Sajid Khan* refuses to allow administration of polio drops to his children. One of his children is paralysed, and another - who died a few years back - had lived with the same disability. Khan claims that his son was born with the disability and that he had tested negative for polio. He holds firmly to the view that polio drives, "backed by foreign powers and anti-state elements" are geared towards making Muslim children sterile.

"This is an anti-Islam and anti-Pakistan agenda," he says.

When asked how he had arrived at this conclusion, he raises doubts over the "concern" that "foreign powers" had for Pakistani lives.

A resident of Dhok Hasu area of Rawalpindi and a native of KP, Khan also advises people in his circle to refuse administration of polio drops to their children.

A family that refuses administration of polio vaccine is liable to legal action. But the situation on ground is complicated. Recalling an armed attack on polio workers in Dhok Hasu area, District Superintendent Vaccination (DSV) Muhammad Hussain says that they had registered a case against a family for refusing polio drops and inciting violence against polio workers, but "eventually had to make an out-of-court settlement as the environment had become too hostile for polio workers.

He says people had started hiding their children during polio campaigns. "As a result, we stopped taking the legal recourse when families refused," he adds.

Jahangir Ali*, a resident of PWD Colony in Islamabad, shares Khan’s views. Whenever someone tries to convince him of the utility of the vaccine, he brings up the Abbottabad incident, where American forces killed Osama Bin Laden following a similar campaign. Ali has five children. He claims that he has never administrated polio drops to them.

DSV Hussain notes that about "80 percent" of refusal cases are from Khyber-Pakhtunkhwa families that have settled here, adding that they have strong misconceptions about these drives being the "nefarious agenda of foreign powers". Other health officials avoid commenting on the percentages but concede that a majority of residents in these areas are native of KP. "Some local residents also refuse drops on account of similar misinformation about these drives," he adds.

Hussain says that misinformation through social media is a new challenge. "Since last year, when a series of fake news videos went viral on social media from KP, claiming that polio vaccine was toxic, the number of refusal cases has jumped up to 30,000 from about 4,000 to 5,000."

Muhammad Kamran, in-charge for polio eradication in Ratta Amral, says: "Refusal cases in this area were hardly 15 to 20 earlier, but after these fake news videos, refusal cases suddenly jumped to more than 200."

The superintendent of vaccination in Rawalpindi, Mohammad Islam says, "People who refuse polio vaccine often ask why global superpowers want to assist Pakistan in polio eradication when they have never supported Pakistan otherwise. They ask, why only Muslim countries are the target of polio eradication efforts?"

These statements represent what all those involved in polio eradication efforts are up against. Even frequent drives, says Kamran, increase people’s doubts in his area. "People ask, earlier there were one or two anti-polio drives in a year. Why are six or more drives being undertaken now? They think that this is due to foreign interests".

The concerned departments, however, maintain that frequent polio drives are not only helpful in sensitising people about the danger of virus but the approach is effective in eradicating polio virus in the city.

Farzana Bibi has been a polio worker for two years. "Many refusing families eventually get convinced. As for those who resist despite our efforts, we note their objections in our registers. Once we conclude the polio drive, we visit them again and if the families are still not ready, we report the issue to the authorities."

Bibi notes that repeat visits to the refusing family sometimes backfire. "They get aggressive. In such situations, we prefer reporting to the department to avoid any untoward situation."

The Health Department has special committees who keep visiting the refusing families until they agree to allow polio drops. In these efforts, they enlist support of prayer leaders, seminary teachers, and local influential people.

Hafiz Muhammad Iqbal, a religious scholar, was among those who once had similar misconceptions against polio drops. Now he is not only administrating polio drops to his children but also helping the Health Department in persuading others.

Iqbal says that there is nothing dangerous for children in this vaccine - "A fatwa by religious scholars and lab test of the vaccine are enough to prove the quality of the vaccine as well as the purity of intentions behind the polio cause". He adds that religious scholars can play a crucial role in convincing people, as "most of most of the refusing families trust them".

