Focus on anti-polio campaign in the NWFP

An old man carrying a small child threaded his way through a group of bearded men who had assembled around a visiting provincial minister and health officials in the courtyard of a small, rural hospital in Landikotal, close to Pakistan’s border with Afghanistan. He held the two-year-old girl firmly, tipping her head back and squeezing her cheeks gently so that her mouth remained open long enough for the minister to position a little vial(bottle containing polio drops) above it: a few polio drops later, a small coup had been achieved. The campaign to eradicate polio in Pakistan’s tribal areas had begun in earnest. A small town with dwellings ranging from the ubiquitous mud-caked residences that dot every Pakistani rural landscape to larger, comparatively more grandiose properties that undulate synchronisedly with the mountainous terrain upon which they are built, Landikotal is situated in the Khyber Agency - one of seven such administrative regions that make up the Federally Administered Tribal Areas (FATA) - just a few miles away from the busy border outpost of Torkham on Pakistan’s border with Afghanistan. It also hosts one of the several deeply religious communities that have traditionally viewed any initiatives - such as the three-day anti-polio campaign, which began nationwide on 2 September - with profound suspicion and, sometimes, outright trepidation. Before the old man consented to bring his child to receive the polio drops, therefore, Inayatullah, the youthful provincial health minister, had to enter into a council-of-war with the local leadership as he tried to convince them about the benefits of participating in the drive to wipe out polio: an illness which can easily circulate in the community and environment, crippling children - most vulnerable under the age of five - for life if the virus takes root. He spoke in Pushto, the local language, to Maulana Hazrat Nabi, the imam of the local mosque where the men had assembled. Both the mosque and the hospital, where the polio vaccines were to be administered later, were built by the social services wing of the Jamaat-e-Islami, one of Pakistan’s leading religious-political parties; and Nabi, a long-haired, turbaned man who had reportedly initially been opposed to an “intrusion” by "foreign medicines" into an essentially conservative domain, listened intently until the minister’s animated monologue came to an end. Outside the small room where the men all sat, cross-legged, on the floor, an air-conditioner groaned as it tried to maintain the temperature inside: the sight as incongruous as it was welcome for the group of visitors from the NWFP capital, Peshawar, about an hour’s drive away through winding roads and breath-taking, though visibly dry, mountainous scenery. Nabi spoke, then, in Pushto and one of the men sitting next to the visitors translated: "He says he was never opposed to polio vaccinations. But he had no idea that this current campaign was an anti-polio drive. He says he doesn’t oppose it." IMMUNISE EVERY CHILD In his office, at the health ministry in Peshawar earlier in the day, Inayatullah, the 20 something minister, told IRIN that his government’s plan was to completely demolish the polio virus in the North West Frontier Province (NWFP). "We plan to immunise every child below the age of five," he said, his staff bustling about the room in readiness for the trip up to Landikotal. "There will be no let-up and we will go house-to-house, if need be, to accomplish our task." His words echoed with good reason: even though a national campaign to eradicate polio started as far back as 1994, Pakistan is still one of four countries - India, Egypt and Nigeria are the others - where polio remains a threat, according to the World Health Organization (WHO). At the end of July, the new WHO director-general Dr. Lee Jong-Wook announced a more aggressive approach was to be followed in attempting to launch mass immunisation programmes aimed at reaching 175 million children. The campaign’s success in eradicating polio, however, depended on how it fared in India, Nigeria, Egypt and Pakistan, WHO said. "Polio eradication is a top priority. I want to see this disease gone once and for all…I’m immediately upgrading WHO’s capacity to support India, Nigeria, Pakistan and Egypt in their efforts to immunize every child against polio," Dr Jong-Wook said, as he announced the appointment of Dr. David Heymann, credited with heading the team that stopped the SARS outbreak, as the Representative of the Director-General for Polio Eradication. In Pakistan, where the 584 confirmed cases of polio in 1999 dropped to approximately 150 cases by the year 2000, the campaign had already gathered momentum at the governmental level with help from WHO and the United Nations International Children’s Fund (UNICEF) and other NGOs.

Posters, such as this one pasted on the wall of the little hospital in Landikotal, have been part of an aggressive awareness campaign.

