Pakistan is one of only two countries where wild polio and vaccine-derived polio strains remain, thwarting global eradication efforts, according to the World Health Organization (WHO). The Independent Monitoring Board (IMB) in its latest assessment of the global polio eradication programme cautioned that if Pakistan does not adopt transformative measures to eradicate poliovirus in the next six months, the situation could become worse in the country. (“IMB says if drastic measures not adopted then polio could be worse in six months,” The News International, 31 August 2020) At least 61 cases of wild poliovirus surfaced in the country until 31 July 2020 when compared to the 56 cases that were reported by mid-2019. Moreover, in 2018 and 2017, the total number of polio cases was 12 and eight respectively. (“Polio storm,” Dawn, 30 August 2020).

With Pakistan reporting more than 80 per cent of the total global polio cases in 2019 of which 90 per cent of them reported outside the traditional core reservoirs. This epidemiological situation is extremely worrying, with the outbreak of wild poliovirus in the southern part of the Khyber Pakhtunkhwa which continues alongside the core reservoirs of Karachi and Quetta. Beyond the traditional reservoirs, the transmission is expanding to previously polio-free areas. (Asif Chaudhry, “Global health body portends poliovirus resurgence in Pakistan,” Dawn, 29 August 2020).

Polio in Pakistan is reported to have resurged in the third quarter of 2018 and intensified in the second quarter of 2019. In this regard, the Pakistan government has made strong statements of commitment and intent in response to the adverse polio situation in the country, however despite the numerous efforts not much has been resolved with the vaccine currently in Pakistan being resented and hated by the communities that need it most. (“The Art of Survival: Independent Monitoring Board of The Global Polio Eradication Initiative 17 Seventeenth Report November 2019: The Polio Virus Continues To Exploit Human Frailties,” The Independent Monitoring Board).

Why has Pakistan failed in its bid to eradicate polio? Here at five reasons.

1. Social Misconceptions and Conspiracy Theories

There is a strong correlation between low immunisation completion and negative socioeconomic factors, in addition to other issues such as illiteracy, poverty and difficulty accessing community health and immunisation services which has all contributed to vaccine hesitancy in Pakistan. Many parents in the country have refused the vaccination due to misconceptions when it comes to the purpose or the effectiveness of the vaccine. There has been a widespread misconception that vaccines can harm or sterilise children, or contain monkey- or pig-derived products which are forbidden in Islam. The repeated administration of the oral poliovirus vaccine (OPV) was also cited as a barrier; with some parents suspecting that this was to ensure that their children were sterilised, or that sub-standard vaccines were being used. Further, many have also been critical of the dosage, where the children in Pakistan are given a higher dose than the number recommended by WHO, causing speculations in the general public because of their poor awareness of the need for booster doses in the tropics.

Further, there have also been numerous conspiracy theories related to the polio vaccine in Pakistan, a major driver of refusals across the country, centre on unspecified “Western” goals to sterilise Muslims or otherwise harm or oppress them. Social networks like Facebook and Twitter, in turn, have provided a platform for these false beliefs to be propagated on a much wider scale giving these theories an unprecedented reach. (Mohammad Ali, Nisar Ahmad, Haji Khan, Shahid Ali, Fazal Akbar, Zahid Hussain, “Polio vaccination controversy in Pakistan,” The Lancet Journal, 14 September 2019)

2. Alienated mistrustful communities

In addition to the already existing social misconceptions around the poliovirus, many communities in Pakistan have become alienated from their government. These communities live without proper sanitary infrastructure, with few health services, or other public services, and little else to call their own. In retaliation to this pitiful condition, rejecting the polio vaccine is the only weapon they have to protest and send a message to their government.

In this regard, very little effort has been made to understand these communities and work with them. This more applicable in the tribal and isolated communities where simply a process of persuasion would be not sufficient for these communities and places where trust in government is low. Thus, it is essential to sit down and understand the concerns of these people before any further steps are taken. For example, a positive and cooperative political relationship has to be forged with the Pashtun leadership if eradication-standard Polio Programmes are to be established in their communities. This would be challenging given the history of tensions and mistrust between successive Pakistan governments and the Pashtun communities. However, this has to be achieved to bring a change in the success of the Polio Programme in Pakistan.

