Eos investigates why polio is on the rise again in Pakistan

The alarming resurgence of polio cases in Pakistan have been traced primarily to vaccine refusals from Khyber Pakhtunkhwa, especially the newly merged tribal areas of the erstwhile Fata. But is it simply misinformation that is leading to refusals? An Eos investigation...

North Waziristan may be described in two Pashto words: ‘spore’ and ‘spaira’.

Spore means dry. Spaira is more difficult to translate in a single word, but ‘misfortune’ comes close. To others, it may mean other things. A dry hot place under a cruel sun, devoid of vegetation except thorny bushes that grow out of a thirsty land; a place where heat and dust never sleep, and snakes and scorpions spill out of the bowels of a parched earth. All of which seems like a fitting description for the natural state of most of North Waziristan. But Waziristan is not hell, nor are its inhabitants heathens deserving God’s wrath. If misfortune has visited this most hospitable people, and if the place itself is in a state of unsightly disrepair, it has been brought upon by man and the curse of geopolitics. Nature, inhospitable though it is, has only toughened them to withstand this misfortune.

For some, this spaira has come in the form of displacement to places equally as harsh and inhospitable as North Waziristan — like the Internally Displaced People (IDP) camp in Bakakhel. To others, who have returned, it comes in the form of ever-present militancy and threats to life and property in spite of the state’s promised security and hollow claims that the region has been cleared of militants.

Amidst all this is polio and a militant commander Hafiz Gul Bahadur, who issued pamphlets this August asking women polio workers to stay away from the vaccination campaign. Or else. Within hours of the pamphlet being circulated, 47 polio workers quit their jobs. By the end of the campaign, a desperate Hameedullah, the district health officer in North Waziristan, had to rope in staff from the WHO’s Expanded Programme on Immunisation to fill the gaps.

A boy being administered anti-polio vaccine | White Star

This is not the first time that the security situation has hampered the polio drive in a tribal district. Militancy, insurgencies, military operations, restrictions on mobility and suspicions in the wake of a Central Intelligence Agency (CIA)-funded vaccine operation that led to the detection and death of Osama bin Laden in Abbottabad, have contributed to the failure to eradicate polio in the region.

In 2014, the year of the Zarb-i-Azb military operation, polio in North Waziristan took on epidemic proportions, with 44 cases detected there. As the virus spiralled out of control, causing a public health emergency, the WHO imposed travel restrictions on those leaving Pakistan without a polio vaccine certificate. Soon the army was pressed into polio service and soldiers joined levies to protect polio workers in remote villages. People travelling in and out of the region were administered drops at entry and exit points.

Polio refusals in North Waziristan are not new, but tying them to the complex tangle of “qaumi” demands from a clan or a tribe is.

North Waziristan’s location puts the region especially at risk, says Hameedullah. The region borders Afghanistan (where, like Pakistan, polio remains endemic), South Waziristan and Bannu — where the highest number of polio cases were reported this year. If the public health adage, that one child with a virus can infect a thousand, is something to go by, then the risk in North Waziristan has just multiplied manifold, with the tribes refusing vaccines for reasons of their own.

People are suspicious of polio vaccines around the country. A small hospital in Mashokhel, Peshawar was burnt in April in response to rumours about polio vaccines. | White Star

BARGAINING CHIPS

In Chota Datakhel, a village close to the district headquarters of Miranshah, abandoned or occupied houses with cracked, mortar-blown and bullet-riddled walls stand precariously. Polio is the furthest thing from the villagers minds here. Antidote for snake venom and rabies is a more immediate concern. As is diarrhoea, malaria and pneumonia, as their children live through harsh summers and winters in makeshift settlements.

Villagers say there is no security here; that the compensation promised to the displaced has not been paid, or not paid in full; that there are no doctors or functional basic health units in villages; that the Ghulam Khan border is closed for trade and local commerce is dead. “We are doomed anyways, so what if polio gets to us?” asks a village elder. “The [nearly 20,000] people from the Madakhel clan who sought refuge across the border during the operation remain there, exposed to polio in Afghanistan,” he says. “Why is the government not doing anything to bring them back home?”

Chota Datakhel is a stone’s throw from the heavily-guarded civil lines in the high security zone. Close by is the Miranshah Market Complex that the authorities raised over the debris of the sprawling old bazaar. It is late afternoon and the complex lies deserted, with shutters pulled down on unoccupied shops. Goats with hennaed heads sit leaning against them.

