The ‘last mile’ of polio eradication in Pakistan has been getting longer and rougher. Every time the goal of wiping out the disease appears to be in reach, a new outbreak occurs, taking the country’s end-polio program by surprise. One area where the outbreaks have been recurring is North Waziristan, a mountainous district of Khyber-Pakhtunkhwa province in Pakistan, with population of 540,546, which is entirely rural (99.19%). The intermittent prevalence of the wild polio virus in this region underlines the gravity of complexities in the area and the need for agility in program design to address fundamental adaptive challenges impeding progress.
The hope of interrupting the transmission of poliomyelitis after recording only one incidence of polio in 2021, received a setback as 19 cases were reported in year 2022. North Waziristan again surfaced as the main reservoir of virus with 17 out of 19 (85%) cases. The two remaining cases were also reported from its surrounding areas. All the cases were under the age of two and 14 of them were Zero Dose, who had never received a vaccine shot. Since, nine out of seventeen cases were reported by informal health networks outside the program, the outbreaks reflect the scarcity of public health facilities in the region. People in this area rely on quacks, hakeems, and faith healers in addition to the government's limited number of medical professionals for their healthcare.
Despite numerous efforts, including the regular OPV (Oral Polio Vaccine) campaigns, the fIPV (fractional dose injectable polio vaccine) rounds, and establishing permanent transit points (PTPs) at border crossings, the virus continues to spread. Though authorities routinely follow up for increased coverage particularly of refusal families, there has been rise in inaccurate reporting and further deterioration in campaign quality, instead.
The frequent countrywide door-to-door vaccination campaigns have failed to eliminate the virus from such militancy affected areas, for obvious reasons. The quality and effectiveness of vaccination campaigns, for children under the age of five, have been far from optimal in these areas where the security situation is precarious, literacy rates are abysmally low (36%), the primary health system is dysfunctional and around half of the geographical area is inaccessible to health workers. The ostensible trust deficit between community and government functionaries has further aggravated the problem.
My personal experience of managing polio campaigns in different districts of the country, particularly that in Khyber-Pakhtunkhwa, informs me that the end-polio initiative can be turned around by transforming the current approach into an adaptive strategy of engaging the community, creating ownership of the program by them, and building local leadership from within these communities.
Without considering the social, cultural, and religious considerations, it is impractical to persuade parents in these tribal areas to vaccinate their children. In such a traditional social structure, men from outside are not allowed to speak to women or visit the houses. The vaccination is refused if the community elders have not approved of it. Access to households is very limited due to non-availability of ample female workers. This situation necessitates a new strategy based on the local culture and constraints.
There is a need to address vaccine hesitancy by involving tribal leaders and community elders. These local community leaders and village elders must be engaged and educated about the importance of immunization in order to gain access not only to children in their houses, but also to their hearts and minds for wider acceptance of polio vaccine.
One factor in these communities' low vaccination rates is the false belief that vaccines have negative side effects, such as male infertility. This misconception could be dispelled by involving religious leaders, especially the imams of the neighborhood mosques, training them, and offering them incentives for cooperation. The suspicion that the immunization program is based on a foreign agenda is another issue that could be resolved by encouraging local ownership of the program. For operational purposes, the polio immunization should be transferred to village and neighborhood councils. Since, public trust is a crucial component for a successful disease elimination program, vaccine acceptance is likely to rise after the local Union Councilors and mosque imams are involved in conducting the immunization campaigns.
Even the security risks encountered by the polio workers in the area, which are higher in these areas bordering Afghanistan, would be reduced when the program is run by local leaders. It is safe to assume that these tribal communities are effectively governed by their elders and imams. Unless these influencers are meaningfully involved in the program, no plan would succeed, and no matter how ‘close to the finish line’ we get, the goal of zero polio in Pakistan will remain elusive.
Ultimately, the micro-democracy model—of the community, by the community, for the community— is the right way forward that can help us to accomplish the goal of any public health initiative. The lessons learnt from successful polio eradication in India and Nigeria have also shown us that inclusive community outreach and local stakeholder participation are vital for attaining the target. The sooner Pakistan’s polio program undertakes the reforms to transform its strategy, the shorter the last mile, though rough, would be to achieve the goal of polio free Pakistan.
