Pakistan, Polio and the Police – Where is the Balance?

Many thanks to PHAIWA and Melissa Stoneham for the latest Journal Watch article.

Melissa Stoneham writes:

I am an advocate for immunisation. I always have been and always will be.

However, there was one short article featured in The Lancet during April which made me think that sometimes we go a little too far when it comes to dealing with failures in health interventions.

But first for some context. Pakistan is one of the last countries where poliomyelitis (polio), which has been eradicated in the West, is still endemic. Pakistan’s vaccination rate is inordinately low for a number of reasons, including attacks on medical workers, the displacement of people due to ongoing military operations and a lack of trust by some families.

Pakistan leads all other countries for the highest number of new polio cases in recent years.  In 2014, Pakistan had 328 cases of polio (inclusive of WPV1 and cVDPV). The next closest country was Nigeria, with 36 cases. To stop polio transmission completely, at least 95% of all children in Pakistan need to be fully immunised.

Polio is a highly infectious viral disease, which mainly affects young children. The virus is transmitted by person-to-person spread mainly through the faecal-oral route or, less frequently, by a common vehicle (e.g. contaminated water or food) and multiplies in the intestine, from where it can invade the nervous system and can cause paralysis.

Initial symptoms of polio include fever, fatigue, headache, vomiting, stiffness in the neck, and pain in the limbs. In a small proportion of cases, the disease causes paralysis, which is often permanent. There is no cure for polio. It can only be prevented by immunisation.

So there is no doubt that polio is a serious disease that needs to be eradicated, and vaccination has been proven to be effective. So why my concerns?

In Khyber Pakhtunkhwa province in Pakistan, a campaign to vaccinate 2.7 million children against polio was commenced. It involved up to 8 000 vaccinators attempting to give oral polio drops to almost every child aged under five each weekend. However, after the first two weeks of the campaign, the province officials learned that there were more than 13 000 cases in which parents had not taken their children to receive the polio vaccine. As a result, in March 2015, Police arrested more than 500 parents in and around the north western Pakistani city of Peshawar for not allowing their children to get the polio vaccine. Peshawar Deputy Commissioner Riaz Khan Mehsud said 513 arrests took place as part of a government campaign to administer polio vaccines in parts of Pakistan’s Khyber Pakhtunkhwa province. The arrested parents were advised they would be released on bailed if they sign an affidavit stating that they will let their children get vaccinated.

There certainly are challenges associated with administering the polio vaccines to the communities but I do wonder if arresting parents for not vaccinating their children, given the political environment in Pakistan, is a little ‘over the top’.

Exploring these challenges further is interesting and makes you appreciate the fact that we live in a largely peaceful society.

In 2011, polio vaccination went from being a health issue to a security issue after U.S. intelligence officials used a vaccination program to help in their search for Osama bin Laden. This caused particular consternation among health officials who reported their efforts to vaccinate children were being frustrated by the CIA’s use of the fake vaccination program and elevating mistrust amongst the community and health officials.

Another challenge is the threat to human life. Since December 2012, the National Emergency Operations Centre has reported that more than 70 medical workers have been killed in attacks. One of the workers, a 30 year old mother of five, was abducted from her home and murdered, the day after taking part in the campaign to eradicate polio in the Khyber Pakhtunkhwa province. In other parts of the country, the threat of attacks by militants has forced health workers to be accompanied by armed police as they go house to house attempting to vaccinate children.

Militants are deeply suspicious of the vaccinations, which have been demonised by radical clerics as supposedly part of a western plot to sterilise Muslim children. They also fear the campaigns could be used as a cover for spies. In 2012, Taliban commanders in Waziristan, a tribal area bordering Afghanistan, banned polio teams until US drone strikes came to an end.

And it is not just the political environment that create the challenges in Pakistan. The lack of maintaining the cold chain caused the destruction of $3.7million worth of vaccines donated by WHO because they were not stored properly. The spoiled vaccines were pentavalent, a type which combines different vaccines in one injection, and were intended to protect children against diphtheria, tetanus, whooping cough, hepatitis B and a bacteria that causes meningitis and pneumonia.

So issues abound…and the authors of the short piece in the Lancet, who are from Pakistan did commend the Government of Pakistan for taking such a bold move to tackle this public health issue. The authors, led by Syed Ather Hussain from the Dow Medical College, Dow University of Health Sciences in Karachi, suggest that this incident will make people understand the gravity of the polio crisis in Pakistan, and will change the incorrect mindset of a section of the population.

But I still have to wonder, given the threats to life, the corruption of fake vaccination programs, the media around incorrect storage and the cultural concerns, whether arresting parents who do not vaccinate their children is really not the best solution to this problem.

Article

Parents in Pakistan arrested for polio vaccine refusal: a necessary step? Syed Ather Hussain, Ritesh G Menezes, Sharath Burugina Nagaraja. The Lancet; Vol 385; page 1059.

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The Public Health Advocacy Institute WA (PHAIWA) JournalWatch service reviews 10 key public health journals on a monthly basis, providing a précis of articles that highlight key public health and advocacy related findings, with an emphasis on findings that can be readily translated into policy or practice.

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Australian & New Zealand Journal of Public Health (ANZJPH)

Journal of Public Health Policy (JPHP)

Health Promotion Journal of Australia (HPJA)

Medical Journal of Australia (MJA)

The Lancet

Journal for Water Sanitation and Hygiene Development

Tobacco Control (TC)

American Journal of Public Health (AMJPH)

Health Promotion International (HPI)

American Journal of Preventive Medicine (AJPM)

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