The South Asia Channel

The Polio Capital of the World

Pakistan's Army and Lady Health Workers are at the center of the global effort to eradicate polio. How successful have they been?

A Pakistan policeman stands guard as a member of a polio vaccination team administers drops to a child during a door-to-door vaccination campaign in Karachi on February 23, 2014. Pakistan is one of only three countries in the world where the crippling virus is still endemic, along with Afghanistan and Nigeria.   AFP PHOTO/Rizwan TABASSUM        (Photo credit should read RIZWAN TABASSUM/AFP/Getty Images)
A Pakistan policeman stands guard as a member of a polio vaccination team administers drops to a child during a door-to-door vaccination campaign in Karachi on February 23, 2014. Pakistan is one of only three countries in the world where the crippling virus is still endemic, along with Afghanistan and Nigeria. AFP PHOTO/Rizwan TABASSUM (Photo credit should read RIZWAN TABASSUM/AFP/Getty Images)

As the world prepares to mark World Polio Day on Oct. 24, Pakistan remains at the center of the global effort to eradicate the virus. Despite facing a host of challenges, Pakistan’s military operation in the country’s northwest paved the way for much needed progress. Sustaining said progress will prove to be the real test for the government.

Last year marked a difficult year for Pakistan’s efforts to combat polio and hence for the global campaign to eradicate the virus. Pakistan recorded 306 cases of wild polio virus in 2014, accounting for 85 percent of the world’s case count.

It also marked the highest number of cases in Pakistan since 2000 and the reversal of the great progress made in the years since slain Pakistani Prime Minister Benazir Bhutto inaugurated the country’s first polio program in 1994. In 2007, Pakistan came close to eradicating the virus, when it recorded only 32 cases.

However, operational challenges, a deteriorating security situation, and lack of political will have gravely affected Pakistan’s fight against polio.

One event dealt a particularly strong blow to the campaign. Shortly after U.S. Navy SEALs killed Osama bin Laden in Abbottabad, Pakistan in 2011, evidence emerged that the CIA had used a vaccination campaign in its effort to confirm bin Laden’s presence there. Actually a Hepatitis B campaign, its erroneous depiction as a polio campaign in a country that was already wary of the vaccine led to a backlash from both public health experts and the Taliban.

The Taliban, which has long considered polio vaccinations un-Islamic, banned vaccination campaigns in North and South Waziristan in June 2012 and started killing polio workers, labeling them CIA operatives. Watching the security situation deteriorate and polio cases dramatically rise, public health experts, enraged by the setback their campaign had received, wrote a letter to U.S. President Barack Obama in January 2013 demanding that the administration cease involving health workers in any of its covert operations.

Since 2012, 79 health workers and security officials guarding them have been killed by the Taliban and 53 more have been wounded in the attacks, according to documents shared by the Prime Minister’s Polio Monitoring and Coordination Cell. Due to the Taliban’s ban in Waziristan, close to 290,000 children were not vaccinated as part of Pakistan’s National Immunization Days over the past three years.

The poor security situation is felt acutely by the workers on the ground. In 1994, Bhutto launched the Lady Health Workers (LHW) Program under the Ministry of Health — a program to train women to deliver healthcare to their communities. In 2014, the ministry deployed close to 110,000 LHW making it one of the most extensive programs in the world. Lady Health Workers are at the fore of the anti-polio campaign, often receiving grave threats from the Taliban yet rarely receiving their salaries on time. A street protest in Punjab drew hundreds of LHW protesting the failure to disburse salaries. Ayesha, a Lady Health Worker whom I spoke to in Peshawar, planned to attend an upcoming protest making a similar demand. Yet she is determined not to give up: “This is our service to our country and we will continue doing this even if we have to die for it. I have been doing this for 13 years now. The government has really let us down. Polio eradication is a success because of LHW and the Army, and no one else should take credit for that.”

Interviews I have conducted with families and health workers demonstrate that insecurity and lack of access to children are not the only reasons the eradication campaign has suffered since 2012. In Sindh province, families turned door-to-door vaccinators away demanding food, water, and electricity instead. In Punjab province, communities have at times refused vaccinations citing concerns regarding the perceived un-Islamic nature of vaccines, their purported use as a sterilization tool, and questions regarding the purported presence of pig fat in the vaccine. On the rare occasion, especially in Khyber Pakhtunkhwa, communities have voiced fears that polio vaccinators were collecting information on children in the community and marking houses for drone strikes.

