On, Oct 15, 2018, after eight long years, I walked out of the Pakistan Polio Programme and took up a political office. I had been appointed the prime minister’s focal person on polio eradication.
The question — why do we continue to have so many un-vaccinated children (referred to as 'missed children') despite successive years of ambitious vaccination campaigns across the country — had challenged me since my days in the eradication programme.
It came back to haunt me.
When I took over, we already had six reported polio cases. A majority of the samples taken from sewage water in different cities were showing the widespread presence of the highly infectious P1 strain of the virus. The question everybody was asking was: 'Why is there a sudden spike in polio cases?'
The easy answer to that is, historically speaking, there has always been a spike in polio cases with each political transition. That it is because whenever a new government takes office, there is a massive reshuffling of district administrations, including in the health sector, across the country. Shifting priorities lead to missed targets.
This has been the traditional explanation for this phenomenon; but I knew I needed to probe the problem deeper.
“Why don't we have more cases, despite such heavy concentration of the virus?” I asked. The standard reply was that the immunity of Pakistani children had reached optimum levels as a result of repeated campaigns. "That is why we don’t see more cases," I was told.
Data told us that out of 40 million children under the age of 5, only 0.3-0.4 million children were missed due to their not being available or because of parents' refusal.
In other words, the data claimed that the Pakistan Polio Programme was reaching over 99pc of its total target. Other countries which successfully eradicated the virus had done it with 95pc coverage of their target population. By that same measure, we should have eradicated the poliovirus many years ago.
Yet here we were. It was clear that the rising polio cases were signalling an underlying problem in our approach. It turned out that the fault was in our polio programme’s continued failure to correctly evaluate the number of missed children and take meaningful measures to rectify it.
In December 2018, there was a massive outbreak in the Bajaur tribal district. An inquiry revealed — to my horror — that rather than reporting refusing children, teams were handing parents identification markers to mark their children as vaccinated with the aim of misleading monitoring teams.
Refusal of vaccination could invite police action, so the polio teams, rather than risking enmity with the parents, simply showed them a way around getting their children vaccinated. This was my first exposure to the phenomena of fake finger marking — something I had never heard of during my eight years in the polio programme.
Later, the Peshawar incident of April 22, 2019 did a lot of damage. For all the hurt it caused to the polio eradication drive, however, it also shone light on the fact that community mistrust continues to be a major problem.
Post April, southern Khyber Pukhtunkhwa, Bannu and North Waziristan suffered one of the worst outbreaks since 2014. It came as no surprise that fake finger marking was also detected in the Bannu division, North Waziristan and Lakki Marwat.
We decided that if we are to win over the community, we must not make use of coercive measures. A ban was subsequently imposed on any punitive action or coercion against refusing parents. That's when a truer picture began to emerge: the number of missed children in Bannu shot up from 1,000 to 18,000; in North Waziristan from 1,000 to 8,000; and in Lakki Marwat from 1,000 to 15,000.
The rise in the numbers of missed children hinted at the scale of the problem: the polio eradication drives had been misreporting their own effectiveness. The average was almost 8pc missed children in each of these districts, which was previously being shown as less than 1pc. Eight percent missed children is a big number — big enough to cause the large-scale ongoing outbreak in the Bannu division.
Thankfully, the challenge is now clear. As the focal person on polio eradication, I am now spearheading new initiatives. Pakistan will counter the anti-vaxxers' campaign by launching a one of its kind public perception campaign in November this year.
Through the programme, we will aim to address the underlying problem of community mistrust and refusals.
A 24/7 call center is being launched to address queries and misinformation. A fruitful collaboration has also been carried out with Facebook, which has helped us remove and reduce dissemination of anti-vaccine content contributing to community mistrust.
Some of the unnecessarily ‘intrusive’ questions that are asked of parents by polio teams are being removed. The frequency of visits of polio teams and their supervisors is also being reduced, which is aimed at empowering parents to proactively demand their child’s right to immunisation.
We are dealing with a ferocious virus; epidemiology doesn’t change overnight, but I assure everyone, including the donors, that I will not sit idle. Our results will speak for themselves.
We came very close to ending polio in Pakistan in 2017, as virus transmission in the core reservoirs — Peshawar, Quetta and Karachi — had been interrupted. Unfortunately, during the low transmission season of the years 2017-18, the programme went into an early celebratory mode. Senior leadership became more focused on getting themselves decorated with medals and seeking service benefits. That was the make or break point for the programme, and should have been leveraged fiercely.
Now, we need to once again address community mistrust in order to confront the problem. I request media critics to put some faith in us. We are working day in, day out for the children of Pakistan, to ensure that they are spared by this deadly and crippling virus.
Everyone needs to play their part, including parents, caregivers, politicians, religious clergy and influencers. We need to reach every last child.
The writer is the Prime Minister’s Focal Person on Polio Eradication.