A new war — against polio- Dr Sania Nishtar

Pakistan‘s security situation and the war on terror has become a top priority for the government. While the need to prioritise 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 Programme on Polio Eradication spearheaded by the WHO and involving many other agencies aimed at eradicating a disease from this planet for the second time in the world’s history since smallpox eradication in 1979, has been ongoing. This initiative, involving 125 countries, more than 20 million health workers and vaccination of over two billion children worldwide has been able to achieve the polio eradication milestone in all except four countries of the world.

The premise is simple: immunisation 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 realisation 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 recognised that there are factors beyond the control of the health sector. The security situation in FATA and the 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 rumours 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 doorstep and the extensive population movement across the Pakistani-Afghan border are the three key factors outside of the health sector. However, it must be recognised 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 immunisation coverage.

Pakistan has had resources to immunise every single child since the early 1990s; however, the Pakistan Demographic and Health Survey, 2007, recently reported that the percentage of fully immunised children in Pakistan currently stands at 47 percent. This is clearly unacceptable. Immunisation 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 institutionalised 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 cold chain is critical to the potency of the vaccine; with the currently eight hours of load shedding on average, 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? Diarrhoeal disease can interfere with the uptake of the polio virus in a child’s intestine; to what extent can a polio programme have control over that, given that overarching issues of poor sanitation and high population density continue to prevail and the result in frequent outbreaks of what gets labelled 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 institutionalised. Then there are conspiratorial theories of there being a vested interest at an administrative level to linger on with National Immunisation 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 immunisation programme must be pursued. Meanwhile, however, other strategic warlike measures aimed at eradication must be developed over the short term. Here we must recognise that despite the high level of 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 a few Grand NIDs, where the entire organisational 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 utilising 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 tranquillity in the war zones of FATA and the 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 globalised world by having made a meaningful contribution to global health.

The writer is founder-president of the NGO think tank Heartfile. Email: sania @heartfile.org

Source: The News, 23/10/2008

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