Pakistan's Polio: Mission Impossible

By Hiba Mahamadi

“By 2012, we had almost eliminated polio in Pakistan. Then the killings started,” Aziz Memon, Chairman Pakistan National Polio Plus Committee Rotary International, tells Newsline, referring to the security crisis that has stunted the country’s anti-polio campaign in recent years. Although mistrust of the anti-polio campaign (the vaccines are rumoured to contain pig fat and cause infertility) has been popular for years, the infamous Shakil Afridi affair, in May 2011, added fuel to the fire. Afridi is a doctor from Peshawar accused of using a fake vaccination campaign – incidentally, it was Hepatitis B, not polio, as was widely reported – to gain access to a number of houses in Abbotabad, in order to locate the whereabouts of Osama bin Laden through his children, identifying them by their DNA samples. It was after this incident that the Taliban leaders, led by Hafiz Gul Bahadur, banned all anti-polio campaigns in North and South Waziristan.

Since July 2012, no child has been vaccinated in that area, says Dr Elias Durray, WHO’s Chief Coordinator for Polio Eradication in Pakistan. In July 2012, two doctors associated with the campaign were gunned down in Karachi and, on December 18, four female polio workers were killed and two male workers injured on the same day in three separate incidents in Karachi. According to Dr Altaf Bosan, 69 workers, including guards, have been killed in the course of Pakistan’s polio eradication campaign since December 2012.

Aziz Memon believes that the security situation in high-risk areas like FATA and Gadap makes it difficult for the government to effect legislation: “What can they do?” he asks. He says the mindset of the tribal leaders stands as a huge roadblock to the anti-polio campaign in Pakistan. When asked about the mindset of the several jirgas, maulvis and ulemas he has met with in the course of his work, Memon responds, rather sarcastically, “I don’t know if they have a mind.” He elaborates, that no thinking person can watch while their loved ones suffer the dreadful effects of polio despite having a cure in hand. “They’re hurting their own children,” he says.

Clarifying the notion that such a mindset only exists among the uneducated, Nadia Naqi, winner of the International Centre For Journalists Vaccine Story Contest in 2013, says that this disconnect with the anti-polio campaign “is not just rampant among the uneducated classes, but is across the board.” And it all stems from a “trust deficit” between the public and the authorities. “The educated classes don’t trust the government or the vaccines it provides. The media campaign run by the government is also not taken seriously.” Eliminating polio in Pakistan, therefore, is not so straightforward, and according to Dr Durray, “Pakistan’s polio eradication programme has faced challenges not faced by any public health programme anywhere in the world.” Despite all this, Aziz Memon still maintains that “the situation is not bad at all.” He refers to the fact that despite the alarming figures – 59 polio cases by early May and 67 by the end of the month – until 2012, Pakistan was doing very well in the anti-polio campaign, having eliminated 90 per cent of the virus from the country. Dr Ali Faisal Saleem, a senior instructor of Paediatrics and Child Health at the Aga Khan University, specialising in infectious diseases, childhood vaccines and childhood malnutrition, tells Newsline that “there hasn’t been a single case of wild type 2 poliovirus in Pakistan since 1999 or wild type 3 poliovirus since November 2012. Currently, only wild type 1 poliovirus has been reported in the country.”

In those parts of Pakistan where the security situation is relatively better, the polio vaccination campaign moves quite smoothly. Mohammad Arshad has worked at Karachi Cantt railway station as a vaccinator for the last 12 years, and is head of operations at the exit point. His team administers OPV to approximately 800–900 children a day. The awareness level among their parents is high, Arshad says, adding that, “Only a few people refuse the drops for their children, otherwise the majority of the passengers want their children to be vaccinated.” Talking about possible improvements to the current vaccination system at the station, Arshad says, “The railway administration should make vaccination mandatory for all travellers. The trains should also be double-checked so that no child is looked over.” Arshad also shares that any untoward incident involving a polio vaccinator anywhere in the country “spreads chaos and fear among our workers,” but he is confident because “Cantt station is inside a boundary, and there is no such problem over here.”

