The ideological battle for polio eradication in Pakistan

The polio vaccination campaign has touched all corners of the globe. Despite its resounding successes, polio has yet to be eradicated in Pakistan, where there is still vehement opposition to vaccines.

Writer: Aamina Mahmood
Editor: Maria Stoica
Artist: Wenanlan Jin

A baby boy in a village in Pakistan catches poliovirus due to poor sanitation. It affects his gut, travels into his blood and invades his central nervous system. The resulting limb paralysis leaves him so weak he can only crawl. His condition makes him a social pariah, unable to play with the other children in his village. As he grows up, scarce provisions for people with his disabilities means that he struggles to provide for his family. His whole life is marred by a disease that is wholly preventable, caused by a virus that, for most of the world, has been eradicated. The biggest tragedy is that a few polio vaccine drops, that his parents refused to give consent for, are all that separated him from a healthy life. His story is not an uncommon one and it illuminates how vital polio eradication is, and why the need to address opposition to the vaccine in Pakistan is so crucial.

The international poliovirus eradication campaign has been ongoing since 1988. In October 2019, it reached another milestone, the eradication of wild poliovirus type 3 worldwide. Despite the efficacy of the vaccine and the ease with which it can be administered in a mass vaccination campaign, there are three countries where polio is still endemic: Pakistan, Afghanistan, and Nigeria. Pakistan is currently affected by wild poliovirus type 1 and vaccine-derived poliovirus type 2, with numbers that have been increasing in recent years.

There are many reasons for this, including inadequate immunisation strategies, political uncertainty, worker dissatisfaction and logistical and financial challenges. But ideological opposition has been consistent, owing to Pakistan’s tumultuous history with terrorism and tribalism. One thing to consider when discussing Pakistan’s attitude to polio eradication is that demographic differences mean that a willingness to vaccinate has not been uniform throughout the country. Studies have shown that Punjab, for example, is more receptive to vaccination than Quetta and Peshawar, which are more affected by polio. A 2015 study in Pakistan even showed that 84.5% of participants believed that the disease could be prevented by giving vaccinations to children. This goes to show that Pakistan as a country, therefore, is not uniquely averse to the eradication campaign, but that this hostility is concentrated in particular areas.

Conflicting narratives

In 2014, when many countries had eradicated polio completely, Pakistan was seeing its highest number of cases in 14 years. The prevailing narrative in some regions characterised the ‘Western’ vaccine as un-Islamic — rumoured to contain pig fat and alcohol, and be part of a plan to sterilise Muslim men. A 2011 CIA mission, where a vaccination team collected blood samples from local people, cemented deep-seated mistrust. This led to attacks on vaccinators, causing a reluctance on their part to work for the eradication campaign. In 2012, the Taliban even banned vaccine administration in certain regions. This ban led to more than 350,000 children remaining unvaccinated for 2 years. In 2015, the Pakistani military succeeded in the Zarb-e-Azb campaign to regain control of areas under the Taliban. Subsequently, the cross party Sehat ka Ittehad campaign was launched, to focus on vaccinating upwards of 3 million children in Khyber Pakhtunkhwa (KP) and FATA, which had been under Taliban influence and made up 88% of worldwide polio cases. Refusal to consent also became a criminal offence, and some effort was made to encourage imams to show their support for the vaccine.

Between 2015 and 2018, the number of cases was consistently low. It seemed as though Pakistan was well on its way to eradicating polio. However, though there was an increase in vaccination numbers, any celebration proved to be premature. Historically, national elections in Pakistan have contributed to an immediate, but short-lived, rise in new polio cases as health officials transfer between posts. The 2018 election was no different and it seemed that, despite the inevitable rise the election heralded, the poliovirus vaccination scheme was still incredibly effective. Data suggested that 99% of children under 5 who needed the vaccine were receiving it, which was well above the 95% recommendation. But sewage water samples showed a different, worrying story of a spike in the P1 strain. Research into the December 2018 polio outbreak in the Baujar tribal district also showed that the ideological battle against the vaccine was still raging. In a bid to evade judicial consequences from refusing to consent to the vaccine, parents were falsely marking their children and lying about vaccinations. The campaign realised that a shift in attitude was needed. By halting arrests for parents refusing vaccines, the extent of the problem was revealed. In North Waziristan, for example, the number of recorded unvaccinated children increased eightfold, evidence that also suggested that vaccine drive statistics were being misreported. Overall in 2019 there was an increase to 147 cases.

