Polio In Pakistan: Immunizing a Population On The Move

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From the October 2016 issue of The Rotarian

Dressed in a black burqa under a blazing sun with temperatures topping 100 degrees, Hina is going from house to house, knocking on doors. Plastered against the walls of the mud-brick homes, neat rows of hand-patted dung cakes dry in the sun to be used for cooking fuel. Open sewers stagnate beside the uneven dirt roads where children play.

At each home, Hina gives drops of the polio vaccine to any children age five and under and records the doses in her log and with chalk outside the home.

An army of women and men like Hina are on the front lines of the war on polio in Pakistan. As a polio worker with the World Health Organization (WHO), she is responsible for 223 households in her own neighborhood, tracking pregnancies and births to ensure that every child is vaccinated against the virus. During this week’s subnational immunization campaign, she works eight hours every day to ensure that she visits every home and immunizes every child.

How I find myself here with her – in a poor suburb of Peshawar, a city near the Khyber Pass on the Pakistani-Afghan border – still surprises me. In 2011, I was fired from my position as the chief financial officer of a global food and beverage company, and I launched a new career as a writer. After joining the Rotary Club of Salt Lake City, Utah, in 2012, I began reporting about polio eradication. As 2015 ended, it appeared that Pakistan might soon see its final case of polio. So I decided to come to this part of the world, where the wild poliovirus still circulates, to witness history being made and to meet the women and men who are hunting down and eliminating the virus by starving it of hosts.

While I wait outside – men are not allowed in when only women are at home with the children – Hina vaccinates Saba, a two-year-old who had previously been vaccinated seven times. Each dose has been logged.

In healthy children, three doses will provide immunity, but malnourished children in Pakistan need as many as eight doses to be protected, so children here, and in neighboring Afghanistan, are immunized repeatedly until their sixth birthday.

Ajabibi, a grandmother at another home where Hina vaccinates five children this morning, says she doesn’t personally know anyone who has had polio. This hints at one reason the final stage of the battle against the virus is so difficult: Now that the disease has been brought mostly under control, many people no longer know anyone who has had it. They don’t remember why they should fear it.

Another reason stems from the problems of infrastructure, basic health care, clean water, and education that go unresolved even as the focus on polio remains relentless. “We go door to door, again and again, with polio drops, but their child lies in bed with a fever,” explains Salah Haithami, a medical officer with WHO. “This is where Rotary’s vision of PolioPlus” – the goal of which is to integrate polio immunization with routine maternal and pediatric health care – “becomes a key strategy.”

Nosherwan Khan, a member of the Rotary Club of Rawalpindi – a city adjacent to Islamabad in northern Pakistan – travels with me for three days, from Islamabad to Peshawar and along rural highways to a village called Khushal Garh. As we drive, he talks about a strategic shift the Global Polio Eradication Initiative (GPEI) has made in the past year. Rather than focusing on the number of children vaccinated, he says, the emphasis is now on reducing the number of children missed, with a goal of not overlooking a single child. The shift is more than semantics. It is relatively easy to count the kids you do vaccinate; it is much more challenging to find and count the ones you don’t, but therein lies the key to success.

Pakistan’s cases of polio spiked between 2011 and 2014, with the country recording 58 cases of wild poliovirus in 2012 and 306 in 2014. In 2013, the partners in the GPEI – Rotary, WHO, the U.S. Centers for Disease Control and Prevention, UNICEF, and the Bill & Melinda Gates Foundation – addressed this with the Endgame Strategic Plan. And in 2015, the government significantly increased its commitment to polio eradication. Aziz Memon, a past governor of District 3270 who is now Pakistan’s PolioPlus chair, met with the president, the prime minister, provincial ministers, and other government officials to press for support

With 74 cases globally in 2015 and only about a quarter as many during the first seven months of 2016, there are reasons to be hopeful. Aidan O’Leary, the UNICEF team lead for polio in Pakistan, tells me that in April, for the first time, none of the environmental samples taken from nearly 40 locations around Pakistan tested positive for polio. It doesn’t signal the end of transmission, but it indicates that we are close

The Endgame plan includes working with religious leaders to develop support for polio immunization. Ammar Shafiq, a communications officer with WHO, has been having these conversations for years. The effort is succeeding, he says, with vaccination refusals down to 24,666 in March 2016 from 62,827 in March 2014, reflecting a rate of less than 0.1 percent of the 35 million children under age five in Pakistan.

