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Editorial
Tales
of woe
Editorial As the country struggles against various odds — the
civil-military imbalance, the Pak-US tensions, the institutional infighting
and an ailing president — the news that Pakistan is one of the four
remaining polio-endemic countries is no less depressing. We are a priority
country for the Global Polio Eradication Initiative for the simple reason
that Pakistan is now reporting more cases than those of the other three
endemic countries Nigeria, India and Afghanistan put together. That the worst statistics of polio came from the most
troubled province of Balochistan was even sadder. So why exactly are we lagging behind the rest of the
world when it comes to polio eradication? We at TNS tried to look for the
reasons and, unfortunately, like overpopulation, were fed a plateful —
starting from war on terror in the tribal areas, cultural barriers and the
conservative Pushtoon and Baloch cultures, undocumented cross-border as well
as within the country movement of people, ineffective programme management. Aoun Sahi writes that “Balochistan which has
registered 68 out of a total of 167 polio cases this year so far has emerged
as the most problematic province in the fight against polio in Pakistan in
recent years — from 8 registered cases in 2005 the number has risen
alarmingly to 66.” He finds out that cultural barriers and a shaky health
infrastructure are the two main issues hampering polio eradication in the
province. “Neither do they permit male team members to enter their homes
nor do they allow their women to form female teams to do the needful… ” This is both sad and criminal. Families that have polio
patients now regret why they ignored the call for prevention. They must be
brought on the national media and asked to narrate their stories. But this not where it ends; the supply side or the
outreach has a host of issues. The availability of the vaccine, its proper
maintenance (it must be kept between 2 to 8 degrees Celsius) and
administration is not ensured. People we spoke to have blamed it on the
absence of local government system when there was “at least ownership of
the campaign at the union council level”. This is the
crippling reality that we face on ground. The health of the nation is
clearly not well.
immunisation With 174 registered cases of polio this year, Pakistan
tops the list of nations that have failed to eradicate polio. This is the
second consecutive year the country has displayed a dismal record in
fighting the disease. Last year, too, Pakistan topped the list with 126
cases. An overwhelming majority of polio cases in Pakistan are
being registered in the volatile tribal areas, the adjoining districts of KP
and three districts of Balochistan along southern Afghanistan, where perhaps
the risk is becoming a threat — because vaccinators are unable to reach
the children in the country for a number of reasons. Experts believe several factors — war on terror in the
tribal areas, conservative Pushtoon culture, undocumented cross-border as
well as within the country movement of people and ineffective programme
management — have stood in the way of complete eradication. They believe
Pakistan needs to re-strategise its polio campaign to achieve the target of
polio-free Pakistan by 2012. “We need to develop a sense of ownership
among the vaccinators and other staff members involved in the campaign,”
Dr Hanif Khelji, chief coordinator of the Rotary Club’s polio eradication
programme in Balochistan tells TNS. “We need to involve local NGOs, political parties and
religious scholars in the campaign. Also, an effective system of
accountability is required most urgently,” he adds. Officials at National Institution of Health (NIH),
Islamabad admit that the emergence of new polio cases every day in the
country is a substantial proof of the poor performance of the polio
programme. Simply, it is not delivering. The experts reiterate the need to make radical changes
in the polio campaign strategies in different parts of the country,
especially the 14 high-risk districts and agencies. “A strong monitoring
and accountability system is needed to evolve which really is lacking in the
current campaign strategy,” stresses one NIH official. Balochistan which has registered 68 out of a total 167
polio cases this year so far has emerged as the most problematic province in
the fight against polio in Pakistan in recent years — from 8 registered
cases in 2005 the number has risen alarmingly to 66. In the Quetta block, comprising Quetta, Pashin and Qilla
Abdullah districts, the strong Pakhtoon area, “cultural barriers and a
shaky health infrastructure are the two main issues hampering polio
eradication. Neither do they permit male team members to enter their homes
nor do they allow their women to form female teams to do the needful,”
says a senior official of health ministry in Quetta, talking to TNS. He believes the Musharraf-introduced local government
system worked better. “There was at least ownership of the campaign at the
union council level. The polio cases have drastically increased after the
local government system was abolished,” he says, adding that lack of
continuity, political interference and no sense of ownership are the main
factors responsible for the polio emergence in Balochistan. “Federal government along with international
organisations need to introduce a new strategy based on these factors,” he
suggests. Noorul Haq Baloch, the focal person for polio campaigns
in the Balochistan health department does not hesitate to admit the
shortcomings of the polio campaigns in the past. “We have completely re-strategised
our planning for the upcoming campaign. Union councils will be our main
focus. We are in the process of hiring medical doctors even at union council
levels to monitor and evaluate the campaign. Paramedics will work under
them,” he says. Another problem that he points out is the free and
unchecked human trafficking between Quetta block and southern Afghanistan.
