Why is polio still here? A perspective from Pakistan
Authors: Rana Jawad Asghar
Journal: The Lancet Global Health (2020)

Poliomyelitis has been eradicated in all countries except Afghanistan and Pakistan. Why have we, as Pakistani government workers, public health officials, and community members been unable to eradicate polio in Pakistan? There is no doubt that our field immunisation staff and the security personnel protecting them have faced unprecedented attacks in a difficult, and in some cases, deadly, working environment. But with the security situation now much improved, the question of why we are witnessing one of the largest polio surges since 2014 remains unanswered. Pakistan had 91 cases of polio as of Nov 26, 2019.1Pakistan Polio Eradication ProgramPolio cases in Pakistan.http://www.endpolio.com.pk/polioin-pakistan/polio-cases-in-provincesDate: 2019Date accessed: October 16, 2019Google Scholar Not only have we had a major outbreak in Khyber Pakhtunkhwa, but all other provinces in Pakistan have also reported multiple cases. In 2018 we had 12 cases, and in 2017 we had only eight cases. Multiple explanations have been put forward from national elections, transition of government, underlying issues of community distrust of vaccinations, to negligence of key staff.2Shakeel SI Brown M Sethi S Mackey TK Achieving the end game: employing "vaccine diplomacy" to eradicate polio in Pakistan.BMC Public Health. 2019; 19: 79Crossref PubMed Scopus (8) Google Scholar, 3Andrus JK Perry HB Community engagement, ownership, and civil society organizations in polio eradication.Am J Trop Med Hyg. 2019; 101: 1-3Crossref PubMed Scopus (7) Google Scholar In its 2019 report, the field mission of the Technical Advisory Group on Polio Eradication, stated that the "Pakistan program is on a failing trajectory, putting the rest of the global program at risk".4Polio TAG Technical Advisory Group on Polio Eradication in Pakistan Feedback from TAG.http://polioeradication.org/wp-content/uploads/2016/07/TAG-recommendations-on-polio-eradication-in-pakistan-20190202.pdfDate: 2019Date accessed: October 22, 2019Google Scholar In 2018, the independent monitoring board of the Global Polio Eradication Initiative reported that it felt the situation in Pakistan has not improved since the gains achieved in 2017 and that the programme in Pakistan is stalling.5Independent Monitoring Board of the Global Polio Eradication Initiative16th Report. How to cut a long story short.http://polioeradication.org/wp-content/uploads/2018/11/20181105-16th-IMB-Report-FINAL.pdfDate: 2018Date accessed: October 22, 2019Google Scholar It also highlighted one of the key issues, which is crucial in the success or failure of the programme but is not openly talked about; the polio eradication programme is considered a foreign programme in some areas of Pakistan as local leaders are not seen leading it. In their absence, foreign technical staff are the ones seen by communities. Further, when one ventures beyond the streets and inside the polio programme offices, they find international technical staff developing strategies and supervising implementation. Polio emergency control centre coordinators are usually the only governmental staff at the centres. Other technical leaders come from different donor agencies. A coordinator could be leading, but major strategic direction still comes from the headquarters of lead technical agencies, in different countries, though with some local input. There should be a good balance of local and international technical leaders in a working environment as complex as Pakistan, especially in a situation in which the programme gains have reversed in a major way. Local experts understand local issues and can come up with local solutions. For example, when the International Stop Transmission of Polio programme experts were unable to work because of security reasons in some of the most high-risk areas for polio transmission in Pakistan, a new programme was developed, National Stop the Transmission of Polio by the Pakistan Field Epidemiology and Laboratory Training Program. Although the names are similar, they are different in their design and implementation. Finding local public health officials from high-risk areas and providing them with epidemiological training resulted in both local acceptance and the technological skills to succeed in areas like North and South Waziristan.6Jones DS Dicker RC Fontaine RE et al.Building global epidemiology and response capacity with field epidemiology training programs.Emerg Infect Dis. 2017; 23: S158-S165Crossref PubMed Scopus (26) Google Scholar To achieve success, we need real partnerships in which local input is used to shape the work plan and strategies in a meaningful way. In its 2018 report, the independent monitoring board for polio eradication recognised a heavy top down approach and inflexibility in accepting local feedback and encouraged polio leadership staff to accept local feedback for strategy development. What we need in Pakistan is to accept that polio eradication is not solely the domain of international agencies, the government of Pakistan should also take ownership. Real ownership comes with local funding, local strategy development, and political leadership at the forefront. The dengue virus outbreak in Pakistan in 2011 is one example in which the government did not ask donors to come forward but designed and implemented its own dengue control programme, which has shown its effectiveness over the years.7Khan IA Abbas F Managing dengue outbreak in Lahore, Pakistan: efficacy of government response and lessons for the future.J Health Manag. 2014; 16: 471-480Crossref Scopus (5) Google Scholar International experts can advise on global strategy alignment but the local action plans should originate locally to be successful. Pictures of leaders administering polio drops is not ownership of the programme. One polio case identified by a surveillance system might mean 1000–3000 polio infections in the community. This is the extent of the problem that Pakistani children are facing. It is time that we not only call the rise of polio a national emergency (we declared it sometime back), but also really mean it. I declare no competing interests.