Bat­tling Po­lio

Pak­istan re­mains one of the last three coun­tries in the world to record po­lio cases. With se­cu­rity threats at an all-time high, the coun­try must take se­ri­ous and ur­gent ac­tion to erad­i­cate the dis­ease for the sake of its own fu­ture.

Southasia - - Contents - By Arsla Jawaid

It was a crisp morn­ing. The Area In­charge had asked po­lio work­ers to re­port to Gul­shan Bu­nir (Karachi) to con­duct the anti-po­lio drive. With se­cu­rity threats at an all-time high, it was im­per­a­tive to make sure that work­ers were home early. That morn­ing, Madeeha woke up slightly late and skipped break­fast. While get­ting dressed she told her mother, also a po­lio worker with 10 years of ex­pe­ri­ence in the field, that her shoes looked old, “Maybe to­mor­row we can go shop­ping for new shoes?” She put on her burqa, her wornout shoes, picked up her bag and left for the field. An hour later, her mother, Rukhsana Bibi, left for the same area.

At 11:00 am on 18 De­cem­ber 2012, Gul­shan Bu­nir was un­der­go­ing a strong po­lio vac­ci­na­tion drive, with a team of eight women dili­gently ad­min­is­ter­ing the oral vac­cine, door-to-door. Madeeha was ac­com­pa­nied by her aunt, Fehmida (40), also a po­lio worker. In a Mosque close by, an Imam ex­changed a quick “Salaam Alai

kum” with two boys on a mo­tor­bike who had come to get their 4-year-old cousin vaccinated. At around 11:10 am two loud shots were fired. Chaos broke loose. The Imam ran out­side to see the young lady in the burqa fall to the ground and the boys on the mo­tor­bike, armed. Fehmida ran in­side a house only to be chased by the men and gunned down. Madeeha, in her burqa, died on the spot. She was nine­teen.

Rukhsana was work­ing three streets away when she heard the gun­shots. Trem- bling and stunned, she was asked by the au­thor­i­ties to im­me­di­ately leave. Fran­ti­cally, she tried to call her daugh­ter. There was no re­sponse. Fif­teen min­utes later, the Area In­charge asked her to re­turn to Gul­shan Bu­nir, now sur­rounded by po­lice and the me­dia. “The mo­ment I saw her body in the am­bu­lance, I didn’t know how to com­pose my­self. I couldn’t think. I couldn’t feel. I screamed. I cried and I knew it would make no dif­fer­ence. It wouldn’t bring her back.”

A young, beau­ti­ful girl, Madeeha was un­e­d­u­cated, hav­ing read only the Qu­ran at a young age. She was mar­ried when she was four­teen and leaves be­hind a daugh­ter (4) and a son (1). Even now, when Rukhsana thinks of her old­est child, she breaks down, “I feel par­a­lyzed. I can’t for­get her face, her voice, the way she walked. She was the light of this house. So brave, so ded­i­cated.” Madeeha’s in-laws took her chil­dren away be­cause of which she was of­ten de­pressed. It was per­haps this in­jus­tice that en­cour­aged her to be­come in­volved in the anti-po­lio drive, “be­cause my chil­dren were taken away from me, th­ese chil­dren of Pak­istan, are all my chil­dren. Their pain is my pain and if I can brighten their fu­ture in any way, I will.” With tears in her eyes but pride in her voice, Rukhsana bibi tells me, “If my daugh­ter Madeeha, had made up her mind to do some­thing, noth­ing could change it. She changed lives and for that she will al­ways be re­mem­bered.” Rukhsana has never been able to en­ter the

po­lio vac­ci­na­tion field since that day.

Pak­istan re­mains one of the only three coun­tries in the world to still record po­lio cases. Since 1988, when the World Health Assem­bly for­mally es­tab­lished the goal of erad­i­cat­ing the dis­ease and launched the Global Po­lio Erad­i­ca­tion Ini­tia­tive (GPEI), wild po­lio virus had dropped by 99%. The dis­ease was pre­vi­ously en­demic in 125 coun­tries with 350,000 chil­dren par­a­lyzed an­nu­ally. With the num­ber de­creas­ing rapidly, in 2011 In­dia suc­cess­fully recorded 0 cases of po­lio leav­ing only Pak­istan, Nige­ria and Afghanistan, as the last re­main­ing coun­tries to record such in­ci­dences. Since 2008, more than 20 coun­tries have wit­nessed out­breaks of po­lio, im­ported from one of the three en­demic coun­tries, rais­ing press­ing con­cerns of resur­gence.