What can be done?

It is clear that there is still work to do to convince some people in Pakistan of the safety and importance of the vaccine. In August 2019, the Prime Minister of Pakistan Imran Khan held a meeting to address the new direction of the campaign. The mindset behind the new policies is that “rather than pushing people, we will pull them into the programme” by engaging social media and mass media, establishing 24/7 call centres, and publicising cases. Social media has facilitated the dissemination of rumours that polio vaccines cause fainting and death, which requires a strong counter-rhetoric. This effort has included asking Facebook and Twitter to take down anti-vaccination posts. To address mistrust, the initiative stopped instructing vaccinators to ask patients intrusive questions, emphasised friendliness, completely halted arrests, and reduced the number of home visits to encourage parents to take ownership of their childrens’ vaccinations.

However, some believe these measures are too superficial. Though engaging constructively on social media will go some of the way to address anti-vaccination sentiment, more needs to be done to confront the root of the problem, which has political and health ramifications. Pakistan is an amalgamation of different ethnicities with distinct histories and cultures. The KP province had 63% of overall polio cases in 2019. Not only did some parts of the province undergo greater discrimination under British colonial rule, but they also had tensions and harboured mistrust against the centralised Pakistani government after Pakistan’s inception, due to their strong connection with Afghanistan. Additionally, they have fallen prey to Talibanisation in a way that other regions have not and share a porous border with Afghanistan, factors which have hindered the containment of poliovirus. Though great efforts have been made to track and immunise children crossing the border, the eradication initiative needs to go further to address the imbalances between this region and others.

Though the Sehat ka Ittehad campaign acknowledged the need for targeted vaccination drives in the province, it did not do enough to erase the ideological influence that still lingers there. Education is key to the future success of the eradication campaign. A study has shown that short educational conversations with mothers about the efficacy and requirements of fully vaccinating ones’ child in Pakistan increased consent for other vaccines. Making use of the tribal and religious ties that engender vaccine antipathy in the first place has also been shown to be successful. Vaccinators have sought help from village elders to encourage consent, and Maulana Sami ul Haq, sometimes known as the ‘father of the Taliban’, also came out in support of the vaccine. Experts say this had a positive effect in increasing consent and could ensure that the eradication campaign focuses on groundwork, alongside mass media, to reach those opposed to vaccination. This mirrors India’s successful eradication strategy that engaged the population’s religious sentiments. Aside from religious and cultural misgivings, there is also a feeling that there needs to be a greater focus on other aspects of public health, such as sanitation and clean water. As poliovirus spreads through faecal-oral transmission, investing in these initiatives would be more efficient at addressing long-term health inequalities and stopping the spread than through vaccine drives, which often require parents to travel long distances multiple times.

Other threats to eradication

Beyond ideology, there are other threats to worldwide polio eradication, such as the resurgence of polio in other countries. In 2019, wild poliovirus 1, transmitted from Karachi, was detected in sewage in Iran, which saw its last case of polio paralysis in 2001. Despite the existence of a vaccine, this could undo a lot of the work done against polio.  There is also concern about vaccine-derived strains of polio, which have been detected in Nigeria, Indonesia, China, and more, spreading to Pakistan. Additionally, President Trump withdrawing American funding to the World Health Organization (WHO) could have knock-on effects for Pakistan’s eradication campaign, which has relied heavily on international donations and aid. Managerial and political unrest in Pakistan itself, including the alleged cover up of the P2 strain, and the resignation of Babur bin Atta, the former Focal Person for Polio Eradication, have likely hindered the programme and caused concern for international donors. Also, owing to the COVID-19 pandemic, the Global Polio Eradication Initiative paused vaccination programmes in March 2020 to aid with the COVID effort instead. Though this was reversed in July 2020, figures comparing polio cases and samples between 2019 and 2020 are showing increases in almost every Pakistani province, especially in the Sindh region.

However, there is still hope. With international support and clear goals, Pakistan’s National Emergency Action Plan for Polio Eradication 2020 has acknowledged the need for community engagement and education, cooperation with Afghanistan, and addressing wider health concerns. Though the current pandemic may hinder progress, the polio vaccination campaign in Pakistan has shown time and time again that it is willing to adapt, and polio eradication is still a profoundly achievable goal for Pakistan.

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