Despite the campaign’s misfortune in 2014, this year is shaping up to be far better. In 2015, 38 cases have been reported compared to 205 cases during the same period last year. The cases come from 17 districts across the country with Peshawar recording the highest (10) followed by Khyber (7). Pakistan is currently undergoing a low transmission season (October-April) during which circulation is slow, making it the prime window to curtail the virus and boost the immune system.

The most significant success for the campaign this year came when vaccinators regained access to children in the Federally Administered Tribal Areas (FATA) as a result of the Pakistan Army’s military operation in Waziristan launched in June 2014. Elias Durry, the World Health Organization’s (WHO) emergency coordinator for polio eradication in Pakistan, told me: “The access to children in Waziristan would not have been possible without the engagement and influence of the Army.” WHO estimates that health workers vaccinated close to 650,000 people who left the areas, including nearly half a million children, at checkpoints on the roads leading out of the tribal areas and in Internally Displaced Persons camps set up by the military. The Army stepped in to play a role in eradication efforts in the Federally Administered Tribal Areas while Rangers and police have been deployed to secure health workers against attacks in Karachi and Peshawar.

The temporary 2014 WHO travel restriction placed on Pakistanis requiring them to produce government-issued polio vaccination certificates if they wished to travel abroad provided an impetus for further action. For too long polio was considered a poor man’s burden. By declaring polio an international emergency, global mechanisms served as critical pressure points for a government that remained ineffective in addressing the crisis.

Despite the great progress made on a number of fronts, tremendous challenges remain. Durry argues that pressing issues of “governance, accountability and quality of workers has never been addressed.” While noting the importance of the military’s efforts in enabling progress, he warns: “the work must not be diluted or we will miss critical intervention. If the national effort is not focused on conducting quality campaigns in high risk areas, Pakistan could very easily slip back into a dangerous situation.”

The risk of the virus traveling with a highly mobile population is still substantial. Environmental samples — polio is transmitted via the oral-fecal route making it particularly pronounced in areas where water sources are not sanitary or children are exposed to open sewages — have tested positive in all major cities including Karachi, Lahore, Multan, Peshawar, Islamabad, and Quetta, implying that the virus remains everywhere; cases recorded this year come from the same places which have traditionally been deemed high-risk.

One day blitz vaccination campaigns in Peshawar and Karachi have helped curb attacks but they have led to concerns regarding the government’s preoccupation with quantity and not quality. Health workers I spoke with in Khyber Pakhtunkhwa complained that young, inexperienced girls are hired to administer vaccines without receiving proper training. Furthermore, payment mechanisms for health workers continue to suffer from inefficiency, and security concerns coupled with a lack of political will has derailed morale.

Of critical importance is the need for a localized and robust communication strategy given the prior suspicion of the campaign. After 2012, publicized campaigns and the involvement of high-profile celebrities garnered negative attention, making it easier to target vaccinators. Greater success has been noted when mosques and religious leaders have been involved in the communities. In some instances, religious leaders have issued sermons in favor of the vaccine or allowed vaccination drives to take place within the mosque boundaries — a strategy that has yielded tremendous and lasting success.

Ayesha Raza Farooq, the prime minister`s focal person for polio eradication, stresses the importance of robust communication and advocacy stating, “Community involvement is key in order to build trust.” While lauding the efforts of the Army in gaining access to the tribal areas Farooq mentions, “the political commitment of the current government is high and the Prime Minister is personally involved in the oversight. Our biggest challenges will be to ensure access and that local districts don’t become complacent.”

While Pakistan celebrates a dramatic decrease in the polio count this year, there is need for caution. With Nigeria now removed from the WHO list of polio-endemic countries and Afghanistan recording just 13 cases this year, Pakistan may be the last place on Earth to eradicate the virus. The one thing it can bet on is the determination and perseverance of its Lady Health Workers.

RIZWAN TABASSUM/AFP/Getty Images

Arsla Jawaid is the former Managing Editor at the Institute of Strategic Studies, Islamabad (ISSI). She is currently pursuing an M.A. degree in International Affairs at Columbia University. Follow her on Twitter: @arslajawaid. Twitter: @arslajawaid

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