Pakistan, along with Afghanistan and Nigeria, remains one of the world’s three polio-endemic countries. While the circumstances vary from one to another, the primary reason why these three have been unable to eliminate the virus is their shared lack of blanket vaccination coverage. According to Elias Durry, the World Health Organization’s chief expert on tackling polio, there is little to no hope of eradication without progress in this area.
In Pakistan, a number of interconnected factors have impeded increased vaccination rates. Many can be linked to the security threat of the Taliban, and ramifications of the campaign against it. In June 2012, the group established certain no-go areas and banned the vaccination drive in North Waziristan Agency in the Federally Administered Tribal Areas, a semi-autonomous region bordering Afghanistan. The Taliban reasoned that these campaigns were a Western conspiracy designed to render Pakistani children infertile. It did not help matters that Dr. Shakeel Afridi, who was the chief asset for the Central Intelligence Agency in locating Osama bin Laden for the United States, had done so by embedding himself in a vaccination team that visited bin Laden’s house.
The Taliban’s direct targeting and murder of dozens of polio team staff members, including female health workers and police constables across Pakistan, has also contributed to the challenges. Nearly 80 polio workers have lost their lives in such incidents since December 2012, which inevitably creates operational and logistical problems.
The military campaign against the Taliban and the group’s subsequent retaliatory attacks have complicated matters further. The government’s Operation Zarb-e-Azb and the National Action Plan on counterterrorism were both launched in 2014 in response to Taliban attacks such as the one on Karachi Airport that saw 36 deaths (including 10 attackers) and the killing of 132 schoolchildren at the Army Public School in Peshawar. While these campaigns and counter-campaigns were ongoing, polio teams simply had no access to affected areas.
A final key factor in the lack of blanket vaccination is the refusal of parents across Pakistan to allow their children to participate. This is a complex and multi-faceted problem that seems to have permeated every part of the country, particularly in the low income and less educated social strata. Since the campaign against polio vaccination is embedded in the socio-religious underpinnings of the country, including perceived Western opposition to Islam, and the message is spread primarily through clerics, countering the narrative is challenging and painstaking.
While these issues certainly persist today, there has been considerable room for optimism heading into 2017. The number of polio cases in Pakistan dropped from 306 in 2014 to 54 in 2015, and to date there have been just 18 reported incidents in 2016. A key factor in this has been the dramatic reduction in attacks on polio health workers. There have been only two in 2016, with one in April claiming the lives of seven police officers, and another in September taking one life in Peshawar. Several reports from independent think tanks corroborate the improving situation.
The adviser to Pakistan Prime Minister Nawaz Sharif on polio eradication, Senator Ayesha Raza Farooq, told me that attacks on polio workers were down by nearly 80% this year. “This is due to a strengthened political commitment under direct oversight of the prime minister,” she said. “This attitude then trickles down at the provincial level to the chief ministers and chief secretaries.”
Senator Farooq said there was now no area in Pakistan out of reach of polio workers. “In 2016, we have managed to reach the farthest, remotest nook and cranny in Pakistan,” she said. The only exceptions to this are small pockets where the military is still clearing out security threats, and there have reportedly been no cases of polio from high-risk reservoir areas since February this year.
A foolproof long-term solution to the health worker problem still seems impossible given that every national vaccination campaign involves over 200,000 people simultaneously taking to the streets; there are simply not enough law enforcement officials to throw at the problem. Yet long-term investment in, and restructuring of, police and security agencies and the criminal justice system could help.
Another, more short-term, solution is offered by Superintendent Police for Security Sahibzada Sajjad Ahmed of the Peshawar police force. “We have daily security briefings on polio vaccinations. We have dramatically expanded our cordon protocols during vaccinations, and we have learned tremendously from our past,” he told me. He said this was one of the reasons for the dramatic decrease in the targeting of polio workers.
The successful conclusion of Operation Zarb-e-Azb in many conflict-prone areas has also increased access to polio-affected populations, though there are still regular skirmishes and air raids against militants. The complete military control of these areas also creates its own problems in terms of limiting transparency, however. The return of displaced people has been less problematic but is occurring at a slow pace.
Targeting the cultural and religious factors that contribute to Pakistan’s poor vaccination rates is a far more complicated process than improving the security environment. Yet three potential solutions do exist. The first is to educate the public, which is, however, cost-intensive and time-consuming and carries no guarantee that the message will reach every person equally. The second is legislation that criminalizes the refusal to vaccinate children. This is far more cost-effective, easily deployable if there is political will, and capable of providing immediate results. The third option is one that Senator Farooq claims has achieved remarkable success, and involves overhauling the process of vaccinating to emphasize strategic science- and evidence-based interventions. This, for example, includes employing vaccinators who are based in their communities, especially in high-refusal areas. This allows them to have better access to local homes and vaccinate the children therein.
While Pakistan’s government once touted 2016 as the year the country would eliminate the polio virus, a range of hurdles prevented reaching this goal. But there is hope that with increasing state cognition of the depth and breadth of the country’s extremist problem and cultural barriers, there are finally mechanisms and methodologies in place that can help achieve this goal in 2017.
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