"There were 57 reported cases in the NWFP in 2000. By 2001, that number had dwindled to 31," Dr. Abraham Debesay, the head of WHO’s programme in the NWFP, told IRIN in Peshawar, adding the figure increased, again, to 33 in 2002 because of an outbreak in a single district where 15 new cases were reported. "So far, in 2003, we’ve had reports of 13 cases," he maintained, adding that the government had stepped up its campaign to administer routine vaccinations to children aged one year or less, stressing the need to follow those up with additional doses and increasing the number of the three-day mass immunisation campaign from five rounds in 2001 to eight for 2002-2003. "This essentially means that the three-day campaign we’re on right now is replicated every six to eight weeks, unlike before when there would be a gap between such campaigns," Debesay explained. The National Immunisation Days (NIDs), as they were called, were planned in great detail: the plans detail everything from targets per population, the number of mobile teams required to visit each district, the amount of centres where people could bring their children, the supervisors needed to oversee the programme’s implementation and the budget - the money for which was provided by WHO, Debesay said. This latest three-day NWFP campaign’s cost is 11 million Pakistani Rupees (US $173,000). Another two million ($346,000) will be spent on the District Surveillance Teams (DST), which consist of medical officers recruited from the districts scheduled to be visited, whose job is to report new cases and monitor the aftermath of the NIDs, according to Debesay. OVERCOMING THE OPPOSITION But, before the latest NID could begin in their province, the NWFP government took a more pro-active approach to reducing fears and opposition to an intensive drive to reach every child. The governor called a meeting of about 150 ulema (religious leaders) and asked UNICEF and WHO representatives to attend also, so that the issue of the many mobile teams which were required to go house-to-house could be explained and to underline the importance of the anti-polio drive. "What we found was that the local, religious leadership is hardly the problem; they are part of the solution," Osama Makkawi, the UNICEF head for the province, told IRIN on the way to Landikotal. UNICEF has played an active role in social mobilisation for the campaign, lobbying tribal and religious leaders to understand and disseminate the information provided them along to the local communities and funding and overseeing the printing of print- and poster-campaigns to increase awareness. Once the importance of the polio vaccinations had been explained to them, the ulema said they would ensure that every community represented at the gathering would participate, Makkawi, a Sudanese who eventually explained the meaning of the word “polio” in an Arabic speech made to the ulema, said. "Social mobilisation in the past was confined to the district level. There’s been a shift in the current round: we’ve organised sessions for local district authorities and one for the ulema, also," Makkawi said, adding that the ploy seemed to have worked. Once the NID started in earnest, all 24 districts in the seven agencies that make the Federally Administered Tribal Areas (FATA) were targeted: more than 14,000 vaccination teams, consisting of two people, were formed; some for house-to-house vaccination drives with others posted at transit points (as elsewhere in the country) such as the airport and the railway station; and fixed center locations were advertised so that people who missed the house-rounds could bring their children to be immunised, Debesay said. NO BOUNDARIES In Landikotal, after the old man with the small child had wound his way out of the assemblage, another small child was brought to Inayatullah, the health minister who deftly squeezed the anti-polio drops into the child’s upturned mouth. Completely relaxed, he blended in with the locals, laughing along as Nabi, the imam, made an emphatic point in Pushto, talking animatedly to yet another man who had brought a third child along to receive the drops. "Whenever we meet failures, we throw the reason for the failure on the religious community," he told the visitors. "Maulana Nabi is not against the campaign. He is going to deliver the message, about how important it is to immunize our children against polio, to the community through the mosque’s loudspeaker." Shortly, thereafter, the minister was taken to a small shop, a few minutes drive along narrow, two-way roads through the mountains. The owner, a frail, old bearded man, listened impassively as the minister’s public relations officer explained the reason for the entourage’s sudden arrival and disappeared through a small door at the back of the shop. He reappeared moments later, cradling an infant and Inayatullah carefully administered the drops: an exercise several times as the man brought four more children. "There was a lot of international pressure felt by the Pakistani authorities to stop the transmission of this disease," Makkawi whispered, as the minister finished administering a dose to the last child brought out by the old man. Dr. David Heymann, the WHO Special Representative for Polio Eradication, had earlier focused on the importance of stopping the disease’s transmission. "Just as with SARS, polio knows no boundaries," he said, soon after taking charge. "In January, a child was paralysed with polio for the first time in 10 years. That virus traveled from India. Unless we stop transmission in the remaining polio-endemic countries, polio will spread to other countries and paralyse children, potentially reversing the gains already made," he added.