We have witnessed a terrible declaration of war on public health in Pakistan, with the murder of 16 polio vaccinators and education workers over the last several weeks. The killing of a policeman protecting a polio vaccination team just last Tuesday is a stark reminder of the continuing challenges of protecting those who risk their lives to deliver vaccines to children. But despite this scheme to strike fear in the hearts of ordinary people, it is heartening to see the extraordinary bravery of polio workers and security officers who are back in the field.
Whatever our response to this tragedy, one thing is definitive: efforts to end polio in Pakistan cannot stop. The world is closer than ever before to eradicating polio, with only 222 cases in 2012. Pakistan is one of the last three countries with active polio transmission. Despite its myriad difficulties, Pakistan has reduced polio cases by two-thirds in the last year, from 198 to just 58. Cases in Baluchistan, a hotbed for polio in 2011, have dropped drastically and Punjab continues to remain largely polio-free.
We have an immense opportunity to ensure that no child in Pakistan and the rest of the world is crippled by this disease. But to achieve this goal, we must look closely at why things in Pakistan have deteriorated to this extent. After years of poor attention to human development and good government, we are in the midst of a yawning governance gap, devolution of health services to the provinces and ongoing conflict. Public health is just one of the many state functions and programs gone awry. The issues are multiple and complex, compounded by conflict, insurgency, and population displacement.
Within this context, it is challenging to focus on a single health issue such as polio eradication. In a country with huge unmet needs in maternal and child health programs, polio eradication acts as a lightning rod for suspicion and criticism.
So what can be done? First, full security for health and immunization staff is needed, which should be coupled with the full deployment of the intelligence apparatus. In the Swat Valley, polio vaccinations were able to resume in 2009 following a ban by Taliban militants, a key example of protecting the vulnerable from the tyranny of those few who are determined to take Pakistan back to the dark ages.
In addition, we need to win the hearts and minds of people to support polio eradication. To do that, we have to reevaluate current strategies to engage the public. I have worked on scaling up vaccines in many countries throughout the world, and it is clear that genuine community engagement and efforts to reach largely illiterate families must address a broader range of health and development issues. This is critical in a country such as Pakistan where maternal and child mortality rates remain among the highest in South Asia and malnutrition rates haven’t improved for decades. For example, more than half the at-risk population of polio has no access to basic sanitation or adequate water, and many remain unaware of the risks associated with polio or enteric infections. Combining prevention of diarrheal and other infections, along with polio immunization strategies, could have great impact.
We can instill confidence around the polio eradication program by integrating it with an expanded child health and immunization strategy. To illustrate, a massive measles outbreak in many parts of Sindh killed at least 300 people over the last few weeks. It is evident this stemmed from a virtual collapse of routine immunization systems and poor coverage data.
The robust polio surveillance system in Pakistan exists independently of the routine immunization and disease monitoring systems. It is time for these two programs to leverage each other’s strengths. We will not be able to successfully eradicate polio in Pakistan without strengthening routine immunization systems and tackling basic determinants, such as environmental health and hygiene, and addressing rampant malnutrition.
Lastly, it is time for the donor community to look at Pakistan through a different lens. There must be some harmonization between Pakistan’s commitments to polio eradication for the world, and the global community’s support toward child and maternal health in Pakistan. The starting point is perhaps a dialogue to develop an integrated immunization, child health, and nutrition strategy.
The message from the obscurantists is clear: volunteers supporting the health and development agenda in Pakistan are neither welcome nor safe. Our response must be equally clear: the people of Pakistan, like all people, deserve to live in a country that protects them against the full range of preventable diseases and prioritizes their health. If Pakistan can find that broader path, it can create a future where the children of Pakistan receive the care they need to have healthy and productive lives.
Dr. Zulfiqar A. Bhutta is the Founding Chair of the Division of Women and Child Health of Aga Khan University, Pakistan.
About the photo: A demonstration to condemn the killings of polio vaccination health workers in Pakistan on December 20, 2012. Credit: HANDS Pakistan