How to eradicate polio?

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Just days ago, another police officer has been martyred while guarding a health team administering polio drops to kids in Pakistan. Since 2012 many hundreds of Pakistani law enforcers and health staff engaged in polio eradication have sacrificed their lives. In a recent article in The Lancet, Prof Dr Zulifqar Bhutta has mentioned that Pakistan has spent nearly $10 billion on polio eradication since 2011, with most of this amount coming directly from international donors. Still last year there was a setback for polio eradication as 74 new cases were found in the country in 2024. Every year different high-level international expert committees meet to evaluate the situation of polio eradication and issue similar recommendations year after year. However, international donors can't absolve themselves of the responsibility, as they are in the driving seat of strategy-making and the implementation of polio eradication in Pakistan. The Government of Pakistan also shares the responsibility for these failures as it relegates its own responsibility to others. But enough of the blame game. Now, what to do to eradicate this deadly disease?

When I was a public health student in the mid-nineties at the University of Washington, many of our senior professors were veterans of smallpox eradication campaigns. Smallpox is the only deadly disease humans have been able to successfully eradicate. Our old professors told us two important things for immunisation campaigns.

First, national immunisation days (NIDs), which commonly happen in Pakistan, actually destroy the country's routine immunisation (RI) programmes. They do this in multiple ways. As resources are diverted from routine immunisations, and salary and perks in disease eradication programmes are much better, there is a major brain drain. Another issue is that NIDs do not end in just one day but last much longer – from one week to two weeks. RI staff is also temporarily engaged in these campaigns, severely affecting routine immunisation work.

Second, in overall public health activities, it's not advisable to engage law enforcement agencies, especially when you are reaching out to marginalised sections of society. Historically, these sections of populations have had very little trust in government agencies, and their presence could make them withdraw from those initiatives. This is a global phenomenon and not a local issue.

However, we have some special circumstances. Health workers safety was compromised with the news of a fake vaccine campaign even though it had nothing to do with polio work. Secondly, the task of polio eradication was taken away from health departments and given under the leadership of administrative officials. More than 10 years ago, it was thought that we were at the very tail of polio eradication, and we needed the full resources and power of the government to push for the final mile. So, the leadership of the polio programme in Pakistan was taken away from health professionals and handed over to the bureaucracy. In the beginning, it showed results because the way a District Coordinating Officer or a Commissioner could muster up all the district resources, a poor District Health Officer couldn't. However, this was meant for short term because it had its own pitfalls that instead of public health strategies, the polio programme was relying on the brute force of district administration. More than a decade later, we are pretty much worse, except for some minor wins.

We need to take some major steps if we are serious about polio eradication. The leadership of the programme should return to public health professionals of Pakistan. Strategy should be built from the ground up and needs to have flexibility. A significant gap in meaningful community engagement needs to be filled urgently. Talks about polio and routine immunisation synergy are just talks for years with zero improvement. News about a government plan for a new hierarchical setup of polio and routine immunisation synergy, headed by a member of civil bureaucracy, will complicate things further. The real polio and routine synergy will happen only when polio becomes part of the package of routine immunisation. We must stop living in illusions.