Only three countries in the world still suffer polio outbreaks. Pakistan’s inoculation campaign aims to get them off the list.

Ryan Hyland
Apr 27, 2017 · 9 min read
Vaccinating team in Kohat, Pakistan. Photographs courtesy of Miriam Doan/Rotary International

This story was originally published on

At a busy toll plaza in Kohat, Pakistan in April 2016, a three-member vaccination team was working fast.

Flanked by armed military personnel, the blue-vested vaccinators approached a white van as it was pulling away from the scattered stream of traffic, cars rattling east toward Islamabad and west to the nearby Afghanistan border. One worker leaned toward the driver to ask a question as another reached into a cooler to prepare the vaccine. Among the crush of passengers in the van, they identified one child who had not yet been vaccinated.

There was no time for second-guessing.

There was not even enough room for the boy to crawl toward the front of the vehicle or through one of the doors; a relative handed the young child to the vaccinators through one of the rear windows. He was quickly inoculated with two drops of oral polio vaccine, and his pinky finger was stained with purple ink to indicate that he had received his dose. He cried as the vaccinator hurriedly passed him back through the window. The van sped off, fading back into the dizzying hum of traffic, as the vaccinators looked for the next car and child.

This scene plays out thousands of times a day at transit posts like this one — makeshift vaccination clinics set up at bus stops, border crossings, army posts, and police checkpoints across the country in an effort to reach children who are on the move.

Here in Pakistan, home to most of the world’s remaining polio cases, these moving targets require a vaccination strategy as agile and stubborn as the virus itself.

At hundreds of sites, teams of health workers verify that every child passing through receives the vaccine. The interaction is fleeting — faster than getting a meal at a drive-through restaurant — but the benefit is permanent. Another child, another family, another generation is protected, and Pakistan moves one step closer to having zero polio cases.

At the beginning of the 20th century, polio — an infectious disease that can lead to muscle weakness, and even paralysis — was a common childhood ailment. By the 1960s, the development of an affordable injectable vaccination helped control the disease in industrialized nations.

But polio continued to affect people in countries across Africa, Asia, and Latin America, leading to the founding of the Global Polio Eradication Initiative (GPEI) in 1988. Since then, more than 2.5 billion children have been immunized against the disease, with the help of over 200 countries, 20 million volunteers, and an international commitment to the tune of $11 billion.

Today, polio has been eliminated from most of the globe — with Pakistan and Afghanistan remaining the last holdouts of the virus. (Nigeria saw four “wild” cases of polio in 2016, but no new cases have been reported since then.) Will these South Asian countries be able to eradicate the disease?

In 2014, Pakistan’s effort to wipe out polio was in crisis. Reports of violence against vaccinators grew common, as did perceptions that the country was an incubator of the disease.

Two years prior, half a million children in mountainous northwestern Pakistan became inaccessible to vaccinators, after the semiautonomous region went under control of militant groups like the Taliban, which prohibited polio vaccinations.

The ensuing outbreak totaled 306 reported polio cases across Pakistan, up from 93 the previous year — or more than 80 percent of the world’s cases that year. Not surprisingly, 70 percent of Pakistan’s cases came from tribal areas in the northwest. One newspaper editorial deemed the epidemic Pakistan’s “badge of shame.”

A pointed 2014 report from the independent monitoring board of the GPEI spotlighted Pakistan’s missteps, humbling government leaders and health officials, who scrambled to find solutions.

“We were emotional and somewhat defensive,” said Dr. Rana Safdar, director of the National Emergency Operations Center in Pakistan. “But the report pushed us to get our act together on polio, for first time. Our program was a threat to the global polio eradication efforts. The upsurge we had in Pakistan was unprecedented.”

The government effectively declared war on polio, condemning the outbreak as a national disaster. Words were soon matched with action.

“The motivation and the commitment of the vaccinators on the front line and government officials became stronger,” said Aziz Memon, chair of Rotary’s Pakistan PolioPlus Committee. “We had more reason to say, ‘Yes, we need to get rid of this disease and fulfill the promise we made to the children of this country: No child in the future will be crippled by this disease.’”

Pakistan intensified immunizations through new strategies, which resulted in a dramatic decrease in polio cases. The number of new infections dropped from 306 in 2014 to 56 the next year. And in 2016, there were only 15 reported cases of polio caused by the wild virus.

To quell spread of the disease and reduce the risk of exporting cases to neighboring countries, Pakistan adopted a National Emergency Action Plan in late 2014. The immediate goals included cutting off transmission of the virus in high-risk areas and reaching missed children.

Routine vaccination campaigns that immunized children door-to-door were no longer enough. Calling it a “paradigm shift in strategy,” Senator Ayesha Farooq, who leads the anti-polio strategy for the prime minister in Pakistan, said the revitalized program now focuses on children who have routinely missed vaccinations.

“Despite the fact we were receiving 80 percent coverage in every campaign, the other 10 to 20 percent that we were missing out on were sustaining the virus,” she said.

Pakistan, together with partners from the GPEI, trained 200,000 front-line vaccinators and sent them to Karachi, Khyber Pakhtunkhwa, and Quetta, the three core reservoirs of wild poliovirus.