“We have set up transit teams to immune people in border areas. We are
also in regular contact with our Afghan counterparts and planning to closely
coordinate surveillance and supplementary immunisation activities (SIAs) on
both sides of the border,” says Noorul Haq. In the Peshin district alone there are more than 130,000
children under the age of five to target in the upcoming campaign but the
elders simply refuse to get their young ones vaccinated. “We are planning
to take religious scholars, local elders, political parties and teachers on
board,” he says. But essentially, reaching out to all the children is not
the only issue. “We have to ensure the vaccine is not wasted before it
goes into the child’s mouth. It must be kept between 2 to 8 degrees
Celsius,” says Jalaluddin, programme manager Research and Development
Foundation, a Peshawar-based NGO working in collaboration with the UNICEF on
making polio campaigns more effective in KP and tribal areas of Pakistan. “Earlier, children as young as 10-12 years of age were
hired for the vaccination campaign. Surely, they are too young to handle a
sensitive job as this. The government must train vaccinators and hire
qualified people,” he urges. Dr Jan Baz Afridi, Deputy Director, Expanded Programme
for Immunisation (EPI), KP, asserts that the situation has improved compared
to previous years: “We are ensuring a government official is made part of
every mobile team and held accountable for the team’s activity.” He adds that the prime minister announced major changes
in the polio eradication effort on November 24. “He clearly underlined
that activities and accountability needed to be tracked and monitored at the
provincial, district and union council levels. We have already constituted
committees on these levels for the first time and hope to achieve maximum in
coming campaigns,” he says. Tribal areas of Pakistan are another problem in
Pakistan. In Khyber Agency alone, more than 200,000 children are out of the
immunisation net since 2009. Polio vaccinators in the Agency tell TNS that
there is not even a single female mobile team out of a total of 113 teams in
the Agency. “Male teams can only go to a certain gathering place
in villages and request village men to bring their children out for
vaccination,” says a vaccinator in Khyber Agency, “We have received no
new instructions for the upcoming campaign and we believe a lot of children
will go amiss.” Dr Abdul Qadoos, in charge of health-related operation
in Khyber Agency, says that there are more than 210,000 children under five
in the Agency. “At least 76,000 of them are inaccessible. We have formed
13 transit teams to vaccinate children of those families who move from one
place to other. We have already suggested to the government to introduce the
more expensive injectable polio vaccine and some incentive to the target
families for vaccinating their children”. He admits maintaining the
recommended temperature for vaccine is a problem in tribal areas due to
hours-long load shedding of electricity. UN agencies working on polio eradications have also been
working closely with the government of Pakistan to re-strategise the polio
campaign in the country. World Health Organisation has been working on
district-specific plans to maximise the impact of supplementary immunisation
activities (SIAs). New approaches are being put in place to increase access
to populations in conflict-affected areas by employing local access
negotiators; implementing the new Short Interval Additional Dose (SIAD)
strategy during windows of opportunity and continuously assessing the
evolving security situation to help guide strategy and update
district-specific plans. “We have several approaches. First, to position
vaccination teams at points of exit where people may be fleeing an area to
ensure that those children are vaccinated. Then following up at the camps
for the internally displaced people or among the communities where they have
taken shelter, with vaccination campaigns”, Sona Bari of Global Polio
Eradication Initiative, a public-private partnership led by national
governments and spearheaded by WHO tells TNS via email. “Also, when there
is a pause in conflict for whatever reason, we use a tactic known as Short
Interval Additional Dose. Thanks to new vaccines, we can deliver doses of
polio vaccine at shorter intervals than before. This advantage is used when
an area is accessible for a short time. Teams will go in and vaccinate twice
during a short period of time,” she says. Due to large-scale population movements with
neighbouring Afghanistan, the two countries will closely coordinate
surveillance and SIA activities. “Technical support has been deployed to
key border areas to improve immunisation activities, and temporary
vaccination posts have been set up at key border crossings and gathering
sites”, she says.
