SWAT M.D.

KARACHI—These days, policeman with AK-47s don’t look out of place during a polio immunization campaign in Pakistan. Neither do elite counterterrorism forces staffing impromptu neighborhood checkpoints, while health workers conduct vaccination drives.

On a February weekend in Karachi, camouflaged paramilitary soldiers cordoned off a neighborhood known as Gadap Town, shut down two lanes of traffic, and refused entry to all non-residents. Motorbikes were temporarily banned, because of the frequency with which militants use them in drive-by shootings. No advance notice had been given that polio immunizations would take place in this neighborhood on this day for fear that it would attract bombings or shootings. That people couldn’t plan in advance to get their children vaccinated was just the price of keeping everyone alive.

Earlier, in January, suspected Taliban militants had shot and killed three health workers in a nearby neighborhood while they were administering oral vaccine drops to toddlers. As a result, the immunization campaign was temporarily suspended until security could be tightened. Even with the protection of security forces, health workers were wary about the possibility of another attack.

"I’ve never seen security so tight and the situation so precarious," said Sadia Shakeel, who conducts neighborhood outreach for polio immunizations at the Gulshan-e-Iqbal Resource Center. "There’s a real sense of unease here."

Ever since the CIA used a vaccination campaign as cover in its hunt for Osama Bin Laden, real medical professionals have found themselves in the crosshairs in Pakistan. The Taliban have banned immunizations and accused those attempting to deliver medical services in the tribal areas of being Western spies. As a result, medical workers armed with polio vaccines have become inadvertent fighters against the Taliban and other militants as they try to rid the country of a virus that paralyzes and often kills young children. Pakistan has never been free of polio, a disease eliminated in the United States more than 30 years ago, and zealots have vowed to make its eradication impossible through a targeted campaign of shootings, kidnappings, and roadside ambushes.

The attacks have been as regular as they are brutal. In early March, 11 workers were killed in two separate bomb attacks in northwest Pakistan. Then on the night of March 23, another female polio worker in Peshawar, the world’s largest polio resevoir, was kidnapped from her home and murdered. A little more than a week later, gunmen on motorcycles shot and killed yet another female polio worker as she returned home from visiting relatives in the country’s northwest.

"The number one challenge we face is security. We are the only country in the world where our frontline folks, our polio workers, are facing the brunt of targeted attacks by terrorists. It’s despicable," said Ayesha Raza Farooq, who leads the Pakistan government’s polio eradication efforts.

Pakistan is one of only three countries in the world, along with Nigeria and Afghanistan, where polio has never been eradicated. While the number of new cases in the other two outliers dropped in 2013, in Pakistan it increased by 60 percent — to 93. So far this year, there are more new cases — 49 — than during the same period last year.

"This isn’t just Pakistan’s problem, it’s everyone’s problem," Dr. Elias Durry, the World Health Organization’s emergency coordinator for polio eradication in Pakistan told Foreign Policy in Islamabad. "If we fail, it’s absolutely clear that the virus doesn’t require a passport and will go out and when it does, it will go out with a vengeance."

Outbreaks of polio in Afghanistan, Egypt, Israel, and Syria, have been traced back to Pakistan, prompting other nearby countries to take precautionary measures to keep the virus at bay. In the last 16 months alone, 17 out of Afghanistan’s 18 new polio cases have originated in Pakistan, according to the virus’ genetic fingerprint, the CDC said. Syria, which had previously eradicated the disease, reported last fall that a polio strain from Pakistan had infected 13 people (the number has since climbed to 35.) And after decades of work, India finally declared itself polio free this year — only to turn around and slap travel restrictions on Pakistanis, requiring proof of polio vaccination. Saudi Arabia and the Republic of Georgia have instituted similar measures.

It is these stubborn last cases of polio — and their potential to cause additional outbreaks — that have driven the World Health Organization (WHO), UNICEF, and the U.S. Centers for Disease Control to embark on a $5.5 billion campaign to stamp out polio worldwide by 2018. The Bill & Melinda Gates Foundation pledged $1.8 billion toward the budget, and a mix of governments and private groups like Rotary International, a U.S. social service group, have kicked in over $3 billion.

"It’s true, finishing off the job is taking more effort than it took to clear other countries," said Dr. Jay Wenger, who leads the Gates Foundation’s polio eradication efforts. "But if we don’t keep going, we will immediately see a rebound in cases and ultimately a re-establishment of polio around the world."

When the world health community first trained its sights on polio in 1998, there were 350,000 cases of the disease around the globe. Last year, there were just 404 cases.

