ISLAMABAD – As Pakistan heads towards general elections on Thursday, February 08, leaders of its polio programme are hoping that improved political stability and a more stable security situation could help make 2024 the year for final eradication of the crippling disease from the country.

Pakistan and Afghanistan, neighbouring countries sharing a porous border, are struggling to completely eradicate the wild poliovirus from their countries.

Experts predict that wild poliovirus could be eradicated globally within the next three years, if all goes well. What happens in Pakistan and Afghanistan are central, however, is central to making that happen.   

According to the Pakistan Polio Eradication Program, six wild poliovirus cases were reported in the country in 2023 – another six in Afghanistan. While several imported cases of wild poliovirus were also detected in Mozambique and Malawi in 2022, those were deemed to have been imported from Pakistan, and no further cases have been reported over the past 15 months. 

In Pakistan, no wild poliovirus cases have been confirmed so far in 2024 – putting the country on track for ending wild poliovirus soon, if not this year. 

First national anti-polio drive of 2024 was hit by militant attacks

However, Pakistan’s first national anti-polio drive, which kicked off last month to immunize 44.3 million children, suffered a notable setback, with two militant attacks in the country’s turbulent northwestern region bordering Afghanistan within a space of just a few days.

As a result of these attacks, which occurred in the same region of the country, a senior health official coordinating anti-polio efforts and at least seven security personnel were killed.

Pakistan’s current caretaker government, as well as previous governments, have always expressed their resolve to provide security to polio campaigns.

However, the recruitment of police personnel providing teams with security, has remained a challenge in the ultra-conservative tribal region of the country – ever since a fake Hepatitis B vaccination campaign was carried out by the CIA in the Pakistan border region in order to obtain the DNA of Osama bin Laden and identify his location in hiding, finally leading to his assassination in 2011.

The country’s polio eradication program and its global partners, Rotary International, have welcomed Pakistan Law Enforcement Agencies’ (LEAs) role in supporting polio team security.  However, polio vaccinators and local political leaders  say that polio vaccination teams still need more support.  

More security still needed

Shahzeb Malik, a polio vaccinator in the northwestern region of Khyber Pakhtunkhwa told  Health Policy Watch that security teams accompany the polio workers in anti-polio drives but there must be better operational coordination on both sides.

“Polio workers and police personnel have been targets of the militants in recent  years, so we need an improved version of the security with this polio program,” he said.

There is no doubt about the strong administrative resolve for ending the polio in the country, he asserted, even in remote regions of Pakistan like his own, he asserted. 

But this year’s  first polio campaign also coincided with election campaigns – a time in which health workers, including polio staff, are also supporting the set up of voting stations and other preparations for the big election day. 

Overcoming the ‘trust deficit’ amongst tribal leaders

The CIA’s operation against Bin Ladin left a lasting legacy for Pakistan’s polio program, resulting in an ongoing ‘trust deficit’ with regards to vaccination campaigns, Dr. Humayoun Mohmand, chairman of  Pakistan’s Senate Standing Committee on National Health Services, told Health Policy Watch. 

He expressed hopes, however, that a new government could begin to bridge the gaps, bringing great political stability and focusing on local solutions to a broad range of problems facing rural tribal communities.

“Absence of political stability and lack of coordination between federal and provincial governments does impact the polio program,” said Mohmand.

Hailing from the tribal region of Pakistan, himself, Dr. Humayoun emphasized the need to engage local ‘Jirga’, referring to local tribunals administered by mosques and Imams [religious leaders] in polio vaccination drives.

“We have to incentivize these institutions and provide financial assistance to include them in the fight against polio,” Mohmand stressed.

Rotary International plays a key role in polio eradication 

Religious leaders, including Imams and Islamic scholars, can also play a vital role in reassuring hesitant parents within their communities about the safety and effectiveness of vaccinations, in line with Islamic principles, asserted Aziz Memon, the chair of Rotary’s International’s PolioPlus national Pakistani committee, in comments to Health Policy Watch. 

Rotary International has been a key player in the global campaign to eradicate polio, committing more than $2.7 billion over the decades to the effort through a funding partnership with the Bill & Melinda Gates Foundation,

In Pakistan, Rotary also supports ulema workshops to build community trust and confidence in vaccines, through the Gates-funded Global Polio Eradication Initiative (GPEI). In addition to engaging trusted religious and community leaders, GPEI partners provide communities with desired (complementary) health services alongside polio immunization.

“Challenges to polio eradication in Pakistan include politicization of the polio program and in some cases, vaccine refusals,” Memom observed. 

“The risk of international spread of poliovirus remains a Public Health Emergency of International Concern”, he added, referring to the longstanding WHO declaration of a global polio health emergency for the virus, which was reaffirmed in December 2023. 

“That’s why Pakistan is implementing and deploying tactics to strengthen essential immunization, better target high-risk areas, and integrate basic health services to complement polio immunization activities including leveraging the capacity of female health workers and religious leaders to build community trust and improve vaccine acceptance.

He said the polio programme prioritizes the safety of the healthcare and frontline workers, and works closely with local governments and authorities to protect these individuals.

“Specifically, the government of Pakistan provides security teams to accompany frontline workers during immunization activities,” said Aziz Memon.

GPEI in Pakistan has also been active in working with political leaders at the national, provincial, and district levels, including during this time of political transition, Memon addded.

“When a new government is established, that advocacy will continue to minimize the impact on the programme,” he predicted.

Insecurity leads to rushed campaigns or campaign postponement

Pakistans polio programme has the full support of law-enforcement agencies, from the police to the army, that provide security cover to teams in each campaign, agreed Dr. Shehzad Baig national coordinator of Pakistan’s Polio Eradication Programme..

Even so, insecurity still contributes to “rushed campaigns or campaign postponement in security-compromised areas, which means we are unable to reach the children who need the vaccine the most,” he admitted.

Political instability has been a particular problem in the tribal areas of polio endemic southern districts, such as Khyber Pakthunkhwa, as well as in Pakistan’s northwestern region.  

The Programme also has built a “robust communications strategy in place across the country, including digital and on-ground social behavior change strategies, to build trust in communities,” Baig added. 

“In places where we see vaccine hesitancy and refusals for whichever reason, we enlist the help of local influencers, tribal elders, social workers, and religious leaders to engage with communities and increase the threat perception of polio,” he said.

Still, it remains difficult, if not entirely impossible, to conduct quality house-to-house campaigns in conflict-prone areas.

“In areas where some children are inaccessible to our teams, we implement a ring-fencing vaccination strategy to vaccinate people going in and out of the area to prevent the virus from spreading and give the population some protection from the virus,” he observed..

As for the impacts of political rhetoric and administrative re-shuffling during election season, Baig asserted that it had not really hindered vaccination efforts. 

“With the upcoming general elections, we have a full strategy in place for interaction and advocacy with the incoming government to ensure polio remains a priority,” said Baig.

“Even as the elections are near, all District Commissioners and health department staff supported throughout January 2024 the national immunization drive to ensure that we reach over 44 million children with the vaccine.” 

Image Credits: Pakistan Polio Eradication Program , VOA/Google Maps.