Battling Polio

Written by Arsla Jawaid  •  Special Features  •  May 2013 PDF Print E-mail

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 worn-out 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 Alaikum” 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. Trembling 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,” she would tell her mother. 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 226mn 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 six cases of polio; the first recorded from Cattle Colony, Bin Qasim 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 high-risk 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 anti-polio 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 at SouthAsia. A Boston University graduate, she holds a Bachelors degree in International Relations, with a focus on foreign policy and security studies.

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