Close to 450,000 children under five die annually in Pakistan. One-third of these deaths could be prevented by vaccines. Every year, 90,000 child deaths in Pakistan would be prevented by universal immunization," - The World Health Organization
Pakistan, the World Health Organization's final battleground in the fight against polio, still has a long way to go before universal immunization becomes a reality. The primary goal of both WHO and Pakistan is the eradication of polio. The number of cases in Pakistan decreased from 20,000 a year to an average of 100 over the last five years. Yet the main problem--mistrust of aid workers by the Pakistani people-- persists.
The Death of Bin Laden and the Immunization Slowdown
To assist the U.S. in finding Osama Bin Laden, the CIA employed Shakil Afridi, a Pakistani physician, in early 2011. Under the guise of implementing a Hepatitis B vaccination campaign, Afridi helped the CIA learn Bin Laden's whereabouts, in Bilal Town, a northeastern suburb of Abbottabad, in northeast Pakistan.
Afridi's collaboration with the CIA fueled anti-Western sentiment among militants in Pakistan's northwestern provinces of Khyber Pakhtunkhwa. In June 2012, the Taliban issued a fatwa, a religious ban, on oral polio vaccine, declaring it poison. National Geographic reported that in Pakistan, it was "open season" on health workers. In 2015, news headlines charged Taliban assassins with targeting polio workers in Pakistan.
On May 2, 2011, U.S. Navy SEALs tracked down Osama Bin Laden near Abbottabad. He was killed in his compound in Bilal Town. As far as the U.S. was concerned, Bin Laden's death was a significant step towards ending the war on terror. But for those fighting the war on polio, it was the worst thing that could have happened to Pakistan's children.
Because of Afridi's involvement with the CIA, Islamic extremists now consider any polio worker a Western spy, and view immunization as a means of sterilizing Muslim children. Rumors have spread that the vaccines were made of pork products, prohibited in Islam. Islamic extremists attacked polio workers more frequently, leading to an increase in the number of polio cases from 93 in 2013 to 327 in 2014. In 2015, of the 73 reported cases, 54 were reported in Pakistan.
Extremists falsely believe that health workers can't be trusted because western medicine promotes western ideology. To further stoke the fire, distrust of health workers increased after word spread about Afridi's role in the undercover vaccination plot to find Bin Laden. Health workers--foreign or native--became targets of the Taliban's assassination plots.
Today, the fight against polio continues, but skepticism surrounding health workers remains rampant in the northwestern and northeastern regions of Pakistan, run by tribes and often controlled by the Taliban and other extremist groups.
Struggling to find a solution
If Western medicine and foreign aid workers represent the enemy, who will fight the battle against polio in Pakistan? Pakistan has attempted to solve the immunization crisis by requiring military personnel to accompany aid workers on their polio vaccination routes. This has resulted in a 70% drop in polio cases in 2015. But while a visible military presence protects aid workers, this also forces parents to vaccinate their children, creating further distrust of Western medicine. The military's involvement also creates suspicions about the Pakistani government's intentions.
Vaccination by military coercion is not an effective or safe method for vaccinating children in Pakistan. Lasting change can only occur by creating trust and incorporating community engagement into Pakistan's health care system. To end polio, a system similar to India's, incorporating sustainable efforts to vaccinate children-- should be put in place. The Indian system actively encourages community participation in supporting maternal and postnatal care. Pakistan and India are culturally very similar, but more importantly, they have similar infrastructures, making the system easily transferable.
In India, Accredited Social Health Workers (ASHA) are trained community health workers who bring children to immunization clinics, encourage family planning, and transport women to hospitals for childbirth, among other roles. A woman from each village offer services to every woman and child in her village, increasing coverage and promoting community engagement. This incentive-based system also provides ASHA workers with an income. In a 2014 report evaluating the ASHA system in 30 villages of North India, 100% of the beneficiaries reported that they were satisfied with ASHA services. Pakistan should implement a similar system to promote community engagement.
Pakistan already has an incentive-based system for vaccination supervisors. However, they are paid only $15 dollars a day-- when the government gets around to paying them. Polio workers are paid five dollars a day. But unlike the Indian ASHA system, which involves long-term community engagement and education, the current Pakistani approach provides only the polio vaccines, without educating the recipient community. The educational component of the ASHA system must be enacted to dispel the mistrust of Western medicine.
Implementing an ASHA-like program specifically geared towards vaccinations would be greatly beneficial to Pakistan--to eradicate not only polio, but also other vaccine-preventable diseases. Community workers could help diffuse any suspicions surrounding vaccination. Paying the workers would not only provide a source of income for the women, but also encourage female independence and empowerment.
A Better Role for the Pakistani government
The Pakistani government says that it wants to eradicate polio from the region. But more than 1,000 Pakistani children under five years old die every day from vaccine-preventable diseases. The Taliban's opposition to vaccinations can only be dispelled by a focused effort on educating the community. To realize its goal of eradicating childhood polio, Pakistan must create a sustainable system for vaccination.