“There is no money left in Waziristan,” says Rehman, a local businessowner. “People put shelves in shops but there is no merchandise to display. The people here were abad [prosperous] even in the absence of industry and agriculture, due to border trade across Ghulam Khan before it was taken away from us.”

Reopening the border is one of the demands put forward by traders who have refused polio vaccine in the neighbouring district of Bannu.

Polio refusals in North Waziristan are not new, but tying them to the complex tangle of “qaumi” demands from a clan or a tribe is. In Chota Datakhel, villagers feel that an absent state conveniently turns up at their door come the polio campaign cycle. They have observed how the Taliban threatened and killed polio workers, and halted vaccination campaigns. And they have watched officials go out of their way to portray the vaccination drive as a success, despite refusals. It seems their takeaway is that, with polio drop refusals, they can make authorities take notice of their call for what they term “basic rights”.

A polio worker in Bannu | AFP

NO PLACE TO CALL HOME

“At the beginning of every campaign they promise to help, only to send a low-level official later who says he is helpless,” says Sakhi Rehman, one of the several tribal elders gathered in a house at Chota Datakhel. The 17 people in the room nod in agreement. Among them is Allahdin, whose survey form shows he has to be paid 400,000 rupees for a “fully damaged house”. He has only received 160,000, rupees — the amount for a partially damaged house.

Others here say their cheques are turned down when they go to claim compensation because they have refused polio vaccination. This despite the fact that Babar bin Atta, adviser to the prime minister on polio, has said that force and coercion will not be used against those refusing polio inoculation. “Legal action is only allowed when someone threatens the campaign, such as targeting staff or preventing them from carrying out vaccination,” Atta tells Eos.

“We were given tents for six months,” says Abid Rehman, a villager here. “But we have lived in the open for two and a half years now. Our tents have turned to tatters.”

Locals insist that they have no choice but to resort to refusing polio vaccinations. “Our resistance is not against polio. It is against zulm [tyranny],” they say.

Officials contest these claims, saying households in Datakhel have “several brothers claiming compensation when it is allowed only to the family head.” They say villagers in Datakhel push one demand after another. “First it was clearance of cheques, then it was more compensation,” says a health official in North Waziristan.

Officials say that giving into the demands is a slippery slope. Just how many demands can be fulfiled when, like the poliovirus itself, yielding to even one has the potential to snowball into many?

Locals, on the other hand, insist that they have no choice but to resort to refusing polio vaccinations. The village chief Naikzalli Khan, an old greybeard with a spiritual glow to him, puts in the last word on behalf of his community, “Our resistance is not against polio. It is against zulm [tyranny].”

Down the road that leads to the border-crossing at Ghulam Khan is the village of Danday Darpakhel, home to the Darpakhel, a sub-clan of the Dawar tribe that has refused polio drops. Among the jagged ruins of structures destroyed in operations here is the site of the house of Hakimullah Mehsud, the Taliban commander who died in a drone attack. The debris from the house still lies around. Amidst it stands the large concrete frame of a door that has somehow survived — a humbling reminder that all tyrants must fall in the end.

"From the field, we have the figure of 200,000 refusals, which is not even close to the actual situation on the ground," Babar bin Atta, adviser to the prime minister on polio, says, estimating that the true number must be closer to 700,000.

The Darpakhel are among the better educated people in North Waziristan. They have made their mark in the fields of bureaucracy, medicine and education. It comes as a surprise then that they have refused polio vaccination. Behind this is the Darpakhel’s decades-old land dispute with the Tabikhel Wazirs. After much bloodshed, the Darpakhel now want the authorities to enforce a 1977 agreement between the two tribes — going back to the original position when a line was drawn between their territories, delineating their respective ownership, before it was ignored and encroached upon.

That night over dinner in the house of a tribal elder, the television is on and the channels have a single item on the news agenda: Kashmir. A 24/7 media blitz with Kashmir at its heart has continued for days now, alongside reports about polio cases and refusals, and the government’s efforts to inoculate every child. There is little coverage of the community demands here.

