A polio vaccinator administers the oral polio vaccine to a child in Pakistan. The country remains one of three in the world where polio is yet to be eradicated. Credit: Zofeen T. Ebrahim/IPS

By Zofeen Ebrahim
KARACHI, Pakistan, Mar 11 2020 (IPS)

Dr. Rana Muhammad Safdar, the coordinator for Pakistan’s National Emergency Operations Centre for Polio Eradication, has sleepless nights thinking about what needs to be done for his country to eradicate polio.

“Not only me but the entire team is having sleepless nights thinking how best and how quickly we can reach the finish line,” he told IPS. “It’s always painful to hear a child getting paralysed for life from a vaccine-preventable disease.”

Last month, over 39 million children under the age of five were vaccinated across Pakistan. And a little more than 180,000 children were missed because their parents refused to have them vaccinated. While the number of missed children is marginal in comparison to those who were vaccinated, it has caused concern.

“The proportion of children missed in the last two campaigns due to refusals is very small (0.5 percent) but where clustered these can still provide the virus with the opportunity to survive longer and re-infect areas that we clean through so much hard work,” Safdar lamented.

The Pakistan Polio Eradication Programme began 26 years ago with the “largest surveillance network” in the world — an army of 260,000 polio vaccinators going door to door to administer oral polio vaccine (OPV) to children under five. Yet the country is only one of three in the world, along with Afghanistan and Nigeria (Nigeria has not reported any wild polio virus cases for a year, however there have been cases of vaccine-derived poliovirus in the West African nation), that has not eradicated the virus.

Last year, for the first time, Pakistan reported 25 positive Wild Poliovirus 1 (WPV1) cases across the country. Since the start of the year 23 new cases have been reported, with more expected to be recorded later this year.

The issue is so sensitive that every small gain by anti-vaccine groups takes the vaccination campaign two giant steps back. A video shared on Twitter last year, claiming that polio drops had some toxic ingredient making children sick, went viral and led to a round of refusals for months afterwards.

The reason for refusals include the same misconceptions that vaccination teams have been facing the past several years and include unfounded beliefs that; the programme is a western-funded campaign with some hidden agenda, polio drops are given to Muslim children to cause infertility and to stem the population of the Muslim community, it has some ingredients that are forbidden for Muslims, and that it causes paralysis.

Abrar Khan, a 29-year-old teacher, contracted polio when was just three. He’s no public health specialist, but Khan has an encyclopedia of knowledge about the virus. Five years ago he was a polio ambassador with the government’s Polio Eradication Initiative.

And he still makes it a point to visit homes in his locality of Baldia Town, in Karachi’s District West, that are marked by polio workers with an “R” because the family refused to have their children vaccinated. “I tell them it is their right to refuse; I try and convince them but even if they say yes to me, I have no way of knowing if they got their child vaccinated,” he told IPS in a phone interview.

He said people were more concerned about the other more common diseases their children where battling with, as well as the failing healthcare system. “One way to win these people over would be to provide better quality healthcare,” said Khan.

Swaleha Ahmed*, who asked for her real name not to printed because she holds a senior position within the polio programme, told IPS that if the government were to provide for the needs of young children, including paying for their healthcare, education and basic needs, “all those parents who hide their kids when polio workers visit their homes will come forward and get their kids registered to avail this childcare fund”. 

Ahmed, who has been with the programme for some 17 years, pointed out that because the campaign was so old, complacency has set in. And as parents continue to refuse to all their children to vaccinated, it was discovered that some vaccinators in Khyber Pakhtunkhwa (KP), where the virus originated and is circulating, were wrongly marking refusals as having been vaccinated.

“It happened in KP in the very remote areas where these workers have to walk miles in knee deep snow only to be told by families that they do not want their kids to be administered drops,” she said.

But the programme is trying to overcome this.

“We are telling polio workers that if they get refusals, it will not make a dent on their daily wages nor will they have to go again as someone else will be sent in their place if they face resistance,” said Ahmed. “They are also warned that if they are found to fake the process and mark the kids without first giving them drops, they can lose their jobs.”

But there is growing fatigue for this campaign from the side of parents as well. Nasik Abbas,who works as a supervisor in Tarnol, some 20 km from the federal capital, Islamabad, has been involved in the polio campaign for over 13 years. “Parents are now annoyed by the regular knocking at their door,” he told IPS.

