Polio in Pakistan: Political, Sociological, and Epidemiological Factors

This review article addresses the political, sociological, and epidemiological factors behind the failure in eradication of polio from Pakistan. Outlining sociocultural challenges such as conspiracy theories, it nonetheless argues that these obstacles are by no means insurmountable, and a joint effort by the government, policymakers, the education department, community mobilisers, and public health professionals can indeed make progress.

A relatively popular Nigerian conspiracy theory about polio vaccines spread in Pakistan and, as a result, there is some considerable resistance to polio vaccination. This theory claims that vaccination programmes seeking to eradicate polio within Pakistan are a scheme created by the United States (US) and Israel to sterilise the Muslim population. Public health officials working on vaccination campaigns have been frequently attacked by militant groups, especially in tribal areas controlled by the Taliban. Despite the Western origins of many elements of this conspiracy theory, Pakistan's complex place in the geopolitical stage after the attacks of September 11 2001 and its uneasy relationship with the US ever since have made it a fertile sociological ground for conspiracy mongering.

As the authors explain, the history of conspiracy theories regarding vaccinations goes back to the very first vaccine. Edward Jenner carried out the smallpox vaccine experiment on a healthy young boy, without being certain in advance what the results would be. Clearly, the boy did not have the capacity to give informed consent, a cardinal principle in medical ethics to be an experimental subject. Vaccines are, for the most part, administered during childhood. At that age, individuals cannot truly give consent, which makes vaccines morally suspicious among some people. To a certain extent, this may be the case with the mistrust of polio vaccination in Pakistan. The original anti-vaccination campaign was derived from a basic political argument that claims that individuals are entitled to control of their own body and, thus, it is oppressive to impose mandatory vaccination. However, as too often has been the case, anti-vaccination campaigns have been far more driven by irrational and emotional appeals.

The most recent anti-vaccination campaign relates to the measles, mumps, and rubella (MMR) vaccine and its alleged link to autism. Despite strenuous debunking of both the ethics and methodology of Andrew Wakefield's (subsequently retracted) 1998 Lancet study, his claims managed to resonate with a growing sector in the US and the United Kingdom. As a result, the vaccination rates of MMR have dropped significantly, and some occasional outbreaks have been reported. Wakefield's original article had little conspiracy mongering, but as soon as his claims became popular in the media, conspiracy theorists added to his original allegations by claiming that the rise in autism prevalence was actually a direct consequence of the pharmaceutical companies' profit. There is no formal data to support the hypothesis that Wakefield's article sparked the polio vaccine controversy, but the authors conjecture that it contributed to the environment of mistrust in Nigeria and Pakistan regarding vaccines in general.

The authors next examine the origins and threads of population control conspiracy theories and the ease with which they can take root in a place like Pakistan. The claim made by conspiracy theorists in Pakistan, following the original Nigerian version, is that vaccines contribute to infertility. The distrust of vaccines and conspiracy theories regarding population control have been mostly a phenomenon of Western origin. Yet, conspiracy-mongering thrives more in regions with specific sociological and cultural circumstances, such as perceived powerlessness and a sense of lack of control at a psychological and a sociological level. Nations that have a historical sense of being cheated, and anxiety over the idea that their fate is controlled by outside forces, have a higher probability of developing conspiracy theories. For example, Pakistan's place in the geopolitical scenery and uneasy relationship to the West (especially the US) has contributed to the collective feeling of suspicion and lack of control of its own affairs. Regarding Osama Bin Laden's death, there is one conspiracy theory that has turned to be true. It was reported that, as part of planning for the military operation that killed Bin Laden, spies posing as polio vaccinators got close to Bin Laden's home and collected information about his whereabouts. "In the minds of lesser-educated Pakistanis (the ones who are most vulnerable to polio), it is fairly easy to make the leap and conclude that, all along, polio vaccinations have been done with malicious intentions, and they can only lead to bad results..."

As reported here, to understand the prevalence and reasons behind the poliovirus, it is also necessary to analyse the literacy rate and epidemiological conditions in the area. In Pakistan, there are places like Sindh and Balochistan where the literacy rate is even below 20%. This literacy rate is not important in terms of family and parents being educated and aware about the poliovirus and immunisation, but it is linked with the awareness and education status of the health workers of those areas. A survey conducted in the Quetta and Peshawar regions found that health workers who are more qualified and educated are more updated and aware about the polio programme, and these people are more dedicated and committed to the eradication of polio from Pakistan.

The authors stress that, especially in light of deadly attacks on polio vaccinators in Pakistan, security for healthcare workers and community engagement are critical. For the acceptance of any public health programme, one of the contributing factors is engaging someone from the local community who is easily welcomed and trusted by the community. For the polio eradication programme, a key recommendation is engaging and hiring local women who represent their society. They can inform and motivate the local community more easily than someone from outside the community.

Furthermore, "It is important for the policymakers to first have an awareness program of healthcare workers so that they understand how big this issue is. There should be a collaborative approach where healthcare workers from Pakistan interact and talk with healthcare workers of other countries where polio is not prevalent now. This approach will help the healthcare workers about their importance, roles, and responsibilities in eradicating polio from Pakistan."

In conclusion: "The country faces opposition towards the vaccination as a result of a combination of the historical, sociological, and political perspectives cultivated in the region. However, tackling the misunderstandings that the Pakistani population has towards vaccines will allow for more successful attempts to eradicate the poliovirus from the country."