ISLAMABAD: Polio in Pakistan began its resurgence in the third quarter of 2018, and intensified in the second quarter of 2019, with a record number of 38 cases in that quarter alone, the Independent Monitoring Board (IMB) of the Global Polio Eradication Initiative (GPEI) said in its report.“This was followed by 30 cases in the third quarter of 2019. Major outbreaks have occurred across North and South Khyber Pakhtunkhwa (57 cases) (data as of 25 October 2019),” the IMB, established by the World Health Organisation (WHO) Executive Board said.
The IMB provides an independent assessment of the progress being made by the GPEI in the detection and interruption of polio transmission globally. It says no drafts are shared with the Polio Programme prior to finalisation. Although many of the data are derived from the GPEI, the IMB develops its own analyses and presentations.
Talking about the dysfunctional teamwork, the 17th IMB report of Nov 2019 said, when the Polio Programme performs badly, the IMB has found in the past that blame is shifted and deflected. The Polio Programme is in such a moment. It is a tense periodwhen the eradication effort has faltered badly. In the past nine months, there has been a deterioration of relationships, in-fighting, silo-based working and behaviours driven by fear of the consequences of failure. Initiatives were launched with insufficient consultation and collaboration.
The report said everyone in the Polio Programme needs to remind themselves that they are “one team,” a single force united in pursuit of a global public good of enormous importance. This is not happening at the moment. A one-team approach would convene all the key stakeholders, leaders, experts and representatives of communities and ask: What do you think about this strategy? Will this work? What other things are missing? How does it need to be aligned? A strategy that is fragmented, or that has been drawn up by a selected few without adequate consultation, is a strategy that is doomed to failure.
Regarding absence of political unity, the report said, until recently there was broad political consensus in support of polio eradication in Pakistan. This is no longer the case. The Polio Programme and the importance of delivering the polio vaccine has become a political football. The Polio Programme remains particularly susceptible in areas where the power structure is divided between different political parties. For example, Karachi, a city of 22 million people, is a longstanding ruling haven of the poliovirus. The Pakistan People’s Party controls the provincial government, whilst the city government has largely been disempowered; it is run by the Muttahida Qaumi Movement. The Pakistan Tehreeke-Insaf (PTI), of course, governs at the federal level. It manages the overall polio vaccination effort.
The report said this fragmentation of power can lead to problems in efficiently carrying out vaccination campaigns. If the government only goes into a neighbourhood for outreach through an elected member of parliament, those who supported his rival are more likely to be skeptical of the Polio Programme. How can the people of Pakistan have faith that the Polio Programme is working in their interests if they hear conflicting messages from their political leaders? At the October 2019 IMB meeting, there could not have been a starker contrast between the Nigeria and the Pakistan government delegations. Both groups were led by the health ministers and those running the programme delivery. However, the Nigeria delegation included all three chairmen of the Health Committees in the House of Representatives and the Senate, who were from different political parties. And what is more, Nigeria has just had a national election, just like Pakistan.
According to the report, the epidemiological situation the IMB spelled out is of grave and very deep concern. Pakistan has reported more than 80% of the total global polio cases this year, with 90% of them reported outside the traditional core reservoirs. The September 2019 campaign reported the highest number of missed children in Pakistan, ever. Throughout the lifetime of the IMB, the Technical Advisory Group for Pakistan has made helpful and constructive criticisms of the Polio Programme in Pakistan allowing technical areas to be addressed and strengthened. The Technical Advisory Group has worked closely with WHO and invariably its reports have been rather encouraging, with a tendency always to see light at the end of the tunnel.
However, the most recent report of this committee made a searing and devastating condemnation of the state of polio transmission in Pakistan. For example, on Khyber Pakhtunkhwa (KP): “The programme in KP has shifted from being an example to the country as a whole to becoming an emblem of the national programme’s current crisis. KP has re-assumed its position as a major global barrier to polio eradication.” And on Karachi: “Transmission in Karachi is now everywhere.” And on Punjab: “Signs of programme deterioration are everywhere.”
The report said there is also intense virus circulation in parts of Punjab, Sindh and Balochistan. The pattern of poliovirus-positive environmental samples is another indication of the depth of the problem. Within the core reservoirs of Peshawar, Karachi and Quetta block, 69% of samples were reported to be positive in 2019 (data as of 19 October 2019). It said this is compared to only 29% of samples in total in 2018. Outside core reservoirs, there has been entrenched transmission in Lahore (88% of 2019 environmental samples were positive; indeed, three sampling sites out of five were reported as 100% positive.
The report said within the core reservoirs (Peshawar, Karachi and Quetta block), transmission has been most intense in Karachi; all 11 environmental sampling sites have reported positive for wild poliovirus. Increased geographical dispersal of the virus is striking: 25 districts have reported polio cases so far in 2019. The comparable figure for 2018 was five districts. The number of infected districts, having either polio cases or positive environmental samples, has almost doubled: 51 (as of 2 November 2019), compared to 27 this time last year.
It said the Pakistan government has made strong statements of commitment and intent in response to the adverse polio situation in the country. The new health minister and the prime minister’s Focal Person on Polio Eradication have led a programme of action. Since taking office, Prime Minister Imran Khan has shown strong and committed leadership. He was already a great supporter of the Polio Programme in his previous political role and this has been carried over to his new role as the country’s leader.
Added to this, the report said, his strong personal and political emphasis on social justice is a powerful positive force connecting to the deep needs of polio affected communities in Pakistan. The prime minister had tasked the Focal Person and the new health minister with finding out what was wrong with the Polio Programme in Pakistan and why there is still ongoing transmission in the country. At the IMB’s October 2019 meeting, Pakistan’s health minister and the Focal Person reported on a meeting of the National Polio Taskforce a few days previously that had been chaired by the prime minister.
There were four major action points agreed for immediate implementation. First, to launch an intensive mass media campaign to counter misinformation and create awareness of the importance of polio vaccination. Second, to increase community engagement to help improve the overall health of polio vulnerable and neglected communities through coordinated efforts. Pakistan has already launched a major social protection and poverty alleviation programme called Ehsaas, (which means “Empathy”). This is being directed at many of those areas where there are communities most vulnerable to polio. Third, to achieve close coordination and full support of the Pakistan Army to help create a secure and enabling environment for the frontline health workers. Fourth, to emphasise the prime minister’s personal commitment and presence to finish the job, and his engagement of all chief ministers to support the Polio Programme.
The GPEI and the IMB have repeatedly stressed the importance of seeing Pakistan and Afghanistan as one polio epidemiological block. This perspective is now deeply embedded in the Polio Programme’s thinking and planning. It is appropriate given the common poliovirus reservoirs and the well-established population flows between the two countries. This thinking also led to the creation of a new polio “Hub.” This organisational structure has been set up since the last IMB report and has the intention of unifying the GPEI’s leadership and coordination functions within closer proximity to the two national jurisdictions.
