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Why isn’t Pakistan polio-free?

July 20, 2019

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The writer is a public health physician, a research fellow at Lums, and author of So Much Aid; So Little Development: Stories From Pakistan.
The writer is a public health physician, a research fellow at Lums, and author of So Much Aid; So Little Development: Stories From Pakistan.

IN April 2019 Dawn ran an article ‘Will Pakistan ever become polio free?” I think the pertinent question should be: ‘Why isn’t Pakistan polio-free?’

The number of cases of polio has continued to increase from 17 in April 2019 to 41 till early July and counting; 33 in KP including the newly merged tribal districts, three each in Punjab and Sindh, and two in Balochistan. These numbers demonstrate a backsliding from last year’s total of 12 cases and eight in 2017. Here we are after three decades of efforts, generous international funding — GAVI alone disbursed $1,291,736,081 and the 2018 Pakistan government budget allocated Rs.7.83 billion for the Expanded Programme on Immunisation. All governments of the past three decades had vociferously declared polio eradication their priority, so there was no lack of political will.

The reason given by policymakers and programme administrators for failure of polio eradication range from lack of quality vaccinations and the mishandling of vaccine by eradication teams, parental/community refusals, religious issues, fear of vaccines and poorly paid vaccinators. Overarching climate change and worsening environmental conditions leading to severe and frequent droughts, settlements without basic sanitation and clean drinking water are recent additions to the list. For example, there are 564 slums in Karachi where drains are full of raw sewage. Poliovirus has been isolated from sewage of cities in KP and is suspected in sewage of other cities as well. Senior government officials blame the ‘culture’ of Pakistan.

If India and Bangladesh can eradicate polio, why can’t Pakistan?

These explanations may ring true. However, they ignore what lies at the heart of this persistent failure. That is the failure of programme leadership to undertake serious analysis to determine reasons for poor performance of the eradication programme, lack of a coherent appropriate strategy based on this analysis, and blind overreliance on antiquated vaccination drives. In this context, hoping to improve vaccination rates by tinkering at the margins of the vaccine delivery programme is not likely to work in future.

What is likely to work?

It is instructive here to look at other countries that have successfully eradicated polio. The example of United States was cited in an earlier op-ed by the writer in this paper (‘Polio: no quick-fix solutions’, Dawn, July 1). Granted United States’ development level is way above Pakistan’s so it may not be considered a useful comparison. Countries closer to home, such as India and Bangladesh have also achieved polio-free status. Even the little Southeast Asian ones, eg Vietnam, are polio-free. Meanwhile Nigeria, one of the three countries — Pakistan and Afghanistan being the other two — harbouring the virus, is on its way to becoming polio-free. Nigeria has not had any case for the past 22 months and even Afghanistan has had only 10 cases this year.

How did India and Bangladesh that are culturally similar to Pakistan and have more or less similar levels of development do it? Briefly, they did it because their leaders did not resort to gimmicks, engaged seriously with the issues, analysed data to design overall programme strategy and a mix of activities, all tailored to local conditions and challenges peculiar to different communities.

For example, India, which as recently as 2009 had 60 per cent of all global polio cases, was declared polio-free five years later in 2014.This achievement was the result of India’s Expert Advisory Group’s recommendation of a strategy designed to ensure that no polio cases are overlooked and no children missed by vaccinators.

Each state conducted a detailed risk analysis and had an emergency plan to deal with any new cases, in line with recommendations from the Independent Monitoring Board. These risk analyses included review of surveillance gaps to allow supplementary immunisation activities to focus on areas with gaps in immunity. Serosurveys were conducted in the highest-risk areas to provide definitive information on children’s immunity status. The analysis led to focus on Uttar Pradesh and Bihar, two of the poorest states which had uninterrupted polio transmission, to target the children of migrant workers. The polio vaccine was given to each child along the trail followed by workers, as they moved in and out of the two states.

Although only 2pc of Bangladeshi children under five years old were immunised before 1985, this number jumped to 60pc within 10 years in spite of the overwhelming challenges faced by the country in the aftermath of it independence from Pakistan. By 2006, Bangladesh was polio-free. This result was possible because the government made the commitment to develop a national strategy in context of local conditions, and by instituting sanitary reforms. The cornerstone of the national strategy was routine immunisations. The strategy was based on local data and micro-planning that included mapping the community down to the most basic level to ensure all children could be reached by routine immunisations.

Sanitary reforms consisted of building latrines to reduce open defecation, to interrupt the faecal-oral route of transmission of virus. The strategy also included Regular National Immunisation Days and development of strong multisectoral collaborations such as mobilising 250,000 youth/student volunteers to educate communities. Bangladesh is now concentrating on quality surveillance and case detection (acute flaccid paralysis) to maintain its polio-free status.

If India and Bangladesh can eradicate polio, why can’t Pakistan?

Pakistan’s prime minister in his address on July 12, as he launched the low-income housing scheme in Islamabad acknowledged the learning and useful consultations he had, amongst others, with people who have done similar work successfully on low-cost housing in Mumbai (Bombay), India. Maybe his technical team for polio eradication should take a leaf from the prime minister’s book and learn from polio eradication experience of Uttar Pradesh and Bihar.

The writer is a public health physician, a research fellow at Lums, and author of So Much Aid; So Little Development: Stories From Pakistan.

Published in Dawn, July 20th, 2019