Monday, November 24, 2014

Pakistan’s Polio Tipping Point

ISLAMABAD – Early this month, tragedy struck Pakistan’s polio eradication campaign once again with the killing of two more polio workers and a policeman on patrol with the vaccination teams. The latest murders in Pakistan preceded the killing of nine polio workers in Nigeria, and follow the slaying of another nine Pakistani health workers in December and the New Year’s Day murders of development workers affiliated with public-health efforts. The continued targeting of such brave workers is posing a severe challenge to these countries’ public-health communities and their collective ambition to reach every child with lifesaving vaccines.

For Pakistan, the irony is that the country has been a success story for polio eradication, with the number of cases falling from 197 in 2011 to 58 in 2012. Despite recent challenges, Pakistan put vaccinators back on the job in 28 districts, where 12 million children needed to be reached. Widespread public support for polio eradication efforts has been reflected in a parliamentary resolution. The Ulema Council, a group of influential clerics, has given its backing as well.

The most recent report by the Independent Monitoring Board of the Global Polio Eradication Initiative, released in November 2012, acknowledged Pakistan’s recent progress – in stark contrast to the bleak outlook of its previous report. But it is critical that the country’s upcoming election does not jeopardize recent gains, particularly during the current low-transmission season, which is the best opportunity to stop the disease in its tracks. All political factions must remain committed to the eradication drive if it is to succeed.

Indeed, despite progress in 2012, we have not been able fully to interrupt the spread of the poliovirus in Pakistan, owing primarily to obstacles affecting program implementation and management. These challenges must be addressed through stronger governance at all levels, particularly given that state authority has been badly eroded in roughly a quarter of the country, where complex factors have created distrust in the name of ethnicity, politics, and religion, resulting in a massive breakdown in law and order.

Moreover, Pakistan shocked the global public-health community last year by adopting a constitutional amendment that led to the abolition of the national health ministry. Unfortunately, the sudden devolution of health responsibilities to the country’s provinces occurred without adequate preparation or oversight.

The simultaneous scaling back of the local-government system, along with the divisive politics of coalition governments in Pakistan’s fragile democracy, continues to undermine implementation of the polio eradication program. The resulting shortcomings in the country’s provincial health systems have manifested themselves not just in the inability to eradicate polio, but also in a recent measles outbreak, which has killed more than 300 children.

At the same time, local governments’ difficulties are having an adverse effect on provision of clean water and proper sanitation, which are vitally important for polio eradication and public health more broadly. There have also been cases of refusal by parents to vaccinate their children, typically at the behest of clergy members, owing to the belief that such public-health efforts are in fact a covert sterilization program. Indeed, refusal to vaccinate accounts for 2% of the children who are missed. A recent smear campaign aimed at discrediting polio vaccination, in which several MPs publicly took part, has complicated matters further.

Daunting as all of this may be, stalling vaccination is not an option. It is well established that when vaccination is impeded, the number of cases rises drastically, as was shown in Nigeria in 2003, where a ten-month delay led to the infection of thousands of people domestically, and to reinfection in more than 20 other countries.

A similar outcome was observed in Pakistan’s Swat Valley after the militant takeover of 2009 rendered the region inaccessible for months. This month’s decision to hold back vaccination in Karachi after health workers there were threatened, though understandable, is nonetheless a cause for serious concern in this respect.

As in Nigeria, vaccination delays will be highly detrimental for neighboring countries. Nomadic populations move freely back and forth across the vast and porous Afghanistan-Pakistan border. In 2011, a polio outbreak in China was traced back to Pakistan. India, polio-free for the last two years, is well aware that lasting domestic success depends on eradication efforts elsewhere.

Potential international risks go beyond the immediate neighborhood. Already, Pakistan is responsible for the recent appearance of wild poliovirus in Egypt. Fortunately, there is no evidence of transmission, but we may not be so lucky in the future. Indeed, the risk that Pakistani pilgrims could carry the problem with them on the 2013 Hajj, the largest annual congregation of Muslims, is not just a theoretical threat. A worst-case outcome there could set back the fight against polio by decades.

The scale of the challenge, and hence the multifaceted response that is needed, must not be underestimated. Polio today has become an example of the complex problems plaguing Pakistan’s state and its society.

Pakistan must increase its efforts on polio eradication for reasons that go beyond fulfilling a global health promise (which is reason enough in its own right). Success would be a sign of Pakistan’s ability to conquer complex challenges, and it would provide a blueprint for further development interventions. In eradicating polio, Pakistan would not just play its part in eliminating the disease worldwide. It would also reclaim its own global prestige and potential for progress in other areas.

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    1. CommentedBabar Shaikh

      I am just back from karachi where I was training District Health Officers from Sindh and Balochistan. My feeling is that Polio is more of a micro level problem and less of a macro level matter, and so is the corruption.

      Infrastructure is deplorable, cold storage is almost absent, vaccinators don't get paid, vehicles are broken down, POL is not available, no money for IEC campaigns, opposition by the local clergy etc. Moreover, Districts officers are not motivated.

      Therefore, highest level political pledges and the President's daughter and sister being the ambassadors of the campaign might not suffice.

      We need to find out an out of the box solution.

    2. CommentedKen Presting

      I can't think of a more apt indicator of the ironies of today's politics, than that a nuclear-armed country like Pakistan should also be filming elected representatives opposing Polio vaccination. I will never forget the change in my sense of human potential, and human responsibility, when I learned that smallpox had been eradicated. No longer can any of us shrug, or throw up our hands, and pretend to ask, "What can be done?" Now we know - we can do anything from fly to the moon, to cleansing the planet of a microscopic germ.

      On the other hand, as I write this I am also reminded of a famous title in a policy journal, 'MAD vs. NUTs" on the debate over nuclear armament. Back then, what frightened us most was our own insanity. There seemed to be no way to avoid a nuclear war, but we did. Today it seems we still have to fear our own insanity more than any natural enemy. But it is genuine progress that the international actors we fear most are small countries and bunglers, rather than the leading nations.

      We all have plenty of work to do as activists, thinkers, and writers. But I believe we are on the right track. We understand the essential elements of the task.

      Success with Polio will breed courage to challenge the status quo on even harder problems, such as global warming.