Foreign
hand The United Nations Children’s Fund (Unicef) warning
that Pakistan is facing a serious risk of being the last polio reservoir in
the world has put it on the global disease watch radar and media limelight.
The extraordinarily high instance of new polio cases is, therefore, yet
another wrong reason for Pakistan to be in the news. The challenge of eradicating this crippling disease has
been accepted by the government and fully supported by organisations like
Unicef and World Health Organisation (WHO). Quite ironically, much is expected from these
international organisations widely criticised by conspiracy theorists on
various charges, such as the vaccine is used as a tool to control population
by making the recipient child infertile or imams (prayer leaders) who term
this vaccine haram (prohibited in Islam) alleging it contains lard. The fact
they have no substantial evidence to prove their claim is however
insignificant. Such claims got some evidential support when it was
confirmed that some individuals under the garb of vaccinators selected DNA
samples of Osama bin Ladin’s family in Abbottabad. Regardless, the role of international organisations in
the fight against polio is integral. At times when finger-marking is still
the main method of verification in the country, a more reliable system of
monitoring is required. TNS talked to representatives of global organisations
and locals working for them to know their observations, experience,
perspective and opinion on how to achieve the goal of polio eradication. Farooq Hameed, who has worked with Unicef in Balochistan
for almost 10 years, terms bad governance the major cause for spread of
disease in the district. “The culture of patronisation is so strong in the
area that District Health Officers (DHOs) are appointed on the behest of
politicians. This promotes culture of corruption as these officials are
protected by the politicians when they are in trouble,” he says. Hameed says he has observed over the years that most of
the health department professionals including Lady Health Workers (LHWs) sit
at home and volunteers have to be depended upon. When the district
management is corrupt, they will resort to activities like selling petrol,
taking vaccinators to fewer places on official vehicles and wrongly
reporting that children or families were not at home. Vaccinators also wrongly use the excuse of children
running fever, he adds. Hameed laments one a dedicated and honest Balochistan
Health Minister had to accept publicly that he failed to execute the
immunisation campaign in the province. He simply failed to take the mafia
head on. Dr Elias Durry, senior coordinator for the WHO’s polio
eradication effort in Pakistan, is also of the view that mismanagement in
the main cause of spread of polio in Pakistan. Without going into details,
he says, the fact that the highest risk areas are Quetta and Karachi —
both provincial capitals — proves inaccessibility is not the major cause
for spread of polio. Durry says WHO provides technical and financial support
to Pakistan to implement the National Emergency Action Plan. Right now
it’s struggling hard to meet the target of vaccinating at least 95 per
cent children. “I would say again what we mostly lack is proper and
quality vaccinators,” he adds. Dr Khalid Jameel, head of the Rehabilitation Department,
Mayo Hospital, Lahore, tells Unicef that he urges international community to
also focus on the rehabilitation of children affected by polio. Popularly
known as Big Brother, Dr Jameel receives polio patients from all over
Pakistan and evaluates their cases before referring their names for support.
Under an agreement reached upon by Punjab Chief Minister
Shahbaz Sharif and Unicef, such affectees get financial support for
education and sustenance and wheelchairs etc. Dr Jameel says unfortunately polio is irreversible;
international community does support immunisation drives at a large scale
but very few go for rehabilitation. Dr Seema Raza, a medical health professional, believes
desired results cannot be achieved without addressing the root causes which
sometime remain unnoticed by locals and foreigners fighting the disease.
