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The World Has Eradicated Polio - Why Hasn't Pakistan?

Updated: Mar 23


Let’s set the scene - Today, 8th February 2024, is the day people are queuing up at polling centres to exercise their right to vote. Stamps are being pressed on to paper, candidates are being chosen, thumbs are being inked and, then, the votes are being shuffled through and counted.

Pakistan General Elections 2024: Voting Commences. Image Source: BBC

What better opportunity is there than today, the day of Pakistan’s General Elections 2024, to discuss a unique issue that has been plaguing the nation - an issue that is a thing of the past across the globe, but not in Pakistan and its neighbour Afghanistan.

Let’s backtrack a couple of years. I distinctly recall the bitter tang of the polio vaccine and the purple marker that stained my thumb as proof that I had been given “polio drops”. Growing up, my mother worked in UNICEF and hearing the words “polio” or “polio vaccine” and learning about their importance from her was not a rare occurrence in our household. I also remember walking the streets of Islamabad and seeing a man on a chair with wheels - he had fashioned himself a wheelchair; he could no longer walk, as in his childhood, the deadly polio virus had struck and taken away use of his legs. Yet he was trundling down the street with his wares, selling them to passersby. His resilience and strength must be applauded. However, why is it that such a preventable thing was allowed to take such a massive toll on this man’s life?



Polio and its Past

Polio is a life-threatening, crippling and highly infectious disease that mostly affects younger children and can lead to spinal and respiratory paralysis, and even death in some cases. It has no treatment. Polio is also known as poliomyelitis and is caused by the poliovirus. It spreads between people and has been around since prehistoric times. Ancient Egyptian images can be seen depicting children with shrivelled limbs walking by using canes for support. 

Ancient Egyptian depiction of a man with a withered leg using a cane to walk. Image Source: CDC

Over the late 19th and early 20th century, the poliovirus became the igniter of great fear. In the worst US outbreak in 1952, it took the lives of more than 3000 people. Those who survived this disease faced a life of permanent disability. Limb deformation meant that survivors had to use leg braces, wheelchairs and crutches all their lives. In cases of respiratory paralysis, iron lungs or other breathing devices had to be used.

Relief came in the 1950s when Jonas Salk created the first successful polio vaccine. It was a killed virus vaccine that Salk tested on himself, his family, and later 1.6 million children in Canada, Finland and the US. In April 1955, the inactivated polio vaccine (IPV) was licensed. After it began to be administered, significant reduction in cases was seen. In 1957, cases went from 58,000 to 5,600. This figure dropped to just 161 by 1961. Salk was committed to creating a vaccine that could eliminate this disease and understood that this was impossible without IPV having little to no cost. Hence, six pharmaceutical companies began to produce IPV and Jonas Salk did not keep any profit for himself. In 1955 during an interview, Salk was asked about who owns the patent for IPV and he answered, “Well, the people, I would say. There is no patent. Could you patent the sun?”. 

Jonas Salk: American physician and medical researcher, developer of the first safe and effective polio vaccine. Image Source: Yousuf Karsh.

Later, microbiologist and physician Albert Sabin created the oral polio vaccine (OPV), which was a live but weakened form of the virus. This vaccine could be administered orally as drops. It is the vaccine that is most commonly used today against polio. 


The Deadly Poliovirus

The poliovirus is highly infectious and is transmitted from person to person through contact. It lives in an infected person’s intestines and throat. It can also contaminate water and food in unhygienic conditions. Polio enters through the mouth. This can be through contact with an infected person’s faeces (faecal-oral route) or droplets from an infected person’s sneezing or coughing. Polio has three types. These are wild poliovirus types 1, 2 and 3 (WPV1, WPV2, WPV3). Types 2 and 3 have been eradicated globally. Type 1 still exists in some parts of the world (Pakistan and Afghanistan), and is the type that is most likely to lead to paralysis. 


Polio in Pakistan

Pakistan is one of only two counties (the other one being Afghanistan) that still has naturally occurring polio cases today. Pakistan’s Polio Eradication Programme was launched in 1994 and has widely been a success. This programme brought poliovirus cases in Pakistan down from 20,000 yearly in the 1990s to just 8 in 2018. According to the Pakistan Polio Eradication Programme, there were a total of 6 polio cases in Pakistan in 2023. This included 2 cases from the province of Sindh and 4 from the province of Khyber Pakhtunkhwa. This eradication programme is run by 339,521 trained workers that go door-to-door and administer OPV to all children under the age of 5. The vaccine is administered in multiple doses, starting from birth. The end goal is to achieve polio-free status. But why has this been unattainable so far?


