The pernicious problem of polio
By Arsla Jawaid
30 April 2014
On the heels of India’s successful campaign against polio, Pakistan continues to face challenges in its efforts to eradicate the scourge.
Completing three years of eradicating the poliomyelitis disease that at one point plagued the entire country, India achieved a historic global health victory. In late March, the country received polio-free certification from the World Health Organization, a rare success story in a region that contains two of the remaining three polio endemic countries.
In 2009, India recorded 741 cases of polio, the world’s highest number of cases that year. By 2010, cases had drastically dropped to 42, and the last case of polio in India was recorded on 13 January 2011 in West Bengal. By contrast, Pakistan recorded 198 cases of polio that year, the highest in the world at the time.
In 1988, wild poliovirus (WPV) remained endemic in 125 countries, paralysing more than 350,000 children every year. In response to a global health emergency, the Global Polio Eradication Initiative was launched under the WHO to address and eradicate polio. As a result, in 2011, 620 cases were recorded in 16 countries. Through concerted efforts by the international health community, national governments and private donors, today polio remains endemic in only three countries – Afghanistan, Pakistan and Nigeria.
While these three countries pose serious concerns for the health community, the world has seen unparalleled success in eliminating certain strains of the potentially fatal disease. Wild poliovirus type 2 (WPV2) was eliminated in October 1999, with the last case recorded in Aligarh, Uttar Pradesh in India, once an epicentre of the poliovirus. Today, all current cases of polio fall within the WPV1 category, the remaining and most commonly detected strain of polio that causes one case in every 200 infections. WPV3 is a more deadly strain related to approximately one in every 2000 infections, but despite causing fewer cases, can transmit widely and go undetected for a longer period. The last known WPV3 case in Asia was recorded in Bara Tehsil, Khyber Agency in Pakistan’s Federally Administered Tribal Areas (FATA) on 18 April 2012.
Poliomyelitis is a highly contagious disease that affects vulnerable humans, particularly children under the age of five due to their weak immune systems. Entering the environment through the faeces of those affected, it persists in contaminated areas and is spread through the faecal-oral route, i.e. contaminated water, food or direct contact with infected individuals. As of yet, there is no cure for the disease but it can be prevented. Eradication efforts have focused on isolating the virus, which disappears from affected communities when all children have been vaccinated and it has nowhere left to go. The poliovirus is particularly active during the monsoon season, when impoverished communities are left exposed to unhygienic conditions and poor sanitation facilities.
While countries struggle to bring an end to this menace, polio exportation has become a serious concern. The situation is grave as even one infected child can serve as a carrier of the virus, thus posing an imminent threat to the entire international community. Over the years, movements of people from endemic countries have led to polio detection in previously polio-free countries, including China, Syria, Israel, Egypt and most recently, Iraq.
India’s success story
Once declared the toughest place in the world to eradicate polio, India responded to the polio menace in an exceptional manner. Equipped with strong political will and national consensus, India was able to declare a polio emergency and, unlike some of its regional neighbours, bring an end to the crisis.
International organisations have played a prominent role in the polio-eradication effort. With UNICEF handling communications and media outreach by employing both modern and traditional methods to create awareness, the WHO has been active on the technical front, collecting data, purchasing vaccines and monitoring activity to identify and address any gaps in eradication efforts. While these two organisations have performed the same duties in other endemic countries, the efforts in India received a boost when the government declared polio a national emergency and adopted a hands-on approach.
Cutting across all sectors, operational strategies focused on gaining access to the most deprived populations to increase immunity, thus halting the transmission of the virus. The government contributed USD 2 billion to the campaign and set up infrastructure to monitor efforts while nationally employing 2.3 million health workers. During the National Immunization Days (NID) the entire state machinery gears up for the polio eradication programme, with monitoring efforts that reach the village level and delivery strategies to maximise coverage. While the international community and government monitor such efforts, the real work is done by health workers on the frontlines. India currently has over 850,000 accredited health workers as part of the National Rural Health Mission. Their job mainly focuses on maternal health for which they receive a mere INR 75 a day. However, these workers also vaccinate children for polio as well as create awareness within communities for immunisation drives, a job that is not always easy.