The hope of interrupting the transmission of poliomyelitis after recording only one incidence of polio in 2021, received a setback as 19 cases were reported in year 2022. North Waziristan again surfaced as the main reservoir of virus with 17 out of 19 (85%) cases. The two remaining cases were also reported from its surrounding areas. All the cases were under the age of two and 14 of them were Zero Dose, who had never received a vaccine shot. Since, nine out of seventeen cases were reported by informal health networks outside the program, the outbreaks reflect the scarcity of public health facilities in the region. People in this area rely on quacks, hakeems, and faith healers in addition to the government's limited number of medical professionals for their healthcare.
Despite numerous efforts, including the regular OPV (Oral Polio Vaccine) campaigns, the fIPV (fractional dose injectable polio vaccine) rounds, and establishing permanent transit points (PTPs) at border crossings, the virus continues to spread. Though authorities routinely follow up for increased coverage particularly of refusal families, there has been rise in inaccurate reporting and further deterioration in campaign quality, instead.
Without considering the social, cultural, and religious considerations, it is impractical to persuade parents in these tribal areas to vaccinate their children.
The frequent countrywide door-to-door vaccination campaigns have failed to eliminate the virus from such militancy affected areas, for obvious reasons. The quality and effectiveness of vaccination campaigns, for children under the age of five, have been far from optimal in these areas where the security situation is precarious, literacy rates are abysmally low (36%), the primary health system is dysfunctional and around half of the geographical area is inaccessible to health workers. The ostensible trust deficit between community and government functionaries has further aggravated the problem.
My personal experience of managing polio campaigns in different districts of the country, particularly that in Khyber-Pakhtunkhwa, informs me that the end-polio initiative can be turned around by transforming the current approach into an adaptive strategy of engaging the community, creating ownership of the program by them, and building local leadership from within these communities.
Without considering the social, cultural, and religious considerations, it is impractical to persuade parents in these tribal areas to vaccinate their children. In such a traditional social structure, men from outside are not allowed to speak to women or visit the houses. The vaccination is refused if the community elders have not approved of it. Access to households is very limited due to non-availability of ample female workers. This situation necessitates a new strategy based on the local culture and constraints.
One factor in these communities' low vaccination rates is the false belief that vaccines have negative side effects, such as male infertility.
There is a need to address vaccine hesitancy by involving tribal leaders and community elders. These local community leaders and village elders must be engaged and educated about the importance of immunization in order to gain access not only to children in their houses, but also to their hearts and minds for wider acceptance of polio vaccine.
One factor in these communities' low vaccination rates is the false belief that vaccines have negative side effects, such as male infertility. This misconception could be dispelled by involving religious leaders, especially the imams of the neighborhood mosques, training them, and offering them incentives for cooperation. The suspicion that the immunization program is based on a foreign agenda is another issue that could be resolved by encouraging local ownership of the program. For operational purposes, the polio immunization should be transferred to village and neighborhood councils. Since, public trust is a crucial component for a successful disease elimination program, vaccine acceptance is likely to rise after the local Union Councilors and mosque imams are involved in conducting the immunization campaigns.
Even the security risks encountered by the polio workers in the area, which are higher in these areas bordering Afghanistan, would be reduced when the program is run by local leaders. It is safe to assume that these tribal communities are effectively governed by their elders and imams. Unless these influencers are meaningfully involved in the program, no plan would succeed, and no matter how ‘close to the finish line’ we get, the goal of zero polio in Pakistan will remain elusive.
Ultimately, the micro-democracy model—of the community, by the community, for the community— is the right way forward that can help us to accomplish the goal of any public health initiative. The lessons learnt from successful polio eradication in India and Nigeria have also shown us that inclusive community outreach and local stakeholder participation are vital for attaining the target. The sooner Pakistan’s polio program undertakes the reforms to transform its strategy, the shorter the last mile, though rough, would be to achieve the goal of polio free Pakistan.