What must Pakistan do to beat polio?

Polio health workers are hoping this year will be better than past ones

Pakistan has yet to report a new case of polio in 2015 - but officials are keeping their fingers crossed nonetheless.

In recent years the Taliban have banned vaccinations in areas under their control, while scores of health workers or policemen guarding vaccine campaigns have been shot dead by gunmen.

It was one of the reasons that in 2014 the country broke its own dubious record of reporting the highest number of cases in a single year for more than a decade - 303, as compared to the previous high of 199 in 2000.

In June 2014, the World Health Organization (WHO) recommended that all international travellers from Pakistan be administered polio drops at airports so as to prevent the proliferation of polio virus.

An October editorial in the Dawn newspaper described this situation as Pakistan's "badge of shame".

Officials responsible for the country's polio eradication efforts feel things have changed in recent years. More areas have become accessible to vaccination teams, and the government has been showing added interest in tackling the virus.

A member of the Pakistani security services stands guard during a polio vaccination in Peshawar

But no one is willing just yet to put a time frame on when Pakistan can be declared polio free.

The global initiative to eradicate the disease started in 1988 - the year Pakistan reported around 2,000 cases.

The country was then dealing with polio as part of its so-called "expanded programme on immunisation" (EPI), which was designed to eradicate six different vaccine-controllable diseases.

Taliban violence

In 1994, officials organised routine campaigns to administer oral poliovirus vaccine (OPV) to children.

There have been questions over the extent of coverage, with suggestions that only between 55% and 85% of children under five years of age had been vaccinated.

"But it did bring the incidence of polio down rather dramatically during the years leading up to 2000," said Ashfaq Yusufzai, Peshawar-based health correspondent for Dawn newspaper.

In 2005, Pakistan recorded only 28 cases - its lowest number ever. But it was also the year a sometimes violent campaign of opposition to polio vaccination started in Swat, a region in the country's north-west which at the time was being taken over by Taliban militants.

Taliban militants opposed polio vaccinations in Pakistan

"Since then, Pakistan's polio eradication effort has been largely held hostage by militants, and flaws in its administrative arrangements have become more glaring," said Ashfaq Yusufzai.

Besides, a constant tug-of-war between the country's civilian and military leadership has prevented civilian governments, at the helm since 2008, from focusing on polio and evolving better eradication strategies.

Parental refusals and occasional manhandling of health workers started in 2005, and became violent after the May 2011 killing of Osama Bin Laden - especially after the ISI intelligence agency accused a doctor, Shakil Afridi, of conducting a "fake" vaccination campaign to help the Americans track down the al-Qaeda chief.

Since then more than 60 health workers or policemen guarding vaccination campaigns have been shot dead by gunmen in the north-west and in the southern city of Karachi, where many people from the north-west live as economic migrants.

In June 2012, the Taliban banned polio vaccination drives in areas under their rule, thereby blocking vaccination of a significant chunk of the population they controlled in the north-western Khyber Pakhtunkhwa province and the adjoining Federally Administered Tribal Areas (Fata).

The funeral of polio health worker Muhammad Sarfaraz in Faisalabad, December 2014

Officials cite this, and the killings of health workers, as the major reasons for the relapse in anti-polio efforts the country suffered in 2014.

But there have been other reasons as well, points out Dr Iqbal Memon, a member of the provincial polio eradication committee in Sindh province, of which Karachi is the capital.

"There has been no accountability, and so various players (the federal task force, the provincial health authorities, WHO and Unicef) have been accusing each other of failures," he said.

In addition, he added, there have been problems maintaining the cold chain of the OPV - or a temperature-controlled supply line - while field officers have been reluctant to discard bad vaccine in a bid to manipulate their coverage figures.

Change for the better

The motivation level of health workers got a hit not only because of assassinations but also because the responsible officials failed to pay their fees on time, he says.

But many say there have been indications over the last few months that things are changing for the better.

Perhaps the most significant move has come from the military, which started an operation in the Waziristan region to clean up the Taliban's major sanctuary on Pakistani territory.

Pakistani army assaults against the Taliban have improved conditions for vaccination workers

Vaccinations in areas adjoining this region have picked up in recent weeks, and there have also been attempts to treat children displaced from the area.

Meanwhile the government has set up new "emergency polio cells" to improve security and access for health workers. The army and police have been made members of these cells in addition to health officials, the WHO and Unicef.

In an ideal world - where all of the population is accessible, vaccinators are not cheating on numbers, a perfect cold chain is maintained and at least 90% of the 40 million or so children are inoculated repeatedly during five to six monthly campaigns - Pakistan can eradicate polio in half a year, says Dr Imtiaz Ali Shah, the chief minister's focal person on polio in the province of Khyber Pakhtunkhwa.

But there's a technical hitch. "Most of our infected children are zero-dose - children who have never had OPV drops before," he says.

"When we are able to restrict the incidence of polio to only those children who've had multiple doses of OPV and were infected only due to low immunity, we can then say that we are close to victory."