Po­lio has be­come a global health cri­sis for a myr­iad of rea­sons. Not cur­able, but cer­tainly pre­ventable, with ef­fec­tive vac­cines in place and tried and tested strate­gies, po­lio can be erad­i­cated in our life­time. Like most dis­eases, po­lio is found in low-in­come, pol­luted ar­eas and usu­ally tar­gets young chil­dren (be­low the age of five) due to their weak im­mune sys­tems. With a virus that af­fects only hu­man be­ings, health ex­perts are con­fi­dent that if ev­ery child is ad­min­is­tered the Oral Po­lio Vac­cine (OPV) reg­u­larly, the dis­ease, un­able to be trans­mit­ted through chil­dren, will be iso­lated and fi­nally erad­i­cated.

Po­lio vac­ci­na­tion cam­paigns are not

only te­dious but also tremen­dously ex­pen­sive, costs of which will be dif­fi­cult to main­tain in the long run, de­spite fund­ing from pri­vate donors and in­ter­na­tional or­ga­ni­za­tions like the IDB ($227mn), Bill and Melinda Gates Foun­da­tion, WHO and UNICEF, amongst oth­ers. Most re­cently, the govern­ment of Ja­pan ex­tended a con­di­tional grant of 226 Ja­panese Yen, through the UNICEF to erad­i­cate po­lio in Pak­istan. Given the grav­ity of the sit­u­a­tion, last year, the World Health Assem­bly de­clared po­lio a pub­lic health emer­gency, and ur­gently called for all 194-mem­ber states to fully fund the GPEI to meet the $945 mil­lion gap in its bud­get for 2012-13. While fund­ing for the erad­i­ca­tion of the po­liovirus may be read­ily avail­able in the short to medium run, in Pak­istan’s case, the emer­gency is much deeper than sim­ply se­cur­ing fi­nan­cial sup­port.

Ever since Prime Min­is­ter Be­nazir Bhutto in­au­gu­rated the coun­try’s first po­lio pro­gram in 1994, poli­cies to erad­i­cate the virus have re­mained con­sis­tent de­spite suc­ces­sive gov­ern­ments. Ac­cord­ing to the PM’s Po­lio Mon­i­tor­ing and Co­or­di­na­tion Cell, Pak­istan recorded close to 40,000 cases in 1994. By 2006, un­der Pres­i­dent Pervez Mushar­raf, the coun­try had suc­cess­fully re­duced po­lio cases to 28 per year; no small feat for a coun­try that was bat­tling a myr­iad of other dis­as­ters. How­ever, over the last five years, with the in­sur­gency in Swat and Tal­iban in­creas­ing, fight­ing po­lio has be­come a chal­lenge for the govern­ment. In 2010, Pak­istan recorded 144 cases; in 2011, the num­ber of cases rose to 198 (the high­est in the world at the time) and in 2012, through con­certed ef­forts taken by the govern­ment, Pak­istan reg­is­tered a 71% de­cline, record­ing 58 cases. How­ever, this year, the coun­try has al­ready recorded five cases of po­lio; the first recorded from Gad­dap Town in Karachi.

2011 was par­tic­u­larly dam­ag­ing for the po­lio vac­ci­na­tion cam­paign. Dr. Shakil Afridi, the man be­lieved to have helped the CIA iden­tify and as­sas­si­nate Osama bin Laden in Abbottabad, ran a fake Hep­ati­tis B cam­paign to col­lect DNA to pass along to the CIA op­er­a­tives. How­ever, the fake cam­paign was soon mis­rep­re­sented as a fake po­lio vac­ci­na­tion cam­paign be­lieved to be con­ducted by for­eign hands with a vested in­ter­est to ster­il­ize, or kill, the chil­dren of Pak­istan. In light of this, mil­i­tant hos­til­i­ties in­creased man­i­fold. Fam­i­lies in ru­ral ar­eas and even ur­ban cen­ters, brain­washed by ex­trem­ist pro­pa­ganda, re­fused the vac­cines, lead­ing to a rise in po­lio cases. In light of this, Pres­i­dent Zar­dari in­tro­duced the National Emer­gency Ac­tion Plan (NEAP), which pro­posed new strate­gies for out­reach, aware­ness and op­er­a­tions to com­bat the de­te­ri­o­rat­ing sit­u­a­tion. The NEAP is a part of the PM Po­lio Cell, which co­or­di­nates with over­seas agen­cies and mon­i­tors the po­lio drives. How­ever, where the govern­ment made ef­forts on the op­er­a­tional side, the po­lio cam­paign suf­fered ma­jor se­cu­rity set­backs as po­lio work­ers were tar­geted in dif­fer­ent parts of the coun­try. Ac­cord­ing to data ob­tained from the PM Po­lio Cell, the to­tal num­ber of health work­ers gunned down since July 2012 cur­rently stands at 16.

