First published by the International Crisis Group.

In the wake of World Polio Day on 24 October, Pakistan remains the greatest impediment to a polio-free world. It has more cases than any other country, reflecting dual policy failures: to prioritise citizens’ health and to curb violent extremism. Despite signs of impressive improvement, with cases fast declining, there is a real risk of another spike unless steps are taken to fully reverse years of neglect of public health services. The prevalence of the disease and conflict are closely interlinked. With militant opposition to immunisation and attacks on polio workers undermining eradication efforts in the volatile federally-administered tribal areas (FATA) agencies, a coercive, military-led strategy should be replaced by a civilian-led approach that encourages community buy-in, respects rights and meets the needs of a marginalised population. Protecting and supporting polio workers and more closely involving communities in eradication efforts should be top priorities. The government should also counter misgivings about the vaccine, created by the anti-immunisation propaganda of Islamist parties and militant sympathisers.

With violent extremists attacking polio workers, particularly targeting women, in the FATA, parts of Khyber Pakhtunkhwa and Balochistan provinces, and Karachi, hundreds of children contracted the disease in 2014. Despite the relative decline in extremist violence, attacks continue, underscoring the importance of protecting the polio workers. Many parents have refused to immunise their children, either fearing militant reprisal or misled by Islamist parties and some mullahs into believing that the vaccine is an un-Islamic Western plot to harm the children.

Having already spanned the porous border with Afghanistan, the only other country where it is endemic, polio could again become a global health risk if its spread is not halted in Pakistan.

While the decline in cases, from 328 in 2014 to 38 as of October 2015, can be partly attributed to increased vaccination coverage of populations fleeing military operations in the FATA’s North Waziristan, South Waziristan and Khyber agencies, these gains could prove fragile. Militant networks have yet to be dismantled, and, as demonstrated by the September attack on an airbase in Peshawar, their capacity to regroup, reorganise and resume strikes against the state and citizens remains intact.

The government has taken some steps after the 2014 wake-up call, when polio cases increased dramatically, stoking international concern about the disease’s possible spread beyond Pakistan. By the end of the year, the government and its partners in the Global Polio Eradication Initiative – a public-private initiative launched in 1988 by national governments and spearheaded by the World Health Organisation to eradicate polio – had initiated measures to overhaul the eradication programme, including through more comprehensive security assessments, better planning and improved coordination and communication between all actors.

Innovative methods, such as reducing reliance on police protection, instead using communities to protect vaccinators and employing vaccinators from within those communities, are being tried on a limited scale but with considerable success in some cities, including Pashtun-majority areas in Karachi that host scores of FATA internally displaced persons and some FATA agencies. However, efforts to convince many mullahs and Islamist leaders to stop misleading communities by depicting the vaccine as un-Islamic and a health risk have had mixed results at best; many parents still refuse to allow their children to be vaccinated.

It is essential to maintain momentum. The key test will come in May 2016, when, at the end of the current low-transmission, relatively cool season, the temperature begins to rise and with it the risk of the virus spreading. It will be possible then to judge whether vaccination teams are reaching every child under five. If Pakistan is to make a durable transition out of its current polio-endemic status, it should complement eradication successes with wider routine immunisation coverage, through the Expanded Programme on Immunisation, and significantly improved basic healthcare and sanitation. In the conflict zones, such as the FATA, this requires better governance and security. Success countrywide will also depend on the government’s willingness to partner with civil society and local and international nongovernmental organisations (NGOs) to protect children from contracting a disease that has been eradicated in most of the world.

RECOMMENDATIONS

To interrupt the transmission of the polio virus:

To the federal and provincial governments:

1. Commit to implementing the National Emergency Action Plan for Polio Eradication 2015-2016 by:

a) demonstrating continued commitment to the federal and provincial Emergency Operation Centres structure that brings together programme partners;

b) enhancing the coverage and quality of polio immunisation campaigns by ensuring oversight and accountability of district administrative heads and polio workers;

c) improving vaccine cold-chain and supply-management systems by training staff and replacing outdated and broken equipment down to the union council level;

d) strengthening and expanding surveillance mechanisms to monitor the presence and circulation of the virus and the onset of the disease; and

e) designing more comprehensive security assessments and plans.

2. Prioritise the safety and other requirements of polio workers by ensuring that:

a) threats and attacks on or harassment of vaccinators and healthcare workers are investigated and action is taken against perpetrators;

b) salaries are provided in a timely fashion, including through the Direct Disbursement Mechanism that centralises all funding streams or any other payment mechanism; and

c) action is taken against any official who fails to provide timely information about workers involved in a campaign, thus delaying and at times preventing workers from being paid.

3. Foster greater community acceptance of polio eradication efforts by:

a) giving polio workers adequate tools, including educational and public information material and advocacy training, to engage mistrustful families and remove misconceptions;

b) mimimising dependence on direct and visible police protection, and expanding the programme of hiring polio workers from communities and ensuring that they are protected by those communities;

c) refraining from using coercive methods, such as arresting parents or guardians, introducing legislation that encourages such methods, or, in the FATA, invoking the Frontier Crimes Regulation’s (FCR) collective responsibility clause; and

d) employing local NGOs with a track record of working with vulnerable communities in polio-eradication programmes.

4. Supplement executive accountability of bureaucrats and polio workers with parliamentary oversight by setting up permanent subcommittees on polio under the National Assembly and Senate standing committees on national health services, regulations and coordination, and similar committees in the provincial parliaments.

5. Counter efforts to limit international NGOs’ and local NGOs’ operational space and take the lead, with civil society input, in forging any future law for regulating such organisations.

To durably transition out of polio-endemic status:

To the federal and provincial governments:

6. Raise routine immunisation coverage and overall population immunity levels by strengthening the Expanded Programme on Immunisation.

7. Provide accessible, non-discriminatory, quality immunisation and healthcare services.

8. Enhance communication and cooperation with Afghanistan on public health surveillance and response to outbreaks of polio.

To the international community, particularly donor countries:

9. Build federal and provincial governments’ capacity to provide citizens with accessible, non-discriminatory, high quality immunisation and healthcare services, including by persuading them to:

a) reject coercive measures in immunisation campaigns countrywide, and more specifically in the FATA context through the FCR; and ensure instead that there is community participation in donor-funded campaigns; and

b) ensure that NGOs, local and international, are not restricted in their ability to access vulnerable populations. DM

Photo: A health worker administers a polio vaccine to a child, in Peshawar, Pakistan, 14 September 2015. EPA/ARSHAD ARBAB.