In a remote village in Khyber Pakhtunkhwa, Pakistan, a young boy named Ahmed, barely three years old, became the latest victim of polio. His story, tragically, is far from unique.
Despite the availability of polio vaccines in Pakistan, Ahmed’s paralysis could have been prevented if not for the combination of cultural resistance, security challenges, and misinformation that plague polio eradication efforts in the country. His parents, influenced by rumours circulating in their community, refused the vaccine, believing myths that the shots could cause infertility or were part of a foreign conspiracy. It wasn’t until Ahmed’s legs began to show signs of paralysis that the devastating reality of polio set in.
Ahmed’s case is a grim reminder of the barriers that still prevent Pakistan from eradicating polio. Pakistan, alongside Afghanistan, remains one of the last two countries in the world where polio continues to spread.
While the global community has made significant strides toward polio eradication, Pakistan’s progress remains fragile. In 2021, Pakistan recorded a historic low of just one case of wild poliovirus (WPV), raising hopes that eradication was within reach. The optimism unfortunately proved short-lived as cases surged again in the following years, including a major outbreak in North Waziristan in 2022, which resulted in 20 confirmed cases. However, by the end of 2024, the number of infected patients has risen to 68, signalling that the battle against polio is far from over. This highlights the urgent need to reassess the current polio eradication strategy and adopt a more integrated approach encompassing hygiene and sanitation.
Polio mainly spreads via the faecal-oral route. The factors behind this persistent transmission are multifaceted: poor sanitation, unhygienic practices, vaccine resistance, security concerns, and inadequate governance play significant roles. The situation is particularly dire in areas like Khyber Pakhtunkhwa, Sindh, and Balochistan, where higher case numbers are linked to health infrastructure challenges and vaccination access.
The continuing presence of polio in the country points to deep-rooted issues that extend beyond health interventions, including governance flaws, societal barriers, and poor infrastructure. Despite decades of vaccination campaigns, the lack of sustained success can be attributed to inadequate hygiene, fragmented strategies, and insufficient commitment from key stakeholders. Addressing these underlying factors is essential for achieving a polio-free future.
A major contributor to Pakistan’s continued struggle with polio is the inadequate sanitation and hygiene infrastructure in many areas. Polio thrives in poor sanitation environments, and access to clean water is limited. In rural and underdeveloped regions, where open defecation remains prevalent, the virus finds fertile ground for transmission. According to Unicef, around 20 per cent of Pakistan’s population still lacks access to basic sanitation, significantly contributing to the spread of the polio virus. In many parts of the country, particularly those with weak health systems, the absence of proper sewage treatment and sanitation facilities exacerbates the problem, putting children at high risk of contracting the virus.
The presence of the virus in environmental samples from numerous cities across Punjab is alarming and demands immediate attention. As per recent reports, the tally of infected districts has reached 83 this year, underscoring the need to address hygiene and sanitation challenges alongside polio eradication interventions.
In addition to poor sanitation, vaccine hesitancy remains a major roadblock. Despite efforts by the government and international organisations to promote vaccination, misconceptions and false beliefs about the vaccine persist. In several regions, rumours claim that the vaccine causes infertility or is part of a foreign conspiracy to harm Muslim children. These myths, which spread through word of mouth, social media, and even some religious leaders, fuel scepticism and resistance to immunisation campaigns. A study conducted in Khyber Pakhtunkhwa in 2020 revealed that these fears and misconceptions shape parents’ decisions about vaccinating their children. In some high-risk areas, vaccine refusal rates have exceeded 10 per cent, further complicating efforts to eradicate polio. The stigma surrounding vaccination also deters many parents from allowing their children to receive the vaccine, fearing social ostracism or conflict with local leaders who oppose it.
Security concerns are another significant hurdle in the fight against polio in Pakistan. In conflict-prone regions, health workers face constant threats, including harassment, kidnapping, and even death. Since the early 2000s, more than 200 polio workers and security personnel have been killed in attacks, primarily in areas like Khyber Pakhtunkhwa, Balochistan, and tribal regions. These attacks not only deter health workers from reaching vulnerable populations but also instil fear and mistrust among communities, further hindering vaccination efforts. The violence has led to a situation where many regions remain unvaccinated due to the reluctance of health workers to operate in high-risk areas.
Another contributing factor to the ongoing polio challenge in Pakistan is fragmented governance and weak coordination between different levels of government. Polio eradication campaigns often face difficulties due to the decentralised nature of Pakistan’s health system. Each province operates independently, leading to overlapping initiatives in some areas. Logistical challenges, such as maintaining a cold chain for vaccines, also complicate the process further, especially in remote areas with inadequate infrastructure.
Despite these challenges, important lessons must be learnt from other countries that have successfully eradicated polio. India, for example, achieved polio-free status in 2014 after facing similar difficulties. India’s approach combined mass vaccination campaigns with efforts to improve sanitation and hygiene, including the construction of subsidised toilets in rural areas. This initiative, part of India’s ‘Clean India Mission’, played a crucial role in breaking the transmission cycle of the virus. India also focused on community engagement, working with local leaders and religious figures to build trust and encourage participation in vaccination campaigns.
Pakistan can learn lessons from Nigeria’s strategy by which the African nation was declared free of wild poliovirus in 2020 and attained this status through robust coordination between national and sub-national levels and by adopting community-based solutions.
For Pakistan, the road to eradicating polio lies in a coordinated, multi-sectoral approach that combines vaccination efforts with improved sanitation, better governance, and targeted community engagement. First and foremost, polio eradication must be linked to broader public health initiatives aimed at improving sanitation and hygiene. Mass immunisation campaigns must be complemented by efforts to promote handwashing and construct toilets in rural areas. Addressing vaccine hesitancy through education and engagement with community leaders is critical. These efforts should be accompanied by a security strategy that ensures the protection of polio workers and vaccinators in high-risk areas.
Strengthening governance and coordination at the national level is equally vital. The National Emergency Operations Centre (NEOC) for polio eradication, which coordinates efforts at the national and provincial levels, must be strengthened further like that of the National Command and Operation Centre (NCOC). Its work during the Covid-19 pandemic was a tremendous success. Lessons from Punjab’s dengue control programme, which involved all stakeholders and regular top-level monitoring, could also be replicated. Innovative technologies like mobile data collection and real-time monitoring could further enhance vaccination campaigns.
Pakistan’s experience with the Covid-19 pandemic and dengue management demonstrates the country’s ability to mobilise resources and respond to health crises effectively. With a strong political will and coordinated efforts, it is possible to eliminate polio from Pakistan. However, this will require sustained commitment from all tiers of society, including the government, international organisations, local communities, and healthcare workers.
The eradication of polio in Pakistan is not merely a matter of public health; it is a matter of justice for children like Ahmed who deserve to live healthy, happy lives free from the debilitating effects of polio. It is time for Pakistan to act decisively and end the rampage of polio that continues to cause permanent disability to innocent human beings.
The writer is a public health specialist.