A child's finger is inked to indicate that he has been administered the polio vaccine | AFP

UPPER KURRAM’S CHILDREN AND A SUFI SAINT

In Sragala, Upper Kurram, little children accompany their elders into the village imambargah. They are here to make a statement against polio vaccines. This is unusual because the scenic Upper Kurram, its villages and valleys, do not have a history of refusals or resistance to the annual polio campaign like much of North Waziristan.

Between 2007 and 2011, through the worst of its troubles as one of Fata’s seven tribal agencies bordering Afghanistan, Upper Kurram managed to take care of its children. Polio drops were ferried in by air and through neighbouring Afghanistan, as inland routes to Parachinar — the agency headquarters that takes its name from tall maples — were closed by militants, with no food, medicine or movement allowed. During those years of militancy, Central Kurram reported four cases of polio. Upper Kurram reported none.

Long before that and after, the valleys of Upper Kurram, encircled by the Safid Koh — the white mountain that stays covered in snow through half the year — have sent polio missions on donkeys to remote, snowed-in villages.

But a day before the launch of the nationwide polio campaign, community elders from villages gathered at the press club in Parachinar to announce their boycott of the vaccination drive. Their children would not get vaccinated unless the authorities open the shrine of Badshah Mir Anwar Shah Syed Mian, they declared.

He says he is willing to lay his life and health for the saint,” says the father, supposedly verbalising for his son. And then adds, “We are aware of the importance of polio vaccination. We haven’t rejected it…”

A 17th-century Sufi saint whose Pashto verse spurned sectarianism and celebrated tolerance and unity, Syed Mian’s disciples — or ‘Mian Mureeds’ — are spread all over Kurram, the districts of Orakzai, Hangu, Kohat, Peshawar and among diasporas in the West and the Gulf. When Mian passed away, he was buried at Kalaya in the Orakzai district, where he had lived and preached. For centuries now, his shrine — that Mian Mureeds claim was built by the Mughal Prince Shah Shuja — has drawn pilgrims from all faiths. There lies the saint whose devotees hold him in eminence and esteem as naib-Imam — a deputy to Imam Ali Reza, the Eighth Imam to the Shia sect.

When militancy came to the region in the wake of 9/11 and Kurram witnessed some of the bloodiest sectarian clashes in its violent history, the authorities asked Mian’s devotees to close down the shrine to save it from Taliban militants who deemed pilgrimage and prayers at shrines as idolatry. “We handed over the keys to the security forces to keep the mazaar safe until the hostilities are over,” says Mahir Hussain, spokesperson for the Anwar Shah Ghag Committee (Voice of Anwar Shah) that seeks to reopen the shrine. “We want to return to the shrine for pilgrimage and repairs but the administrations in Orakzai district, both civil and military, have been saying that we need to take the local Sunni population into confidence.”

The shrine, both a religious and heritage site from the Mughal era, has been damaged by militants. It needs immediate preservation efforts, says Hussain. Among others, the committee has sought intervention from Khyber Pakhtunkhwa Chief Minister Mahmood Khan. It met Khan and threatened a sit-in if the shrine was not reopened. Khan urged the committee not to, in view of the imminent KP-Fata provincial assembly elections in July — the first-ever in the history of the tribal districts. He promised to renovate the shrine after the elections.

The shrine of Badshah Mir Anwar Shah Syed Mian | Photo by the author

But the provincial government has not kept its word and the frustrated Mian Mureeds have been holding huge protests locally that the mainstream media has failed to cover. Until now, that is, when the committee and the saint’s devotees refused to support the polio campaign unless the shrine is reopened. The boycott resulted in nearly 11,000 children going without the polio vaccine. For its part, the committee says it has not refused vaccinations but boycotted them. “Once they deliver the shrine of Shah Anwar, we will have our children inoculated against polio,” says Hussain.

Not everyone here agrees with using polio as a pressure tactic but everyone seems to be united over the demand to reopen the shrine. Divided as they are over the boycott, certain families have allowed vaccination while others have not. When Hameed Ali, Kurram’s district health officer, went with his team to administer the drops, a father told him that he could sacrifice his children [by refusing polio] in the name of the saint. Ali says it is up to the authorities to resolve the issue but Kurram remains a high-risk theatre for polio. “Once the matter of the mazaar is resolved, we can double up efforts to reach the children who have missed vaccinations.”

