Early this month, tragedy struck Pakistan’s polio eradication campaign once again with the killing of another two polio workers and a policeman on patrol with the vaccination teams. The latest murders follow the slaying of nine health workers in December and the New Year’s Day murders of development workers affiliated with public-health efforts.
The continued targeting of such brave workers is posing a severe challenge to Pakistan’s public-health community and its collective ambition to reach every child with lifesaving vaccines.
The irony is that Pakistan has been a success story for polio eradication, with the number of cases falling from 197 in 2011 to 58 in 2012. Despite recent challenges, Pakistan put vaccinators back on the job in 28 districts, where 12 million children needed to be reached. Widespread public support for polio eradication efforts has been reflected in a parliamentary resolution. The Ulema Council, a group of influential clerics, has given its backing as well.
The most recent report by the Independent Monitoring Board of the Global Polio Eradication Initiative, released in November 2012, acknowledged Pakistan’s recent progress – in stark contrast to the bleak outlook of its previous report.
But it is critical that the country’s upcoming election does not jeopardise recent gains, particularly during the current low-transmission season, which is the best opportunity to stop the disease in its tracks. All political factions must remain committed to the eradication drive if it is to succeed.
Indeed, despite progress in 2012, we have not been fully able to interrupt the spread of the poliovirus in Pakistan, owing primarily to obstacles affecting programme implementation and management.
These challenges must be addressed through stronger governance at all levels, particularly given that the state’s authority has been badly eroded in roughly a quarter of the country, where complex factors have created distrust in the name of ethnicity, politics, and religion with massive breakdown in law and order, as a result.
Moreover, Pakistan shocked the global public-health community last year by adopting a constitutional amendment that led to the abolition of the national health ministry. Unfortunately, the sudden devolution of health responsibilities to the country’s provinces occurred without adequate preparation or oversight.
The simultaneous scale-back of the local government system, and the divisive politics of coalition governments in Pakistan’s fragile democracy, continue to undermine implementation of the polio eradication programme.
The resulting shortcomings in the country’s provincial health systems have manifested themselves not just in the inability to eradicate polio, but also in a recent measles outbreak, which has killed more than three hundred children.
At the same time, these difficulties of the local governments also lead to problems in providing clean water and proper sanitation, which are vitally important for polio eradication and general public health.
There have also been cases of refusal by parents to vaccinate their children, typically at the behest of clergy members, owing to the belief that such public-health efforts are in fact a covert sterilisation programme. Indeed, refusal to vaccinate accounts for two percent of the children who are not vaccinated. A recent smear campaign aimed at discrediting polio vaccination, in which several legislators publicly took part, has complicated matters further.
Daunting as all of this may be, stalling vaccination is not an option. It is well established that when vaccination is impeded, the number of cases rise drastically, as was shown in Nigeria in 2003, where a ten-month delay led to the infection of thousands of people domestically, and to reinfection in more than 20 other countries.
A similar outcome was observed in Pakistan’s Swat valley after the militant takeover of 2009 rendered the area a no-go region for months. This month’s decision to hold back vaccination in Karachi after health workers there were threatened, though understandable, is nonetheless a cause for serious concern in this respect.
As in Nigeria, vaccination delays will be highly detrimental for neighbouring countries. Nomadic populations move freely back and forth across the vast and porous Afghanistan-Pakistan border. In 2011, a polio outbreak in China was traced back to Pakistan. India, polio-free for the last two years, is well aware that lasting domestic success depends on eradication efforts elsewhere.
Potential international risks go beyond the immediate neighbourhood. Pakistan is already responsible for the recent appearance of wild poliovirus into Egypt. Fortunately, there is no evidence of transmission, but we may not be so lucky in the future.
Indeed, the risk that Pakistani pilgrims could carry the problem to the 2013 Haj, the largest annual congregation of Muslims, is not just a theoretical threat. A worst-case outcome there could set back the fight against polio by decades. The scale of the challenge, and hence the multifaceted response that is needed, must not be underestimated. Polio today has become an illustration of the complex problems plaguing Pakistan’s state and its society.
Pakistan must increase its efforts on polio eradication for reasons that go beyond fulfilling a global health promise, which is more than a reason to support in its own right. Success would be a sign of Pakistan’s ability to conquer complex challenges, and it would provide a blueprint for further development interventions.
In eradicating polio, Pakistan will not just be playing its part in eliminating the disease worldwide, but also reclaiming its global prestige and potential for progress in other areas.
The writer is the founding president of the NGO think tank, Heartfile. Email: sania@heart file.org