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The polio story

February 14, 2012

PAKISTAN has failed to educate its children. It is now failing to protect them from communicable diseases like poliomyelitis, an untreatable crippling disease caused by a virus.

Preventive vaccines have however been developed and large regions of the world have been declared polio-free. It is, therefore, a pity that Pakistan is losing its war against polio. A spate of stories in the print media lately point to this tragedy. This is not at all surprising, given our criminal neglect of the health sector.

What is the polio story? When Pakistan launched itself on the long road to polio eradication in 1994, it showed remarkable success. It set up an effective surveillance cell and national immunisation days were undertaken.

The number of polio cases in the country fell from 1,155 in 1997 to just 28 in 2005. Then came the crunch. The war on terror in Fata made many areas inaccessible to the vaccinating teams and migration of populations from war-torn areas became a regular phenomenon. Polio made a comeback and in 2011 the Geneva-based Global Polio Eradication Initiative (GPEI) recorded 198 cases in Pakistan, the highest in any country for the second consecutive year. In 2010, the polio toll in Pakistan was 144. The country has now been dubbed a polio danger zone.

We thus have a giant share of the world total of polio cases of 647. There is unprecedented international interest in Pakistan’s polio policy today. Even one case here means a child anywhere remains vulnerable, so globalised has the world become. This argument has been vindicated by our recent ‘success’ in exporting the virus to China which recorded 18 cases of polio with the strain of the virus being traced to Pakistan.

Multiple factors are responsible for this failure. Broadly speaking, the high level of poverty and the near-collapse of Pakistan’s health delivery structure have made polio eradication an enormous challenge. So far as the specifics are concerned, the immunisation strategy is said to be flawless but not its implementation.

Ten to 12 national and sub-national immunisation days are held annually. Funds have been no problem either as foreign donors have been generous. There is no shortage of manpower — if anything there are too many cooks spoiling the broth.

What can be faulted is the implementation process that fails to cover every region of the country. Notwithstanding the loud claims made, serious doubts have been expressed by insiders about the coverage. The fact is that not every child under five receives the polio vaccine. This lapse is due to the prevailing insecurity that prompts parents not to open their doors to strangers. Others are influenced by the propaganda of clerics who discourage parents from cooperating.

It is not clear why a more democratic approach is not adopted. It is important that the local social mobilisers and trusted community leaders are taken into confidence and asked to facilitate access of vaccinators to their neighbourhoods. Dr Samrina Hashmi, president of the Pakistan Medical Association (Sindh), points out that the cooperation of GPs and the mohalla physicians who are the backbone of community health, could transform the polio immunisation drive.

The GPEI’s report also speaks of the health workers not being motivated enough, lacking ownership of the programme and there being issues of governance in the wake of the 18th Amendment. One source even spoke of ‘ghost’ vaccinators who draw hefty allowances but don’t exist. Conversely, efficient and committed individuals can make a difference.

There is the case of the health secretary in Punjab, who kept the EDOs on their toes and the province reported not a single polio case that year. Then he was transferred and you can guess what the results were after his departure.

These are problems of governance that can be handled if the political will exists. More difficult to resolve are the problems related to health, migration and poverty. Many paediatricians have pointed out that it is now an established fact that undernourished and weak children fail to derive immunity against polio from the vaccine they are administered.

Dr Hasina Shahani, the secretary general of the Pakistan Paediatrics Association (Sindh), says this is one reason why many children contract the disease in spite of receiving multiple doses. If they are suffering from diarrhoea or are debilitated, immunity may not develop. In Pakistan, 40 per cent of children are underweight and 50 per cent have stunted growth.

Dr Shahani also points to high mobility in the population especially from Khyber Pakhtunkhwa and Fata. Most of the cases recently recorded have been in Pakhtun children — even in Karachi — indicating the challenge faced in the war-torn regions which do not receive coverage. Families migrating from there infect new areas. The size of the infected population is actually larger — only one per cent show the symptoms and are diagnosed only when paralysis sets in — but others are carriers and can transmit the disease.

The problem can be solved by introducing greater accountability and transparency in the campaign. Let every EDO be responsible and answerable for his own district. Those whose districts remain polio-free for a year should be honoured.

A strategy must be developed of targeting the area where a case is detected with a follow-up mop-up campaign. The Expanded Immunisation Programme, which had reached impressive coverage a decade or two ago, is said to be on the decline. It should also be spruced up. Above all, we need peace. We now know that war and polio go together in Pakistan.

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