Apart from conducting timely and rigorous vaccination campaigns, anti-polio communication efforts in India have focused on both the local and national levels, from mullahs issuing letters deeming the vaccine safe and in accordance with Islam, to Bollywood celebrities such as Amitabh Bachchan appearing in public service advertisements earnestly requesting families to inoculate their children. Such communication strategies introduced by the government and UNICEF have had an enormous impact and also assisted health workers in creating awareness in communities with high refusal rates. Reports from India’s National PolioPlus Committee of Rotary International show that refusal rates were particularly high in Muslim communities. Of the 676 polio cases recorded in India in 2006, 548 were from Uttar Pradesh. Of these, 59 percent were from the Muslim community. WHO reports showed that Muslim families in India tended to refuse the vaccine, believing that it contained pig fat or was a ploy to sterilise children and eliminate Muslim families from India.
By bringing together various constituent groups, communication strategies – particularly those involving the ulema, or community religious leaders – have yielded tremendous results. By reaching out to the ulema at the local level and gaining their approval, UNICEF managed to create positive awareness for the anti-polio campaign by issuing flyers, making banners and, in some cases, holding polio vaccination drives within the mosque premises, thus alleviating the concerns of many within the Muslim community. Furthermore, health workers who went door-to-door administering vaccines faced decreased opposition by carrying letters signed by the ulema urging families to vaccinate their children.
India’s unprecedented progress is not due to any single strategy. Its strength lies in the cohesive structure that it created and utilised. Meticulous data monitoring, vaccine procurement, timely and consistent campaigns, sensitive surveillance and emergency response plans have all contributed to the success of the programme. While these mechanisms are also in place in other endemic countries, India’s ability to transform itself was bolstered by a strong contingent of health workers, dynamic communications strategies, and, most importantly, political will and national consensus.
Pakistan’s continuing campaign
From the outset, Pakistan’s polio story seems bleak and points to alarmingly dismal results. In 2005, Pakistan recorded 28 cases of polio, but only five years later, the country experienced a significant regression with 144 cases. Further illustrating the alarming upward trend, 198 cases were recorded in 2011, making Pakistan the highest polio-infected, endemic country in the world. Through concerted efforts by the government, the WHO and UNICEF, Pakistan showed a remarkable 71 percent decline in 2012 with a reduction to 58 cases. While many deemed it on the path to recovery, optimism took a backseat when only last year 93 cases were recorded. So far in 2014, Pakistan has recorded 50 cases of WPV1.
The statistics raise serious alarm bells for the international community and prove problematic for the country. A constant fluctuation in the numbers would seemingly demonstrate that polio eradication efforts have had minimal success, and the situation in the country remains a major threat to the global health community. In January 2012, 21 cases of polio in China were linked to a virus emanating from Pakistan. The same virus strain also led to the discovery of polio in Israel, Egypt and Palestine, prompting emergency vaccination drives in all three countries. Furthermore, with the rapid movement of fighters from Pakistan to the Syrian civil war, the poliovirus has also travelled to an already conflict-ridden zone, generating 38 cases of polio and sparking international concern and outrage. Should Pakistan fail to show a decline in polio cases by 2015, those travelling from areas with active transmission of polio could face vaccination requirements. Desperate to maintain its polio-free status after striving to eradicate the virus, India has already issued a travel ban and has stationed oral polio vaccine administrators at border check posts, for fear of the virus returning.
This year, of the 50 cases of polio recorded in Pakistan, FATA accounts for 39 and Khyber Pakhtunkhwa (KPK) province has had eight, with three other cases registered in Sindh. Of the 39 cases in FATA, 34 emanate from North Waziristan, which has seen a vaccination ban since July 2012, thus depriving close to 290,000 children from ever receiving the vaccine. Pakistan has suffered not only from bad management and a lack of political will, but also damaging controversies, the most prominent being that of Dr Shakil Afridi, who assisted the CIA in locating Osama Bin Laden in May 2011 by running a fake polio vaccination campaign. The effects of this have been devastating and since then anti-polio campaigns have been viewed with tremendous suspicion as being a CIA ploy to spy on Pakistanis. Believing the vaccine to be against Islam, the Taliban have consequently exploited this sentiment to ban vaccination drives in Waziristan. Most disturbingly, since June 2012, attacks on health workers and security personnel have claimed the lives of as many as 54 people, seriously affecting the morale of workers and even halting some vaccination drives.