In Nowshera, a city of almost 1 million east of Peshawar, I visit a madrassa, a school attended by 220 boys, and speak with Zahid, a religious scholar. He is courteous and attentive toward his foreign visitor. Anticipating that sitting on the floor might be uncomfortable for me, he points to a pillow, and, rather than the traditional tea, he brings me a Coca-Cola.

The soft-spoken 35-year-old, wearing traditional white robes and a full beard, says both of his children have been immunized for polio and other diseases. Since 2014, he says, he has been a vocal advocate for polio vaccinations.

In the field, the members of the GPEI work as one team. In one office, I meet employees of the government, WHO, and UNICEF. In another, I talk with workers funded by Rotary, UNICEF, and a local nonprofit run by Tayyaba Gul, a member of the Rotary Club of Islamabad (Metropolitan).

Gul, who was my guide for a day, works for the Global Fund to Fight AIDS, Tuberculosis and Malaria in Islamabad. A past president of her club who holds two master’s degrees, she says, “I just contribute my part as a Rotarian. I am happy working in remote areas, especially with women, motivating them to play their role in society.” It’s clear to me that Gul is a role model for them.

She runs a Rotary-funded health care center in Nowshera, where her team of Rotary-funded Lady Health Workers (almost always referred to as LHWs) strives to remove cultural barriers. The LHWs, working in a neighborhood of ethnic Afghans displaced by conflict in tribal border regions, strive to develop trust with women in the community in order to persuade them to view polio immunization as a normal part of postnatal care.

Gul’s workers are also part of a pilot program to use cellphones for daily data reporting, allowing them to send field reports directly to the National Emergency Operations Center. Workers in the field used to hand-write tally sheets, but now, WHO’s Haithami says, “we get that information immediately. We can analyze it for any discrepancy and communicate back in real time.”

Just as field workers across organizations collaborate, so do the leaders. The WHO representative in Pakistan, Michel Thieren, tells me the staff members from the partner organizations work so closely together that he sometimes can’t remember who works for which member of the team. “Frankly, I don’t see any difference between a colleague from UNICEF, from Gates, or Rotarians when we discuss polio, whether technically, operationally, or financially,” he says. “There is a sense of a whole team.”

The scale of that team is incredible, with 225,000 polio workers across the country, and the massive effort has two primary strategies. First, health workers like Hina go house to house to vaccinate every child they find. Second, the GPEI has established hundreds of “permanent transit points” around the country. The PTPs operate year-round and provide millions of vaccinations to children who are away from home, including those who don’t have homes, those who are traveling, and those who are in hospitals.

At Lady Reading Hospital in Peshawar, the largest hospital in the province of Khyber Pakhtunkhwa, teams of vaccinators are strategically positioned around the medical campus. Each team immunizes about 200 children per day. As Ihsan, a polio worker employed by WHO, gives drops to Asalam, a boy about six months old, I visit with the baby’s mother and grandmother, who partially removes her burqa to speak with me. She is excited, she says, to see her grandson immunized; her eldest daughter, now 40, was paralyzed by polio as a child. She is the only person I meet during my weeklong stay in Pakistan with an immediate family member who is a polio survivor.

The GPEI also operates PTPs along rural highways, including routes leading to the border regions of Waziristan and the Federally Administered Tribal Areas. Near the village of Khushal Garh, we visit a PTP at a military checkpoint. Nosherwan Khan and I meet a team of five polio workers who have already vaccinated 303 children this day. As we wait, with temperatures near 110 degrees in the shade, all I can think about is the polio workers, standing under scorching sun, devoted to eradicating polio. Some of the children coming through already have purple pinkies, the marking used around the world by polio vaccinators, but as I watch, vaccinators find a girl, aged about four, without a purple pinkie and give her the protective drops. Children in transit are at the greatest risk of being missed during campaigns, so the PTPs are a vital part of the system.

As I leave for home, I am humbled by the people of Pakistan who work so hard to help end polio. I am in awe of the massive coordination necessary to organize the efforts of 225,000 people. And I am proud to belong to Rotary, for while it is clear that Rotary could no more eradicate polio alone than we could build an elevator to the moon, this work would not be happening now if Rotary were not leading the way.

I ponder something WHO’s Thieren told me. He brought up the adage about leading an elephant as he contemplated the size of the operation. No amount of pushing alone will work, he said. You have to give the elephant a “teaser,” something to get it to use its own power to move forward. With respect to polio in Pakistan, he said, “Now there is a teaser that is very powerful: the end. Zero cases is in sight.”

Devin Thorpe with additional reporting by Miriam Doan

The Rotarian

19-Sep-2016

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