Hifza Tahir, who works in Islamabad’s Bahria Town has been facing another dilemma. “They turn me away saying they will get their kids vaccinated from the hospital.”   

Ahmed said the working hours and ways of working for polio vaccinators, some 62 percent of whom are women, needed to be reevaluated.

“We should not bind these workers by time and attendance. We are dealing with kids and their parents. So we should give the workers flexi times in which they must cover the required number of homes,” said Ahmed. In some cases, she said, it would make more sense to visit the house later in the day when the decision maker, usually a father, was home from work, or early morning before the kids went to school. 

Ahmed, however, admitted that despite the challenges the polio programme has come a long way. “Today, the polio workers are better trained to deal with parents, have an ID card to prove their identity, are provided security and everything is documented,” she said.

The campaigns will continue with another round of special vaccination in high risk districts this month followed by a nationwide campaign in mid-April, said Safdar.

“Our efforts from December 2019 till April 2020 will push the virus back to 2017-18 levels and from thereon we will further push it towards zero polio by focusing on routine immunisation, improving basic health services, malnutrition as well as ensuring safe water and sanitation,” he said.

A Pakistani child receives a dose of the oral polio vaccine (OPV). According to the WHO, Pakistan is responsible for 80 percent of polio cases worldwide. Credit: Ashfaq Yusufzai/IPS

By IPS Correspondents
KATHMANDU/PESHAWAR, Pakistan, Oct 24 2014 (IPS)

The goal is an ambitious one – to deliver a polio-free world by 2018. Towards this end, the multi-sector Global Polio Eradication Initiative (GPEI) is bringing out the big guns, sparing no expense to ensure that “every last child” is immunised against the crippling disease.

Home to 1.8 billion people, roughly a quarter of the world’s population, Southeast Asia was declared polio-free earlier this year, its 11 countries – Bangladesh, Bhutan, Democratic People’s Republic of Korea, India, Indonesia, Maldives, Myanmar, Nepal, Sri Lanka, Thailand and Timor-Leste – joining the ranks of those nations that live without the polio burden.

United in the goal of eradicating polio, an infectious viral disease that invades the nervous system and can result in paralysis within hours, governments across the region worked hand in hand with community workers, NGOs and advocates to make the dream a reality.

“Pakistan has the highest [number of polio cases] among the three endemic countries worldwide." -- Elias Durry, emergency coordinator for polio eradication with the WHO in Pakistan
According to GPEI, immunisation drives reached some 7.5 billion children over the course of 17 years, not just in city centres but also in remote rural outposts. During that time, the region witnessed some 189 nationwide campaigns that delivered over 13 billion doses of the oral polio vaccine (OPV).

High-performing countries like Sri Lanka, the Maldives and Bhutan eradicated polio a decade-and-a-half ago while India, once considered a stubborn hotbed for the disease, clocked its last case in January 2011, thus bringing about the much-awaited regional ‘polio-free’ tag.

But further north, dark clouds in the shapes of Afghanistan and Pakistan blight Asia’s happy tale. Together with Nigeria, these two nations are blocking global efforts to mark 2018 as polio’s last year on this planet.

Celebrating success from Nepal to the Philippines

For countries like Nepal, home to 27 million people, the prevalence of polio in other nations in the Asian region threatens its hard-won gains in stamping out the disease.

“There’s always fear that polio may see a resurgence as the disease hasn’t been eradicated everywhere,” said Shyam Raj Upreti, chief of the immunisation section of Nepal’s child health division (CDH).

Anxious to hold on to the coveted polio-free status, Nepal recently introduced the inactivated injectable polio vaccine (IPV) into its routine immunisation programme, the first country in South Asia to do so.

“While the oral polio vaccine has been the primary tool in polio eradication efforts, new evidence shows that adding one dose of IPV – given to children of 14 weeks by intramuscular injection – to the OPV [schedule], will maximise immunity to poliovirus,” Upreti explained.

He credits his country’s success to a high degree of social acceptance of the importance of child health in overall national development. “Female health volunteers play a key role in making the community understand why immunisation is important,” he said, adding that these volunteers provide services to some of the poorest segments of the population.

Between 1984 and 2011, Nepal’s immunisation coverage more than doubled from 44 to 90 percent. Ashish KC, child health specialist at UNICEF-Nepal, said that immunisation programmes didn’t stop even during the ‘people’s war’, a brutal conflict between the Maoists and the Nepali state that lasted a decade and killed 13,000 people.