But security issues and a lack of awareness are not the only reasons for Pakistan’s poor performance in the race to eliminate polio. Dr Saleem is currently working on a WHO-funded research project to identify polio eradication strategies in Pakistan and, according to him, although it is true that “we tend to vaccinate the same children all the time,” mainly because it is easier to administer drops to children in safer areas than penetrate into the Northern Areas, malnutrition also plays a key role in reducing the efficacy of polio vaccination campaigns. “A very important issue in Pakistan’s anti-polio campaign is chronic malnutrition. Our recently completed polio vaccine trial in chronically malnourished children found that the immunity level to the polio virus in these children was lower compared to relatively better nourished children, despite the former having received many polio drops.”

Moreover, the “administration and execution” of polio campaigns in the country – and this has nothing to do with security issues in certain pockets – are another reason for the high number of polio cases, according to Dr Memon. He says success rates as high as 100–120 per cent have been recorded in the past, whereas the real figure is closer to 80 per cent (this issue was recently raised in the Senate as well). People making up the paper work are inefficient. “And then there’s the money that goes into the coffers,” he adds.

Although Mohammad Arshad credits the media for the high level of polio awareness in Pakistan today, others paint quite another picture. In the noise that erupted following the WHO recommendations, the Minister of State for National Health Services, Saira Afzal Tarar, commented, “It is the media which has created panic in the country.” Aziz Memon agrees that journalists tend to portray the negative aspect of any story, as they are taught that only “negative news is news, while positive news is not.” One example of such journalism is a newspaper report, published in November 2011, claiming that vaccines purchased using funds provided by the Global Alliance for Vaccination and Immunisation had proved fatal or debilitating to populations in Pakistan and other regional countries. But, while figures for deaths that had occurred in other countries were reported, no hardcore facts were provided for Pakistan. Even if such reports which discourage the anti-polio drive are true, which Dr Memon says he highly doubts, the fatalities represent only a small percentage compared to all those children who have been successfully vaccinated against the virus (in 2004, 30 million children under the age of five years required polio vaccinations in Pakistan): “This cluster of so-called reported deaths, where do they fit in?” he asks. Journalists are “jumpy, they do not have the time and the energy which they should apply in exploring a report before giving it to the people,” Dr Memon says, citing the recent example of a report that claimed 46 children in Thatta had died due to rubella, whereas his own enquiries revealed that less than 10 deaths had occurred and all due to measles, not rubella. “What has already been done [to eradicate polio], the media does not want to talk about. But, if just one new case of polio is discovered in the country, it is reported,” says Aziz Memon.

But, Nadia Naqi believes that such “panic” is precisely the need of the hour as it gets people thinking about polio. On the other hand, she also says that “while the media in Pakistan has done a lot [for the anti-polio campaign], most channels do not discuss the issue during their primetime segment. They probably think political issues are more important,” she says.

While health issues are simply not on the government’s list of priorities – “Just look at the government’s spending on health, it’s never been up to the mark,” Naqi says, citing the condition of public hospitals – this laissez-faire attitude is not just limited to the ruling elite. “For people in Pakistan to be health-conscious, and it’s unfortunate, they need to suffer first. Unless they themselves contract the disease they never become serious about tackling it. We just don’t take health seriously,” says Naqi. Then, many vaccinators themselves lack the passion for their work simply because “they are not permanent employees, they are not paid on time and only get about Rs 450 for a day’s work…” There is not just a lack of political will, but also public will.

Still, there is hope. The May 5 WHO Temporary Recommendations, no matter how ill-suited and disgraceful for Pakistan, have helped rouse the country. “Now everyone is waking up,” Dr Memon says. For example, in a cabinet meeting on May 15, the government decided to make polio drops for all children travelling from FATA to the rest of the country mandatory and the army was given the duty of overseeing this process. Dr Durray maintains that “it is possible to eradicate the polio virus in 12 months and, from China’s example, we know that it can be stopped in even less than that time.” Although, back in December 2012, Durray had the same thing to say – that polio could be eradicated in Pakistan within the next year, unaware that the threat to Pakistan’s anti-polio campaign had only just begun.

Nevertheless, Dr Memon is positive, because “the steps taken in the last few days prove that there are ways to work around the security problem, and access the impenetrable Northern Areas. If we have the will, we’ll find a way.” All that is required is a final push to completely eliminate the virus from the country, and perhaps the WHO recommendations will provide just that.