Explaining her point, she says, not less than 80 per cent childbirths take
place at homes, mostly in far flung areas. The newborns in these cases are not administered polio
vaccine soon after their birth whereas in hospitals, whether government or
private, it is mandatory to do so. Those who reach hospitals are advised to
get further doses in time and they mostly follow the advice, she adds. Dr Raza points out another problem in this regard — a
child affected by polio virus has to be isolated immediately to save others.
This is not possible in rural areas where awareness is negligible and so the
space to accommodate family members in different rooms constricted.
perspective Pakistan is one of the four remaining polio-endemic
countries in the world, making ours a priority country for the Global Polio
Eradication Initiative, according to the World Health Organization (WHO).
The virus, which also led America’s Central Intelligence Agency to catch
their biggest target of the decade — Osama bin Laden — this May near
Islamabad through a fake polio campaign, is still on the rise and spreading.
Of the four countries in the world that are not
polio-free yet — Nigeria, Afghanistan, India and Pakistan — the last
three fall in South Asia. The WHO reports say Pakistan is also the cause of
a recent detection of a polio case in China as the said child carries the
virus similar to the one in Pakistan. Correspondingly, the WHO has warned
other countries of the world against the presence of the genetic link to the
wild poliovirus type-1 detected in China’s Xinjiang province, bordering
Pakistan, in the past few months. Since the launch of the special polio vaccination
campaign in 1994, the country has made substantial progress towards the
eradication of the disease that cripples children. However, the conflict
zones of the country — chiefly Balochistan and the tribal areas — are
still under threat by the virus. The latest number of polio cases in Pakistan (recorded
early December) this year has reached 174, according to official reports.
This number includes five cases in Punjab, 30 in Sindh, one in
Gilgit-Baltistan, 19 in Khyber-Pakhtunkhwa, 51 in the Federally Administered
Tribal Areas (FATA), the war-hit zone; and 68 in Balochistan, the most
sparsely populated and the most poorly managed province. In the early 1990s, the annual incidence of polio was
estimated at more than 20,000 cases a year, but over the past few years an
average of only 100 cases per year has been reported. “Currently, Quetta zone and Fata are the most affected
areas in Pakistan,” says a senior official in the polio eradication
coordination department at federal level. He says the major reasons are lack of strategy, quality
of campaign, and accessibility. The vaccination teams are not achieving the
required target. There are still 180,000 children in this area left to be
vaccinated as compared to 300,000 a couple of years ago. Pakistan is now reporting more cases than the cases of
the other three endemic countries Nigeria, India, and Afghanistan put
together. After 23 years of commencing the WHO-led Global Polio
Eradication initiative, billions of dollars in investment, mobilisation of
20 million health workers and a population wide intervention in 125
countries, vaccinating more than two billion children, there are only four
countries in the world which continue to harbour the disease. Pakistan is
the only country where cases have steadily increased since 2008, says the
WHO report. There are only five important districts for polio
eradication in Balochistan — namely Quetta, Pishin and Kila Abdullah,
making a triad and adjoining districts of Nasirabad and Jaffarabad. KP and
Fata continue to be at risk. Several areas in these conflict regions have
been inaccessible for vaccination, leaving too many children insufficiently
protected against polio. The Sindh programme has demonstrated its capacity to
interrupt poliovirus transmission; however, the achievements could not been
sustained. One type-3 polio case was reported in 2010. In 2009, Sindh
reported 12 polio cases. Epidemiological data complemented by genetic
analysis of polioviruses confirms the ongoing circulation of type-3
poliovirus in Karachi. “One of the major reasons for non-eradication of polio
in the province is people’s refusal to have their children vaccinated,”
KP Health Secretary Asmatullah Kakar says. Misinformed religious factions challenge the writ of the
state and the campaign against polio widely, on the notion that vaccination
is forbidden in the religion because it affects fertility. Pakistan has run 118 anti-polio special campaigns since
1994, while it started its normal polio campaign in 1982, recalls Dr Azhar
Bhatti, Additional Director, Expanded Programme for Immunisation (EPI),
Punjab. According to Bhatti, recent researches have shown that
the potable water of Lahore, Multan, Faisalabad and Rawalpindi is
