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Photo Source: Dawn

Pakistan Reader# 525, 19 January 2023

Pakistan’s polio crisis: Between social misconception and poor health care



Pakistan's polio crisis remains complex because of the social misconceptions surrounding vaccinations and poor health infrastructure

Abigail Miriam Fernandez

On 4 December 2022, UNICEF’s Regional Director for South Asia George Laryea-Adjei expressed hope of polio being eradicated from Pakistan by the end of 2023. He stated that Pakistan is in a better position to eradicate polio than a year ago, revealing that according to the current data, the virus was under control in the country. Pakistan remains one of the two countries endemic to Wild Poliovirus Type 1 (WPV1). In 2022, 20 cases of WPV1 were reported, when compared to the one case reported in 2021, 66 in 2020 and 147 in 2019. In 2022, all the cases were reported from districts in the Khyber Pakhtunkhwa province including, 17 cases from North Waziristan, two from Lakki Marwat and one from South Waziristan. Meanwhile, 32 environmental samples of WPV1 were collected in 2022. Of the samples, 22 were detected in Khyber Pakhtunkhwa, nine from Punjab and one from Sindh. This comes as the government carried out three Sub-National Immunization Days (SNIDs) campaigns and special anti-polio campaigns in separate provinces.
 
Why is polio endemic in Pakistan?
Pakistan, along with Afghanistan are the two countries in the world to still have active transmission of WPV1. The reasons why polio continues to persist in Pakistan are multifold. The challenges include sociological, logistical and governance issues. When it comes to governance challenges, low immunization completion, difficulty accessing community health services and poor health infrastructure are obstacles to eradicating the virus. Social challenges arise from misconceptions, vaccine hesitancy and conspiracy theories around the vaccine. Lastly, the logistical challenge because of Pakistan’s difficult geography in terms of terrain and population density become barriers to eradicating polio in the country. Another issue is the conflict and security challenges that surround the polio vaccination campaigns across the country making it difficult to carry out the polio eradication initiatives. Another reason why polio remains endemic to Pakistan is the challenge in its last-mile efforts to eradicate polio is the ‘missed children’ in the delivery of polio vaccines. According to the Centers for Disease Control and Prevention, 400,000-500,000 children continue to be missed during the vaccination drives.
 
How has the government addressed the problem of polio?
Pakistan formally began its polio eradication programme in 1978 with the Expanded Programme on Immunisations (EPI) after the WHO launched its Expanded Programme on Immunisation in 1974. During that period, routine immunisation against polio and five other diseases was launched with the national EPI. Later in 1994, the government launched the Supplementary Immunisation Activities (SIAs) specifically targeting polio in line with the Global Polio Eradication Initiative (GPEI). In 2000, the campaign incorporated house-to-house visits. Further, in 2003, 2006 and 2009, the government in Pakistan implemented the Partnership for Polio Eradication project with the World Bank through which more vaccines were procured. Currently, the government follows the National Emergency Action Plan for Polio Eradication (NEAP) which was implemented in 2011 and outlines a plan for an eradication strategy, priorities, and innovations yearly. Apart from the campaigns, the governments in Pakistan have begun including religious clerics in their awareness campaigns intending to curb the hesitancy of society.
 
Why is there hesitancy from society?
The vaccine hesitancy emanates from the social misconception surrounding the polio vaccine as a result of socioeconomic, cultural and religious factors. Many parents refused the vaccinate their children because of the skewed knowledge of the effectiveness of the vaccine. The widespread misconception that vaccines might harm or sterilize children, or contain monkey or pig-derived products, forbidden in Islam has stopped parents from vaccinating their children. Additionally, some parents suspect the repeated administration of the oral poliovirus vaccine (OPV) claiming that this was to ensure that their children were sterilized. Some are also critical of the higher dosage given to children in Pakistan, unaware that children in the tropics require a higher dose of the vaccine. In addition to the existing social misconceptions, many communities in Pakistan have become alienated from the government because of the lack of proper health infrastructure, service and proper sanitary infrastructure. In retaliation, they choose to reject the polio vaccine in protest against the government’s inefficiencies. Apart from the social misconceptions, cultural issues regarding the presence of all-male vaccinator teams when a woman is alone at home with the children or when permission is not granted from senior members of the family for immunization become challenges and reasons for why there is hesitancy in society.
 
What are the conspiracy theories around polio?
The social misconception surrounding the polio vaccination has been fueled further by numerous conspiracies. One of the major reasons for the refusal of the vaccine is centred around the assumption that the vaccine is a western goal to sterilize Muslims. Many also believe the vaccinators to be spies for the US Central Intelligence Agency’s (CIA) drone programme. This speculation grew after the success of a CIA-funded fake hepatitis B vaccination campaign in Abbottabad to trace Osama bin Laden. Social media platforms such as Facebook and Twitter have been used as tools in propagating these false beliefs on a larger scale giving these theories an unprecedented reach.
 
How has polio become a security issue?
The attack on polio workers has become a major challenge and cause of concern for the government. Polio vaccination teams often come under attack during the vaccination drives, threatening the lives of polio workers, volunteers and their security personnel. According to an independent tally by a media report, over 100 people associated with the polio immunisation campaigns have been killed in the last decade. Meanwhile, the conflict itself in parts of Khyber Pakhtunkhwa and Balochistan has led to a dramatic rise in polio cases and has affected the polio eradication campaign to a great extent. 
 
Is polio a tribal belt problem?
In 2022, the polio crisis in Pakistan looks like a tribal belt issue with all the cases being reported from the erstwhile Federally Administered Tribal Area (FATF). This region continues to be plagued with security and governance issues which in turn triggers the spread of polio. In particular, the grim security situation in the region has not old hampered the vaccination campaigns but has also resulted in increased transmission of polio due to the movement of internally displaced people from the region. Additionally, the constant targeting of polio workers and security forces has been a major problem in this region. Apart from the security aspect, the tribal belt has been largely ignored by both the federal and provincial governments leaving these regions undeveloped and inaccessible. This poor management has directly impacted the vaccination campaigns in this region as it continues to be a major polio reservoir.

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