From the roofs of inundated mud houses, it was an incredible sight earlier this week to see two polio vaccinators wading through waist-deep rainwaters to deliver vaccines.
They were headed to a remote village in northwest Pakistan where their colleagues were engaged in administering jabs to children.
Raging floods caused by ongoing torrential monsoon rains have submerged large swathes of Pakistan, but unfazed polio vaccinators are administering jabs to children under 5 in many parts of the northwestern Khyber Pakhtunkhwa (KP) province, which borders Afghanistan. The province is the hardest hit by polio.
A short video on social media shows men carefully cuddling the blue vaccine boxes and trying to maintain their balance in the gushing muddy brown rainwaters in the remote village of Dera Ismail Khan, a southern district in KP.
It prompted a barrage of praise for the vaccinators, who have been leading the country's anti-polio fight against the odds.
Meager salaries, armed attacks and on top of all, refusal from parents to get their children vaccinated on faux religious grounds, have led the South Asian nation to continuously miss the mark of a polio-free country.
The country has seen a surge in armed attacks on polio vaccinators, mainly in KP, coinciding with the capture of Kabul in Afghanistan by the Taliban last August.
"Vaccinating the nation's future is an honor for us. But, no doubt, it's dangerous as well, particularly in the tribal region, and other remote parts of KP," said Naseebullah Khan, a polio vaccinator from Peshawar, the capital of KP.
Khan, a father of three, confirmed to Anadolu Agency that many vaccinators have refused to continue to work in vulnerable areas in recent years due to armed attacks and threats.
In the latest attack, assailants gunned down two policemen guarding a team of vaccinators in KP's Tank district, earlier this week.
Some militant groups often target vaccinators, mainly in border areas of KP and southwestern Baluchistan.
They see anti-polio campaigns as part of an elaborate anti-Muslim, Western conspiracy and often issue death threats to vaccinators, many of whom are women, for administrating the vital vaccines to children.
Many, especially in rural Pakistan, reckon that the vaccine is part of a Western conspiracy, which aims to sterilize Muslim children.
Media reports said around 150 people associated with the drive, including security personnel, have been killed in Pakistan since December 2012.
"The danger (of attack) is continuously lurking but we are not going to give up. It's a do-or-die situation for Pakistan because there is no cure for polio," said Khan.
Target was nearly achieved
Prime Minister Shahbaz Sharif launched the new phase of polio vaccination Friday that involves 108 districts.
Pakistan is one of two countries, the other is Afghanistan, where polio still exists and the country remains under a polio-linked travel restriction imposed by the World Health Organization (WHO).
The UN health agency made it mandatory in 2014 for all those traveling from Pakistan to carry a polio vaccination certificate. The ban has been extended every six months.
Fourteen cases, 13 in the restive North Waziristan tribal region near the Afghanistan border, have been reported from different parts of the country in 2022, according to official statistics.
Last year, one polio case was reported in the South Asian nuclear country compared to 84 in 2020 and 179 in 2019.
"We had almost achieved the target as only one case was reported last year. The second case surfaced after 14 months," Dr. Shahzad Asif Baig, national coordinator of the National Emergency Operations Center for Polio Eradication, told Anadolu Agency.
According to the WHO standards, a country needs to be without a single case for three consecutive years to be declared polio-free.
Apart from armed attacks, Baig enumerated the refusal of parents and "fake finger marking" as key reasons behind the resurgence of cases in Pakistan.
"Almost 98% of the targeted children are vaccinated every time. The issue is arising because of this 2% due to refusal from parents and the fake finger marking by our vaccinators," he said.
A majority of vaccinators, he said, belong to local communities, who either under the influence of their own beliefs or on parents' insistence do not administer the vaccine but simply mark the thumbs of their children.
"Our monitoring teams assess the number of vaccinated children through marked thumbs. Unfortunately, some of them are just marked but actually not vaccinated," according to Baig.
After the resurgence of cases, authorities ordered an inquiry a few months ago that revealed the foul play.
"In order to contain this problem, polio vaccinators in troubled areas have been ordered to gather the children at an open space or community center to administer the vaccine in front of the health officials," he said.
‘More focused’ approach required
The rate of parents' refusal and fake marking is not more than 2%, according to Dr. Rana Safdar, a senior adviser to the US Centers for Disease Control, which has been assisting Islamabad in its fight against polio.
“Some 90% of Pakistanis have no doubts about polio vaccination. Half of the remaining 10% have some doubts, which can be cleared through a well-designed communication strategy, “ Safdar told Anadolu Agency.
He said, however, that an “intense community engagement” is required to persuade the remaining 5% of those who are wrongly convinced against vaccination.
Safdar observed that a “less-coordinated” approach compared to the previous two years, has resulted in a surge in cases.
“We had launched effective door-to-door campaigns, with special focus on vulnerable zones in 2020, and 2021, taking advantage of the coordination among different government departments, which was created during the country’s fight against the coronavirus pandemic. That campaign ultimately resulted in a deep decline in the number of polio cases,” said Safdar, who is a former national coordinator of the government’s polio eradication program. “We need to repeat the same better strategies to attain the desired results.”
Endorsing Safdar's views, Abid Iqbal, a Karachi-based vaccinator, said that a recently adopted strategy involving communication officers from local communities has helped to persuade "ignorant" parents.
After the new strategy, Iqbal told Anadolu Agency, the refusal rate has dropped by 60% to 70% in Karachi, home to 20 million people.
Meager salaries and bereft of other incentives, according to Iqbal, have been affecting the efficiency of vaccinators.
A vaccinator, usually hired temporarily from the local community, receives a little more than PKR 10,000 ($47) per week.
Help of religious leaders
Characterizing a huge cross-border movement between Pakistan and Afghanistan as a key reason behind virus travel, Safdar urged the two neighbors to produce a “more coordinated” strategy to contain the virus spread.
The resurgence of cases has forced health authorities to again seek the help of religious leaders to woo defiant parents.
"We have long been in contact with the religious leaders to persuade the parents, particularly in remote areas, to get their children vaccinated. And let me tell you, it really helped," said Baig.
In many areas, he said, religious scholars apportion a part of Friday sermons to highlight the importance of the polio vaccine.
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