Pre­vi­ously, where mass me­dia cam­paigns an­nounc­ing national vac­ci­na­tion drives were put into place, po­lio drives, start­ing in 2012, were stag­gered and con­ducted door-to-door with op­er­a­tions del­e­gated through po­lice and dis­trict ad­min­is­tra­tion of­fi­cials. UNICEF con­ducts the mass pur­chase and dis­tri­bu­tion of the vac­cines and Lady Health Work­ers (LHW) go door-to-door, ad­min­is­ter­ing two drops of the vac­cine ev­ery 6 weeks to chil­dren be­low the age of five. As part of the NEAP, two LHWs are manda­to­rily as­sisted by one po­lice­man. To col­lect real-time data, when a child is vaccinated, a black mark is put on his fin­ger, de­not­ing he has re­ceived the vac­cine.

High-risk ar­eas tend to be Pash­tun dom­i­nated ar­eas of KPK and FATA where fam­i­lies refuse the vac­cine due to re­li­gious rea­sons, the Afridi syn­drome or sim­ply due to lack of aware­ness. Many fam­i­lies be­lieve it is unIs­lamic and will ster­il­ize the child. Oth­ers sim­ply do not trust it. Liv­ing in a coun­try fraught with con­spir­acy the­o­ries, Alam Za­heer Khan has re­fused the vac­cine for all four of his chil­dren. Dis­mis­sive at first, he even­tu­ally blurted, “Amer­ica doesn’t give any other medicines for free. Why only this? I don’t trust my chil­dren’s lives with this.” In ef­forts to cor­rect mis­con­cep­tions, the PM Po­lio cell has

part­nered with mod­er­ate cler­ics who have is­sued fat­was in fa­vor of the vac­cine and have also as­sisted in cre­at­ing aware­ness by al­low­ing po­lio vac­ci­na­tion drives to take place in the mosque. How­ever, the Chief of Pak­istan Ulema Coun­cil, Al­lama Tahir Ashrafi re­cently said that, “Cler­ics can only give fat­was and will con­tinue to come to­gether and con­demn such acts. What good are fat­was if the govern­ment doesn’t pro­vide se­cu­rity?” Karachi, Quetta and ar­eas in KPK re­main the most sen­si­tive and high­risk ar­eas for po­lio work­ers.

The se­cu­rity threats from the TTP have dealt a hard blow to the po­lio cam­paign. Even with govern­ment ef­forts in place and mod­er­ate cler­ics speak­ing in fa­vor of the vac­cine, the coun­try’s 35 mil­lion chil­dren un­der the age of five, re­main at risk. Dr. Alain Labrique of the John Hop­kins School of Pub­lic Health laments that South Asia was very close to erad­i­cat­ing po­lio but be­cause of “un­for­tu­nate po­lit­i­cal sit­u­a­tions and the fail­ure of a com­pre­hen­sive health sys­tem, the strength of the anti-po­lio pro­gram has se­verely de­te­ri­o­rated.” The use of so­cial me­dia and ac­cess to mo­bile phones in var­i­ous parts of the coun­try can how­ever play an in­te­gral role in not only cre­at­ing aware­ness but also dis­pelling the myths in­cor­rectly as­so­ci­ated with vac­cines. While real chal­lenges lie in the de­liv­ery of vac­cines in parts of the coun­try, Labrique ar­gues that “so­cial con­scious­ness has for­got­ten the grav­ity and ur­gency of erad­i­cat­ing fa­tal dis­eases.”