The campaigns installed more than 600 permanent transit posts across the country, which operate year-round and provide millions of vaccinations to children and families who are away from home or otherwise on the move. None are more important than those operating along the porous 1,500-mile boundary between Afghanistan and northern and western Pakistan.

Recently, the two governments agreed to work closely on synchronized immunization campaigns. Because Pakistan and Afghanistan are part of the same epidemiological block, Farooq said, “we have to work in tandem with our Afghan partners to eradicate polio from the region altogether. We need to build immunity so that there is no cross-border importation.”

In July, Rotary bolstered this effort by opening a kiosk at the Friendship Gate, a border checkpoint in the Chaman area in northern Baluchistan. Along with migrants, each day, between 10,000 and 15,000 Pakistani and Afghan traders pass through the gate.

More than 1,000 children are vaccinated at this Friendship Gate point each day. In total, this strategy has vaccinated more than 68 million children who would otherwise be missed.

A year prior, a sweeping military offensive in 2015 pushed the Taliban out, forcing more than a million civilians to flee to neighboring areas and across the border into Afghanistan. The military action created a refugee crisis, putting tens of thousands of people in camps for the internally displaced.

Still, it also cleared the way for vaccinators to inoculate hundreds of previously inaccessible children, said Dr. Malek Sbih, a doctor with the World Health Organization.

“The military operation provoked an enormous exodus of people from the region, inside and outside the borders. It’s unfortunate. But fortunately for us, it gave us the opportunity to reach 265,000 kids,” he said.

Regardless of how thorough the improved vaccination campaigns are, the overall polio eradication effort in Pakistan hinges on a single, crucial touch point: community trust.

“This is where the rubber hits the road,” said Aidan O’Leary, UNICEF’s chief of anti-polio efforts in Pakistan. “Everything boils down to the critical interaction between a vaccinator and the parent that leads to a successful vaccination of every child inside that house. Everything. Success is success at the doorstep.”

Public mistrust and intimidation by militant groups played a part in many parents’ refusal to have their children vaccinated.

To counteract the intimidation, Rotary opened eight polio resource centers to build community trust in high-risk areas. The centers, in addition to giving polio vaccinations, sponsor health camps that offer immunizations against measles and other diseases, as well as free medical examinations, medicine, and eyeglasses.

Rotary trained local, permanent vaccinators, mostly women, and as a result, have reduced the number of refusals from 87,000 in March 2014 to 23,000 in March 2016 — a refusal rate of less than 1 percent.

“What we’ve seen is our female vaccinators are driving every single operational gain that is being made,” said O’Leary. “These are not strangers. They are actually drawn from the communities that they serve. They know all the mothers and their children. They know when parents are available and when is the best time to reach them.”

This, O’Leary said, is resulting in better coverage. But he added that deploying female vaccinators in the most difficult-to-reach areas comes with risks. As teams become a regular presence in these communities, they become more susceptible to attacks. To increase security, the GPEI partners work with government officials to provide military protection for vaccinators.

In addition to working with women, Rotary also worked with leading Islamic scholars to form the Pakistan Ulema PolioPlus Committee. “The committee is doing a wonderful job at holding workshops and gathering Islamic leaders to educate them about how important these polio drops are,” Rotary’s Memon said. “We are telling them that 52 other Muslim countries have eradicated polio with the same polio drops.”

Virologist Shoukat Ullah, who is also a mufti, or an Islamic legal expert empowered to rule on religious matters in his community, said outreach to Muslim leaders can make a “huge impact.”

In his city of Nowshera, Ullah attends community gatherings and Friday prayer ceremonies to talk to families and other Muslim leaders about the benefits of polio vaccinations. “People will follow their Islamic scholars,” he said. “Community members will help volunteer … if asked by scholars. We can make a big difference in the perception of polio and any cultural barriers.”

The global footprint of polio has never been smaller. While Pakistan is hoping that its last case of polio occurred in 2016, significant challenges remain. The country must continue to implement its National Emergency Action Plan at all levels, ensure that funding is in place, enhance surveillance quality in core reservoirs, and secure the safety of all front-line health workers.

The polio team in Kohat, along with the thousands more across Pakistan, has the same goal as the global health community: Reduce the percent of children who miss vaccination campaigns from twenty to zero. It’s why they’re often pushy, rarely taking no for an answer. On average, the toll plaza team vaccinates around 800 children per day.

But refusals happen. About two in 10 vehicles flagged down do not participate in any vaccinations. Whether it’s for religious reasons, or because parents insist that their child has already received the vaccination, team members have to be ready to convince families that the drops they have in their hands are critical to reaching their goal and making history.

“With polio eradication,” says O’Leary, “there’s no other health program in the world that I’m aware of where your goal is zero in everything you do.”

The Development Set is made possible by funding from the Bill & Melinda Gates Foundation. We retain editorial independence. Follow The Development Set on Facebook and Twitter.

The Development Set

Stories and conversations about global health and social impact.

Ryan Hyland

Written by

Senior Writer — Rotary International

The Development Set

Stories and conversations about global health and social impact.

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