers that serve as reservoirs for the virus. Over 200,000 people participate across the country every vaccination campaign, simultaneously operating in 102 districts. The campaign is so well-executed in areas where militancy, military operations or killings are not an issue, that this team could conduct a highly accurate census of Pakistan, a task not accomplished since 1998, in a matter of four days.

“The polio eradication strategy is well-tested and has been successful in a large number of countries around the world. The equation is simple – in Pakistan and everywhere else: if you reach enough children enough times with the oral polio vaccine, then the polio virus will go away,” explains Dr. Durry. “And the current situation in Pakistan actually gives testimony to the effectiveness of that strategy: it is namely in the areas where polio teams have been unable to administer drops for extended periods of time that we see children paralyzed by the virus.” The fact of the matter is that Pakistan has come a long way, and the fight against polio is well-planned, well-executed, and a highly complex affair managed by some of the smartest minds Pakistan has to offer. Corruption, while at one point crippling for the campaign, no pun intended, has largely been curtailed through payments of polio workers through bank accounts, which leave a paper trail and drastically improve accountability. Control has been taken from the Executive District Officers (EDOs), most accused of corruption and embezzlement, and given to Deputy Commissioners (DCs), with a level of responsibility that both trickles down to the areas coordinators at the union council level, and float up all the way to provincial Chief Ministers, and the Prime Minster at the federal level. This is not to say that the situation is not alarming. There is a very real and distinct possibility that Pakistan may be the last polio endemic country in the world, a stamp of shame for a country that has come so far in its fight against polio.

PAKISTAN’S POLIO PERCEPTION PROBLEM

The biggest problem right now is that of sustaining this multifaceted endeavor. The vaccination campaigns are extremely difficult to manage, take an incredible amount of planning and precision, and a very strong monitoring and accountability framework to function well. The campaign in Pakistan is trying to play catch-up, where the above mechanisms exist, but there is a barrier between the vaccinator and the child in some parts of the country. These chinks in the armor are circumvented by continuing the campaign full-strength in every other part of the country, not only to deny entry to the virus being carried around by migrant populations, but to empirically establish that the polio campaign, where it is allowed to operate, works in eliminating polio one hundred percent.

Sustaining this level of commitment, however, is prone to battle fatigue over time. Some of the individuals in this fight have been combating this menace for two decades, yet they continue because there is still that sliver of hope that we can eliminate polio completely, that we are so close, down to the last one percent.

Dr. Durry is very clear about his stance on what needs to be done. “Eradication is of course a tangible possibility in Pakistan – but it will not happen by itself and we cannot be complacent. In order to achieve eradication, it is of crucial importance that the problem of inaccessibility is resolved. This issue is the real game-changer. Should attempts to ensure access for vaccinators to all parts of the country fail, God forbid, then there is a risk that the eradication effort will also fail. If this happens, then it will definitely encourage other governments to take action to protect their own populations.”