Setback year

In 2014, Pakistan’s effort to wipe out polio, a disease that can paralyze, was in crisis.

Political pressure to root out the virus was being tested, reports of violence against vaccinators were common, and perceptions that the country was an incubator of the disease grew. Massive population movement and displacement had pushed the anti-polio campaign to its limit.

The consequence? Reports of the disease spiked to alarming levels.

The explosive outbreak that year totaled 306 reported cases, up from 93 the previous year. Pakistan had 82 percent of the world’s cases of polio in 2014. One newspaper editorial at the time called the epidemic Pakistan’s “badge of shame.”

Dr. Rana Safdar, director of the National Emergency Operations Center in Pakistan, on the success of Rotary’s PolioPlus strategy.

A pointed 2014 report from the Independent Monitoring Board of the Global Polio Eradication Initiative spotlighted Pakistan’s missteps, humbling government leaders and health officials, who scrambled to find solutions.

“We were emotional and somewhat defensive,” says Dr. Rana Safdar, director of the National Emergency Operations Center in Pakistan. “But the report pushed us to get our act together on polio, for first time. Our program was a threat to the global polio eradication efforts. The upsurge we had in Pakistan was unprecedented.”

The government effectively declared war on polio, condemning the outbreak as a national disaster. Words were soon matched with action.

“The motivation and the commitment of the vaccinators on the front line and government officials became stronger,” says Aziz Memon, chair of Rotary’s Pakistan PolioPlus Committee. “We had more reason to say, ‘Yes, we need to get rid of this disease and fulfill the promise we made to the children of this country: No child in the future will be crippled by this disease.’”

Led by this renewed commitment, the country rallied, intensifying immunizations through new strategies that resulted in a dramatic decrease in polio cases over the next two years.

The number of new infections dropped from 306 in 2014 to 56 the next year, a decrease of 82 percent. In 2016, only 15 cases of polio caused by the wild virus were reported.

‘A paradigm shift’

To quell spread of the disease and reduce the risk of exporting cases to neighboring countries, Pakistan adopted a National Emergency Action Plan. The immediate goals: to cut off transmission of the virus in high-risk areas and to reach missed children.

Polio cases in Pakistan 2016: 19 cases 2015: 54 cases 2014: 304 cases 2013: 93 cases 2012: 58 cases

Routine vaccination campaigns that immunize children door to door were no longer enough. Calling it a “paradigm shift in strategy,” Senator Ayesha Farooq, who leads the anti-polio strategy for the prime minister in Pakistan, says the revitalized program focuses heavily on children who have routinely missed vaccinations.

“Despite the fact we were receiving 80 percent coverage in every campaign, the other 10 to 20 percent that we were missing out on were sustaining the virus,” she says.

Rotary launched the world’s first global polio immunization program, PolioPlus, in 1985. In 1988, it became a founding partner of the Global Polio Eradication Initiative (GPEI). It continues to work for polio eradication with the World Health Organization, UNICEF, the U.S. Centers for Disease Control and Prevention, and the Bill & Melinda Gates Foundation.

Rotary has contributed more than $1.6 billion and countless volunteer hours to immunize more than 2.5 billion children worldwide. Polio cases have plummeted by more than 99.9 percent, from 350,000 cases in 1988 to 27 in 2016.

Vaccinators track a population in motion

For nearly four years, from 2012 to 2015, half a million children in the Federally Administered Tribal Areas in northwestern Pakistan were inaccessible to vaccinators.

The mountainous, semiautonomous region, including North Waziristan, was controlled by militant groups such as the Taliban, which prohibited polio vaccinations.

These areas were not under-vaccinated; the children were not immunized at all.

This fueled the 2014 outbreaks, with about 70 percent of cases coming from the tribal areas.

After a sweeping military offensive in 2015 pushed the Taliban out of the northern tribal region, more than 1 million civilians fled to neighboring areas and across the border into Afghanistan.

Inside the Jalozai Camp for Internally Displaced Persons.

The military action created a refugee crisis, putting tens of thousands of people in camps for the internally displaced.

Still, it also cleared the way for vaccinators to inoculate hundreds of previously inaccessible children, says Dr. Malek Sbih, leader of WHO’s strategy of vaccinating children as they travel.

“The military operation provoked an enormous exodus of people from the region, inside and outside the borders. It’s unfortunate. But fortunately for us, it gave us the opportunity to reach 265,000 kids,” he says.

According to Sbih, who had previously worked to stem the cholera epidemic in Haiti after the 2010 earthquake, polio vaccinations more than doubled, from 11 million in 2013 to 24 million in 2015.

But even today, as vaccinations are up and new cases are down, the country’s high rate of population movement — travelers headed to religious festivals, migrant workers, nomads — poses a daily challenge to the polio campaign.

“Population movement from under-immunized and high-risk areas plays a huge role in the spreading of the polio virus,” Sbih says. “The challenge really is to adapt on the ground to these specific movements.”

To do this, Pakistan and the GPEI partners had more than 200,000 trained and dedicated front-line vaccinators fan out to Karachi, Khyber Pakhtunkhwa, and Quetta, the three core reservoirs of wild poliovirus.

The boosted campaigns also installed more than 600 permanent transit posts across the country. Known as PTPs, these kiosks operate year-round and provide millions of vaccinations to children and families who are away from home or otherwise on the move.

From Karachi in the south to Islamabad and the tribal areas in the north, Rotary has negotiated to place PTPs in high-traffic areas, including highways, toll plazas, train and bus stations, airports, markets, and even amusement parks.

As the infection rate dropped, the polio program changed its emphasis from quantity to quality, reducing the number of posts from over 600 to fewer than about 400. The remaining posts operate at strategic sites along busy interprovincial and international borders and in the core poliovirus reservoirs.

Rotary has directly funded more than 30 robust PTPs, outfitting repurposed shipping containers with solar-powered refrigeration and furniture. Each is staffed by security personnel as well. These additions are crucial at posts that require round-the-clock service and staff.