“We understood that [we] needed a multi-sector approach, so service delivery was decentralised, and access was made easier,” KC told IPS. “Immunisation went beyond health, it became a part of [our] development plans.”

Such a mindset is also apparent in the Philippines, where the government recently decided to include the IPV into its national health plan, making it the largest developing country to do so.

According to a press release by Sanofi Pasteur, the multinational pharmaceutical company working closely with the Philippine government on its eradication initiatives, many Filipinos feel deeply about polio, having had a prime minister who was a survivor of the disease and lived with lifelong disabilities as a result.

“What’s striking about the Philippines is how strong a partnership there is around vaccinations,” said Mike Watson, vice president of vaccinations and advocacy at Sanofi Pasteur, referring to the unprecedented support shown by government officials and civil society at an event in Manila earlier this month that ended with several children receiving the IPV, the first of some two million children who will now be vaccinated every year.

“Getting the vaccine out to distribution centres on the smaller islands obviously poses a logistical challenge, but the Philippines has proven it’s really good at that,” Watson told IPS.

He added that strong networks of community health workers have enabled the Philippines to move into the “endgame”, the last stage in global eradication efforts that will require the 120 countries that aren’t currently using the IPV to introduce it by the end of 2016, representing one of the biggest and fastest vaccine introductions in history.

Over 5,700 km away from the Philippines, however, lives the lingering threat of polio, with thousands of children still at risk, and hundreds suffering from the debilitating results of the disease.

Pakistan’s polio troubles

This past June, the World Health Organisation (WHO) recommended a travel ban on all those leaving Pakistan without proof of immunisation, in a bid to prevent the spread of polio outside the country’s troubled borders.

But absent swift political action, travel bans alone will not staunch the epidemic.

A 2012 Taliban-imposed ban on the OPV has effectively prevented over 800,000 children from being immunised in two years, health officials told IPS.

In 2014 alone, Pakistan has recorded 206 cases of paralysis due to wild poliovirus, the most savage strain of the disease. Last week, 19 new cases of this strain were brought to the attention of the authorities.

“Pakistan has the highest [number of cases] among the three endemic countries worldwide,” Elias Durry, emergency coordinator for polio eradication with the WHO in Pakistan, told IPS.

The situation is most severe in the northern tribal areas, where the Taliban has used both violence and terror to spread the message that OPV is a ploy by Western governments to sterilise the Muslim population.

“The militancy-racked Federally Administered Tribal Areas (FATA) accounts for 138 cases, while the adjacent Khyber Pakhtunkhwa (KP) province has 43 cases,” Pervez Kamal, director of health in FATA, told IPS.

North Waziristan Agency has registered 69 cases, while the Khyber Agency and South Waziristan Agency are struggling with 49 and 17 cases respectively.

In a tragic development, an 18-month-old baby girl named Shakira Bibi has become the latest in a long line of polio victims. Her father, Shoiab Shah, told IPS that “Taliban militants” were responsible for depriving his daughter of the OPV.

In an unexpected twist, a military offensive aimed at breaking the Taliban’s hold over northern Pakistan has given health officials rare access to hundreds of thousands of residents in the tribal areas.

With close to a million people from North Waziristan Agency fleeing airstrikes and taking refuge in the neighbouring KP province, community health workers have been delivering the vaccine to residents of displacement camps in cities like Bannu and Lakki Marwat.

Still, this is only a tiny step towards overcoming the crisis.

Altaf Bosan, head of Pakistan’s national vaccination programme, said 34 million children under the age of five are in need of the vaccine but in 2014 alone “about 500,000 children missed their doses due to refusals by parents to [defy] the Taliban’s ban.”

The government has now elicited support from religious leaders to convince parents to submit to the OPV programme.

“Islamic scholars from Pakistan, Saudi Arabia, Egypt [and] Afghanistan have issued a fatwa [edict], reminding parents that it is their Islamic duty to protect their children against disease,” Maulana Israr ul Haq, one of the signatories, told IPS.

According to the WHO, Pakistan is responsible for nearly 80 percent of polio cases reported globally, posing a massive threat to worldwide eradication efforts.

Excerpt:

Families and health workers defy the Taliban's ban on oral polio vaccines (OPV). Credit: Ashfaq Yusufzai/IPS

By Ashfaq Yusufzai
PESHAWAR, Pakistan , Jul 11 2013 (IPS)

Four-year-old Muhammad Jihad is handicapped, and his parents know who to blame: the Taliban.

