Polio eradication: Culture eats strategy for lunch!

We burst into celebratory fire a little sooner than we should. We protect the status quo rather than challenge it. The undeclared motto is – if one can spin it well with flashy power points aided by chic sounding acronyms, one can win organizational approval, though the larger problems will persist.

Everyone wanted an easy way out. For every problem, there was an almost formulaic quick-fix method rather than probing deep to into the malaise. Wounds look ugly when opened and we want things to look good, hence the cosmetic measures.

After eight years, I walked out of the Pakistan Polio Programme into my political transition; the question – why the number of missed children could never go down in successive years of vaccination campaigns across the country — still haunted me.

From Health Communication, I stepped in to the world of political communication. The five years spent in this new arena expanded the horizon of my vision — a larger canvas, more autonomy, the liberty to create ideas and implement them, a leadership that valued and believed in my abilities to do the impossible — changed the paradigm through which I viewed the world.

This is what I believe in today. This is what my leader and mentor, Imran Khan, has taught me — never shy away from getting to the core of a problem by asking the right questions and stand up to those who protect the status quo whatever the consequences may be.

On October 15, 2018, I was appointed as Prime Minister’s Focal Person on Polio Eradication. As soon as I took office, the first question I asked was what I had been pondering over since my days as an officer in the same program. ‘What is the exact number of missed children’ answer to which meant the difference between forging ahead or remaining in denial pushing the real issue under the rug.

The question in the public domain is why is there a spike in the Polio cases? Chronologically there is a spike in olio cases with each political transition. Whenever a new government takes office, there is a massive reshuffle of district administrations including the health sector across the country. This is the traditional line of argument, but I needed to probe deeper.

I strongly believe that rising Polio cases is a mere symptom of an underlying disease. The disease is Polio Program’s continued failure to evaluate the correct number of missed children which is entirely dependent on data from the field.

When I took over, Pakistan had already reported six Polio cases while majority of the sewage water samples were showing the widespread presence of highly infectious P1 strain of the virus. “Why don’t we have cases, despite such heavy concentration of the virus,” I asked. One of the standard replies was that the immunity of Pakistani children had reached the optimum levels due to repeated campaigns, and that is precisely why there were no cases.

I believe that Pakistan has always failed to achieve optimum or 95 % coverage and interrupted transmission only due to missed children. Other countries that have successfully eradicated the virus and have done it with 95% coverage of the target population.

Data tell us that 0.3 to 0.4 million children out of 40 million under the age of 5 are missed due either for not being available or for their parents’ refusal. This simply meant that the Pakistan Polio Programme was reaching over 99% of the total target and by now should have eradicated Poliovirus many years ago. Not to mention some national Polio campaigns where data have shown 101% coverage!

We came very close to ending Polio in Pakistan in 2017 as the virus transmission in the core reservoirs of Peshawar, Quetta and Karachi had been interrupted. Unfortunately, during the low transmission season of the years 2017-18, the program went into an early celebratory mode with the senior leadership getting themselves decorated with glittering medals for high performance and seeking service benefits. That was the make-or-break point for the programme and should have been leveraged fiercely.

In December 2018, there was a massive outbreak in Bajaur tribal district. The inquiry revealed to my horror that rather than vaccinating children, their parents were handed identification markers to mark their children as vaccinated with the aim to mislead the monitoring teams. This was my first exposure to the phenomena of fake finger marking something I never heard of during my eight years in the Polio Programme.

Though the Peshawar drama of April 22, 2019 did a lot of damage, it brought to light community’s mistrust that lies at the core of the issue.

Post-April, southern Khyber Pukhtunkhwa, Bannu and North Waziristan suffered one of the worst outbreaks since 2014It came as no surprise that the plague of fake finger marking had also infected the Bannu division that included North Waziristan and Lakki Marwat. Enmity upon reporting Polio refusal led Polio teams to hand Polio markers to families so they could mark their children as vaccinated to avoid police action.

The Bannu revelations strengthen my belief that in the face of increased Polio virus circulation, if we are to win over the community we must not make use of force and coercion.

A ban was imposed on any punitive action or coercion against refusing parents.. To my utter shock the number of missed children in Bannu shot up from 1,000 to 18,000, in North Waziristan from 1,000 to 8,000 and in Lakki Marwat from 1,000 to 15,000. The average is almost 8 percent missed children in each of these districts which was previously shown as less than 1 percent. Yes! 8 percent missed children is a number big enough to cause the large scale ongoing outbreak in the division. If global Polio eradication history is to be believed this could never have happened with 1 percent missed children as reflected in the data of all previous campaigns. Data on missed children has been misleading us since long; this however, does not imply that all data lacks credibility.

The world is in the grip of one of its worst anti-vaxxers movement including in New York, arguably one of the most aware cities of the world. Pakistan is no exception.

I am spearheading new initiatives: —

A. Pakistan will counter the anti-vaxxers’ campaign through a unique public perception campaign to be launched in November this year to address the underlying problem of community mistrust and refusals.

B. A 24/7 call center is being launched to address queries and misinformation

C. A fruitful collaboration was carried out with Facebook which helped us remove and reduce dissemination of anti-vaccine content contributing to the community mistrust. Some of the unnecessarily ‘intrusive’ questions are being taken out.

D. Frequency of visits of Polio teams and their supervisors is being reduced which is aimed at empowering parents to demand their child’s right to immunization.

We are dealing with a ferocious virus; epidemiology doesn’t change overnight but I assure everyone including the donors that I will not sit idle and results will speak for themselves. I request the media critics to believe that we are working day in and day out for the children of Pakistan to ensure that they are rendered immune to this crippling virus. All — parents, caregivers, politicians, religious clergy and influencers — need to play their part.

We need to reach the last child. Unless we address community mistrust and not shy away from confronting the problems, we may keep munching on data and strategy to no avail. (The writer is Prime Minister’s Focal Person on Polio Eradication)