Pakistan’s War Against Polio Is Difficult and Dangerous

On November 30, a Tehrik-i-Taliban Pakistan (TTP) suicide bomber blew himself up near a truck carrying police personnel protecting polio vaccination workers in Pakistan’s Balochistan province. Although the attack was not aimed at the immunization campaign per se – the TTP subsequently claimed that it was in retaliation for the killing of a TTP leader in August – it will adversely impact Pakistan’s efforts to eradicate polio from the country. It will shake the confidence of thousands of immunization workers who put their lives on the line to administer polio vaccination drops to Pakistani children, and of parents who get their children immunized against polio despite militant diktats forbidding it. 

Pakistan and Afghanistan are the only two countries in the world where endemic wild poliovirus (WPV) transmission has never been broken and persists. Other countries, like Algeria, Chad, the Democratic Republic of Congo, Ethiopia, and Nigeria, were declared polio-free but reported new cases in recent months. The global battle against polio has been largely successful, but it is far from over in Afghanistan and Pakistan.

Since the launch of the Global Polio Eradication Initiative (GPEI) in Pakistan in 1994, the number of polio cases in the country has dropped from around 20,000 each year in the early 1990s to 147 in 2019, then 84 in 2020. One case was reported in Pakistan in January 2021. No fresh cases were reported for 14 months thereafter, raising hopes that Pakistan was on the brink of eradicating polio. Then on April 22 this year, a new polio case was reported. The numbers have surged since. 

Pakistan has reported 20 new cases as of late November 2022, all from the Khyber Pakhtunkhwa province.

As in other developing countries, poor governance, inadequate health infrastructure, inaccessibility to public health resources, disinformation, and lack of awareness have impeded polio eradication efforts in Pakistan. Many Pakistanis believe unfounded conspiracy theories that the polio vaccine causes infertility and that vaccination campaigns are in fact Western plots to limit Muslim populations. The polio immunization campaign in Pakistan became even more strongly linked with the West after 2011, when it emerged that the CIA used a doctor who organized vaccination programs in Abbottabad to gather information about the whereabouts of al-Qaida founder and chief Osama bin Laden.

Religious radicals and conservatives have played a major role in blocking immunization efforts. They have carried out powerful propaganda campaigns falsely claiming that polio drops are un-Islamic as they contain pig fat and alcohol. Some clerics have issued fatwas against polio vaccination. The impact of negative propaganda has been particularly strong in rural Pakistan.

Polio eradication efforts in other countries have struggled also against religious propaganda and low awareness. Prior to the launch of the GPEI, India reported an estimated 200,000 polio cases each year – 50 percent of the world’s total. The Pulse Polio program launched in 1996 brought down the number of cases, but Uttar Pradesh, India’s largest state, continued to report a large number of fresh cases. In 2002, 1,242 of India’s 1,600 polio cases were in Uttar Pradesh. Immunization experts realized that regular vaccination campaigns were not enough to eradicate polio from the state.  

Resistance to polio vaccination was high in areas populated by Muslims, many of whom believed that immunization was part of a government plan to systematically reduce the minority population. Public health experts saw the need for an inclusive strategy.

The strategy to transform resistance into acceptance involved sending the “right messages” to communities resistant to vaccination and using the “right channels” to do so. Religious leaders and institutions were brought on board to send the message that vaccines neither go against religious tenets nor cause infertility. Clerics were roped in to kick off campaigns and polio drops were administered in places of worship. 

A strategy that included religious figures worked: Resistance levels dropped from 4 percent in 2004 to 0.9 percent in 2012, according to a June 2013 UNICEF report, “Eradicating Polio: Working with religious leaders to enhance community ownership.”

Since January 13, 2011, India has not recorded a single case of WPV transmission. In 2014, it was declared polio-free.

Since around a third of those who refuse polio immunization do so for religious reasons, Pakistan also roped in religious leaders and institutions to bolster its vaccination campaigns. Religious leaders mobilized support for immunization; fatwas endorsing the polio vaccine were issued. The Council of Islamic Ideology, a constitutional body that works with the Pakistan government, has endorsed hundreds of pro-vaccine fatwas. 

However, the problem that immunization efforts in Pakistan face from religious conservatives is far more complex than the challenge India faced. In Pakistan, those opposing polio immunization are armed and dangerous. The TTP has enforced its opposition to vaccination campaigns with the power of the gun. Over a hundred immunization workers and police protecting them have been killed by TTP militants over the past decade. 

Worryingly, the targeting of those associated with immunization campaigns has grown in recent months. In March this year, militants gunned down a female immunization worker on her way home after participating in a vaccination drive in Khyber Pakhtunkhwa. In June, two policemen and an immunization worker on a door-to-door vaccination drive in Khyber Pakhtunkhwa were shot dead. A policeman guarding a vaccination team was killed in Balochistan in October. 

Additionally, unlike in India where vaccination workers had full access to all villages and towns, Pakistan’s Khyber Pakhtunkhwa is a conflict zone, where it is the TTP’s writ that dominates in swathes of the province.

Furthermore, neighboring Afghanistan is not free from WPV transmission either. Two cases were reported in 2022, one in Paktika province and the other in Kunar province, both bordering Pakistan. Thirteen environmental samples, all from areas bordering Pakistan, were found to be WPV-1 positive in 2022. 

With the TTP calling off its ceasefire with the Pakistan government recently and the Pakistan military expected to launch robust military operations in Khyber Pakhtunkhwa, the province and especially its North Waziristan district, which is Pakistan’s “Ground Zero” for polio, will become even more inaccessible to immunization workers. 

Amid the otherwise distressing outlook on the polio front in the region, there are a few rays of hope. A high-level global delegation on polio that visited Pakistan recently is optimistic about the country’s efforts on fighting polio. According to WHO Regional Director Dr. Ahmed Al-Mandhari, Pakistan is in the “final stretch” of the road to the eradication of polio. “The progress this year [2022] has well-positioned the country to end all poliovirus transmission in 2023,” he said.

Meanwhile, across the border in Afghanistan, the Taliban regime, after opposing polio immunization efforts for years, extended support to the global vaccination campaign. Over the past year, 3.5-4.5 million previously unreachable children were vaccinated in Afghanistan.