WHEN the polio vaccination drive in April 2019 outside Peshawar had to be abandoned because parents refused to have their children vaccinated, it was a reminder that the challenges to eradicate polio remain as large as ever. On the surface misinformation about the vaccine and resulting panic played a role in failure of this vaccination drive, the reality is that the actual failure is that of the vaccine delivery system.
During the drive in Punjab, Nasreen, a 30-year-old mother of three from a middle-class family, had refused to have her two-year-old son — born after two daughters — given polio vaccine, because no one had addressed her concerns regarding the vaccine. She had heard rumours that expired vaccine was being used. Also how did these ‘little drops’ protect against such a ‘big’ disease? The vaccinator came back in the evening with a police officer threatening arrest. The issue was resolved when Nasreen’s father-in-law, a schoolteacher, reprimanded Nasreen. The household will forever lose face in the community — their daughter-in-law, entangled with the police! Now during a vaccination drive, Nasreen takes her children to her parent’s house in a remote village where the vaccination teams do not come.
Pakistan’s Polio Eradication Programme and Expanded Programme on Immunisation, as vertical programmes with separate administrative structure and personnel, provide no other service except deliver vaccines. Vertical programmes are to be used when enhanced services are needed in special circumstances, or in special geographic areas. They are not to be a replacement for the fixed/ established vaccine services delivery system. Unfortunately in Pakistan, since effective vaccine services through fixed system are unreliable, these programmes remain the government’s sole strategy for vaccinating 38 million children with a new cohort added each year.
Since vaccination drives are donor supported, with earmarked funds, vaccinators are under pressure to meet the stipulated targets and to show ‘results’. It is up to them to convince, coax, threaten, bully and intimidate parents to comply. Policymakers in Islamabad assume that this strategy works, but it does not — national vaccination coverage rates on average hover near 50 per cent. At times this strategy backfires spectacularly. One step forward turns into two steps backwards.
Religion is not the reason Pakistani parents refuse the polio vaccine.
Funded by Shahid Hameed Foundation, Lums’ faculty has recently reviewed the EPI/ polio programme in Kasur district. Distrust of the system, lack of knowledge about infectious diseases, vaccine schedule, and how vaccines work were the main reasons for parental refusals. Mothers ignorant of the side effects of vaccination, once side effects occur — fever, loss of appetite — interpret these as sickness caused by the vaccine. When they seek help, the system that two days ago was right in their homes, is not available. The health centre, if there is one in the village is closed, or the doctor is not available. ‘Why is it that when we need medicine, there is no one? Otherwise they come into our house to give these drops and injections,’ is an oft-repeated question.
Writing about a similar effort in Nigeria — one of the other two countries aside from Pakistan and Afghanistan where polio remains endemic, the New York Times in November 2012 said that in “many communities targeted by the (polio) programmes, people perceive a gulf between global programmes like polio eradication and more immediate local health needs”.
The government’s point person for the vaccination programme, Babar Atta, acknowledged lack of trust and “severe community resistance against vaccination”. Mr Atta promises reduction in the number of vaccinator visits to homes, and the number of questions put to parents during subsequent drives. And the police will not be called. Let’s hope these tactics help, but they do not address the real reasons for refusals.
This problem of distrust and ignorance about vaccines has been repeatedly documented. It is quite baffling why policymakers do not take it seriously. Why are they not able to generate a strategy grounded in an analysis of why people react the way they do to this critical preventive health service brought to their homes for free, when they spend a substantial portion of their household income and travel long distances to seek curative health services for their children? The magical thinking and quick-fix solutions proposed by Mr Atta do nothing except further decrease credibility and increase distrust of the government.
Eradicating polio is not easy but countries have done it. US governments’ Vaccine for Children programme — that includes vaccination for polio, was successful because vaccines were delivered to children of all income levels, not only the poor, through the participation of public and private healthcare providers, insurance companies, state and federal public health officials, vaccine manufacturers, and parents. VFC programmes built and supported ‘medical homes’ for children integrating paediatric care with vaccinations as the mainstay of health services for children.
The other contributors to successful eradication of polio are a knowledgeable public and sanitary infrastructure. Pakistan’s literacy rate in women is 45 per cent and still lower in poor women whose children are the targets of the polio programme. The poliovirus is excreted in faeces, and because sanitary facilities are poor — almost 45pc of Pakistani population defecates in the open, the virus persists in the sewage providing a continuously available reservoir. Poliovirus has been isolated from sewage water in Peshawar, Bannu, and Mardan for the past two years. It is suspected to be in the sewage of other cities as well.
In his maiden speech to the nation almost a year ago, prime minister identified high child mortality rates as major concern of his administration. His technical team should think seriously about how to protect children from vaccine-preventable diseases, the major contributor to these rates. They need to be humble about the chronicity and complexity of the problems and without resorting to gimmicky tactics, design appropriate, integrated and well-supported service delivery systems, with ability for year-round vaccination delivery and related services. Periodic vaccination drives using vertical programmes should be part of that vaccine delivery system and not its substitute.
The writer is a public health physician currently a research fellow at Lums.
Published in Dawn, July 1st, 2019