Pakistan had all but eliminated polio. Then things went badly wrong.

By Haq Nawaz Khan and Pamela Constable

PESHAWAR, Pakistan — Nobody saw it coming.

The virus was so close to being wiped out. Millions of young children had been repeatedly inoculated, and in March older ones were added in a final nationwide vaccine push to ensure that Pakistan — one of only three countries where polio remains endemic — could be officially declared polio-free.

But another danger was lurking, in the same communities where vaccination efforts had long been underway. It was fear and suspicion, and it was so visceral — and so fast-moving in the digital age — that a single rumor of vaccinated children falling sick in a village school last month triggered panic and violence nationwide.

Since then, the anti-polio drive has been suspended until July while officials scramble to regroup. Half a dozen vaccinators or their guards have been killed, and new cases of children with numb or paralyzed limbs are being reported every week, setting back years of effort to eliminate the virus, health workers say.

“We blundered badly. We wanted to achieve a technical and operational success, a data-driven masterpiece. But we forgot that for a father and mother, the most sensitive thing is their child,” said Babar bin Atta, the government’s top anti-polio official. Despite intensive efforts to educate the public about the benefits and safety of the vaccine, he said, “we underestimated the degree of community resistance.”

At a time when fear and rejection of vaccines are rising globally and measles cases are spiking, polio is seeing at least a momentary resurgence in Pakistan. Between 1994 and last year, the number of infected children in Pakistan plunged from 20,000 to just 12. But 15 new cases have been reported this year. Unless the vaccination drive starts up again soon, some health experts fear that new cases could exceed 50 this year.

The threat of polio remains relatively low compared with that of measles, which was officially eradicated in the United States in 2000 but appeared in 350 new cases in 2018 and more than 700 this year. Across Europe, 34,000 measles cases were reported in January and February alone.

Measles can be fatal, especially to babies, and it caused more than 110,000 deaths worldwide in 2017. Polio, though rarely fatal, is incurable, and it can permanently paralyze a child within hours of infection. It is spread through fecal matter, especially in poor and unsanitary conditions, and is endemic only in Nigeria, Afghanistan and Pakistan.

“It is so depressing. One day of drama has ruined three years of work,” said a government epidemiologist in Pakistan, speaking on the condition of anonymity because he is not authorized to speak to the media. “People who used to welcome our teams into their homes are now closing the doors.”The hysteria that started at a school in the northwestern village of Mashokhel — and quickly spread via mosque loudspeakers and WhatsApp — had both unique cultural roots and broader, ­modern-day lessons.The northwest tribal belt, an ethnic Pashtun region near the Afghan border and the epicenter of polio in Pakistan, is deeply conservative, religious and suspicious of authority. Refusals for polio vaccines were once common there; many people suspected that the drops were part of a Western plot to control the Muslim birthrate, and Islamist militants periodically attacked vaccination teams.

Over the past several years, Atta and health officials said, educational campaigns and support from Muslim clerics helped change public opinion, extremist groups were driven from the ­region, and vaccine refusals plunged. But this spring, when officials announced that all children up to age 10 would be required to get polio drops, suspicion began to creep up again.

“We created a nuisance,” Atta said. “People got fed up with our teams making so many visits and asking so many questions. It only took one spark.”

On April 22, vaccinators spent the morning at a school in Mashokhel, a few miles outside Peshawar, the capital of Khyber Pakhtunkhwa province. Soon after they left, school administrators reported that dozens of students were vomiting and fainting. Among local residents, long-suppressed suspicions burst into a frenzy. An angry mob attacked the school and burned down the local health clinic.

“People were pelting my house with stones,” said Arshad Khan, 35, a longtime local health-care worker. He said that even during the years when Islamist militants were attacking vaccination teams, he stayed on the job. “There is nothing wrong with the drops,” he said, “but this misunderstanding, these fake reports, have hurt our efforts all over the country.”

As the news circulated that day via social media and cellphones, frightened parents rushed 40,000 children to hospitals in Peshawar. Health officials later reported that almost all were found healthy and sent home, but by then it was too late to contain the panic. Across the country, hundreds of thousands of parents refused to let their children receive the drops, and the vaccination drive was suspended.Police arrested 16 people in connection with an alleged plot to sabotage the polio campaign, including several staff members at the school, and pernicious messages and videos were posted online that added to the crisis. One showed a man, who was later arrested, instructing schoolboys to lie down on hospital cots and pretend to be sick. Another showed an unidentified man denouncing polio vaccinators as pimps and prostitutes working for the United States.Pakistani officials placed some of the blame on Facebook, saying they were in the process of asking the company to take down the posts. “They call this free expression, but there are some crazy pages with people playing a dirty game,” Atta said, adding that Facebook has millions of users in Pakistan. “They are exhorting anti-polio elements to go after our workers. People are being killed.”

Polio workers have long been targeted by Islamist militants, with more than 100 killed in the past decade. But over time, the attacks dwindled to a few incidents as public support grew and militancy was quashed. Now, in just three weeks, six vaccinators or their guards have been shot dead in Khyber Pakhtunkhwa and Baluchistan provinces. Some attackers, officials said, may not be religious fanatics but tribal militia members trying to “protect” their areas. In Peshawar, people are still shaken by the Mashokhel scare, and this week some said it had revived their suspicion of polio drops. Even some local officials said they plan to refuse to vaccinate their children. Some demanded to know why the government kept focusing on this particular disease and not others that are more common, such as malaria or dengue.

“I don’t understand why the government is forcing children to be vaccinated,” said Ashraf Ali, 38, a trading merchant who said he had now decided not to let his 2-year-old daughter receive the drops. “They keep insisting, but I keep refusing. I am the father of my children, and it is my choice.”

In Rawalpindi, a large city in Punjab province, water and sewer samples from many poor Pashtun communities have repeatedly tested positive for the polio virus. Health officials said they had hoped to vaccinate about 14,000 children there in the past month, but more than half of the parents refused. Several vaccinators were beaten.Noor Jahan, 30, a veteran vaccinator, made the rounds last week in a Pashtun neighborhood she has visited dozens of times. She chatted with families, trying to convince them that the drops were safe and that their children still needed a series of doses to become immune. People were polite but not really swayed.

“Look at how we live. The water is low, the sewers are bad, there is no health care when we get sick. But by hook or by crook, the government keeps bringing these drops to our houses and chasing our children in the street. Why?” said Ahsan Bahadur, 35, a father of two. “This is not up to the vaccine or the virus. It is up to God.”