Polio Eradication in India: Lessons for Pakistan?

Ravi Patel

Screen Shot 2013-03-25 at 11.55.51 AMIt has been claimed that “apart from the atomic bomb, America’s greatest fear was polio” in post-World War II America[i] However, this American fear was conquered in 1956, when Dr. Jonas Salk developed the first polio vaccine. Salk’s polio vaccine has been highly effective, and today has led to the eradication of endemic polio in all but three countries worldwide: Afghanistan, Nigeria, and Pakistan.[ii]. Although separate countries today, Pakistan and India were both carved out in 1947 from a single territory then known as British India. As a result of this common heritage, the two countries face similar social, political, and, most importantly, developmental challenges today. Along with similar historical and social contexts, both India and Pakistan share similar per child cost of vaccination, another factor placing Pakistan’s polio crisis in context of India’s past experiences (Figure 1). Specifically, this paper analyzes the case of polio eradication in India, and in tandem identifies potential lessons for Pakistan in its quest to eradicate polio.

Screen Shot 2013-03-25 at 11.55.57 AMToday, Polio can be found in four main areas in Pakistan: FATA (Federally Administered Tribal Areas), Khyber-Pakhtunkhwa and Baluchistan (along the border with Afghanistan) as well as in parts of Sindh. (Figure 2) These locations also happen to experience the greatest security vulnerabilities from radical Islamic groups such as the Tehrik-i-Taliban Pakistan. The poor security conditions in these places enable polio to thrive because of difficulties in sustaining a robust public health infrastructure.[iii] The vulnerability of polio workers in Pakistan was best illustrated by a series of coordinated attacks in Khyber-Pakhtunkhwa and Karachi by Taliban associated militants in December 2012 and January 2013.[iv] In total, 16 health workers were killed, including 12 women, and the U.N. decided to temporarily suspend its operations against polio in the country.[v] Women health workers are an essential element in Pakistan’s battle against polio because in the conservative Pakistan culture women, unlike men, can get access to children and other women in the household.


The four regions in Pakistan home to polio are tribal in nature, and have large, migrating populations, making vaccine distribution difficult to organize. The Taliban and other fundamentalist Islamic groups have also banned polio health workers from delivering care in certain parts of the county where they exert influence claiming that these workers are American spies.[vi] This misconception was reinforced with a fake polio vaccination campaign in Abottabad carried out by Dr. Shakil Afridi under CIA supervision to obtain DNA confirming Osama Bin Laden’s presence.[vii]

Coupled with this continuing suspicion, many in Pakistan believe that the polio vaccine is a Western rouse to sterilize Muslim.[viii] A similar distrust exists in Nigeria exists, where some religious leaders have called for boycotting polio vaccination because they believe it causes sterility in girls, spreads HIV and cancer.[ix] Resistance ultimately led to several northern Nigerian states boycotting the polio vaccine for about 10 months during 2004.7 The fallout of Nigeria’s struggles with immunization in 2004 not only led to polio spreading to previously polio-free areas in Nigeria, but to also spread to 8 polio-free countries surrounding Nigeria.[x] Beyond these existing issues, Pakistan faces poor public health infrastructure and possesses a critical shortage in human resources. Experts have argued that Pakistan faces a massive funding shortfall for polio eradication. So far, Pakistan’s government has so far only been allocated half of what was budgeted for the 2012-13 by the Global Polio Eradication Initiative (a public-private partnership led by organizations such as the WHO and the U.S. Centers for Disease Control and Prevention to eradicate polio).[xi] Clearly, Pakistan faces immense political obstacles as it seeks to eliminate polio.

India, Pakistan’s neighbor to the west, has also faced a long battle against polio. As recently as 2009, India had the highest number of polio cases in the world.2 Like Pakistan, India faces rampant poverty, high birthrates, large populations and remotely located communities. Along the same lines, Screen Shot 2013-03-25 at 11.55.28 AMIndia has weak public healthcare infrastructure, reflected in its poor track record of delivering medical care. For example, India was ranked 112th of 191 by the WHO in terms of its ability to deliver adequate healthcare to its citizens.[xii] Despite these challenges, India has implemented measures that such that January 2010 marks the last reported case of polio.[xiii]  Political commitment was the primary change that made India successful in its fight against polio. With political backing from the ruling Congress Party, the Indian government apportioned significant resources to polio eradication campaign. By 2013, India will have invested nearly $2 billion to combat polio.[xiv] As a result of this political support nearly 170 million Indian children are immunized through two national polio vaccination campaigns each year. Furthermore, India was effective with targeting nomadic populations by using better mapping technologies in conjunction with the aid of local community workers. Not only did these workers better understand nomadic populations, but they also were able to gain the trust of people they served. India’s robust surveillance and immunization network was crucial to polio eradication operations 4as well. To date, India has 33,700 reporting sites, managed with the assistance of 2.5 million vaccinators.11 The infrastructure established by India’s polio campaign has encouraged additional immunization campaigns. Because of these customized political measures, India has been able to defeat polio, a threat that has dominated the land for hundreds of years.

While it is difficult to gauge whether Pakistan will successfully embrace the polio eradication policies exercised in India, it is obvious that failed strategies in Pakistan will require intervention. Polio conditions in India vastly improved subsequent to employing techniques used in neighboring Bangladesh (also carved out from colonial British India like India and Pakistan as well). Bangladesh eradicated endemic polio in 2000. India, in particular, was able to adopt some lessons from Bangladesh (also carved out of British India like India and Pakistan), which eradicated endemic polio in 2000.[xv] In the case of Bangladesh, the campaign against polio was particularly successful because it was able to build a robust infrastructure monitoring polio. In Bangladesh, more than 90% of cases where acute flaccid paralysis, clinical symptom of polio, are investigated within 48 hours of notification.[xvi] Based on these lessons, India was able to improve the robustness of its polio surveillance network and this move was one of the key factors that help it win its own battle with polio.