But the push to zero is not assured. The global campaign to stamp out polio has missed deadlines in the past, and may be about to miss another one at the end of this year. WHO first vowed to end polio transmission by the year 2000. When it came up short, the deadline was pushed back to the end of 2012 — and then to the end of 2014. Health officials with the Global Polio Eradication Initiative, a WHO-led partnership that oversees the current campaign, now suggest privately that the end of 2015 is a more realistic goal. (For the world to be considered polio free, countries where polio is present must be free of the disease for three years.) The chairman of the initiative’s independent watchdog, Dr. Liam Donaldson, wrote in the group’s October report that the deadline "now stands at serious risk. This situation must be turned round with the greatest possible urgency."

Pakistan is frequently cited as the most worrisome country in the world for the polio fight because of the security situation. The watchdog group cited the vaccination ban in Waziristan and the government’s slow move to address the rising number of cases as causes for concern. "The current situation in Pakistan is a powderkeg that could ignite widespread polio transmission," wrote Dr. Donaldson. "If the current trend continues, Pakistan will be the last place on earth in which polio exists."

When the world health community first announced its goal of eradicating polio, it was coming off the success of eliminating smallpox. But polio has proven a much tougher opponent. Smallpox was dispatched with after a 10-year fight, whereas polio continues to live 25 years later. Not only is polio more difficult to identify than sma

llpox, which brought with it a distinctive red rash, it requires four vaccine doses as opposed to one. The polio vaccine also needs to be stored in a cool spot until it is administered, whereas the smallpox vaccine can be kept at 98F for up to one month.

"I don’t think the ultimate outcome is preordained," said Dr. D.A. Henderson, who led the global fight to eliminate smallpox and is now a distinguished scholar at UPMC Center for Health Security at the University of Pittsburgh. "You can’t put a lot of money on this and assume it’ll be eradicated."

The number of polio cases has ebbed and flowed globally for the last few years, mainly because of security problems, incomplete vaccination drives, and a lack of government oversight in countries that are affected. As a result, fatigue has set in and some governments have shifted money and resources to other problems. In Pakistan, for example, workers have falsely claimed to have vaccinated children and entire regions have gone untargeted in vaccination drives.

In recent years, however, Pakistan has gotten more serious about fighting the disease. Alarmed at the rising number of polio cases in late 2011, Prime Minister Yousaf Gilani drew up a national action plan, listing vaccination gaps and delegating authority to fix them. He also established a group to coordinate efforts nationwide in January 2012. A few months later, WHO declared a world polio emergency and pressured Nigeria, Afghanistan, and Pakistan to ramp up their efforts to stamp out the disease.

From the beginning, however, the fight to cleanse Pakistan of polio was complicated by the country’s precarious security situation. The Pakistani Taliban (TTP), an umbrella organization estimated to include as many as 50 different militant groups, is at war with the government and frequently attacks military installations, courthouses, newspapers, and government offices. Polio teams provide appealing targets because they create chaos and discredit the government. Militant attacks have killed at least 55 health workers and wounded 39 since 2012, according to UNICEF.

But the real catalyst for the TTP’s war on polio workers was the CIA’s use of a hepatitis-B vaccination campaign as cover in its hunt for Bin Laden. After the program was revealed by the the Guardian, the Taliban banned immunizations in North and South Waziristan and vowed not to allow medical professionals back into the tribal areas until the United States ended its drone operations there. Since the ban was implemented in 2012, 80 percent of Pakistan’s new polio cases have originated in that region, according to WHO.

"This is one of the Taliban’s signature achievements. They see this as their badge of courage," said Michael Kugelman, a senior program associate for South and Southeast Asia at The Wilson Center in Washington, D.C.

Even before the CIA-led raid on Bin Laden’s compound, the polio vaccination effort was running into strong headwinds of mistrust and ignorance. There is a widespread misconception in Pakistan that the vaccine makes children sterile and is a Western-based plot to cut Muslim birthrates. Some parents believe the vaccine contains ingredients that are not halal — or banned by Islam. Others think the vaccine is useless because some children have contracted the disease even after being vaccinated.

Some Muslim clerics have also denounced the vaccine as un-Islamic and questioned the attention the government has lavished on polio. Mullah Fazlullah, the leader of the TTP and a self-appointed religious leader, has issued a stream of fiery indictments against the campaign, calling vaccinations unnecessary and un-Islamic on his pirate radio show in the early 2000s. As "Mullah Radio," as he is known, rose through the Taliban ranks, he made his opinion official party doctrine. His indictments come despite the fact that he contracted polio as a child and has a mangled right foot.

