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March 29, 2016

Polio: one last push


March 29, 2016

“Not since the eradication of smallpox in 1980 has the world had a chance to wipe out an incurable, but preventable, human disease,” says Dr Hamid Jafari, former director of the World Health Organization’s (WHO) Global Polio Eradication Department.

Each year of delay in stopping the wild poliovirus, which is transmitted person to person through contact with infected human faeces, costs the global community a billion dollars. That’s what it takes to maintain the immunisation programme that must be sustained as long as even one case of polio is detected.

Pakistan and Afghanistan remain the only two countries where the wild poliovirus is endemic. This year, Afghanistan has detected one polio case and Pakistan has detected six so far.

Both countries are still hoping to stop its transmission, working towards that goal, and tantalisingly close to becoming polio-free. If no wild poliovirus case is detected for 12 months, there is a good chance the transmission has been interrupted – something that is confirmed once a country has been polio-free for an additional two years.

Once Pakistan and Afghanistan reach this goal, it would pave the way for the world to be polio-free, eliminating the risk of children becoming cripples or, in rare cases, dying.

Consider the progress made since polio vaccines were developed in the 1950s. Polio crippled about 35,000 children a year in the 1940s and 1950s in the United States alone. By 1979, the US was polio-free. Worldwide, polio declined from 350,000 cases in 1988 to 74 cases in 2015.

March 27 of this year was the second anniversary of the South East Asia region being certified as polio-free by the WHO. Nigeria stopped the spread of polio in 2014. If it remains polio-free by July 2016, the entire continent of Africa will have not detected any wild poliovirus for two years.

In 2012, India was declared polio-free – a country that had appeared to have no hope of emerging from its polio-endemic status, given the size of its population and large pockets of vulnerable populations.

India carried out an aggressive, sustained and innovative programme. The National Polio Surveillance Project, 2007 to 2012, was headed by Dr Hamid Jafari, assigned by the WHO as the main technical advisor to the Indian government.

Dr Jafari, whom I’ve known since he was a medical student in Karachi, supervised a staff of over 2,300 and supported the efforts of the government, Rotarians and other partners to ensure that polio vaccines reach 172 million children each year. As in Afghanistan and Pakistan, they were mostly from migrant families or lived in remote or hard-to-access areas.

Dr Jafari’s multi-faceted, research-based and tight-net strategic approach ensured that vaccinators reached the most vulnerable, particularly in areas with poor sanitation and high rates of diarrhoea.

This involved targeting high-risk areas like flood-hit districts and migrant and mobile populations for vaccination campaigns and routine immunisations. Mobile vaccination teams used motorcycles and boats, and even waded through water to reach children. They administered vaccines at bus stops and on trains and went house-to-house to routinely register new-born babies and ensure they were vaccinated.

India’s last known polio case was discovered on January 13, 2011. Why should Pakistani or Afghan children remain the only ones in the world at risk of being crippled by polio? In both countries, polio is now only found in pockets, mostly in conflicted areas and communities of displaced people and mobile populations. And it’s not the communities that resist vaccinations – less than one percent of parents refuse.

The question is how to reach the vulnerable areas. We must examine which children are not getting vaccinated and why, says Dr Jafari. Why are children from areas around Peshawar, Gadaap or Quetta being missed?

“This requires a continuous probing in a way that doesn’t get people defensive but focuses on the barriers that must be overcome. The key is to involve and empower the affected communities and engage people in their own language and on their terms,” says Dr Jafari.

There is no shortage of dedicated teams and community leaders in Pakistan. Plus, in 2015, the government made important structural changes to enable health workers to reach every child through the National Emergency Action Plan (NEAP).

The NEAP places the responsibility for the vaccination campaign on all levels of administration, each accountable to the other: polio-eradication committees, task forces and steering committees at the union, council, district, divisional and provincial levels, further linked to provincial task forces, the Prime Minister’s Focus Group on Polio Eradication and the National Task Force on Polio Eradication.

Pakistanis can no longer blame the government for inaction. The onus now lies on the regularity of the coordination committees’ meetings and their determination in identifying and closing the gaps, whether they be transport, security or salaries.

“A lot depends on the vaccinators, how they are being trained and treated and how are they working and communicating,” says Dr Jafari, “and the level of follow up with the command and control, emergency and accountability structures.”

Since these structures were implemented, Pakistan has seen a dramatic decrease in polio: 80 percent in 12 months – from 306 reported cases in 2014 to 54 in 2015. This is no small feat for a country beleaguered by so many other issues.

The odds are not worse than those in India or Nigeria. Yes, there is an insurgency but not all militants oppose polio vaccinations. Taliban leader Mullah Omar actually issued a letter in 2010 endorsing the polio vaccination campaign. The Afghan Taliban allow polio vaccination campaigns to take place, observing a truce during campaign days.

Looking ahead, we need a paradigm shift. Says Hamid Jafari: “We have to find ways to get women educated and children vaccinated even where there is fighting and long running conflicts. Important lessons are being learned in the fight against polio in Pakistan. These lessons could guide strategies that may not only maintain delivery of essential services to the most vulnerable populations rather than waiting for the conflict to end, but will also enhance the potential for building peace.”

The argument that Pakistan can’t eradicate polio unless Afghanistan does, because of the porous borders, is a false narrative, he says. Both countries export polio to each other but Pakistan, as the larger, more complex country, has to be the major driver.

Pakistan is not the world’s poorest, most conflicted or fragile state. Pakistanis have shown tremendous resilience and determination in overcoming all kinds of odds. This too, is a fight that we can win. We must win. It just needs one last push.

The writer is a freelance journalist, editor and filmmaker based in Cambridge, MA.

Twitter: @beenasarwar