For years the red pins stuck into the large map of Pakistan on the wall of one of the UN’s most experienced polio-busters have shown the disease in steady retreat. Where once they could be found all over, the pins – each one representing a child killed or crippled by the disease – had been pushed back by relentless public health campaigns into just three clusters. Two are located in and around the cities of Karachi and Peshawar in the south and north-west, where the disease flourishes in unsanitary slums in which drinking water is easily contaminated with human waste. But the majority erupt from a small pocket of land representing less than 1% of the country on the border with neighbouring Afghanistan.
The explosion of pins on the map is not an accurate depiction of the scale of the problem, with 54 cases in the tribal agency of North Waziristan this year. “We ran out of space for more pins a long time ago,” said Elias Durry, the head of the World Health Organisation’s anti-polio effort in Pakistan, who is also a veteran of successful campaigns to stamp out the disease in Africa and Yemen.
North Waziristan’s ability to generate more than half the world’s polio cases in the past year has made it the biggest threat to the global effort to stamp out a disease that can easily reinfect areas that have been cleared.
It poses such a risk that since 1 June most travellers, young and old alike, have had to get revaccinated before leaving the country in case they take the disease with them.
While everything about tackling a highly infectious disease in a country with widespread poverty is hard, curbing the uncontrolled outbreak in North Waziristan has been impossible. No health polio vaccinator had been able to step in to the tribal agency since June 2012 when the militants who controlled the area banned all health workers in what they said was retaliation for US drone strikes. It followed revelations that the CIA had used a hepatitis B vaccination programme in the city of Abbottabad as a front for trying to track down the former al-Qaida chief Osama bin Laden.
Health workers compared North Waziristan to a gushing tap that could not be turned off, forcing the campaign to focus resources on elaborate efforts just to stop it spreading. So the launch on 15 June of a massive military operation against the foreign and domestic terrorists who had come to rule North Waziristan is seen by Durry and his colleagues as a huge step forward.
“It’s a real opportunity for us,” he said. “We have been desperate to get access to these people for a long time.”
While it has created misery for about half a million people who have had to flee their homes, the internally displaced have been forced to pass through army checkpoints, where they have been vaccinated. Already almost 200,000 previously unreachable civilians fleeing hostilities have been treated with drops of a solution containing a highly weakened form of the polio virus. But in underdeveloped countries one treatment is not sufficient for often malnourished and sick children to develop the immunity required to ensure the virus eventually dies out. It means children have to be continuously re-dosed, with those in low-risk areas generally expected to receive about six doses a year while those living in the teeming slums of big cities receive the drops up to 15 times annually. Such efforts are helping to drench Pakistan’s children with polio drops – in the past two years more than 420m doses of oral polio vaccine have been administered.
The displaced children of North Waziristan will have to be tracked. Making the task harder is the unwillingness of most civilians from the area to stay in the refugee camp set up by the army. The country has already mounted a huge effort to target children more or less at random as they travel around the country, in addition to the traditional door-to-door campaigns. Teams are operating at hundreds of “transit stations”, such as the grand Raj-era train station in Rawalpindi, where young polio vaccinators and their police guard have 15 minutes to work their way down the trains before they press on with their journeys. Passing through the grimy old carriages, a two-man team look for children younger than five. If their parents agree, the vaccinators whip out small plastic phials from a cooler box and briskly put drops into the children’s mouths.
On a train containing dozens of families travelling en masse from the sprawling port city of Karachi – a polio hotspot – to the town of Mirpur in Khyber Pakhtunkhwa (KP) province, there isn’t enough time to cover everyone and the train pulls out of the station before they reach the final two carriages.
“We do our best, but the trains are always very busy,” said Bilal Aftab, one of the vaccinators, as he watched the line of green carriages trundle onwards. Not surprisingly, vaccination fatigue is setting in among some parents. One mother crossly swished away the vaccination team when they poked their heads over a privacy sheet tied across their section of the carriage. “We gave it to our daughter many times and it gave her a bad stomach,” she said, adding that she had heard stories of the drops damaging some children.
Parental opposition is just one of the many problems that have made Pakistan a particularly hard nut for global polio elimination efforts. There is widespread misinformation about the vaccine, which has been demonised as being part of a western plot to curb birth rates in the Islamic world.
Police commandos guard a polio vaccination team at a security checkpoint. Photograph: Hasham Ahmed/AFP/Getty Images In late 2012 militants began killing vaccination teams, many of them led by an army of “lady health workers”, creating yet more problems.
It has all added to the already difficult and expensive task of wiping out the last vestiges of the disease. About $227m (£133m) will be spent this year in Pakistan alone.
It is the sort of outlay that horrifies sceptics, who believe the ambition to eradicate rather than control polio is a grandiose pipe dream that overburdens developing countries and diverts resources from many other pressing health needs. With only one other human disease – smallpox – successfully eradicated, some argue the goal is ultimately unrealisable. They point out the target year of 2000 for global eradication has been repeatedly pushed back.
Advocates say it is worth it because once polio is eradicated from the three remaining countries where it is endemic the benefits will be cost-free for the rest of time. Durry says the intense focus on polio has helped push through essential reform of the country’s health service, which was once plagued with “ghost” vaccination teams. This year Peshawar pioneered a massive campaign to inoculate entire populations of children under the age of five on a single day, repeating the operation for up to 12 consecutive weeks. To deal with the threat from gunmen, the streets were flooded with 4,000 policemen on vaccination days, while neighbourhoods were cordoned off and motorbike-riding banned.
There have also been efforts to challenge popular suspicions about a high-profile, well-funded campaign backed by international bodies and western philanthropists such as Bill Gates. Local campaigns have been renamed and rebranded so there is no longer any mention of international organisations. The Islamic Development Bank has come forward to pick up the bill for the 2014 effort. Respected religious scholars have been pressed into publicly supporting the effort and many teams carry small booklets of pro-vaccination edicts issued by scholars.
But despite growing optimism that the campaign derailed by Pakistan’s religious militants may at last be getting back on track, the fundamental difficulty of attacking the disease means the red pins will not disappear completely for years to come.
The article was published in Gaurdian