Jihad’s father, Muhammad Rishad, says the boy tested positive for polio on May 6 at the National Institute of Health in Islamabad.

The family had travelled from their home in North Waziristan, a mountainous region that comprises part of Pakistan’s Federally Administered Tribal Areas (FATA), to ensure their son had the best possible care, only to be told that the virus had spread too far, and little Muhammad would likely never walk again.

"The Taliban are enemies of children. They are against education and vaccination, both of which are necessary for a child’s development.” -- Noor Gul, a schoolteacher in northern Pakistan
A distraught Rishad told IPS, “The Taliban militants are responsible for my son’s (paralysis) – they placed a ban on the oral polio vaccine, so my son could never get immunised.”

Rishad is a daily wage-labourer, who had few dreams beyond securing a decent life for his only son. Now, he says, the Taliban have robbed him of his little hope for the future.

“When he grows up, my son will condemn the militants,” Rishad added, even though such thoughts bring him little solace.

Experts here say children are the future of this troubled country of 170 million, and should be protected at all costs.

Sadly, such advice has fallen on deaf ears in the militancy-ridden northern regions, where the Taliban have imposed a complete ban on all vaccines against preventable childhood diseases, including polio – sometimes referred to simply as “infantile paralysis” due to its crippling effects on a child’s nervous system – measles, diphtheria, hepatitis, meningitis, pertussis, influenza and pneumonia.

Children in all seven agencies of FATA have been the worst affected by the ban on the oral polio vaccination (OPV), which the Taliban have described as a ploy by the United States to render the Muslim population infertile. Over 160,000 children in North Waziristan and 157,000 children in South Waziristan are now at risk of contracting deadly ailments.

The Taliban have used violence and terror to implement the ban – since December 2012 at least 20 volunteer health workers and policemen have been assassinated for daring to defy the militants’ orders by participating in immunisation drives in the Khyber Pakhtunkhwa (KP) and Sindh provinces.

Two years ago, polio had been wiped out in all but three countries worldwide: Afghanistan, Nigeria and Pakistan. In Pakistan, the recent recurrence of the disease marks several steps back from successful attempts at eradication: from just 28 cases in 2005, the country saw a rapid increase of up to 117 cases in 2008, and 198 cases in 2011.

Eighteen cases have already been reported in 2013, and experts fear that number could rise very quickly.

Dr. Farman Ali, based at the Agency Headquarters Hospital in the town of Miranshah in North Waziristan, told IPS “an outbreak of polio” is never far off when large numbers of children remain unimmunised while the virus is in circulation.

According to the Health Department, medical workers have recorded over 50,000 incidents of families refusing the vaccination in FATA and the KP.

“The Taliban have strictly warned us to stay away from vaccination. They have broken the iceboxes of health workers and threatened to kill them if they (continue their work),” Ali said.

Taliban Spokesman Ihsanullah Ihsan told IPS last year that his “leadership decided to ban the vaccine because it was an excuse for the U.S. to send in its spies and expose Taliban leaders to drone strikes…we will allow vaccination when the U.S. stops its drone strikes.”

But rather than the U.S. government, it is poor families who are paying the price for this ban.

Gul Daraz, a resident of North Waziristan Agency, has a three-year-old son who had already received his first dose of the OPV when the ban was announced. Because he was never allowed to complete the full course of three doses, as required by the World Health Organisation, he is now handicapped.

“Every time my wife sees our crippled son, it reduces her to tears,” Daraz, a poor shopkeeper, told IPS.

Sadly they are not alone in their plight. According to FATA Health Director Dr. Fawad Khan, “We have only been able to vaccinate 400,000 of the 900,000 target children under five years in FATA.”

He told IPS 58 cases were reported across the country last year, including 27 in KP and 20 in FATA, of which 12 of the victims had been prevented from receiving the OPV.

Zareen Taja, a housewife in FATA’s Bajaur Agency, told IPS over the phone, “My son is very beautiful, but he will not be able to walk like normal people. I have no one to blame but the Taliban.”

At this rate, she added, Pakistan will never achieve its goal of eradicating this preventable disease that has been stamped out in all but two other countries in the world.

Noor Gul, a schoolteacher in the Frontier Region Bannu, whose son is one of the two affected children in the province, labeled the Taliban “enemies of children”.

