Pakistan’s success and failure is now linked to a rapidly multiplying number. From 188 polio cases on October 2 at 1pm to 194 at 9pm to 202 on October 3 at 10pm and now 207; the last 22 days have seen at least 41 new cases.
In a population of nearly 200 million, these 207 children represent 0.0001035% making it easy for some to forget how a three-digit number has changed the lives of thousands, and continues to risk the lives of millions across the world.
They forget that roughly one in 200 polio infections lead to irreversible paralysis while over 95% of children infected are asymptomatic, or silent, infectors.
The world was quick to do the math and slapped travel restrictions on Pakistan. The latter briefly focused on polio before turning to numbers about protest crowds and ballot papers.
Sitting inside his office in Clifton, silver-haired Memon turns his focus on the topic which takes up most of his waking hours – polio.
“We always thought the last stumbling block for a polio free world would be India,” Aziz Memon, the national chair for Pakistan PolioPlus Committee, told The Express Tribune a few days before Pakistan’s count touched 194.
PolioPlus was initiated by Rotary in 1985 but it was preceded by Rotary’s pledge to provide oral polio vaccines to six million children in the Philippines in 1979. According to Memon, Rotary has so far spent $1.2 billion on polio prevention, including $105 million in Pakistan. Globally, Rotary has helped raise over $8 billion from the governments of the world, he added.
Memon wants to see the glass half full, after all he along with WHO and other stakeholders have spent decades pouring in efforts.
“Numbers should not be a problem, look at the bright side, we have eradicated poliovirus type 2 and 3,” he said. “We just need two good rounds with good results; coverage should be good, refusals should be less. Two good rounds and we will be done.”
Memon smiled, “Political will chahiyay hai; political will.”
The Muslim effect
Before India came to zero, “it had around 780 cases a year,” said Memon. “Then India got rid of polio from all the states of the south ten years before they were able to move from Bihar. India got stuck in Bihar and Uttar Pradesh.”
“Various reasons – illiteracy, density of population, but,” Memon paused for effect, “the most (significant) factor was the resistance from Muslim groups.”
It was nothing like the Taliban, he said, referring to that organisation’s polio vaccination ban in Waziristan and constant attacks on polio vaccinators, one of which took place recently on October 10 in Mohmand Agency.
“It was soft resistance, not like the dedicated refusal we face here; hum samjha daitay thay, woh maan jatay thay.”
Outside of India, Rotary has been successful in eliminating polio from countries at war: allowing for ceasefires just to immunise children. So why not in Pakistan?
“The biggest thing to remember is that wars are of different types – ours is more savage,” said Memon. “The way they fight, their principles and the area.”
The use of perceived threats to cultural Islam to shore public support or make people believe they have a common enemy in the West is not limited to Pakistan.
According to a paper in the journal Global Public Health, five northern Nigerian states suspended the use of OPV in 2004 over “rumours endorsed by high-ranking public figures that OPV was an American conspiracy to spread HIV and cause infertility in Muslims.” The same paper links polio refusals in Khyber-Pakhtunkhwa (K-P) and Fata in 2007 to similar misinformation spread through extremist clerics on their radio stations.
This gave the virus a new foothold in Pakistan, made worse in 2011 when Dr Shakil Afridi was associated with a fake vaccination campaign which helped catch Osama bin Laden.
“Dr Afridi didn’t have anything to do with polio,” added Memon, visibly frustrated with the dissemination of misinformation, partially attributed to a “lousy media”.
Talking about a man from Fata who had brought his paralysed 18-month-old son to Lady Reading Hospital in Peshawar, Memon lamented how the public can be misled.
In this particular case, Memon told the man if he had given just two drops, his son would have been walking. “The colour of his face just changed,” recalled Memon.
“He said, ‘What nonsense are you talking, are you God? It was written in his fate that he would suffer from this. How could you or I stop it?’”
However, by the end of that discussion, Memon had successfully convinced the father that protecting his child from polio was sound parenting, just like protecting him from a cold. The man walked away with regret, having learnt his son’s paralysis could not be cured.
“How many such individuals can you go tackle?” questioned the PolioPlus national chair. Rotary, UNICEF, WHO have all worked with local opinion leaders and held global conventions advocating the benefits of immunisation but refusals persist.
In July, Ban Khalid Al-Dhayi, spokesperson of UNICEF Pakistan, told The Express Tribune there were at least 47,000 refusals. By September, according to some reports, refusals had only gone up.
Now the three remaining countries are Nigeria, Afghanistan and Pakistan.
“Nigeria’s health minister is fully committed; the country has just six cases this year and not a single one over the last four months.”
Afghanistan is doing well, “very very well.” The few cases recorded there were genetically traced back to the reservoirs of Khyber-Pakhtunkhwa and Fata, he added.
Coverage
Even with the TTP ban in place, Rotary and other agencies have persisted. After Operation Zarb-e-Azb, the otherwise inaccessible population of North Waziristan Agency was suddenly available.
“But the IDPs didn’t just remain in Bannu, they spread all over,” creating a bigger problem of containing the epidemic.
“Except for one in Sanghar, all cases are Pukhtun-linked.”
Sehat ka Insaf was a good thing, said Memon, “but the reservoir in Peshawar is still intact, from where the virus originates.” Consistency is key; “There has to be a follow-up, just getting a political leader to come and give two drops before he goes away to do other things just does not work.”
Though, it is good to have the political parties on board, even in Karachi, he said. “But the federal government needs to do more, they have to eradicate polio.”
The bureaucracy effect
“In 2012 we were almost done with polio; we had no cases in the first seven months. All the cases hovered along Fata and then linked to Taliban-controlled areas in Karachi, but the city didn’t have a single case.” Memon attributed it to a lack of security issues in the city; “We used to do health and cleaning camps in Gadap then.”
Memon added, “Prior to the 2013 elections, our government was fully committed; the national taskforce used to meet every three months, chaired by the prime minister,” said Memon.
Then, “the caretaker government came and rolled back the polio programme, closed the PM’s Polio Monitoring Cell – a big setback.” When the new government came in, they had a lot of issues to tackle, said Memon. “In fact even with so much pressure from Rotary and other donors, it took them nine months to appoint a polio focal person.”
Bureaucracy was in full bloom, he added, “They kept telling the government that polio was not such a big issue; only one PM polio taskforce meeting was called and lasted only 40 minutes,”
According to Memon, “Wherever we have eradicated polio, at the end of the day, ownership was with the government.”
Going back to India’s success story, he pointed out the country’s federal health minister, Ghulam Nabi Azad knew every last detail.
“With us, unfortunately the 18th Amendment has been a big blow to the health and education sector of Pakistan,” claimed Memon. “It was not very well thought of; we tried our best but the MNAs were so adamant that [devolution] is the right way. We gave them the example of 56 countries, where the health sector was with the provinces, but there was a federal health minister on top.”
Pakistan does not have that, so “donors don’t have such a system of giving to provinces. Now to camouflage that, they have created a ministry called the ministry of regulatory affairs which is a substitute for the health ministry.”
Responding to a question about the ministry headed by Saira Tarar, Memon said, “She can’t be called a minister of health, they have yet to appoint a federal health minister.”
Memon said he met PM Nawaz Sharif just when he had taken oath, “I asked him one question – do you want Pakistan to be the last country to eradicate polio? History will write it down, I told.”
The PM’s response was No, said Memon.
“But Pakistan is the last now, beyond a doubt.”
Published in The Express Tribune, October 14th, 2014.