When will Pakistan stand on two legs? A polio story

By guest contributors Dr Fyezah Jehan and Dr Kheezran Ahmed

Imagine living in an area where you fear leaving your home. A place where a regular health checkup means taking a taxi and traveling miles to the nearest big city. A place where when men leave to earn, the children skip school to fetch water from remote areas. Imagine small stone houses, deserted lands with scanty population, and barbed wire checkpoints ever so often. Lastly, imagine an area filled with people who fear the unknown, traumatized by attacks on their schools, hospitals, homes, and even their families. North Waziristan is that area. According to the United Nations Development Program, the area has been ranked the lowest in the country in education, health, and standard of living.

The concept of health equity is one no medical health care professional is unfamiliar with. It has been defined as differences that are unjust, avoidable, and unnecessary. Recently, after a year and a half long polio-free Pakistan, there was some rising hope that we might have finally ended the decades-long battle against this crippling disease. However, two new cases and then three, four…and now seven cases of the Wild Polio Virus (WPV) emerging in the North Waziristan district of Pakistan, bring forth the question; will social stratification be a reason for children to suffer?

The last two countries facing the polio crisis are Pakistan and its neighbor Afghanistan. This is no surprise as geographically, North Waziristan shares an almost porous border with Afghanistan on the West, where people and animals pass through.

It’s not a mystery that countries that face the three deadly P’s i.e., poverty, pollution, and political instability are mostly the ones that suffer from high rates of illness, especially infectious diseases and malnutrition.  Poverty and polio are inseparable realities. Both countries face issues such as poor health infrastructure, poor water, and sanitation. There is a lack of access to most basic health care services. Health infrastructure in Waziristan is an unfortunate collateral damage in the war against terror.

Political instability coupled with poverty also factors into a lack of awareness, especially concerning the need for childhood vaccination. Since 2012, the rise of militancy in the area has led to several deadly attacks on polio workers, killing scores of healthcare workers on the polio frontlines and scaring many away. Of the last seven cases, most of the children had not received even a single routine dose of the polio vaccine.

High rates of illiteracy thwarts the anti-polio campaign. With a lack of basic education, the role of clerics in spreading false beliefs and misinformation has led to an increase in parental doubt about the safety of the vaccine. In 2019, 17 of the 45 polio cases recorded in Pakistan came from Bannu, an area of Khyber Pakhtunkhwa with barren mountainous terrain and hard-to-reach areas. It was found that the parents were putting fake ‘pinkie marks’ using markers to escape their child being vaccinated. It has been reported that the area has consistently recorded virus cases, according to the polio eradication program. One of the reasons can be accounted to such misinformation spread such as vaccination being foreign propaganda to sterilize children and Anti-Vaccination groups claiming pig and alcohol (both considered forbidden in Islamic religion) are the key components of the vaccine.

The Covid-19 pandemic also made routine vaccination programs to come to a standstill. During the lockdown, door-to-door polio vaccination campaigns were interrupted. The national call centre that was set up for queries about polio was expanded to include Covid-19. While Pakistan’s sophisticated polio network and its data monitoring cell contributed in its pandemic success, one cannot deny the setback that the pandemic did to routine immunization which is the cornerstone of any eradication effort.

Despite all this, hope is not lost. Pakistan’s National Polio Emergency Operation Centre houses a team of enthusiastic individuals who are still optimistic and aware of how close we are to ending this decades-long battle. The center boasts more than 340,000 frontline workers providing door-to-door vaccination for over 43 million children under the age of five. Under the Global polio eradication initiatives (GPEI) end game strategy, strict adherence is emphasized to mass vaccinations, ensuring strong supplies of the vaccine as well as containment through surveys and inventories. Pakistan has the largest environmental surveillance network in the world which can help track down poliovirus wherever it may exist. (2)

Eradicating polio in Pakistan means eradicating it in Afghanistan as well. The global health efforts towards vaccine procurement and delivery must continue. We have persevered through the unprecedented Covid-19 pandemic. We must not forget the terror of poliovirus. We must not forget that seven kids (to date) who are disabled for life from a disease eradicated forty years ago in a luckier part of the globe.

Kheezran Ahmed is a recent medical graduate and the Deans clinical research fellow in the Department of Pediatrics and Child Health at the Aga Khan University, in Karachi, Pakistan.

Fyezah Jehan is the Ruby and Karim Bahudar Ali Jessani endowed Chair of the Department of Pediatrics and Child Health and an Associate Professor of Pediatric Infectious Diseases at the Aga Khan University, Pakistan.