Although such facts are difficult to dispute, upon closer inspection Pakistan’s story is not as disappointing as it may seem. In 1994, when Pakistan first launched its anti-polio campaign, the country reported 25,000 cases. By 2013, the number dramatically dropped to 93. WHO monitoring data shows that the virus has been isolated to certain pockets of the country, and where consistent campaigns have been carried out it has been eradicated. In 2013, Punjab saw seven cases of polio, Sindh recorded 9, KPK had 11 cases while FATA recorded an overwhelming 66. Balochistan recorded no cases in 2013, proving that polio strategies and vaccination can be effective. Major polio reservoirs in Quetta have all been eradicated, and specific strategies to deal with intensifying reservoirs in Karachi and Peshawar have been introduced in addition to an umbrella programme. Furthermore, this year the majority of cases have emerged from North Waziristan, which is currently the epicentre of uncontrolled transmission.
While the virus has been isolated towards Pakistan’s northwestern border, it still poses a threat not only to the rest of the country, but also to Afghanistan, due to a porous border and regular movement of people. Afghanistan and Pakistan fall within the same epidemiological block, and the uncontrolled virus poses a major threat to Afghanistan, where 13 of the 14 cases reported last year were all linked to a virus emanating from Peshawar. In February, Kabul recorded its first case of polio since 2001, with the virus believed to be traced back to Pakistan.
Answering the challenge
Contrary to common criticism, the primary issue facing Pakistan is not scepticism about vaccines, refusal rates due to religious beliefs or the general reach of the anti-polio campaigns in safe areas. Regular and spot campaigns, despite the threats, continue vigorously in an effort to curb the crisis. Emergency outbreak response strategies are in place to address outbreaks in non-endemic areas such as Punjab and interior Sindh. Permanent Transit Points across the country also have vaccination centres for those travelling to mitigate the transmission of the virus. The national rate of refusal currently stands at 0.5 percent, and the majority of refusal cases are a result of deprivation of basic amenities such as food and water rather than suspicion of the vaccine due to its perceived lack of potency. Health workers in the field report that families living in impoverished areas question the motives of the government, which fails to provide them with basic amenities of food and water but readily sends health vaccinators knocking at their doors. Out of agitation and anger at the government, families refuse polio vaccines, deeming them unnecessary in the grander scheme of things, and demand health workers bring them food and clothing instead.
Communication strategies, much like in India, have involved sports celebrities (such as cricketer Shahid Afridi), but mass media campaigns have previously attracted negative attention, and unabated attacks on polio workers have cost the country dearly. Keeping in mind the Indian model and cognisant of the effect ulema have on local communities, revised strategies have focused on involving religious leaders to issue fatwas in favour of the vaccine or sponsoring anti-polio campaigns within mosque premises.
The most crippling problem for polio eradication in Pakistan, however, is the inability to reach children, particularly those in areas that are difficult to access. While better management and political solutions can go a long way in alleviating the problem, military campaigns in tribal regions, the Taliban’s ban on vaccination in FATA, and growing violence in Peshawar and Karachi make the areas highly dangerous for polio vaccinators to enter.
Despite the odds against it, Pakistan has made tremendous progress in eradicating polio through a range of different mechanisms that have helped isolate the virus to certain reservoirs. Most recently, the KPK provincial government executed a vaccination programme in Peshawar, administering polio vaccines amongst other vaccinations. Instead of conducting a staggered campaign, the drive was conducted and completed in a single day (Sunday) for twelve consecutive weeks. With law enforcement agencies providing tremendous security, the campaign not only helped boost the morale of health workers but also illustrated the overwhelming success of a health campaign when supported by the government.
Given the success of the Peshawar campaign, the same programme is now being implemented in other parts of the country. However, stronger political will is needed to address the polio problem, and the government must work to remove the obstacles preventing vaccinators from accessing children. Regardless of the operational and communication strategies in place, polio eradication will show limited results if the existing reservoirs are allowed to intensify. Dr Elias Durry, head of the WHO’s Global Polio Eradication Initiative in Pakistan, is confident that if “access to children in North and South Waziristan can be granted, there is no reason why Afghanistan and Pakistan won’t be able to achieve polio-free status in the near future.”
Pakistan stands the risk of remaining the only polio endemic country, sandwiched between two neighbours that have successfully eradicated the disease. It is imperative that the Pakistani government not only deem polio a national emergency, but also take cohesive and concrete measures to remove certain hurdles that threaten progress. Pakistan’s future is at risk and the time for apathy is long past.
~ Arsla Jawaid is a journalist and Managing Editor at the Institute of Strategic Studies, Islamabad. She holds a bachelor’s degree in International Relations from Boston University and can be followed on Twitter @arslajawaid.