Polio Is Back in Pakistan: Public Health Watch

A region that has seen its share of suffering in recent decades is starting to see more.

According to media reports, a polio outbreak that stretches across the shared border between Afghanistan and Pakistan continues to grow, despite renewed efforts to expand vaccination programs in the area. Although the disease remains endemic in both countries, the current outbreak has likely been made worse by ongoing conflict—owing in part to the presence of the US military in Afghanistan since 2001—and political turmoil, given that Pakistan experienced a contentious national election in 2018.

“Conflict is certainly 1 of the main reasons we see outbreaks of diseases such as polio, but it is not the only reason,” Sona Bari, resource mobilization and communications coordinator for the World Health Organization’s (WHO) Polio Eradication initiative, told Contagion®. “After every political transition, there’s always a period of catching up in terms of providing services, but because polio eradication depends on vaccinating every child, anytime you have children left unprotected it creates a problem. Needless to say, we are concerned and monitoring the situation in [both countries] now.”

Launched in 1988, the Polio Eradication initiative has made significant progress in increasing vaccine uptake and, thus, eliminating the virus from much of the developed world. However, the current outbreak suggests efforts may have taken a step back—at least in these 2 countries. According to WHO figures, there are 41 confirmed cases of polio in Pakistan to date in 2019—up from 12 in all of 2018; Afghanistan, meanwhile, had 21 confirmed cases last year and has 10 so far this year.

Among the issues, experts on the ground say, is distrust of health care providers within local communities. Earlier this year, for example, false rumors spread on social media, as first reported by The New York Times, suggesting that children receiving the polio vaccine experienced fainting spells. “Fake news” aside, it doesn’t help that there are real issues with proper and professional medical practice in Pakistan, as Contagion® reported in June.

“Social media and other forms of mass communication mean that information and misinformation about epidemics can disperse quickly across informal networks, triggering panic,” noted Robert Peckham, PhD, MB, Lee Professor in the Humanities and Medicine and director of the Centre for the Humanities and Medicine at the University of Hong Kong, who has written about polio in the Middle East. “There is a perception among many local communities that the West only cares because the infection threatens it. Given the high infant and child mortality from diarrheal and other diseases, and the lack of basic infrastructure, [leaders in the region] may have other priorities.”

Indeed, Bari acknowledges that those working on the Polio Eradication initiative are aware of these issues and are taking steps “to do better” in addressing them. Bari said workers on the ground are engaging local political and religious leaders in Pakistan to assess community needs (including those beyond polio) and improve education outreach efforts to increase vaccine uptake. They are also enhancing programs designed to “educate and empower” local health care providers, with the goal of—hopefully—improving the overall standard of care available in the region.

That said, challenges remain, including reaching the largely migrant population of the region to provide vaccination and other care services and the ongoing ban on United Nations and nongovernmental organization activity in areas of Afghanistan not currently under central government control.

“What’s astounding is that most of Afghanistan remains polio-free, despite being in the midst of a [long-running] conflict,” Bari said.

“Conflict across the region over many decades, particularly in the ‘tribal’ borderlands of Pakistan and Afghanistan, has displaced populations, eroded basic infrastructure, and undermined trust between local, provincial, state, and international agencies—in other words, it has produced conditions that drive disease and make effective public health interventions hard to implement,” Peckham added. “Trust between health workers and local communities is key. To overcome suspicion and distrust, it is important that local health workers come from the communities they serve. In other words, they need to understand the cultural contexts and the reasons for fear.”

Unfortunately, to date, the “reasons for fear” in this part of the world have been all too obvious. Here’s hoping that changes soon.