Last year while I was in Pakistan, a bus I took from Peshawar to Islamabad was hailed down by a small team of polio vaccinators. This wasn’t surprising — we had after all, left a city the World Health Organization has called the single “largest reservoir” of the polio virus — but what proceeded seemed to undermine any hope that the disease which has been eradicated in most of the world can be fully snubbed out in Pakistan.
The bus driver pulled over to a small gravel patch just as stretches of mustard fields and mud huts turned into modern walled bungalows with tidy little gardens. The vaccinator who had hailed us down strode over, pulled open the door, and pointed at two small children clinging sleepily to their mothers in the first row of seats.
“Have your kids been given drops?” one of the health workers asked, using a general term for polio vaccines, which are to administered orally for times before a child turns six.
The two women nodded.
“My son was given drops at school,” one woman added for good measure.
“All right,” the vaccinator said, “You can go.” He slammed the sliding door closed and tapped on it twice. With that, the bus rumbled away from the city from which a full 90 percent of polio cases in Pakistan and where the majority of cases in Afghanistan originated in 2013. Along with Nigeria, the two neighboring countries of Pakistan and Afghanistan are the last hold-outs against full vaccination against the virus which can forever cripple or even kill its victims.
Given the dire situation, authorities are taking more severe measures to combat the spread of the disease.
On Tuesday, police in Peshawar arrested more than 450 parents for refusing to vaccinate their children against polio.
“[The arrests were] the last resort as there was no other option. There is a lot of pressure on the local administration to tackle these refusals,” Pervez Kamal Khan, the head of health services in the province of Khyber Pakhtunkhwa said.
According to national figures, 60,000 children have not received the polio vaccine because their parents did not consent to it.
Among the three countries where polio is endemic, Pakistan is the worst at containing the spread pf polio — not least because of a violent campaign on the part of terrorist groups to kill polio vaccinators and to discredit the actual intention of the polio vaccine. The threat posed by groups like the Taliban is not to be understated: it’s estimated that more than twice as many people were killed while administering the vaccine than people who died because of polio last year.
Still, militant attacks and extremist ideologies are not the only reason Pakistan has struggled to eradicate polio. It’s also just hard to keep tabs on which children have been vaccinated and which have not as I saw firsthand on that bus to Islamabad last spring. The vaccinator didn’t ask for identification numbers for the children. He didn’t ask for the vaccination documents children are given when they are vaccinated. He simply took their mothers’ responses as the truth — and, in so doing, may have let two cases of the highly contagious disease infect others.
“Without surveillance, it would be impossible to pinpoint where and how wild polio virus is still circulating, or to verify when the virus has been eradicated in the wild.”
“Surveillance underpins the entire polio eradication initiative,” notes the Polio Global Eradication Initiative. “Without surveillance, it would be impossible to pinpoint where and how wild polio virus is still circulating, or to verify when the virus has been eradicated in the wild.”
And yet, from what I saw while in Pakistan, very little in the way of surveillance is actually taking place. Polio vaccinators risk their lives to prevent children from developing the virus, but without tracking who they reach, their work — and their deaths — may all be in vain.
Last March, I visited Kasur, a rural district in Pakistan’s Punjab province where a massive vaccination drive was underway. A vaccinator administered both measles and polio vaccines to children in a crowded one-room schoolhouse as part of an effort to reach 12 million children in less than two weeks. Parents brought their children to the makeshift vaccination station after hearing announcements about it at local schools and mosques.
“Hopefully we can vaccinate 100 percent of children so that such outbreaks won’t happen again,” Dr. Zulfiqar Ali, who coordinated the vaccination drive in Kasur, told me.
Unfortunately, there didn’t appear to be any system in place to make sure 100 percent of children were vaccinated. After giving children a measles injection and polio drops, health workers simply colored in their index fingers with a thick black marker — a way to make sure they wouldn’t get a double dose, but not a way to maintain records of which children have gotten vaccinated, and which fell through the cracks.
Pakistan also has an issue with parents who deliberately refuse to get the vaccine. Ever since the story broke that Osama bin Laden was tracked to his Abbotabad, Pakistan home with the help of people posing as vaccinators, terrorist groups have decried their use.
But dangerous rumors circulated around polio vaccines even before the 2011 raid. These have been given new life by terrorist groups and extremist clerics who claim that the vaccines are a part of an ongoing plot by America and its allies to undermine the power of Muslim-majority countries like Pakistan. Some of the longest lived rumors about the vaccine are that it causes infertility, but there are others as well.
“I heard that the vaccine contains pig, that it’s haram (forbidden in Islam),” Haider Khan, a 27-year-old Peshawar man told AFP.
Rubina Ashraf brought her three children to the vaccination station in Kasur when a neighbor told her it would be happening.
When asked if she was worried about rumors, Ashraf said she believed the polio vaccines were be safe since the drive was organized by the government.
“The government doesn’t want anything bad to happen to its people,” Ashraf told me in Urdu. “Whatever the government does, it’s for the best.”
But even if parents trust the government, some of it may be misplaced. Days after the massive vaccination campaign was carried out, a doctor who specializes in immunizations questioned the quality of the vaccines administered. Dr. Waqar Ahmed said the cold chain — an important component in maintaining the potency of each vaccine — may have been broken.
“If the cold storage isn’t working properly, nobody can guarantee the efficacy of the vaccine,” Ahmed told Paksitan’s Express Tribune.
Provincial governments in Pakistan have largely resorted to large-scale vaccination drives. While in Peshawar, I was blocked into traffic several time as vaccinators set up and guarded sites where children could be vaccinated en masse throughout the day. Polio vaccinators also go door-to-door to reach children whose parents might not have brought them to get vaccinated.
Pakistan is a country with nearly 200 million people — a third of whom are under the age of 14. It’s challenging for the government to track cell phone registrations much less medical histories. Although some new technology solutions have been deployed to prevent contagious diseases like measles or dengue fever, the polio problem has remained pernicious.
Making school enrollment contingent upon vaccination records isn’t as viable an option. According to a recent study by the United Nations, half of all Pakistani 4 year olds aren’t in school, and about a quarter do not attend elementary school.
Nine cases of Polio have already been tracked in Pakistan this year. More than three hundred people contracted the virus there last year — the highest number since 2000. Pakistan had ten times more than cases of polio than Afghanistan and 50 times more than ones in Nigeria, the other two countries where polio is endemic. How effectively Pakistan can administer — and track — polio vaccines will greatly impact how soon the entire world can be rid of the deadly virus.