GIVEN the recent resurgence of polio in Pakistan, there is a danger that polio may bounce back in the world, as measles did recently in the US.
Pakistan and Afghanistan are the only countries, where the virus is still endemic. Afghanistan had 13 cases reported in 2019, down from 21 cases reported in 2018, whereas Pakistan has documented 62 cases so far this year, mostly from Khyber Pakhtunkhwa. Nigeria, one of the last three countries with endemic polio, has not had a polio case for the past three years.
Pakistan’s polio eradication programme — not an easy challenge — has remained unchanged for almost three decades. For the same number of years, the country has been in the middle of continuous change .The turmoil of terrorist attacks, natural calamities, and displaced populations has created a moving reservoir of infection. The programme has witnessed turmoil of its own. Parents are misleading vaccinators by putting completed vaccination marks on their children thus indicating widespread vaccine refusals and vaccine hesitancy. Angry parents have beaten, even killed vaccinators.
There has been misinformation about vaccines, rumours and conspiracy theories, particularly following the Abbottabad raid of 2011. News of alleged CIA involvement in the vaccination programme continues to ricochet in local communities. These issues are on top of underlying systemic problems — low rates of education, malnourished children and poor sanitation; besides, almost one-third of the population practises open defecation. Karachi’s filth and flies are now international news. What chance do polio drops have in such circumstances?
Unless there is a change in strategy, Pakistan’s polio crisis will spill over into other countries.
The programme’s activities, unfortunately, are less than satisfactory, with less than optimal management — not counting the current blame game between representatives of past and present governments. As way back as 2011, the Independent Monitoring Board for polio highlighted this issue: “Pakistan’s progress now lags far behind every other country in the world. Without urgent and fundamental change, it is a safe bet that it will be the last country on earth to host polio.” The Technical Advisory Group on polio has called the communication strategies being used by the KP polio programme “not fit for the purpose”.
However, in spite of these challenges the polio eradication programme continues due to the government’s commitment and the extraordinary dedication and resilience of the programme staff, as well as with funding from generous donors. In 2017 when polio cases had come down to eight we felt hopeful. Now there have been 62 cases in these eight months. This resurgence has polio watchers worried about a potential spillover to the rest of the world, undoing the 30 years and $13 billion worth of work done by the Global Polio Eradication Initiative (GPEI). Given the serious potential for such a possibility, maybe it is time to admit that something may be missing in Pakistan’s polio eradication programme.
Analysis of national-level research over the past decade and recent research funded by the Shahid Hussain Foundation have demonstrated that what’s missing in Pakistan’s polio eradication programme is, one, an understanding of the big picture. This means, in part, acknowledging that money and technology do not work in a vacuum, but are applied in particular ways to particular contexts. And two, an overreliance on standard donor-funded vaccination drives, while neglecting routine vaccination services.
An examination of the Pakistani context shows us that there are systemic problems on the demand and supply side of the programme. On the supply side, for example, health services that include routine vaccinations are extremely poor, while polio vaccinations are proactively pushed. People are suspicious of a system that otherwise unresponsive to their routine needs chases their children aggressively every three months to administer the polio vaccine. The reporting requirement of the GPEI, that provides policy direction for polio eradication, distracts managers from formulating local implementation activities. Field monitoring systems are nonexistent, the cold chain is maintained erratically, and managers do not have the flexibility or the funding to implement solutions to problems in the field.
There are multilayered complexities in the nature of demand for polio vaccination services that the vaccination programme ignores — which has implications for parental compliance. An example is the communities’ prevalent framework of health-seeking behaviour, which is to seek medicine — vaccines are considered medicine, when children are sick, and not for prevention from the disease
Vaccine hesitancy has genuine reasons. Parents do not have knowledge of disease prevention principles, of side effects of vaccines and the vaccine schedule on one hand. On the other, there is lack of serious engagement on the part of programme staff that resorts to aggressive bullying to increase coverage rates, to ‘deliver results’.
“When someone can answer my questions and not just bully me then I’ll consider giving polio drops to my child,” said a mother who refused polio drops for her year-old son.
In his maiden speech a year ago, the prime minister promised to make decreasing childhood mortality a top priority of his government. Yet a year later, there is not much change in strategies for child health services delivery or improvements in routine vaccination or in the polio eradication strategy of past decades. In such a situation, hoping for different results is irresponsible, and Pakistan and the world cannot afford to take that risk.
To improve vaccinations in children including polio vaccination, the government’s technical team needs to translate the prime minister’s promise into an effective country strategy — a U-turn from the previous one. It should be based on community-specific needs and local implementation challenges; activities should respond to local constraints of supply and demand for services in specific localities. Pakistan’s polio eradication efforts need to be coordinated with those of Afghanistan’s. Poliovirus transmission in the two countries will not be interrupted unless all reservoirs are stopped simultaneously, including the reservoir corridors.
Proceeding as usual will not deliver promised results. It will undermine the prime minister’s credibility. We face the terrible possibility of worldwide resurgence of polio, spearheaded by Pakistan.
The writer, a public health consultant, and author, is a research fellow at Lums, Lahore.
Published in Dawn, September 23rd, 2019