Polio: The final battle

Many people in Pakistan are suspicious of the polio vaccine, despite the fact it saves lives. But tensions were running even higher than usual.

The day before their visit, a mass vaccination at a village school in the suburbs of Peshawar had ended in violence and arson.

The headmaster of the school, in Mashokhel village, had previously refused to allow the polio vaccine. This time he had bowed to government pressure and the inoculations had gone ahead. But shortly afterwards he rang parents to tell them their children were fainting and vomiting.  

Dozens of students from the school were taken to hospital. All were found to have no symptoms and were discharged. But it was too late to contain the panic, which had spread quickly via social media.

Furious parents gathered outside a local government health facility, broke down its boundary wall with hammers and sticks, kicked down the front gate, and barged inside to burn it down. All of this was shown live on local TV, which sparked even greater alarm in Peshawar.

In all, about 30,000 children from various schools in the city were taken to hospital, according to the government. In a press conference, the provincial health minister said the panic had been further fuelled by local mosques urging parents via loudspeaker to rush their vaccinated children to hospital. All the children had been found to be well, the minister said.

But the incident threatened to derail an already fragile vaccination programme. That month’s vaccination round, held for three days in April, culminated in three deaths - one of a polio worker, two of policemen accompanying them.

“People were harassing us on the streets, village shopkeepers told us to go away - one of them even said, ‘You are here to poison our children!’” says one woman in Khan’s team.

The government has since suspended the national campaign until the atmosphere is less febrile.

But health workers are clear that the vaccinations are important.

They are the only defence against a dangerous childhood disease which invades the nervous system and causes paralysis in one in 200 cases. Polio can be fatal within a few hours if it paralyses the lungs. There is no cure.

Vaccinations have been largely successful in eradicating it from the world, and only three countries are still home to endemic polio - Pakistan, Afghanistan and Nigeria. Nigeria, which has not had any cases since August 2016, is expected to be declared polio-free in the next few months.

Gulnaz is one of the 262,000 vaccinators on the front line of the battle against polio. She joined a vaccination team along with Madeeha and Fehmida in Karachi in 2011. They went door-to-door during regular vaccination rounds offering polio drops to all children under five.

Almost 70% of Pakistan’s polio workers are female - women are more likely to be granted access to people’s homes, and the work gives less educated women an opportunity to earn a reasonable wage that they might not otherwise have.

But Gulnaz says she underestimated the risks.

“I never realised that the threat was so real,” she says.  

Madeeha and Fehmida were two of five health workers killed in the space of 20 minutes that day in 2012. There were three separate attacks in Karachi and another in Peshawar. Another four workers were murdered the following day.

Gulnaz’s family put pressure on her to get a different job.

But she says the tragedy only strengthened her resolve.

“One should not let one’s fear dominate… [otherwise] you can’t do anything.”

But continuing came at a price.

She had to move to a different neighbourhood at the request of her neighbours, and was terrified of another attack. She would frequently change her route to work.

“Initially I was so paranoid that while walking home, [even] if a bike went past me, I used to get scared.”

Pakistan’s jittery parents are reacting to decades of national suspicion of the polio vaccine.  

Only a year or so after Pakistan’s national vaccination campaign first began in 2000, a new Pakistani Taliban commander came to prominence.

Mullah Fazlullah, a ruthless idealogue, took control of Swat valley in 2007 and banned the vaccination campaign in the region.

He went on to become head of the Taliban in Pakistan, and was the mullah who ordered the assassination of schoolgirl Malala Yousafzai in 2012.

Back in 2007, he was known as Radio Mullah after he installed several dozen FM transmitters across the valley and used them to broadcast his sermons. He preached against the polio vaccination, arguing it was a Western conspiracy to sterilise Muslims.

The bogus claim created widespread paranoia, which was then compounded by another development in 2011.

Days after Osama Bin Laden - the founder of militant group al-Qaeda who ordered the 9/11 attacks on the US - was killed in a US military raid, a Pakistani doctor was arrested.

Dr Shakil Afridi was accused of helping the CIA track Bin Laden down by running an unauthorised vaccination campaign as a pretext to go door-to-door, looking for him. The story dealt a further blow to Pakistan’s battle to eradicate polio.