"We have published special booklets containing fatwas and test reports of polio vaccine. These documents are with polio teams and other stakeholders," claims DSV Hussain. However, when asked for a copy of the document, both the fatwas and the lab reports of the vaccine were missing from the booklet he had on his table.

Rasheed Ahmed, a member of the Rawalpindi Cantonment Board, says, "The local representatives in Cantt areas have no role in polio campaigns since the matter has been handed over to the district administration. Earlier, the local representatives were involved in these campaigns," he says, adding that they are ready to cooperate in the best public interest.

As per health officials, the total population of Rawalpindi district is 5.6 million. It is divided into 46 union councils and cantonment regions. As many as 286,200 children are the target population for administration of polio drops. The health management has 2,500 mobile teams, 454 area in-charges, and 226 medical doctors as part of the force to administrate polio drops as well as create awareness among people regarding importance of polio drops.

No polio case has been reported in Rawalpindi district after 2010. Earlier, one case each was reported in 2008 and 2009 respectively. However, health officials say that the potential threat of virus transmission is still there as people in parts of Rawalpindi still refuse administration of polio drops to their children.

According to official sources, most refusal cases come from UC3: Hazara Colony, UC4: Dhok Mangtal, UC5: Dhok Hasu Shumali, UC6: Dhok Hasu Jonobi, UC7: Awan Colony, UC8: Fauji Colony, UC9: Bangash Colony, UC10: Khayaban-e-Sir Syed Awan Market, UC11: Khayaban-e-Sir Syed, Sector 3&4-b, CTR1: Qasimabad, CTR2: Allahabad, CTR3: Sultanabad, CTR4: Westridge, CTR5: Habib Colony and CTR17: Dhok Mustaqeem.

Dhok Mangtal and Fauji Colony area are more vulnerable to poliovirus as a high number of refusals come from these localities. Out of a total 79,629 target children in eight UCs and six CTRs, 6,019 parents refuse administration of polio drops to their children.

Officials maintain that the sample to test existence of poliovirus is drawn on a regular basis, and most of the samples come out negative.

Talking about future vaccination drives, Islam says a polio drive was due this month but had to be postponed because of staff shortages.

"The next polio drive will be undertaken in October," he says.

Islam says they were planning to advertise jobs and will be hiring new people soon. He says that they are planning to induct people from within the communities, so that the issue of resistance can be solved on permanent basis.

*names changed to protect identities

Countering social media untruths

Director Information Health Hamid Iqbal says social media propaganda against polio drops has emerged as a serious challenge for the department and demands proactive strategies.

When asked whether the department was thinking of a strategy to overcome the problems caused by circulation of videos that hurt the polio cause on social media, he says that he did not know of such a strategy but could check with senior officials.

However, when contacted again for any updates, he says that the department is already working on short-term and long-term strategies but a strategy to counter the social media issue is not on the cards.

Most stakeholders have suggested that senior management’s involvement could potentially play a vital role in removing public misconceptions. When asked about the involvement of senior management, Iqbal says, "Higher authorities are more active and vigilant on the issue."

Tallies from across Pakistan

At least five polio cases have surfaced in the Punjab this year, including four in Lahore and one in Jhelum. In Punjab, 12 polio cases were reported in 2012, seven in 2013, five in 2014, two in 2015, one in 2017 and five in the first eight months of 2019. Besides, over 60 WPV-1 cases have surfaced in the first eight months of 2019. This number was 12 in 2018.

According to a recent WHO report, Pakistan is one of the only three countries in the world (along with Afghanistan and Nigeria) where polio remains endemic.

No report of polio cases after 2010, and reports about the non-existence of poliovirus in parts of the district are some good developments, but the threat of polio transmission still remains and fluctuation in refusal cases due to fake news on social media is an additional point of concern.