Eradicating Polio in Pakistan: An Analysis of the Challenges and Solutions to this Security and Health Issue

"Pakistan's polio eradication campaign provides important lessons for the delivery of future global health initiatives; the role of traditional social and religious norms and their wider diplomatic, security, economic and social repercussions in an era of increasing globalisation should not be underestimated..."

This analysis focuses on the historical and contemporary challenges facing Pakistan's polio eradication programme and the impact of conflict and insecurity there. In exploring lessons and solutions learned from the campaign, it sheds light on strategies to combat vaccine hesitancy, engage local communities, and build on progress towards polio eradication in Pakistan.

As explained here, since its launch in 1988, the Global Polio Eradication Initiative (GPEI) has had to operate in a complex and ever-changing geopolitical landscape and to contend with many factors, particularly the impact of conflict. However, it would be incorrect to assume that conflict alone has been the main barrier. In many cases, polio-endemic countries like Pakistan have faced numerous additional challenges, such as poor health communication strategies. For instance, as documented in Northern Nigeria and Pakistan, polio eradication has been hampered when provincial and district health agencies, which control most vaccination resources, are not sufficiently engaged and when religious and community leaders have not advocated to support the campaign.

Pakistan's polio eradication programme has come under international scrutiny due to its position as the main driver of global wild poliovirus spread in recent years. From 2000 onwards, the campaign strategy incorporated house-to-house visits with at least 7 rounds of national immunisation days (NIDs) and targeted "mop-up" supplementary immunisation activities (SIAs) during negotiated ceasefires in conflict regions, based on local surveillance results or in response to disease outbreaks. These efforts have seen challenges, including vaccine hesitancy. Illiteracy, as well as socioeconomic, cultural, and religious factors, have all contributed to parental refusal due, for example, to misconceptions regarding the purpose or effectiveness of immunisation. These faulty beliefs include the misconception that vaccines can harm or sterilise children or that they contain monkey- or pig-derived products that are forbidden in Islam. Cultural issues such as the presence of all-male vaccinator teams when the mother is alone, or when family or community elders have not given consent for vaccination, have also been cited as barriers to immunisation in some communities.

That said, the persistence of poliomyelitis in Khyber Pakhtunkhwa (KP) and the Federally Administered Tribal Areas (FATA), the major wild poliovirus reservoirs in Pakistan, is intimately linked to active conflict and insecurity in these regions. A concerted propaganda campaign by militants operating from the Pakistan-Afghanistan border region, and supported by some religious clerics, linked vaccination programmes to a Western plot to sterilise Muslims and painted vaccinators as spies for the United States (US) Central Intelligence Agency's (CIA) drone programme, especially after revelations that the CIA funded a fake hepatitis B vaccination campaign in Abbottabad to trace Osama bin Laden. This has led to a deep suspicion of the polio eradication campaign. Furthermore, the Taliban-imposed ban on vaccination in 2012 has been detrimental to polio eradication efforts, especially in parts of FATA. Targeted attacks against immunisation teams since 2012 have killed scores of vaccinators; this climate of fear and insecurity has also impacted the recruitment, training, and retention of vaccinators.

The article explores several strategies to improve Pakistan's polio eradication campaign, one of them being community engagement and education. There have been examples of visible partnerships between political and religious authority figures playing a role, such as in ending the 2003 polio immunisation boycott in Northern Nigeria. Saudi Arabia's enforcement of World Health Organization (WHO) recommendations with fatwas (formal Islamic rulings) to vaccinate pilgrims undertaking the Hajj in 2005 also helped dispel suspicions that the polio eradication campaign aims to sterilise Muslims. This strategy has also been applied in Pakistan, where prominent Islamic scholars issued a fatwa endorsing the polio vaccination campaign and have also led door-to-door campaigns in parts of the country.

Furthermore, gaining support from influential public figures and the use of mass communication strategies for health awareness and social mobilisation can help shift negative perceptions of the polio vaccine campaign and reduce vaccine refusal rates. Efforts to improve health communication drawing on these approaches are underway in Pakistan. The United Nations Children's Fund (UNICEF), for instance, has partnered with imams to facilitate immunisation in thousands of schools and madrassas across the country and has launched media campaigns to highlight the risks of polio and the importance of vaccination.

Pakistan's civil society organisations (CSOs), many of which provide community health services in regions without a public health infrastructure, can also be recruited to support campaign efforts. Many of these CSOs have already built strong partnerships with the communities they serve, are privy to local concerns, and have the logistics to facilitate the immunisation campaign and associated health initiatives.

In discussing the role of global health diplomacy in polio eradication, the article points to one lesson from Pakistan's case: how the exclusive use of health outcomes failed to realise the collateral and indirect effects on local cultural and religious sensibilities. Pakistan's National Emergency Action Plan (NEAP) outlines efforts to address these concerns, including support from media organisations and community outreach programmes to improve vaccine education among recipients. However, addressing the long-term health inequalities in Pakistan will require an overhaul of the health bureaucracy as well as improve access to health in hard-to-reach areas. Global health initiatives have the potential to facilitate these changes. Cited here is the importance of increased collaboration between foreign policymakers, diplomats, and global health professionals to establish appropriate standards and protocols to account for socioeconomic, political, foreign policy, and primary health interests when designing global health projects so as to mitigate negative health and security consequences.

In conclusion, the article affirms that conflict and insecurity have been damaging to polio eradication efforts in recent years, especially in FATA and KP. However, Pakistan's polio eradication effort can be buoyed by addressing that country's inequities in its strategy and infrastructure, helping shift perceptions against vaccination through more concerted community engagement and education initiatives, and addressing vaccine hesitancy using tools such as mass media campaigns. Strengthening collaborations with influential religious leaders and organisations can also help mitigate the religious and political dimensions of vaccine hesitancy in Pakistan.