3. The politicisation of polio and governance issues

Until recently, the Polio Programme and the importance of delivering the polio vaccine according to the IMB has become a political football. The Polio Programme in the country has remained particularly vulnerable in areas where the power structure is divided between different political parties, thus lacking political unity. The centre-province politics has left caused this fragmentation of power leading to problems in efficiently carrying out vaccination campaigns. Further, when the Polio Programme performs badly, it only becomes a matter of a blame game with the issue being deflected. Often, there has been a deterioration of relationships, in-fighting, and behaviours driven by fear of the consequences of failure, causing initiatives to be launched with insufficient consultation and collaboration.

Further, Pakistan still spends less than one per cent of its GDP on health services while an adequate health infrastructure and service delivery system is severely lacking in many parts of the country. Although the country’s Global Polio Eradication Initiative (GPEI) operation has been well-financed, its efficiency is compromised by a lack of transparency in governance, an under-resourced public health delivery service and a poorly regulated private health sector. Further, there has been a lack of investment in Pakistan’s Expanded Programme on Immunisations (EPI) which is crucial in achieving polio eradication in the country. (“The Art of Survival: Independent Monitoring Board of The Global Polio Eradication Initiative 17 Seventeenth Report November 2019: The Polio Virus Continues To Exploit Human Frailties,” The Independent Monitoring Board).

4. Conflict, militancy and the attacks on polio workers

Poliomyelitis cases began to increase from 2006 as the Taliban insurgency intensified in Khyber Pakhtunkhwa and the former Federally Administered Tribal Area (FATF), leading to the displacement of millions of people and inward migration to major urban centres such as Karachi and with it, the spread of wild poliovirus to other parts of Pakistan and other countries, caused it to be a challenge for the administration of the vaccination. In 2012, the Taliban-imposed ban on vaccination, this proved to be detrimental to polio eradication efforts, especially in parts of FATA where more than 350,000 children remained unvaccinated for more than two years.

In addition to this, Polio vaccination teams have suffered several attacks since a countrywide vaccination drive with Polio workers, volunteers and their guards are frequently targeted in the South Asian country. At least 11 polio workers were killed in Pakistan, raising the number to 92-95 deaths since 2012. These systematic attacks gained legitimacy in the minds of many Pakistanis after 2011 when certain reports claimed that a local doctor, Shakil Afridi posed as a Hepatitis B vaccinator while working for the CIA to locate and kill Osama Bin Laden. However, before 2011, polio campaigns had been a target with clerics like Sufi Mohammad spreading false information that the vaccine caused infertility. (Shoaib Fahad Hussain, Peter Boyle, Preeti Patel, Richard Sullivan, “Eradicating polio in Pakistan: an analysis of the challenges and solutions to this security and health issue,” Globalization and health, 12 October 2016).

5. Challenges Of “Last Mile” Vaccination Efforts

The primary underlying challenge in last-mile efforts to eradicate wild poliovirus transmission (WPV) is the missing children in the delivery of polio vaccines. In April, almost 40 million children missed their polio drops in Pakistan after the cancellation of the nationwide vaccination campaign. The challenges which continue to persist apart from the social and cultural misconceptions are challenges faced by frontline workers in areas that are hard to reach due to geographical isolation, mobility and mass migration and this issue of inaccessibility. To address these challenges, strategies such as an “Afghanistan–Pakistan hub, expanded partnerships and rapid response teams have been strategically proposed. However, efforts put in have not been able to sustain.

Further, while the Polio Endgame Strategy 2019–2023 states a clear requirement for integrated services, there has been no currently no budget allocated to support it, as would be expected in project management terms. This gives the impression of there being no true commitment to integration.

The resurgence of polio is not a biological mystery, rather it should have been prevented. With the crisis seeing no end soon with the current state of polio eradication looking bleak. Moreover, there are many fractious relationships at all levels of the Polio Programme, angry communities, and a loss of staff morale at the frontline that contribute as root challenges. Further, cases of poliovirus had increased fivefold between 2018 and 2019, with uncertainty and doubt surrounding the effectiveness of strategies and tools emerging. As suggested by the IMB, only when there is an integration of the technical and epidemiological perspective with the human factors can transformational results be achieved. Further, with the pandemic posing to be a challenge, the reality is that the Polio Programme will now have to coexist with and adjust to, the dominant effect of the COVID-19 pandemic. (“Polio in pandemic,” Dawn, 29 August 2020) (“The New Normal. Eighteenth Report July 2020 Finding the Path Back to Eradication in the time of Coronavirus,” The Independent Monitoring Board).

About the author

Abigail Miriam Fernandez is a research assistant at NIAS.