contaminated with the polio virus. The government is working on eliminating
the risk in collaboration with the WHO, he adds. The tremendous progress towards the eradication of polio
in Pakistan is threatened by stagnation due to managerial and implementation
failures and a lack of accountability in these districts. “One of the main reasons behind the persistent
circulation remains the inconsistency of campaign quality at the
sub-district level and continuing sub-optimal routine EPI coverage,” says
an official report of Government of Pakistan. “On the other hand, inaccessibility to children in
security compromised areas such as KP and Fata and pockets where the people
refused the vaccination have also contributed to the persistence of the
disease’s circulation in KP and Fata. Additionally, the movement of over
400,000 internally displaced persons from active conflict areas of KP and
Fata which have both non-immune and under-immune children because they are
inaccessible or refusals resulted in a significant disturbance in the
epidemiological situation and contributed to an upsurge in cases in KP and
Fata, Islamabad and Punjab.” Moreover, malpractices such as absenteeism in public
facilities, ghost vaccination teams, well-institutionalised pilfering from
the supply chain, crony managerial appointments, collusion in monitoring
records and embezzlement at the field level are also cited as reasons for
the failure of such campaigns. The gaps in the governance of the Polio Eradication
Programme are an impediment to an effective translation of the National
Emergency Plan for Polio Eradication into concrete action on the ground and
all the sensitisation, awareness creation and commitment mobilisation at the
highest level, ultimately comes to a naught, according to an official
report. Global status of
polio Till Nov '11 Countries
Confirmed
Confirmed Confirmed
Confirmed
cases 2008 cases
2009 cases 2010
cases 2011 Afghanistan
31
38
24
47 India 559
762
44
01 Nigeria 798
388
18
42 Pakistan
117
89
144
174 (till now) Reasons for
non-eradication - Inaccessibility - Hard-to-reach areas - Lack of political will - Religious propaganda - Lack of accountability - Low quality campaign - Lack of proper monitoring - Negligence of staff and teams - Lack of coordination - Transfer of virus through travel - Poor district level supervision - Following the cold-chain
of
vaccine - Inconsistent quality of vaccination
activities in a few
key reservoir areas - High population movement - Injudicious distribution of vaccinators
at union council
level - Improper utilisation of resources
in a few key districts
and towns - Selection of inappropriate/incompe- tent
volunteers/vaccina- tion
staff during the campaign - Non-existence of regular outreach
EPI activities
Tales
of woe In Regi village in the suburbs of Peshawar, a cleric
opposed to polio vaccination has constantly urged people to avoid
administering polio drops to their infants, as in his view it is a
conspiracy of the West to make their next generation impotent and decrease
population of the Muslims. Interestingly, the cleric’s own son became victim to
the poliovirus as a result of his refusal to vaccination campaigns. However,
instead of showing any regrets, the cleric thought it was the Will of the
Almighty and must not be meddled with. A common villager, however, is having second thoughts.
Khan saheb (real name changed), a resident of a small village in KP, is sad
because listening to the fiery sermons of the cleric cost him his daughter
Hafsa’s health. Scared he might be picked on for “daring to differ,”
Khan says ruefully how a number of medical workers visited his house to have
his child vaccinated against poliovirus but he refused to all of them,
saying it was “un-Islamic”. Sadly, he learnt the lesson the hardest way. “My
daughter has become paralysed for life and I feel guilty like anything,”
he says. “I hold myself responsible for her plight.” Khan is not loath to blame the orthodox thinking of the
clerics who propagate against polio vaccination, rejecting any efforts on
the part of the government to eradicate the virus from the face of the
earth. Apart from the tribal areas where militancy, military
operations and malicious propaganda by certain clerics have contributed to
the rising number of polio cases, the vaccinators are faced with similar
challenges in Khyber-Pakhtunkhwa. KP recorded 19 cases this year, five of
them in Peshawar, the provincial capital. Senior health officials are of the view that besides
reasons such as a lack of security for vaccinators in different areas,
insufficient resources and corruption, propaganda against vaccination by
clerics has made it difficult for them to convince parents to have their
children administered with polio drops. In Peshawar areas where the literacy
rate is low, parents continue to refuse vaccination to their kids. With financial assistance and technical support from
donor organisations, the provincial health department and the EPI organised