The World Has Eradicated Polio - Why Hasn’t Pakistan?

In a 2019 report, the Technical Advisory Group on Polio Eradication said “Pakistan's program is on a failing trajectory, putting the rest of the global program at risk”. Although major progress has been made, Pakistan is still not 100% polio free. Let us delve into some reasons as to why this is, as by understanding the reasons, we can work to find solutions. 

In the past, field immunisation staff and their security personnel have faced major, and at times, deadly threats. In one instance, a healthcare worker and two policemen who were a part of a polio vaccination team were attacked and killed in Northwestern Pakistan. However, the security situation in the country has now greatly improved. In certain areas of Pakistan, the polio eradication programme is seen as something alien as local leaders are not seen to be involved in it or, at certain times, in support of it. This is coupled with a lack of education stemming from general public illiteracy and lack of awareness being spread in meaningful ways to the public, particularly in remote areas, about this deadly disease and the importance of vaccination against it. Parents and family members being distrustful of the contents of the vaccine and refusing its administration to their children is also a cause of failure of the eradication programme. Such suspicions can also be paralleled to people’s qualms about the COVID-19 vaccine and their hesitance to receive it. 

A child receives a polio vaccine dose from immunisation staff in Pakistan. Image Source: Global Polio Eradication Initiative.

Moreover, there is frequent movement between the border of Pakistan and Afghanistan, leading to spreading of the poliovirus between the two countries. This is reflected in the fact that, in 2023, Khyber Pakhtunkhwa had the most cases of poliovirus in the country - this province houses part of the Pakistan-Afghanistan border. 

 Furthermore, polio immunisation workers in Pakistan mark the thumbs of children who have received their dose of polio drops. To avoid their children being given the vaccine, some families and certain tribal areas mark their children’s thumbs by themselves without them having received OPV and assure the polio workers and the government that they have been vaccinated. Some families also conceal the fact that they have children under the age of 5 in their households for the same reasons. Over the years, myths and misconceptions about the polio vaccine have also run amok. Examples of such fallacies are people believing the vaccine is being administered to sterilise their children and make them infertile, or that Western countries are using the drops to install microchips in individuals.

Other problems for polio eradication in Pakistan include governmental issues, lack of health facilities, lack of quality healthcare, lots of public movement, and insufficient awareness and education. The COVID-19 pandemic also brought a halt to eradication efforts, creating yet another obstacle. 

However, the question arises: many of these problems are prevalent in several places around the world. But why is it that those nations have still managed to eradicate polio, but Pakistan and Afghanistan have failed to do so?


Solutions 

To ensure all Pakistani children receive their required OPV doses before the age of 5, certain measures should be put into place. The government should be more committed to polio eradication and give this cause high importance. Greater funding can help immunisation campaigns become sturdier and more high quality, and hence reach all vulnerable children in all parts of the country. Better surveillance and response is required, alongside coordination with the Afghan Polio Eradication Programme. More involvement and support from religious leaders, tribal and local leaders, healthcare providers, and local influencers will help gain trust and acceptance of the polio vaccine, particularly in remote areas. This will also help clear people’s questions, misconceptions and worries. It must be highlighted that the polio vaccine is completely safe and extremely effective, and that the consequences of people refusing it being given to their children can be severe. 

Currently, we can see great efforts being put into polio eradication. There are often television campaigns being run to raise awareness and educate the public on the importance of immunisation for children. It is not rare to leave the house and see that polio immunisation staff have left writing on our house gates, indicating that they have checked our homes for children under the age of 5.


As voters’ thumbs are inked on this day, let’s spread awareness about the situation of polio in Pakistan so that more and more children’s thumbs can be painted with purple pen, the mark of having received OPV drops. Let’s save our children from life-long disability due to this crippling disease and achieve the end goal of a polio-free country together.  

A girl shows off her purple thumb - the ink indicates she has received a dose of polio vaccine drops. Image Source: World Health Organisation.

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