Public health groups have sought to counter the TTP’s stance with a campaign to convince Muslim leaders that the vaccine comports with Islamic law. In the last two years, 750 clerics have agreed and issued fatwas or edicts in favor of the vaccine and appealed to their congregations to eradicate polio. In February, the Imam of Mecca’s Grand Mosque declared that vaccinating children was in accordance with Islam and that exposing children to risk was a sin. Even Maulana Sami ul-Haq, known as the "father of the Taliban," reversed his opposition in December and declared that all Muslims should vaccinate their children. Ul-Haq, who carries tremendous weight with both the Afghan and Pakistani Taliban, runs Pakistan’s most famous religious seminary, where many militants, including Afghan Taliban leader Mullah Omar and Jalaluddin Haqqani, chief of the militant Haqqani Network, were educated.

But it’s not just radical clerics that are to blame for Pakistan’s lingering polio problem. Poverty and ignorance also help explain why parents don’t immunize their children. Refugees fleeing drone attacks, insurgents, floods, and earthquakes crowd into the slums of major cities like Karachi and Peshawar, where sanitation and clean water are in short supply and diseases are rife. Many don’t know about vaccines and if they do, food and shelter are their primary concerns.

Sameena, a 25-year-old mother in Karachi, wasn’t aware of the seriousness of polio or where to get a vaccine until it was too late. When she became pregnant, Sameena and her husband left their native village in Balochistan, a province ravaged by sectarian war, because she didn’t want to lose a fourth child to disease. With the help of a midwife, Sameena gave birth to a healthy daughter, Dua, and together they prayed she would live past the age of one. No one mentioned that polio was a crippling threat in their neighborhood or that a vaccine was available. Within seven months, Dua developed a high fever and pains in her right leg that neighborhood doctors could not explain. One finally told her that Dua had polio and that there was no cure. Now four years old, Dua has a twisted right leg that makes standing or walking on her own impossible.

"Dua sees other children running or jumping and begs me to let her run and jump with the others," said Sameena. "I tell her she can’t. She feels terrible about it and there’s nothing I can do."

Although the attacks on polio workers keep coming, one as recently as March 31, the vaccination campaign continues. Public health authorities don’t want to halt immunizations now because the vaccine is more effective in the winter and spring, when cold weather slows transmission and there are fewer diarrheal diseases circulating that can compete with the polio vaccine. Malnutrition and diarrhea can prevent the body from developing antibodies that ward off polio, and can cause the vaccine to pass through the body before it has a chance to replicate. Because of the prevalence of these illnesses, children under the age of five are frequently vaccinated up to 10 times to make sure the vaccine has taken hold.

"You can’t be over immunized," said Carol Pandak, polio program director at Rotary International, which has led the fight against fought polio worldwide for the last 25 years.

In Pakistan’s restive northwestern Khyber Pakhtunkhwa province, home to the world’s biggest polio reservoir, its capital city of Peshawar, authorities are trying a new tactic. After health workers and policemen were killed and wounded in door-to-door campaigns, the government organized a series of secure camps every Sunday where children would be immunized. Thousands of police officers have been deployed and entire neighborhoods cordoned off. Cell phones are banned. Since they started in mid-Feb

ruary, after a month-long delay because of security problems, over 500,000 children have been immunized in this manner.

"Just because some factions of the Taliban are against it, why shouldn’t I be for it?" Imran Khan, chairman of the Pakistan Tehreek-e-Insaf party that runs Khyber Pakhtunkhwa, said at his villa outside Islamabad. "There’s too much at risk not to fight it. With polio, we have to go all out for it."

Innovative efforts like Khan’s "Health for All" campaign, which include vaccines for nine childhood diseases administered across the province, are needed if Pakistan is to succeed in eradicating polio. The state of Sindh, where Karachi is located, started similar one-day vaccination drives and has inoculated hundreds of children in three rounds thus far. Rotary International has imported many of its successful methods from India to Pakistan. These include staffing health workers at railroad stations, airports, border crossings, and toll plazas, looking for children under 5 to immunize.

Rotary also works with victims of polio, and has agreed to fit Dua, the young girl from Karachi, with a brace so she can climb the stairs to her second-floor schoolroom. Her mother, Sameena, has immunized her against other diseases and held her out as a reason for other members of the community to vaccinate their children. Despite her vaccinations and coming leg brace, Sameena worries the little girl will never live a normal life.

"What is her future?" Sameena said. "Can anyone marry her? What will happen to her when she grows up?"