Published in The News International on October 23, 2008:
Pakistan’s security situation and the war on terror has become a top priority for the government. While the need to prioritize issues is understandable, attention to some other matters of the state on a war footing is also warranted. In many ways, the case of polio eradication is analogous to the war on terror given the international context within which it is being waged and the gains at stake. Since 1998, a Global Program on Polio Eradication spearheaded by WHO and involving many other agencies aimed at eradicating a disease from this planet for the second time in the world’s history since Small Pox eradication in 1979, has been ongoing. This initiative, involving 125 countries, more than 20 million health workers and vaccination of over 2 billion children worldwide has been able to achieve the polio eradication milestone in all except four countries of the world.
The premise is simple: immunization is a right of every child, vaccination is the most cost effective health intervention and a few drops of polio vaccine can prevent a crippling disease; theoretically, it appears as simple as that! But for Pakistan, which unfortunately is one of the four countries that have not achieved the eradication milestone, this has turned out to be a challenge. Today, polio in Pakistan is not just a ‘health issue’ but an insight into the way policies translate into implementation and a realization that health and other development outcomes are a multi-sectoral responsibility. This comment provides a snapshot of the determinants of failure and proposes a few next steps.
In terms of the determinants, first of all it must be recognized that there are factors beyond the control of the health sector. The security situation in FATA and NWFP, the ongoing fighting and consequent limited access of vaccinators to these areas; the tragic disinformation about polio vaccination as being harmful by misinformed religious leaders; the conspiratorial rumors about vaccine safety and the resulting refusal on part of parents to vaccinate children, even when the facility is being provided by the state at their door step and the extensive population movement across the Pak-Afghan border are the three key factors outside of the health sector. However, it must be recognized that new cases of polio, a resurgence of which has lately been picked up by Pakistan’s sensitive polio surveillance system are not solely arriving from areas that are fraught with issues of accessibility and refusal and import from Afghanistan but are occurring due to long-standing problems with existing immunization coverage.
Pakistan has had resources to immunize every single child since the early 1990s; however, the recently reported Pakistan Demographic and Health Survey, 2007 has reported that the percentage of fully immunized children in Pakistan currently stands at 47%; this is clearly unacceptable. Immunization is one of the simplest public health interventions and these outcome data indicate that there must be systemic flaws in our systems of health service delivery and their means of monitoring and mechanisms of accountability. Absenteeism in public facilities, shaving off hours by paramedical staff, the well institutionalized ways of pilfering commodities from the supply chain, collusion in monitoring records and lack of motivation to achieve targets are issues the health sector has long been grappling with. The critical role of these malpractices in undermining the effectiveness of well resourced initiatives backed by strong political commitment should become evident through the case of polio eradication.
Additionally, there are also problems specific to polio eradication as an initiative per se. The vaccine cold chain is critical to the potency of vaccine; with the currently on average 8 hours of load shedding, the question of how that is being maintained becomes relevant. Mobility of vaccinators is a prerequisite for ensuring coverage; with paucity of vehicles, volatility in prices of fuel and variable availability, and temptation to embezzle allowances at the field level, how is that being ensured? Diarrheal disease can interfere with the uptake of polio virus in a child’s intestine; to what extent can a polio program have control over that given that overarching issues of poor sanitation and high population density continue to prevail and result in frequent outbreaks of what gets labeled as ‘gastro’. Capable and committed EDOs of Health are critical to the success of this initiative; with rapid turn over, how can performance be ensured and how can accountability be institutionalized. Then there are conspiratorial theories of there being a vested interest at an administrative level to linger on with National Immunization Days—the key instrument of polio eradication—because of the incentives linked to them. All these factors interact and are responsible for failure to eradicate the disease in Pakistan. What are the implications? So long as a single child remains infected, children in all countries are at a risk of contracting polio!
What are our options to pursue the polio eradication goal? On the one hand, evidence based systemic reforms of the immunization program must be pursued. However, meanwhile other strategic war like measures aimed at eradication must be developed over the short term. Here we must recognize that despite the high level political commitment of several governments, two critical gaps remain—simply, some populations in Pakistan are not being reached and the issue of effective targeting in areas that are accessible, looms large. What therefore is an urgent imperative for the government of Pakistan to enable it to achieve the polio eradication goal?
The priority would be to recast the NIDs and aim for few Grand NIDs, where the entire organizational might of the government is put behind the shoulder to this wheel on a war footing. After all, China was able to eradicate polio only after three NIDs but with an effort that truly involved all actors of the state. The following measures would be important in this regard. First, the outreach drive in NIDs must go beyond traditional vaccinators under the umbrella of EDOs to involve actors that can truly deliver in catastrophic situations. The armed forces have traditionally been part of catastrophes, emergencies and devastations. If saving lives is part of their mandate constitutionally, and waging war a core responsibility, involvement in polio eradication appears fully justifiable. Such an approach will have many caveats relating to image and acceptability but can be addressed with careful planning. Second, the government has to commit to utilizing all its resources and prerogatives on a war footing to ensure a seamless supply chain over a few days; airlifting of vaccines, allowing access to areas on horseback, procurement of new cold chain equipment and possible imposition of curfews for the duration could be part of this approach. Third, through the creative use of quotes from the Quran we can link polio to the right to life and negotiate access in areas where refusal is an issue and solicit ceasefire for the days of the intervention—for all we know, this could be the path to peace and tranquility in the war riddled zones of FATA and NWFP.
Operation polio, as we should name this, will have to be based on a careful evidence-based strategic planning exercise to fashion these new tactics. Such a plan, which leverages all these unconventional channels for a health objective is ambitious and requires high level political commitment; in Pakistan’s current scenario, it appears that if we want to achieve the eradication objective—as we must—then there aren’t many other options available. By winning this war, we can not only provide the much needed boost to our population’s morale but also stand solid in a globalized world by having made a meaningful contribution to global health.
The author is the founder present of the NGO thinktank, Heartfile. E mail: firstname.lastname@example.org