“They are against education and vaccination, both of which are necessary for a child’s development.”

An international conference of Islamic scholars held on Jun. 6 in the capital, Islamabad, condemned Taliban militants for killing Pakistani polio workers, and held them responsible for the resurgence of the disease.

Dr. Muhammad Wesam, chief scholar of Al-Azhar University in Cairo, told conference participants that the Taliban’s campaign “contravenes Islam”.

Thirty-four scholars from Pakistan, Yemen, Egypt and Saudi Arabia issued a decree saying that those impeding vaccination efforts were committing a crime, for which God would hold them accountable.

Such interventions by clerics are crucial to correcting the misconception that OPV is “anti-Islamic”. Dr. Jan Baz Afridi, head of the KP immunisation programme, told IPS his office is working with religious scholars and volunteer health workers to continue vaccination drives.

“We are under tremendous pressure to immunise all 5.2 million children in the KP in order to effectively wipe out the disease,” he added.

The Agency Headquarters Hospital (AHH) in Bajaur Agency, shortly after a Taliban suicide bomb attack. Credit: Ashfaq Yusufzai/IPS

By Ashfaq Yusufzai
PESHAWAR, May 1 2013 (IPS)

Akbar Shah was sitting with his sick wife in the gynaecology ward of the Agency Headquarters Hospital in Bajaur Agency, a division of northern Pakistan’s Federally Administered Tribal Areas (FATA), when a bomb ripped through the facility, scattering patients, doctors and medical supplies.

“We immediately rushed my wife to Peshawar (capital of the neighbouring Khyber Pakhtunkhwa province) because the doctors, paramedics and nurses were panicked and unable to look after patients,” Shah told IPS.

Hours later, the Taliban claimed responsibility for the Apr. 20 suicide mission.

"The Taliban are just inviting the wrath of God Almighty by targeting healthcare facilities...The patients should be shown mercy."
Shah’s wife is now being treated in a hospital in Peshawar and though her condition is showing signs of improvement, Shah still curses the Taliban for its ruthless campaign against health facilities in the region.

The entire medical community, along with a large majority of the general public, has slammed this latest attack, which killed four people, as a plot to deprive FATA’s population of six million people of adequate healthcare.

According to Dr. Shaukat Ali at the FATA Health Directorate, the 200-bed Agency Headquarters Hospital (AHH) had provided treatment to over 100,000 patients annually, with the help of 120 doctors and 100 paramedics.

“It is the only specialised hospital in FATA,” he told IPS, but it is now devoid of both patients and doctors, who have fled to Peshawar.

With 26 hospitals, 10 rural health centres and 419 community health centres, FATA is well equipped to deal with all of its residents’ medical needs. But if the attacks do not stop immediately, Shaukat Ali warned, the entire health system here will be rendered ineffective.

Meanwhile, medical facilities in Peshawar are struggling to keep pace with the influx of patients from tribal areas on the Afghanistan border, who say they are “too afraid” to visit hospitals that might be targeted by militants.

Dr Ahmad Sher at the Khyber Teaching Hospital in Peshawar told IPS his facility received about 20,000 patients from FATA in 2012 alone.

“The Taliban are just inviting the wrath of God Almighty by targeting healthcare facilities where patients are treated for different ailments. The patients should be shown mercy,” he said.

So far the Taliban have destroyed about 400 health facilities in FATA and the Khyber Pakhtunkwa (KP) province.

“Since 2008, the Taliban militants have damaged 128 health facilities in FATA,” Secretary of the Provincial Doctors Association (PDA) Dr. Muhammad Irfan told IPS, while the adjacent KP lost 55 health facilities between 2007 and 2009, during the Taliban’s illegal rule over the Swat district.

Militants have been particularly unforgiving of those who defy the so-called “ban” on polio immunisation, which they have labeled “un-Islamic”. The group also claims the oral polio vaccine (OPV) was designed to render the recipients impotent and infertile in order to “curb” population growth of Muslims.

In the past three months the Taliban have claimed responsibility for the deaths of 17 policemen, female vaccinators and volunteers in polio-related violence.

Last year, out of a total of 58 cases of polio in the country, 27 were recorded in the KP and 20 in FATA, which experts believe is likely the result of the Taliban’s interference with immunisation drives.

Fathema Murtaza, Pakistan spokeswoman for Doctors Without Borders (known by its French acronym MSF) told IPS it is crucial that medical structures and patients be spared from violence.