Among such children is a little boy at the gathering in Sragala. When a slight drizzle suddenly turns into pelting rain, forcing everyone in the imambargah’s garden to seek refuge indoors, his father stops the conversation in the prayer hall by raising a finger. “My son wants to say something.” All heads turn towards the little one expectantly but he shies away, hiding his face behind his father’s arm. “He says he is willing to lay his life and health for the saint,” says the father, supposedly verbalising for his son. And then adds, “We are aware of the importance of polio vaccination. We haven’t rejected it…”

A child is given polio drops in Bannu | AFP

LIVING ON THE PERIPHERY

On the face of it, Khyber Pakhtunkhwa’s Bannu, Balochistan’s Jaffarabad, Punjab’s Attock and Sindh’s Larkana may appear like they do not have much in common, considering their diverse settings, people, cultures and ethnicities. A similarity they share, however, is that their residents have refused polio vaccinations.These are also all places where people have lost faith in the state, it appears — and with good reason. Even though they fall in mainland, ‘settled’ Pakistan, their socioeconomic indicators are only marginally better than the tribal districts bordering Afghanistan that have just been initiated into the body-politic of the country after over 70 years of neglect.

Unconscionable as vaccine refusals are, people living on the periphery of Pakistan believe that polio is not what plagues them; they consider the absence of rights, freedoms and opportunity to be more rampant diseases. To them, refusal of vaccination is only a desperate measure to help wrench these from a distant and seemingly indifferent state.

The people in Bannu invoke the nightmare of sterility in one breath and attribute a quick onset of puberty to polio drops in another. They are known to give polio drops to chickens because the drops’ “hot nature” makes them lay more eggs.

“There is a certain naivety at work when people in a neglected region see vaccination more as a reflection of the state’s interest than their own,” says Khalid Hussain, a development communications professional. But the people, he adds, cannot be blamed. They see money and massive mobilisation, and are met with force and coercion instead of efforts to answer their questions. They become even more suspicious when they see that the campaigns are run by NGOs funded by foreign donors.

Atta agrees. “When polio vaccination that runs on foreign funding comes in, it creates room for questions from the community,” he says.

Conspiracy theories are abundant. As has been widely reported, people also suspect that polio vaccinations will sterilise their children.

The people in Bannu invoke the nightmare of sterility in one breath and attribute a quick onset of puberty to polio drops in another. They are known to give polio drops to chickens because the drops’ “hot nature” makes them lay more eggs. But the roots of this irrational behaviour go deeper than where pro-vaccine communications, aimed at short-term campaigns and emergencies, dare to venture.

BUSINESS UNUSUAL

In Bannu division, where 32 polio cases were reported this year, parents and vaccinators have colluded to mark their children’s fingers black without administering polio drops.

Atta is aware of this practice, and says that the on-ground situation is likely worse than has been reported. “From the field, we have the figure of 200,000 refusals, which is not even close to the actual situation on the ground,” he says, estimating that the true number must be closer to 700,000. The difference in numbers can largely be attributed to force and coercion, Atta says. “Parents hide refusals or put fake marks on their children’s fingers.”

Bannu division drew much attention when traders in the region threatened to resist vaccination. Shah Wazir, president of the Bannu Chamber of Commerce who announced the boycott, says the act was meant to get the government’s attention to withdraw the unprecedented increase in taxes. Once the objective was achieved, the boycott was withdrawn, says Wazir, who is ironically a founding member of the Traders Polio Eradication Committee.

Wazir certainly managed to catch the government’s attention. He drew criticism from the prime minister, Khyber Pakhtunkhwa’s chief minister and the provincial minister for information.

But Wazir does not think he was in the wrong.

“For 35 years now, this region has been affected by the Afghan War, the influx of refugees, War on Terror, Talibanisation, Zarb-i-Azb and IDPs,” he says. “Under the circumstances, one would expect the state to support us,” he says, adding that instead the increase in taxes has forced many traders to close shop. Wazir says Pakistan continues to do business with India but has closed down trade routes with Afghanistan, pushing the province and its people further into an economic crisis. “CPEC was taken away from us. From Swat to Waziristan, our homes, businesses and assets were destroyed.”

GAPS IN THE SYSTEM

Even the monitoring and administration of polio campaign seems to be marred by politics. Currently, the administration and monitoring is undertaken by bureaucratic district administrations, with minimal involvement of qualified staff and monitors from the health department (even though this is done under the WHO’s supervision).