Po­lio erad­i­ca­tion is a metic­u­lously planned op­er­a­tional strat­egy, spear­headed by the WHO that as­sists with im­prov­ing rou­tine im­mu­niza­tions and con­duct­ing cam­paigns. Ac­cord­ing to Dr. Durry, Emer­gency Co­or­di­na­tor for Po­lio Erad­i­ca­tion in Pak­istan, the or­ga­ni­za­tion strives to en­sure the sus­tain­abil­ity of health by mon­i­tor­ing po­lio cases and in­tro­duc­ing mop-up cam­paigns in in­fested ar­eas to en­sure that the en­vi­ron­ment re­mains clean, pre­vent­ing the virus from re­turn­ing. But even now, “The virus is at its worst dur­ing the Mon­soon sea­son (Au­gust-Oc­to­ber) in Pak­istan. That is a big chal­lenge and the se­cu­rity sit­u­a­tion will only set us back fur­ther,” says Dr. Durry.

Cer­tainly, with TTP threats and con­spir­acy the­o­ries on the rise, the cam­paign faces even greater chal­lenges. But un­like In­dia, Pak­istan de­layed the po­lio cam­paign for twenty years, dur­ing which it broke the mo­men­tum and lost its value. In ad­di­tion, nu­mer­ous re­ports show that in many ru­ral ar­eas, fam­i­lies do not re­ceive the vac­cine on time, po­lio drives are de­layed or vac­cines are left in the heat for too long thus be­com­ing in­ef­fec­tive. Fur­ther­more, the level of cor­rup­tion in health of­fices re­mains un­ac­counted for and per­me­ates through ev­ery rank, mak­ing the goal of erad­i­cat­ing po­lio a dis­tant dream. With elec­tions around the cor­ner, anti-po­lio ef­forts have un­for­tu­nately taken a back­seat whereas loom­ing con­cerns of ter­ror­ism, eco­nomic woes and poverty have be­come more per­ti­nent.

Em­a­nat­ing from the se­cu­rity cri­sis is the “real prob­lem of missed chil­dren,” adds Dr. Durry. This is ver­i­fied by UNICEF, which pro­vides tech­ni­cal as­sis­tance to the anti-po­lio op­er­a­tions con­ducted by the Govern­ment of Pak­istan. De­spite progress, the larger chal­lenges lie in the se­cu­rity sit­u­a­tion in Gad­dap Town, per­for­mance is­sues and ac­cess in the Pishin dis­trict and the ban on vac­ci­na­tions in North and South Waziris­tan. Ac­cord­ing to Michael Cole­man, Com­mu­ni­ca­tion Spe­cial­ist (Po­lio) at UNICEF, gen­eral health re­mains dis­mal with child im­mu­nity se­verely low. Fur­ther­more, en­vi­ron­men­tal sam­ples show that while the dis­ease is re­stricted only to hu­mans, it can travel as pop­u­la­tions mi­grate, rais­ing con­cerns of con­tain­ing po­lio in one area. UNICEF helps not only in vac­cine pro­cure­ment but also in gen­er­at­ing sus­tain­able aware­ness through re­peated cam­paigns. Funds for ac­quir­ing the vac­cine are trans­ferred di­rectly by in­ter­na­tional or­ga­ni­za­tions to UNICEF, which buys vac­cine stock from WHO cer­ti­fied and ap­proved ven­dors. Ac­cord­ing to Cole­man, the “me­dia has a strong role to play in dis­pelling the myths. There is a ten­dency to sen­sa­tion­al­ize and pro­mote anti-Amer­i­can­ism. The vac­cine is per­fectly safe and is nec­es­sary for the vul­ner­a­ble chil­dren of Pak­istan.” The global ex­pec­ta­tion to erad­i­cate po­lio is Year 2018, if pre-req­ui­sites such

as op­er­a­tional con­cerns, data on miss­ing chil­dren, se­cu­rity is­sues and vac­cine pro­cure­ment are ur­gently ad­dressed. Pak­istan has had a stel­lar record in re­duc­ing po­lio cases with­out se­cu­rity con­cerns “and there is no rea­son why the coun­try can­not do it. We have great hope from Pak­istan de­spite the dif­fi­cult con­cerns it is bat­tling.”