several seminars and workshops with the aim to removing misconceptions
attached to polio vaccination. Even the services of eminent religious
scholars were utilised and they personally attended functions, issued
religious decrees in support of the polio campaign and through sermons urged
people to save lives of their children from being paralysed forever by
administrating polio drops in time. But all such efforts appear to have gone to waste since
the virus has not been eradicated. Senior officials of different donor agencies say over Rs
500 million are being spent on each of the nine anti-polio campaigns every
year to administer Oral Polio Vaccine (OPV) to around five million children. According to Dr Jan Baz Afridi, EPI chief in KP, refusal
cases have been brought down from 26, 000 to 16000 during the past few
months. In North Waziristan, where even the Taliban led by Hafiz
Gul Bahadur and influential religious clerics publicly announced their
support to polio vaccination, it was the health department and people
associated with polio education programme who failed to reach out to the
children living beyond Miramshah and Mir Ali, the two major towns of the
tribal region. An official of health department in Miramshah tells TNS
that due to a lack of checks and balances by the high-ups based in Peshawar
and Islamabad, the vaccination campaign has never achieved its target in the
region. Hence, polio teams supposed to visit each and every house just end
up handing over vaccines to villagers in far-flung areas they meet at a bus
terminal or markets in Miramshah. The villagers are advised to take vaccines along and
administer to kids in their villages. Since the vaccines require a standard
temperature, therefore it has lost its efficacy by the time it reaches its
target areas.
Province
of issues Eighteen months old Asad Khan from Kharotabad area of
Quetta, was crippled because he had not been administered polio drops. His
father’s voice drops as he speaks of Asad’s plight. This is not the first case of polio in Balochistan. The
province has, in a short span of two months, seen as many as 27 polio cases
registered in different districts of the province including Quetta, Qillah
Abdullah, Jaffarabad, Khuzdar, Nushki, Pishin and Loralai. The current tally
becomes 66. One reason for the resurgence of the crippling disease
in Balochistan is that the drinking water in most cities of the province is
turbid and unhygienic. According to an EPI report, the number of polio cases
in Balochistan during the current year has risen to 275 where the 138 cases
have not been confirmed. Nevertheless, 66 cases were confirmed to be
positive. The report of 24 cases is yet to come. The efforts of the Balochistan government to save the
children have mostly been aborted as the number of polio patients continues
to grow. Due to the non-administration of polio vaccination, the
virus is rapidly spreading, says Asmatullah Khan Kakar, Provincial Secretary
Health Department, talking to TNS. The real causes of the spread of poliovirus in
Balochistan are said to be poor literacy rate, propaganda against polio
vaccination campaign and professional negligence on the part of the medical
workers. For a three-day awareness campaign, each worker is only paid Rs 250
a day. As for the workers they are neither trained nor supplied with
community maps of the field. On the other hand, the residents in suburban areas hold
the view that since the vaccines are manufactured in western countries, they
will have harmful side effects on their kids. Another health fallacy seen in interior Balochistan is
that when sick a patient is carried to the local mullahs
(religious/spiritual clerics) who either gives them a charm amulet or some
sort of ‘spiritual’ treatment that not only wastes time but also
aggravates the ailment. Most polio cases in Balochistan have occurred in the
Afghan-Pakistan border areas. According to the officials of provincial
health department, the Afghan refugees who come into Pakistan bring with
them the virus. In the given situation, legislation is under
consideration against all violators of polio vaccination, whereby those who
refuse to get the vaccination will be arrested. Since polio is a water-borne disease, most inhabitants
of Balochistan and its suburbs people are vulnerable to it because they are
generally not careful about potable water, especially with regard to miners.
It is a pity that 85 percent population of Balochistan is simply deprived of
clean drinking water despite all claims by the provincial government. The allocation of annual health budget for the province
goes to waste when the same is not properly implemented, coupled with the
paucity of related health facilities and an absence of official medical
practitioners from the district headquarter hospitals that aggravate the
already dilapidated health situation in Balochistan.
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