Striking a balance: Vaccination efforts pay off as more children accessible to polio teams

There has been great improvement in campaign throughout tribal areas

PESHAWAR: “She died,” Naveed Khan tells polio vaccinators when asked about his nine-month-old daughter in a far-flung village of Landikotal. After weeks of exhaustive efforts, the officials managed to obtain the records of the three children in his house near the Afghan border.

Naveed is a lecturer, but has denied polio vaccinators any access to his children. The health workers are worried as the village of Mirad Khel reported a polio case in 2015.

Khyber Agency tops the list of areas potentially infected by the virus. For two days, the teams attempt to verify the infant’s death. However, there is no death certificate nor did any cleric lead her funeral prayers. That led the health workers to the obvious conclusion – the man was lying.

The house is located at a distance from the rest of the village and assurances from locals are of little use.  The team decides to involve the political administration and after persistent efforts, the father finally agrees. All three children are ultimately vaccinated. Unconventional problems demand similar methods and solutions. The story of the polio campaign in the war-torn Federally Administered Tribal Areas (Fata) has been that of a struggle to strike the right balance between security and resources. The tribal areas now have a coverage area of 94%, far greater than any other region of the country.

In 2014, Fata reported 179 cases of polio, which accounted for 65% of the total cases globally. Targeted attacks against humanitarian workers and the ban on vaccination by the Taliban were major hindrances, while a special committee of the International Health Regulations (IHR) imposed travel restrictions on Pakistanis in November of that year.

There were 325,000 children who were not accessible to polio workers in Fata alone.

A review of the entire polio eradication initiative showed that the problem was not with the process or resources. “The real issue is to ensure teams reach every house,” says Fata Law and Order/Planning and Development Secretary Shakeel Qadir Khan. He was tasked with the additional responsibility of being the coordinator of the FATA Emergency Operation Center.

By handing the polio eradication initiative to the law and order department in FATA, the coordination for security measures and access to out-of-reach areas was possible. “On our first joint meeting with the military, we were told that all those areas which lay behind advancing forces were accessible,” he says. “There were perspectival differences which were sorted out,” he added.

After consistent brainstorming, a hotline was established with the 11-Corps and teams facing access issues had to immediately report the problem on the spot as moving the entire machinery again after a delay was not feasible.

SOURCE OF ILLUSTRATIONS: EMERGENCY OPERATION CENTER FATA

An agency polio eradication committee was formed to chalk out a pragmatic working plan for every tribal area. This immediately had an effect and while there were some problems, cases of polio immediately reduced to 16 in 2015.

Currently, there are hardly any refusal cases in Fata, Naveed told The Express Tribune. However, there is the persistent problem of ‘missing children’. In 2015, there were 10,510 that could not be reached by polio teams. That number has reduced dramatically in the current year and stands at just 2,900.

The methodology adopted is again unconventional – parents whose children were not immunised were summoned by the political agent. Failure to obey his orders could result in being jailed for non-compliance. In other instances, an influential tribal malik, who did not allow vaccination teams in his area, was approached by a jirga of almost 80 other tribal elders. They decided to remain at his hujra till an agreement was reached. After three days of caring for the needs of 80 people, as is the custom along the tribal belt, the malik agreed.

Another issue is migration. A number of the children have left the area with their parents and are not available at their specified residences. In other cases, the Fata administration has handed over the lists of displaced families to the administration of settled districts so they can be identified and immunised. The current number of children absent from the campaign in July is below 1,400.

Migration

And while migration and displacement from North Waziristan and other areas due to military operations may have played an important role in making children accessible to vaccinators, the flip side is that the recent polio case in South Waziristan, which appeared in Fata after a span of almost seven months, was a child who migrated with his family to Afghanistan.

“The child spent two years there and did not receive a single dose of vaccination,” says Shakeel Qadir Khan. “He came to South Waziristan 32 days before he tested positive for polio despite receiving both OPV and IPV at the camp.”

He added the boy contracted the virus due to his low immunity level.  Similarly, the genetic coding of the polio virus in South Waziristan shows that the child contracted the virus in Gadap Town, Karachi.

Apart from OPV, IPV was introduced into the campaign  in January 2015. “The injection is a symbol of cure among the masses,” an official says. “It seems to have turned the tide in a campaign that was rather slow till then.” Official figures show that every single campaign has yielded results of around 94%, the national passage for any campaign is 80%.

However, that does not mean there is no resistance to the campaign. In areas like Bara, the number of registered children at Tirah Bazaar was 1,132 that increased to 1,653 during 2016. There were many ‘silent’ refusals. One of them was a cleric affiliated with the hardline Panjpir sect in the Sipah area – once a stronghold of the Laskar-e-Islam which did not allow polio campaigns. His disagreement with the regular vaccination drive could have led to at least 47 children remaining unvaccinated. This can put the entire population at risk. The unit supervisor had to travel all the way to Swabi and inform the head of the Panjpir seminary, who wrote him a Fatwa in support of the polio vaccination. It was only then that the teams could access children in the area.

While Fata’s polio campaign may have struck the right balance for now, the project is run on a loan of US$270 million from the Islamic Development Bank, the interest of which is paid by the Bill and Melinda Gates Foundation. While the deadline for the repatriation of people of Fata nears and more children return back to their homes, the question is whether the campaign will be able to sustain itself with the continued resources.

Published in The Express Tribune, July 26^th, 2016.