“MSF…calls for respect for the safety and security of patients, health facilities, and medical staff,” the group said in a press release last week. “All actors in the area must ensure that medical activities can take place unhindered and not be targeted.”

Since March, MSF medical teams have been running mobile clinics in Bajaur, providing services in three Basic Healthcare Units (BHUs) where about 200 patients are treated every week, Murtaza said.

“The safety and security of healthcare is essential for MSF to continue to expand its medical intervention in Bajaur,” she added.

The PDA’s Dr. Muhammad Irfan condemned the Taliban and asked the government to tighten security on hospitals so patients can receive necessary treatment undisturbed.

“We will hire private security guards and will impart training to our watchmen and other staff on how to foil terror (plots),” FATA’s director of health, Dr. Fawad Khan, informed IPS.

In that same vein, the female staff of government-run hospitals will be trained on how to conduct body searches of female visitors and take appropriate measures if they encounter anything suspicious.

The health directorate has also sought the services of the KP police in the training of health personnel.

Like other experts and medical professionals here, Khan believes the targeting of health facilities is particularly egregious in a region that is already lagging behind global health indicators, particularly with regards to maternal mortality.

“About 365 women (per 100,000 live births) die every year in Pakistan’s four provinces, while in FATA the number is closer to 400 due to pregnancy-related complications,” he said.

Similarly, FATA only has a 40 percent immunisation rate, compared to a nationwide rate of 67 percent.

A majority of FATA’s 400 qualified doctors are too afraid to go to work because of the dangers that loom over them every day, he added.

(END)

Families of the deceased health workers mourn the loss of their loved ones in Karachi. Credit: Adil Siddiqi/IPS

By Ashfaq Yusufzai and Zofeen Ebrahim
PESHAWAR/KARACHI, Dec 21 2012 (IPS)

The murder of nine health workers vaccinating children against polio in Pakistan’s northwest cities of Peshawar and Charsadda in the Khyber Pakhtunkhwa (KP) province, and its southern port city Karachi, have elicited shock and outrage.

Four female health workers were killed in Karachi, shot dead by masked men on motorbikes. The other five victims, including a 17-year-old volunteer, were slain in Peshawar and Charsadda.

These killings were preceded by another death in Karachi’s Sohrab Goth area on the first day of a planned three-day immunisation campaign across the city, which has now been suspended in the provinces of Sindh, Balochistan and parts of KP, located on the Afghanistan-Pakistan border.

For activists and health workers familiar with the political terrain here, this attack – heinous as it is – is just the latest incident in a long campaign spearheaded by the Taliban that will likely continue long after the media hype has died down.

Back in 2005, Maulana Fazlullah, leader of Tehreek-e-Nafaz-e-Shariat-e-Mohammadi (TNSM), a fundamentalist militant group intent on imposing Sharia law throughout the country, began using a local radio station to spread an anti-vaccine message in the Swat district of the KP.

“The campaign began long before militants set foot in Swat – Fazlullah would deliver sermons from mosques, warning people to stay away from the vaccination because it was ‘against Islam’,” Dr. Rasool Khan, with the Expanded Programme of Immunisation (EPI) at the Aga Khan University, told IPS.

As militants began to gain a stronghold in the Federally Administered Tribal Areas (FATA), Fazlullah became commander of the Swat chapter of the outlawed Tehreek-e-Taliban Pakistan and his opposition to the vaccine became an official Taliban slogan.

“Everywhere in Khyber Pakhtunkhwa and the adjacent FATA, the Taliban came out to oppose vaccination,” Rasool Khan said. The militants argued that the oral polio vaccination (OPV) was a ploy used by the U.S. and its Western allies in the ‘war against terror’ to render Muslims infertile and stem population growth.

This argument found favour with the local population, who had become sceptical of the campaign after observing United Nations officials and aid workers travelling around the region in limousines while carrying out immunisation drives.

By 2011 polio was endemic in only three countries worldwide: Pakistan, Afghanistan and Nigeria. After coming very close to eradication, with only 28 cases nationwide in 2005, Pakistan saw a rapid increase to 117 cases in 2008 and 144 in 2010. By 2011, the country had registered 198 cases of polio.

Since 2007, immunisation drives in the KP and FATA have recorded about 50,000 incidents of families refusing the OPV, according to the Health Department.