Screen Shot 2013-03-25 at 11.55.23 AMA simple “cut and paste” of India’s public health set up may not by itself eliminate polio in Pakistan. These lessons, nevertheless, do highlight crucial changes that would serve as a starting point for Pakistan to be more effective against polio. In Pakistan, there is political support against polio at the highest levels of government. For example, Pakistani President Asif Ali Zardari announced at the UN General Assembly in September 2012 that he and his government would work to make Pakistan polio free.[xvii] This elite political support has not yet trickled down to the local and provincial level. From my informal conversations with local PPP (Pakistan People’s Party, the ruling political party in the country) workers in rural Sindh, the persistence of polio can be attributed to the lack of coordination on polio eradication efforts between the districts themselves. Even with widespread political backing, failing to coordinate the battle against polio and provide vaccine access to nomadic communities has caused polio to continue to plague the people of Pakistan. Obtaining greater political support at the local levels might also lead to an improved security environment for health workers because obtaining support from these local leaders lessen resistance from local communities. Pakistan could develop a robust surveillance and immunization network akin to that of India. Adopting India’s approach will bring Pakistan one step closer to eliminating polio, and potentially other preventable diseases, from its own land.

Collaborating with India on polio eradication would reduce, if not eliminate, the polio burden from the country, serving as a bridge in an otherwise frosty bilateral relationship.  Furthermore, cooperation on the polio issue between the two countries could be a conduit for further collaboration on other critical public health issues such as HIV/AIDS or tuberculosis. Perhaps, greater cooperation in public health could have implications for other regional development issues such as the prospect of building more cross border trade. By applying lessons from India’s experiences defeating polio, Pakistan can save more lives from experiencing the effects of this disease.

 

References:

[i] “The Polio Crusade” American Experience. Public Broadcasting Service. 2009

[ii] John, Jacob and Vipin Vashishtha. “Path to Polio Eradication in India: A Major Milestone” Indian Pediatrics. Volume 49, Number 2 (2012), 95-98.

[iii] Muhammad, Peer. “Security Situation a risk to anti-Polio effort: WHO.” The Express Tribune. 2012. Available at: http://tribune.com.pk/story/419545/security-situation-a-risk-to-anti-polio-effort-who/ Accessed Dec 1, 2012

[iv] “The War on Pakistan’s Aid Workers.” The New York Times. 2013.Available at: http://www.nytimes.com/2013/01/05/opinion/the-war-on-pakistans-aid-workers.html  Accessed Jan 10, 2013.

[v] Walsh, Declan and Donald McNeil Jr. “Female Vaccination Workers, Essential in Pakistan, Become Prey.” The New York Times. 2012. Available at: http://www.nytimes.com/2012/12/21/world/asia/un-halts-vaccine-work-in-pakistan-after-more-killings.html?pagewanted=all. Accessed Jan 10, 2013

[vi] Walsh, Declan. “Taliban Block Vaccinations in Pakistan.” The New York Times. 2012. Available at: http://www.nytimes.com/2012/06/19/world/asia/taliban-block-vaccinations-in-pakistan.html Accessed Dec 1, 2012

[vii] Tohid, Owais. “Move to Get Bin Laden Hurt Polio Push.” The Wall Street Journal. 2011. http://online.wsj.com/article/SB10001424052970204190504577038781784474056.html Accessed Dec 1, 2012

[viii] Personal Conversations with local Pakistani Political Leaders in December 2011.

[ix] Jegede AS (2007) What Led to the Nigerian Boycott of the Polio Vaccination Campaign? PLoS Med 4(3): e73. doi:10.1371/journal.pmed.004007

[x]  “Polio boycott is unforgivable.” British Broadcasting Corporation. 2004. Available at: http://news.bbc.co.uk/2/hi/africa/3488806.stm

[xi] Winsten, Jay and Emily Serazin. “Victory Against Polio is Within Reach.” The Wall Street Journal. 2012. Available at: http://online.wsj.com/article/SB10000872396390444025204577546562570306028.html Accessed Dec 1, 2012

[xii] “World Health Report 2000.” World Health Organization.

[xiii] UN Health agency marks WPD with renewed efforts to eradicate the disease. Available at: http://www.un.org/apps/news/story.asp?NewsID=43366&Cr=polio&Cr1=#.UIzLBMXA8kk Accessed Dec 1, 2012

[xiv] “Building on India’s Success on Polio.” The Wall Street Journal. 2012. Available at: http://blogs.wsj.com/indiarealtime/2012/10/24/building-on-indias-success-on-polio/ Accessed Dec 1, 2012

[xv] Schaffer, Teresita. “Polio Eradication in India: Getting to the Verge of Victory and Beyond?” Center for Strategic and International Studies. 2012.

[xvi] USAID/Bangladesh. Polio: On the Brink of Eradication. Available at: www1.usaid.gov/bd/files/polio.doc. Accessed Dec 1, 2012

[xvii] Zardari’s Pledge to Polio. Dawn. 2012.Available at: http://dawn.com/2012/09/28/govt-taking-polio-eradication-campaign-seriously-zardari/ Accessed Dec 1, 2012