Pakistan & Polio

In recent weeks, police in Pakistan have arrested hundreds of parents for refusing to vaccinate their children from polio [1]. In the northwestern province of Khyber-Pakhtunkhwa, the police issued warrants for 13,000 to 16,000 refusal cases [2]. According to one official, 471 people had been arrested in the city of Peshawar alone [1]. Police officials are exercising this action under a Pakistan law against endangering public safety [1]. While arrests have been made in the past, they have been few and far in between. This recent mass crackdown on vaccination refusal is being done in an effort to end the polio crisis that has plagued Pakistan, for good [2].

All About Polio

Poliomyelitis, otherwise known as polio, is caused by poliovirus [3]. There are two strains of poliovirus currently circulating — wild poliovirus Type 1 and vaccine-derived poliovirus [15]. Highly contagious, polio is spread through person-to-person contact via the fecal-oral route [3]. Once internal, polio lives in a person’s throat and intestines, waiting to be shed [3]. Infected people can shed the virus from a few days before the onset of symptoms to almost two weeks after they appear [3].

The virus affects mostly those under five years of age [4]. Approximately 72% of those who become infected with polio are asymptomatic [3]. However, in about 25% of those who are infected, flu-like symptoms appear, including: fever, sore throat, fatigue, nausea, and stomach pain [3]. These flu-like symptoms often last two to five days, before resolving on their own [3]. According to the World Health Organization (WHO), one in two hundred polio infections leads to irreversible paralysis — the virus can invade and infect a person’s brain, causing spinal damage and paralysis [3, 4]. Among those with paralysis, about 10-20% die due to immobilization of lung muscles [4].

The Battle Against Polio

Since 1988, polio cases around the world have drastically dropped by 99% — from 350,000 cases spread across 125 countries in 1988, to only 416 cases globally in 2013 [4]. At the end of 2014, Pakistan was one of only three countries that remained polio-endemic (the others were Nigeria and Afghanistan) [4]. There were 306 polio cases accounted for in the country last year — the leading number globally, with thirteen cases thus far in 2015 [6]. Regions such as the Federally Administered Tribal Areas (FATA) and Khyber-Pakhtunkhwa are where polio remains most entrenched and where transmission is most intense [5].

Since 1978, routine immunization against polio has been mandatory in the country; but, according to a recent vaccine coverage survey, WHO-UNICEF approximates that only 66% of the country has been fully immunized [7]. To be considered fully immunized, an individual must receive a “primary series of at least three doses of inactivated poliovirus vaccine (IPV), live oral poliovirus vaccine (OPV), or four doses of any combination of IPV and OPV”[8]. National Immunization Days, during which mass vaccination occurs, have been pushed over recent years. These activities are held as complementary to routine immunization and as only a strategy meant to interrupt the circulation of poliovirus through blanket coverage of eligible children [9].

Defying the History of Violence

What has kept Pakistan from eliminating polio for good? In 2012, the Pakistani Taliban banned polio immunization. As a result, efforts to vaccinate in Taliban-controlled regions have halted, and has led to the deaths of more than 60 polio fieldworkers [10]. Threats of violence from the Taliban extend beyond vaccinators and also include parents who allow for the polio immunization of their children [10]. The Taliban’s oppositional stance arose as a response to the United States Central Intelligence Agency’s (CIA) pursuit of Osama Bin Laden [10]. In an attempt to lure and confirm Bin Laden’s whereabouts, the intelligence agency set up a fake hepatitis vaccination campaign in Abbottabad, Pakistan [10]. Before the Taliban’s vaccination ban in 2012, Pakistan was on track to eliminating polio. According to Mufti Muneeb Ur Rehman, a moderate cleric in Pakistan, the resurgence of polio in Pakistan is a direct result of the CIA’s conduct [10]. Other militant oppositionists believe that the polio vaccines are a conspiracy to “spoil” Muslim children — a reference to rumors that the vaccine causes infertility [13]. The consequences of these actions and beliefs reverberate today.

On February 13, 2015, a polio vaccination team disappeared after working in the southwestern town of Zhob, located in the province of Balochistan [11]. As with most typical polio field teams targeted, the kidnapped included two vaccine workers, two security personnel, and a driver [11]. Four days after their abduction — the team was found murdered, assumingly seized and executed by Taliban militants [12].

However, in the town of Karachi, defiance against the Taliban’s murderous campaign provides a glimmer of hope in the long standing battle against the disease. In fact, recruitment for polio workers has not been a problem for the city, which boasts a population of more than 20 million [13]. Shahnaz Wazir Ali, provincial coordinator for public health in Sindh province, attributes this to “continuous engagement with the workers and constant direction with local government officials” [13]. Others distinguish the polio worker’s salary as a motive to enlist in the cause, despite known security risks [13].

The Eradication Initiative

The organization Rotary International began spearheading polio eradication efforts in 1985 [14]. It is responsible for an estimated vaccination of 2 billion children across 122 countries and their efforts have been in collaboration with other prominent organizations such as the Gates Foundation, UNICEF, and WHO [14].

Prior to intense opposition and even in the midst of current violence, Rotary has implemented simple strategies such as village-to-village and door-to-door vaccination to battle polio in Pakistan [14]. The group has also distributed cell phones among community health workers — particularly, midwives — who canvass areas to aid in surveillance and tracking of unvaccinated children and pregnant mothers, especially difficult for villages located primarily off the grid [14]. The cell phones provided allow for data to be collected and later uploaded to a central source [14]. Other efforts to eradicate polio include a collaboration with the Coca-Cola company, to build a reverse-osmosis water plant, within the city of Karachi — this helps to curb the spread of polio through the provision of clean water [14].

There exists vaccines for the prevention of polio, but no cure. To fulfill the goal of polio eradication, the effort must overcome underlying government suspicion, factionalism, and an ever-growing world of inequality. For the idealists, therein lies the perfect challenge.