For years, vaccinators have been terrified for their lives, while others have avoided joining the campaign for fear of drawing the ire of militants.

Tahseenullah Khan, national coordinator of the National Research and Development Foundation (NRDF), which has supported the UNICEF-sponsored mobilisation campaign in KP and FATA since 2009, says his organisation hired the services of religious scholars and began to make progress in getting through to the local population.

But the scandal involving Shakil Afridi – a CIA agent posing as a doctor who set up a fake immunisation centre in the northern town of Abbottabad as a front to gain information on Osama bin Laden last year – worked greatly in the Taliban’s favour.

“Now the majority of people believe that what the Taliban were saying about the ulterior motives of the U.S. to send spies to militant strongholds was true,” Tahseenullah Khan told IPS.

But health workers refuse to be deterred. Through the grief comes a determination to re-double eradication efforts. Dr. Imtiaz Ali Shah, the focal person for polio immunisation in KP, told IPS that health workers are devising a new strategy to re-launch the campaign through elected representatives.

“We want to have a full-scale campaign to wipe out the ailment before it assumes the shape of a full-blown epidemic,” he said.

This determination is not limited to the tribal areas, which have long borne the brunt of fundamentalism and militarism, but is now widespread down in Pakistan’s urban centres as well.

Shahnaz Wazir Ali, adviser on polio to Pakistan’s Prime Minister Raja Pervez Asharf, who flew in from Islamabad to visit the injured and condole with the families of the four deceased health workers here, told IPS, “The Sindh government will have to do some serious stock-taking and revisit its present campaign – we need to reach every child.”

But experts in Karachi are not certain who was behind the well-coordinated killings. The Taliban have denied any involvement in the incident.

“I visit Landhi’s Gulshan-e-Buneer area every month and know the place like the back of my hand,” said 35-year-old Nasim Munir, head of the anti-polio campaign in the area where two women were killed, told IPS. She refuses to believe that the two health workers, Fehmida and her neice Madiha, were shot dead because of opposition to the OPV.

“If there was any ill-feeling, they (the health workers) would have been turned out of people’s homes or refused entry – not killed,” she stressed.

“This is a bigger plot and needs to be probed further,” she added.

“Till the investigations are complete, we can only speculate. The timing is significant in Karachi, where there is already much uncertainty and unrest,” said Wazir Ali.

President of the Sindh chapter of the Pakistan Medical Association, Dr. Samrina Hashmi, also remains uncertain about the Taliban’s hand in this, but speculated that the attacks were an attempt to “cause anarchy, and to try and disrupt the upcoming elections”, scheduled for March 2013.

“There is little doubt that this was a concerted plan to counter and block anything that was high priority for the government,” Wazir Ali added. She believes shooting women health workers sends the message that there are elements “capable of doing anything”.

“Who (else) would want to kill people who are working for the health of children?” Dr. Altaf Bosan, working as technical focal person for the Prime Minister’s Anti-Polio Cell, asked.

But he stressed, “We will not let anyone sabotage this programme, it was going very successfully.”

Indeed, with only 56 cases recorded in 2012, Pakistan has made good progress this year, contributing to the global decline in fatal and harmful cases of polio from 350,000 in 1998 to less than 1,000 last year.

But while the polio virus lives in even one child, the world remains at risk, experts say. The discontinuation of the campaign in the Sindh comes as a huge blow to health experts and others involved in the immunisation drive.

Dr. Mazhar Ali Khamisani, heading the Sindh Expanded Programme on Immunisation, told IPS, “It’s a major setback for our campaign. We have suspended the programme and have asked the government to conduct (a proper investigation) and catch the culprits before our volunteers venture into the field again.”

According to a government public health expert who has worked with the polio campaign since it began in 1994, speaking to IPS on condition of anonymity, “Today they stopped the campaign in Karachi, tomorrow they (could) stop it throughout Pakistan. Do we want a nation of handicapped people?”

While it is impossible for the government to provide security to each and every health worker in the field, Hashmi believes intelligence agencies need to be vigilant enough to outwit and preempt militants’ plans.

Meanwhile, the tragedy appears to have had one significant political repercussion: it has chilled the cosy relationship the Taliban once enjoyed with several religious groups across the country. Soon after the killings, Tahir Ashrafi, heading the Pakistan Ulema Council, said 24,000 mosques associated with his organisation would condemn the tragedy during the Friday prayers.