On the brink of eradication

February 11, 2024

Even after years of immunisation campaigns, polio remain endemic in Pakistan

On the brink of eradication


olio, the highly infectious virus that dominantly targets children under five, has been a global menace for many years. In 1988, there was an agreement towards eradicating the virus from around the globe, with an eventual 99 per cent decrease in cases reported. Nevertheless, Pakistan is still fighting its war against this disease, with another nationwide immunisation campaign having begun. The year 2023 concluded with a total of six polio cases, yet the more alarming factor was the large environmental detections, bringing the total to 82 by the end of the year. Pakistan now stands at the brink - either to perpetuate the global scourge or rise triumphant as the last rampart vanquishing polio into the history books.

Polio being a disease that can transmit to other people, the world is not safe from the risk unless the whole world is free from it. Polio is also among the few diseases for which no cure has been found once a person is infected. For Pakistan, a developing country with health infrastructure issues, eliminating the endemic is an utmost priority. For the citizens themselves, being safe from this virus remains a priority as it can have long-lasting consequences as devastating as permanent paralysis and muscle weakness if one is affected by it. Since it is a contagious sickness, there is a risk of an abrupt increase in cases unless everyone takes the vaccines. Exposure to this virus can potentially risk dependency for life, hindering one’s progress through life.

Despite the efforts of both local and international bodies, the disease remains endemic in Pakistan. Among the various issues regarding the immunisation programme, the most prominent are the myths and misconceptions surrounding the vaccine. While they are far from the truth and engulfed in propaganda, these misconceptions play an adverse role in the immunisation campaign. Once, there was a myth that the vaccine itself was haram, made up of ingredients forbidden by Islamic law. A prevalent myth is that infertility is a side effect of the vaccine. As a result, some parents have been hesitant to accept vaccinations for fear that their children would be sterilised. In some cases, these misconceptions and myths have led to violence. There have also been cases of polio teams being attacked by gunmen during door-to-door vaccination drives.

Apart from resistance to the vaccine itself, the campaign faces administrative issues as well. This further reduces the efficiency of the programme. Owing to the societal values of keeping women of the house away from men, the campaign has to be conducted by female volunteers to ensure access to most households. Not every area has women willing to carry out these drives.

Recently the risk to polio campaign workers prompted the government to assign security personnel to ensure their safety. Government and other agencies rely on the data collected by these volunteers to assess the performance of their intervention. Special ink will now be used to mark the thumbs of the children who receive the vaccination to keep a count. The reported numbers give the agencies an idea that the campaign went smoothly and achieved the desired goal. However, there have been reports of fake markings. Some parents, suspicious of the vaccine, managed to get hold of one of the pens used by the teams to mark the children as vaccinated and prevent them from getting a dose of the vaccine. The incident shows the extent to which some people will go to prevent their children from getting vaccinated.

The number of polio cases in major cities like Lahore is negligible, but that does not mean the threat has been averted for good. Given the densely populated nature of the city and the risk of rapid faecal-oral spread of the virus, there is a need for appropriate planning and intervention to ensure that the risk remains subdued. Furthermore, the abrupt emergence of eleven cases of polio in North Waziristan in 2022 highlights the need for actively addressing the concern, as in the year before, there was only one reported case of polio.

One of the key takeaways from the debate regarding the obstacles can be the lack of awareness and acceptability of the vaccine, especially in areas where education is not common. Here, knowledge needs to shift from the perspective of the policy implementor to the poor. There is a need to understand their concerns before choosing a solution. Instead of viewing those who resist the vaccine as a problem, a change in mindset is needed to consider how answering their concerns and acknowledging their existence can be the key to winning the trust of people with similar minds and moving them towards accepting the dose.

Covid-19 in Sierra Leone is a relatable example. A few cases in an area occupied by the poor, away from the main urban centres, were overlooked. A lack of information then blinded the authorities to the potential risk, vulnerability and suffering the inhabitants of the area faced. Eventually, an initiative to co-produce knowledge helped the authorities realise the danger, paving the way for policies to address it.

Given the urban sprawl in Pakistan, the task of overlooking and delegating the immunisation campaign is fairly difficult, especially on account of the existence of informal settlements. Demographic and health data are almost nonexistent for many informal settlements. This fact leads to urban health inequality. Taking a leaf from the enumerators’ book, data can be acquired to improve the decision-making at the city level. The concept of enumeration and mapping of informal settlements is not alien to developing countries. The technique has been successful in India, Kenya, Namibia and Uganda.

The initial question is the need to document informal settlements and their inhabitants. From a legal aspect, with no form of identification, the settlers may be considered illegitimate. Having no address on record, they will be excluded from household surveys or immunisation campaigns that go from door to door. Owing to the need for people to grasp the seriousness of this issue, enumeration will not only prove efficient but also serve as an awareness method.

The concept of enumeration revolves around community empowerment. Once people realize the nature of the issue, measures can be taken to ensure that they tackle the problem. Enumeration requires training for locals, upskilling and equipping them with the necessary tools to carry out the relevant tasks. In this case, the tools range from mapping, household surveys, census and questionnaires regarding responses to polio campaigns undertaken previously.

Upon approaching a community, interviews are conducted to understand their opinions on the vaccination programmes and address their concerns. Randomised surveys in a community can ask questions ranging from the number of polio doses their children have taken to the last time a team visited them and the common myths they have heard about the vaccine. Analysis of the survey data then leads to a better, targeted approach for the specific area. When the community is approached again, their concerns are addressed with supporting evidence. Experts from the field are cited (a doctor if the myth is about biology; a religious scholar if the concern is about religious sanction). Awareness raising through personal contact is often more effective than television or billboard advertisement as it is specific to an audience. Once a community backs the campaign, they can be asked for help with gathering data, raising awareness and conducting a polio vaccination campaign in their area.

While enumeration might seem an ideal solution, there are numerous obstacles associated with this approach. Unlike trained personnel from government institutions, volunteers from the community often need extensive training. Here, the lack of skilled manpower can prove a major hindrance. Considering the low literacy rates in some areas, it is not always easy to find people with the required skills to conduct these activities.

However, data generated by an enumeration exercise provides the state a sound basis for design of interventions. There is also an opportunity for the communities to engage with political and health stakeholders, voicing their concerns and having their issues resolved. In the case of polio, all misconceptions and myths can be refuted once people speak up and are promptly reassured with evidence-based answers. People residing in slums or informal settlements are typically more vulnerable to infections such as polio due to malnutrition. Enumeration is a powerful tool to help them and collect accurate data. With this, the health interventions have a greater impact and the ambiguity regarding the success of the campaigns is reduced.

Pakistan is now on an epochal cusp. Cultural obstructionism and disinformation can shelter endemic polio transmission, resigning thousands of the country’s vulnerable children to the debilitating misery. Alternatively, truth and community camaraderie can prevail and consign the scourge to history. The pieces align tantalizingly: innovative surveying, myth-busting, indigenous information systems and caregiver advocacy. The courage, knowhow and grit already reside within the people.

The writer is a UCL graduate with a master’s in urban economic development.He is the co-founder of HamSukhan, a community-based learning platform. X: @HamSukhanPk

On the brink of eradication