The streets are strewn with lit­ter and sewage is open, al­low­ing flies and mos­qui­toes to con­gre­gate with ease. Shah Al­lah Ditta is a quiet colony, near the fed­eral cap­i­tal, home to a con­ser­va­tive, yet vi­brant, com­mu­nity. Most peo­ple here rely on daily wages and while the men go out to earn, the women stay be­hind to tend to the kids. How­ever, nes­tled within this com­mu­nity are some strong and am­bi­tious women; an anom­aly in a place where most would ex­pect women to stay in­doors and re­frain from ap­pear­ing in pub­lic. A cramped area, with mud houses and shards of cloth that dou­ble as doors, this com­mu­nity re­mains rel­a­tively iso­lated yet in­creas­ingly pop­u­lated.

Mehrunissa Shah* is a Lady Health Worker (LHW) who en­tered the field some 15 years ago. Tall, soft-spo­ken yet au­thor­i­ta­tive, Shah is in her early for­ties and ev­ery vac­ci­na­tion sea­son, goes door-to-door, happily ad­min­is­ter­ing vac­cines to the chil­dren in the area. She is ac­com­pa­nied by a vol­un­teer and a po­lice­man. Like many LHWs and su­per­vi­sors, she too is deeply con­cerned about the es­ca­lated se­cu­rity threat and the im­pact it can have on an­tipo­lio vol­un­teers. “If law and or­der is not ad­dressed and tar­get killings con­tinue, we might not have as many vol­un­teers and that could jeop­ar­dize po­lio drives around the coun­try.”

Through the years, Shah has seen the at­ti­tude of fam­i­lies change. Vac­cines were ini­tially viewed with sus­pi­cion due to ru­mors of for­eign in­ter­fer­ence and the el­ders in the vil­lages dis­cour­aged it for re­li­gious rea­sons, cit­ing its per­ceived unIs­lamic na­ture. How­ever, apart from ad­min­is­ter­ing the vac­cine, LHWs are also charged with the duty to cre­ate aware­ness, dis­pel the myths and work with re­li­gious lead­ers to en­cour­age the vac­ci­na­tion. “To­day, fam­i­lies are open­ing up and are ask­ing for po­lio drops. This is a ma­jor change from how it was be­fore. If at the grass­roots level we can erad­i­cate po­lio, then we can suc­cess­fully at­tain a health­ier Pak­istan.”

But the se­cu­rity threat re­mains very real. Earn­ing a mere PKR250 for ad­min­is­ter­ing po­lio drops in the field, many young peo­ple have opted out of vol­un­teer­ing for fear of their lives. Mass me­dia cam­paigns an­nounc­ing dates and lo­ca­tions have been halted and most National Im­mu­niza­tion Days (NIDs) have been stopped due to se­cu­rity rea­sons, se­verely ham­per­ing progress. An­nu­ally, Pak­istan con­ducts four Spe­cial­ized NIDs (SNIDs) in high-risk ar­eas and four NIDs, in at­tempts to at­tract min­i­mal at­ten­tion. How­ever, po­lio work­ers con­tinue to be at risk. Two of Shah’s friends have been gunned down over the past year, in­still­ing fear in those who con­tinue to serve. Those still ac­tive are of­ten pelted with stones, deemed ‘im­moral traitors’ or ac­cused to be for­eign spies.

But brave and ded­i­cated women like Shah un­der­stand the value of the work they do. They are deeply cog­nizant of the risks in­volved and can re­late to the lives lost, on a per­sonal level. But know­ing that they are se­cur­ing a healthy fu­ture for a child who might oth­er­wise suc­cumb to a fa­tal dis­ease, is re­ward­ing in its own way. Ac­cord­ing to the PM Po­lio Cell, to­day there are ap­prox­i­mately 106,000 Lady Health Work­ers in Pak­istan. When I ask if she feels afraid, Mehrunissa Shah looks right at me, con­fi­dent and steady, “I am not afraid. It is our duty to the fu­ture of Pak­istan. We will find a so­lu­tion. We will not stop.” *Names have been changed in the in­ter­est of pri­vacy. Arsla Jawaid is As­so­ciate Edi­tor of SouthAsia. A Bos­ton Univer­sity grad­u­ate in In­ter­na­tional Re­la­tions, her fo­cus is on for­eign pol­icy and se­cu­rity stud­ies.

Photo Credit: K.M. Chaudary / As­so­ci­ated Press

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