Fighting the war on polio in Pakistan
The World Health Organisation (WHO), UNICEF and the Rotary Foundation came together in 1988 to lead a public health movement to eradicate poliomyelitis (polio) infection from the world. It was an ambitious task but due to the relentless effort of governmental and non-governmental bodies all over the world, polio incidence has dropped by more than 99 percent. This is a huge success which should be celebrated. But what is hindering this initiative from getting rid of the last 1% and ultimately wiping out polio from the world? Why are critics fearful that the world’s largest public health initiative may fail? Three-word answer: Pakistan and Afghanistan.
Pakistan along with Afghanistan is the only remaining country in the world where polio is still categorised as an endemic viral infection. Polio mainly affects children under 5 and one in 200 infections leads to irreversible paralysis (usually in the legs). Among those paralysed, 5 to 10 percent die when their breathing muscles become immobilised.
It is claimed that the polio immunisation campaign in Pakistan started in 1974 but in reality the efforts for eradication officially started in 1994. According to data published by the Global Polio Eradication Initiative (GPEI), 2014 was the worst year in more than a decade in terms of polio infections for Pakistan, with at least 306 cases reported. This was in sharp contrast to the 63 cases in 2013. Though last year the number of reported polio cases dropped to 53 but the question remains: Does the project have the capacity to completely eradicate polio from Pakistan or is the country’s healthcare system resilient enough to prevent and counter potential resurgence of polio virus in the near future?
India, which was once considered as one of the most difficult places in the world to eradicate the virus, is celebrating its five-year mark of without reporting a single case of wild polio this year. The strategies developed in India also helped Nigeria to put an end to the disease in the country.
Svea Closser in her book Chasing Polio in Pakistan provides a brilliant account of the polio eradication effort in the country and sheds light over the some of the problem areas. She rightly pointed out the global health leaders and major polio programme funders failed to take political concerns and power hierarchies into account, which is true for most of the foreign led or funded projects. Without understanding the local context, no ready-made solutions can be adopted and implemented. Especially in a society like ours where the government is grossly mistrusted and the local populace is easily swayed by conspiracies and factually incorrect information propagated by self-assumed experts.
The often-deadly attacks on polio field workers carried out by local Taliban fighters have made it particularly difficult to recruit and retain workers. The extremists spread various rumours like that polio drops are a Western conspiracy to sterilise Muslims or that the health officers are working as foreign spies. Much to our dismay, the local population has reasons to believe in the latter.
In 2011, the CIA recruited a Pakistani doctor, Shakil Afridi, to set up a fake vaccination programme for hepatitis B in Peshawar as a part of the hunt that finally killed one of world’s most wanted terrorists, Osama bin Laden. Extreme circumstances call for equally tough measures but while discussing the problems of social acceptability of polio health workers, we are forced to ask whether the American government even considered such costs whilst making the decision to violate the territory of a sovereign country? Or if there is ever going to be full local level support for foreign funded development projects in the country?
These problems also stem from the lack of government ability and political will to own the programme. Closser perfectly narrates the bureaucratic hurdles of the system in the following exchange between WHO officials and some high level government officials.
Government official 1: The provincial government can take the lead on it.
Government official 2: We can write a letter or can arrange a meeting. How many districts are there?
WHO official: Six or seven.
Government official 2: They will be happy to come here.
WHO official: It’s better if you go to the province…
Government official 1: The provincial office should take the lead.
Government official 2: We can write a letter.
WHO official: My suggestion is: If we want zero transmission by May, now is the time — a high-level federal-level mission going from Islamabad to this area.
Government official 2: When?
WHO official: Within a week’s time.
Government official 2: Dr A’s availability is very important and Dr A is not available next week.
Even after raising and discussing the issue in the meetings that followed, the cheques were finally given to the families in Islamabad months after they were originally supposed to be given.
However, the PML-N government has done far better than its predecessors and we hope that the recent collaboration with the Canadian government to eradicate polio succeeds. This means the government will also have to deal with the vast ranging and inter-connected issues of insecurity, weak health systems, shortage of staff and poor sanitation in the country. Approaching the local educational centres, madrassas and clerics to champion the cause of polio vaccination seems like the most viable option. Mediums of mass communication can be effectively utilised to transmit the seriousness and relevance of the issue to a common man. Involvement of medical anthropologists is imperative to prevent scenarios that we faced during the National Polio Campaign ’15 when over 16,400 families across the country refused to get their children vaccinated only within the first two days of the campaign. The unchecked migration of infected patients from Waziristan as a result of the on-going military operation, Zarb-e-Azb in the region is another potential threat that can sabotage the efforts to eradicate polio in Pakistan.
With all eyes on Pakistan, our leadership has promised to eradicate polio from Pakistan this year. Let’s hope that this doesn’t turn out to be another case of cultural optimism where politicians always claim that the breakthrough is just around the corner.
This article illustrates how difficult it has been for CDC to eradicate Polio due to politics and ignorance. We continue to work towards this goal, in addition to dealing with Ebola and Zika virus.
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