And then a year later, in 2012, US drones began targeting militant bases in Pakistan’s tribal areas that border Afghanistan. Taliban commanders in North and South Waziristan banned the polio vaccine in the region, accusing the polio workers of spying for the US.

The bans were eventually lifted when the Pakistani military regained control of the areas under Taliban control, but they were followed by a systematic and sustained anti-vaccination propaganda campaign by mullahs using religion to fuel mistrust.

They issued fatwas [religious decrees] claiming that the polio vaccine contains haram [forbidden by Islam] ingredients such as pig fat, and can make children impotent. The WHO says this is categorically not the case. The anti-vaccine mullahs also stated that the female polio workers were spreading “indecency” and that it was the duty of Muslim men to forcibly marry them.

His mission is significant. Hameedi’s home town of Killa Abdullah is in Balochistan province. The area is dominated by the Taliban - close as it is to the Afghan border - and has a strong history of resistance to polio vaccinations.

The cleric says the locals have been led to believe that people working with NGOs have a hidden agenda, and want to convert people to Christianity.

But he says a considerable number of refusals are based on a belief that there should be a reward for getting vaccinated.

“Parents want the government to give them an incentive. They want roads, schools and hospitals - some even want money.”

Despite the resistance, since Hameedi started supporting the vaccination campaign in 2014 the number of polio cases in Killa Abdhullah has decreased. No polio cases have been reported from the area since 2017.

The cleric uses the pronouncements on hygiene in the Koran and other Islamic texts to emphasise the importance of halting the spread of disease.

“My job is tough, but I feel that even if a single child is saved by my efforts, it’s worth taking all the risks.”

At the foot of Margalla’s lush green hills, outside Islamabad, lies an almost impenetrable building surrounded by barriers, armed guards and sniffer dogs. Visitors are extensively searched before being allowed inside.

It could be an army barracks. It is, in fact, Pakistan’s National Emergency Operation Centre, and the headquarters of its polio eradication programme.

Babar Atta, Pakistan’s most senior government official in charge of the programme, talks to me in his office surrounded by charts and graphs. On the wall is a giant map marked with coloured pins to indicate the country’s high risk areas.

Despite the recent setbacks, Pakistan’s polio programme has achieved significant success over the last 25 years.

But any programme of this size would be vulnerable to difficulties.

In Pakistan, there are more than 40 million children under the age of five, according to Atta. The government says an average of 500,000 children remain missing from national campaigns, but Atta believes the number is far higher.

“If the polio virus is still present in our environment, it points to just one thing - that we are missing a large number of children in every campaign.”

Children who have been vaccinated are given ink marks on their fingers. But polio vaccine ambassador Abrar had suggested to me that polio workers were marking the fingers of children who hadn’t been vaccinated, to inflate numbers.

Atta agrees this could be happening.

“I have worked in Pakistan’s polio programme for eight years, and I was the one who identified fake finger marking,” he says.

He says one of the reasons the Pakistani public is so suspicious of the polio vaccination programme is because the CIA fake vaccine scandal created such a backlash.

The CIA and doctor accused of being involved have always denied the scheme took place but the Pakistan authorities are adamant it did, and Afridi remains in jail.

“It created mistrust among people - they ask why the West, particularly the US, is so bothered about polio in Pakistan? We will have to de-link the polio programme from the West if we want to make it successful.”

And he is determined to signal that the government will not tolerate fake news surrounding the vaccine. A few weeks after I visited him he announced the government had suspended seven schools in Peshawar found to have been involved in creating “mass hysteria” over the vaccine in April.

Atta is adamant that the key to success is to win parents’ hearts and minds.

“We need to win people over. It’s the parents’ right to ask questions, and it’s the government’s responsibility to respond to them.”

Back on the streets this is down to polio workers like Gulnaz to wrestle with parents’ fears. And in Pakistan’s battle with polio, fear is all too often followed by violence.

“I don’t feel intimidated any more, because I am not alone in this. There are people who are working in more dangerous areas and are doing a far better job. I get a lot of strength from my colleagues, and Allah is with me. I like this job; my heart finds solace in it,” she says.