“There are two types of polio workers — those who belong to the health sector and those brought in from other departments,” says Dr Amir Taj of the Provincial Doctors Association. “The field staff from the health department are assigned areas as volunteers. They are, however, not committed to carrying out a vaccination campaign because of poor incentives,” he says. A worker gets 300 rupees to 500 rupees per day, he estimates. And they are sent to areas that are highly insecure, where distances are great and mobility limited.

But Atta clarifies that, “At the district level, the Deputy Commissioner has to ensure vaccination as a state obligation.” Adding that, “Even as he faces refusals, he has to carry out the campaign reaching the target population. If he refuses when faced with community resistance, he can be booked under 3MPO — a law providing for preventive detention and control of persons and publications for reasons connected with public safety, public interest and the maintenance of public order.

Bannu division drew much attention when traders in the region threatened to resist vaccination. Shah Wazir, who announced the boycott, says the act was meant to get the government’s attention to withdraw the unprecedented increase in taxes.

“This has resulted in such flaws in the polio campaign as force and coercion. The community understands this and uses vaccination as a bargaining chip,” says Atta.

In the past, Atta has also questioned the commitment of the previous government, saying their polio-eradication programme was the most neglected. “He forgets that previously, like now, it was the PTI government in power in Khyber Pakhtunkhwa, where the most cases of polio have been reported this year,” says a public health practitioner. “Government transitions shouldn’t affect our commitment because the funding is international and the district coordinators remain even if governments move on.”

Every government over the past two decades has shown its political will and commitment to vaccinations in general and to polio eradication in particular, says Dr Samia Altaf, a public health professional with 40 years of field experience. “What’s missing is the translation of the objectives into actual plans — an overall strategy and implementation plan with committed funding from the government that demonstrates an ownership of the programme,” she says.

“All governments have relied on the donors to fund vaccination drives which, though generous, is always ear-marked for specific activities agreed in advance. They have to be spent on a particular activity, even if later the field situation advises against this use,” she adds.

Atta agrees that Pakistan has to “own the programme as its own.”

“The programme has failed to create demand, while insisting on ‘forced supply’,” he says. He claims that this is going to change. “In our communication strategies in the run-up to the next campaign in December, we are focusing on creating demand [wherein] people can see polio as a health concern.”

ROOM FOR CHANGE

Since 1994, Pakistan’s Expanded Program on Immunization has changed very little in terms of design and implementation. But while the programme has remained largely unchanged, the country, of course, has not. The population has increased, resources have undergone change and skill sets have altered, as have institutions and government systems and the reality of people’s lives. “But when it comes to health, assumptions remain simplistic,” says Dr Altaf. “Taking service delivery programmes to a large scale needs different and context-specific skills that are sorely lacking in the Pakistani health system [that is] trained to treat diseases,” she says.

“Given the recent setbacks in the polio programme, experts advocate the organisation of a well-functioning system of routine vaccinations,” she adds.

This recommendation has been ignored in the past and the polio programme remains vertical in nature — monitored and administered through a highly centralised system at the federal level, when health is a provincial subject. This way of organisation causes confusion, inefficiency and lack of ownership. Like the family planning programme before it, vertical programmes are not well integrated into the primary health system at the district level.

“The financial coverage for primary healthcare is hardly 10 percent of the budget whereas the polio-eradication programme, which remains independent, has 100 percent coverage,” points out anthropologist and development professional Zaigham Khan. “With this neglect, space for all kinds of narratives naturally crops up,” he says. “In the former Fata or parts of Balochistan, where infant mortality is high due to diarrhoea, people fail to see where polio fits in their scheme of concerns.”

Still Atta insists that there is a need to see the bigger picture. “To understand refusals, one has to look at their cause and context,” he says.

“The polio programme was designed to ensure herd or group immunity against a virus. It is not aimed at individual needs. Which is why children have to be covered across the length and breadth of the country through simultaneous vaccination,” he says, adding that, “Pakistan has suffered due to militancy, insurgency and conflict in recent years that has negatively impacted the healthcare environment...

“People don’t know polio vaccination is not a ‘disease control programme’ but one aimed at ‘virus eradication’. It has to focus on a specific area, which is seen as neglect of the general healthcare system that has collapsed for the reasons cited,” he says.

The writer is a Peshawar based journalist

Published in Dawn, EOS, September 29th, 2019