Until recently, polio was considered a poor man’s problem in Pakistan — a crippling virus that festered in the mountainous tribal belt, traversed the country on interprovincial buses, and spread via infected children who played in the open sewers of sprawling slums.
But since the World Health Organization declared a polio emergency here last week — identifying Pakistan, Syria and Cameroon as the world’s main reservoirs of the virus — the disease has become an urgent concern of the wealthy, too.
A W.H.O. recommendation that travelers not leave Pakistan without a polio vaccination certificate has caused confusion. Doctors, clinics and hospitals have been inundated with inquiries. The association of travel agents has reported “panic” among air travel customers.
Sakhina, a 3-year-old girl from Kabul, has contracted polio, the first confirmed case in the capital in 12 years. Her family previously lived in Pakistan and her father is a taxi driver who travels frequently to the tribal areas.Polio’s Return After Near Eradication Prompts a Global Health Warning MAY 5, 2014
“It’s very worrisome,” said Mohammad Akbar Khan, a passenger at the Karachi airport on Thursday, as his family clustered around a desk on the departures concourse normally used to immunize infants. “We just found out about this on the news, and we’re trying to find out what to do.”
The government, which is scrambling to meet the W.H.O. requirement, says it needs two weeks to make arrangements at airports and buy more vaccines. But to most Pakistanis, it is a jolting reminder of the gravity of a crisis that has been quietly building for years, and which is now, according to the W.H.O., spilling into other countries, threatening to undo decades of efforts to eradicate polio across the globe.
Despite years of multimillion-dollar immunization campaigns, led by the government and international organizations, this year Pakistan reported 59 new polio cases, by far the most of any country. The W.H.O. had reported only 68 cases worldwide as of April 30.
Instability is driving the crisis. The Taliban, which had long opposed the vaccinations as part of what its leaders said was a Jewish conspiracy, has stymied immunization efforts in the northwest and the tribal belt, where infection rates are highest. The Taliban have forbidden vaccinations in North Waziristan for years, and killed vaccination teams in other areas.
Suspicions among the Taliban and others that the vaccination campaign was an espionage effort gained currency after 2011, when a covert, C.I.A.-financed vaccination campaign used to try to find Osama bin Laden came to light.
The sense of urgency that has gripped health professionals for years, however, was largely absent among the upper class, who have had limited exposure to polio. “There was a total disconnect” in society about the problem, said Dr. Anita Zaidi, a pediatric infectious diseases expert and a member of the National Immunization Technical Advisory Group.
Some of the highest refusal rates for polio vaccination were recorded in wealthy Karachi neighborhoods, where residents had little faith in public health care, Dr. Zaidi said, citing a 2011 study. Now, the vaccination requirement has drawn an ambivalent response from the wealthy.
Ibrahim Shamsi, a textile exporter who intends to travel to Canada, called it “a lot of botheration.” He said, “I’m sure I was vaccinated as a child so I don’t know why I need to do it now.”
Seher Naveed, an artist with travel plans for Berlin and Amsterdam, said she was worried that the vaccine could have an adverse effect on adults.
In Lahore, Pakistan’s second largest city, residents of the wealthy Gulberg neighborhood also expressed unease about the new requirements. Jameel Ahmed, a businessman, said he was embarrassed to have to take a vaccination at the age of 57.
A woman who gave her name as Mrs. Ahsan said the restrictions were discriminatory and unfair. “We have been singled out in the world,” she said. For some experts, the worry is that immunizing all travelers will divert scarce resources from efforts to fight polio where it is most prevalent. Dr. Zulfiqar A. Bhutta of the Center for Excellence in Women and Child Health at Karachi’s Aga Khan University, said the W.H.O. travel advisory was “unfortunate,” and would foster an erroneous sense that polio is a universal problem in Pakistan.
“It’s not — it’s a geographic problem, and this will take the pressure off the hot spots,” he said.
One such hot spot is on the edge of Karachi where, on a desolate stretch of road at the city gates, the fight against polio is being fought bus by bus.
Buses filled with ethnic Pashtuns, fleeing poverty or conflict in the northwest, enter the city every day; some are unwittingly carrying the polio virus from areas where infection rates are highest, W.H.O. officials say.
On Friday morning a team of eight government health workers, clad in bright yellow jackets and blue caps, boarded passenger buses as they entered the city, administering the vaccine to children under the age of 5.
One vaccinator, Nadir Ali, wove through the crowded aisles with a box filled with vaccines. Children bawled in protest, and passengers looked bemused. “Shh,” one mother said to her crying baby. “You’ve gotten the drops, now quiet.”
Every day Mr. Ali and his fellow vaccinators, who are paid $2.50 a day, immunize at least 2,800 children. Some eight million children were immunized at 10 such transit points across the country in 2013, in a program that is partly financed by Rotary International and supported by the W.H.O. “Terrorists may want to destroy Pakistan, but this virus is destroying our nation,” Mr. Ali said.
Karachi’s importance in this battle stems from its position as a trade and transit hub, which facilitates the movement of migrants, travelers and, more recently, the polio virus.
“Karachi acts not only as a reservoir for the disease, but also as an amplifier,” said Dr. Zubair Mufti, the national coordinator for the W.H.O.’s polio campaign.
Efforts to banish polio from the city have also been hurt by the growing Taliban presence in ethnic Pashtun neighborhoods. There have been several militant attacks on polio vaccination teams since the first in July 2012; over the same period reported cases of polio — a disease that can be carried by adults but mostly strikes infant children — have steadily risen. Eight cases were reported in 2013; so far this year the figure is four.
The latest Taliban attack in Qayumabad, an area close to the upscale Defense neighborhood, on Jan. 21 resulted in the death of three female health workers.
One Pakistani Taliban militant, who identified himself as Gul, said in an interview that his group had attacked two polio teams in Karachi in 2012 because “they were trying to find the hide-outs of our leaders in these areas.”
But some experts say the bin Laden factor has been overstated, noting that the Taliban started to target polio workers long before the American commando raid that killed the Al Qaeda leader.
“The Taliban in North Waziristan didn’t stop the campaign because of Shakil Afridi, they did it for political reasons,” said Dr. Bhutta, referring to the Pakistani doctor hired by the C.I.A. to run the vaccination campaign in 2011. “And they’ve done themselves and the country a lot of damage.”
But for Mr. Ali, the immunizer jumping between buses outside Karachi, the most immediate problem is persuading reluctant parents. Some passengers offered up their children enthusiastically for immunization; others were cajoled into compliance by fellow passengers or even bus drivers.
But one mother, on a bus from Bahawalpur in Punjab Province, staunchly refused his entreaties to immunize her baby son.
“The vaccination is necessary against the virus. There are no side effects,” he pleaded.
“I’m his mother,” said the woman firmly.
Mr. Ali shrugged and retreated.
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