Tough challenges hound Pakistan’s anti-polio campaign, but all may not be lost.
[dropcap]S[/dropcap]itting across from Tahseenullah Khan was the anti-polio campaign’s most vociferous critic, Maulana Fazlullah—the militant leader of Swat, who used his illegal radio transmissions to stir up propaganda against life-saving immunizations. Khan and his three colleagues from the nonprofit National Research & Development Fund had come to implore Fazlullah and his dozen or so comrades to allow health workers safe access to local children. Swat Valley, said the black-turbaned chieftain, would do no such thing. The anti-polio drive is un-Islamic, he continued, a conspiracy hatched by Jews and Christians to clip Muslim population growth.
But Khan kept at it, and the militant finally began to crack. Vaccinations will only be allowed once U.S. troops leave Afghanistan, Fazlullah offered, or if the killing of Palestinians cease. Six hours of patient presentation later, the campaigner extracted the concession he had come for. While Fazlullah refused to retract his previous statements, he did acquiesce to the government’s fresh anti-polio campaign. Fazlullah’s surrender may have had personal motivations. As Khan got up to leave Fazlullah’s madrassah, he recognized the Taliban leader’s limp. “Have you been tested for polio?” he cautiously asked, knowing the answer. Fazlullah, flanked by two gunmen, stood silent for a few moments, then hobbled away.
For Khan, this was the toughest sell in his 14 years as a mediator between rank ignorance and government-funded efforts to root out the disease. The tense exchange with Fazlullah happened in 2008, when Pakistan had 117 confirmed cases of polio, an epidemic. This year the country has had 56, according to the World Health Organization. Next year, though, could well be a different story. After last week’s attacks over two days by gunmen on motorcycles in Karachi, Peshawar, Charsadda and Nowshera, the latest three-day nationwide vaccination campaign has been suspended. Nine health workers, including six women, are dead.
Opposition to the anti-polio campaign is hardly new, but the deadlier dimensions it has now assumed, despite endorsement from religious leaders, will imperil the lives of countless children in Pakistan—U.N. officials estimate that 3.5 million of them missed vaccinations just as a result of the latest violence—and even abroad. To rescue the hostage anti-polio campaign, the government may have no choice but to cut deplorable deals with the militants.
“Cruel, senseless and inexcusable,” is how Ban Ki-moon, the U.N. secretary-general, described the polio murders. In their joint statement WHO and UNICEF called on the leaders of “the affected communities and everyone concerned to do their utmost to protect health workers and create a secure environment so that we can meet the health needs of the children of Pakistan.” Some 2,000 staff members of these U.N. organizations had been assisting Pakistan’s at least 225,000-strong anti-polio volunteers.
The crippling poliomyelitis virus is a waterborne disease which infects only humans, mainly children under 5. One in 200 infections leads to irreversible paralysis. Among those paralyzed, it is fatal to 5 to 10 percent. Polio has no cure.
Outrage in Pakistan over the polio killings crosses party lines. “We cannot allow these people to dictate what we can and cannot do,” said Aseefa Bhutto Zardari, the president’s youngest daughter and ambassador for polio eradication. “The vaccine can save millions. It is not against Islam to promote healthy children.” Conservative politicians are also furious. “The killing of polio workers is outrageous,” said Imran Khan. “What kind of twisted mindset would target those fighting disease. Condemn these sick criminals.” Former prime minister Nawaz Sharif has urged clerics to rally support for the annual nationwide immunization drives.
Who killed the health workers? Tehreek-e-Taliban Pakistan spokesman Ihsanullah Ihsan has denied the involvement of his group. But another Taliban spokesman in South Waziristan has claimed responsibility citing, according to Reuters, the health campaign as part of “a secret Jewish-American agenda to poison Pakistanis.”
Madness without Cure
Pakistan’s eradication efforts keep encountering obstacles—sometimes in the form of superstitious fears and wild rumors and other times in the form of undisguised politics. Last summer a Pakistani Taliban leader in North Waziristan issued a decree forbidding any further vaccinations in his area until America ended its drone attacks targeting militants. Pamphlets stigmatizing the anti-polio drive as a conspiracy and an espionage exercise were littered across the federally-administered tribal areas. (Similar literature appeared in the previous two years as well, especially in Bajaur and North Waziristan.) Soon afterward an anti-polio worker was attacked in Islamabad, and gunmen in Karachi wounded a Ghanaian doctor working for WHO and his driver. Other instances of harassment, murder and kidnapping followed—in Balochistan province and in Punjab’s capital.
International agencies assisting Pakistan overcome polio have long been aware of the challenges, and their workers have persevered—often at great personal risk. Through local organizations like the National Research & Development Fund, anti-polio partners have been wooing religious leaders and highlighting the urgency of saving children’s lives, especially in areas dominated by the conservative and often roving Pakhtun population. Pakhtuns make up some 15 percent of the country’s population but account for three quarters of polio cases, according to WHO. Cricketer Shahid Afridi, a Pakhtun, was drafted by the government as an anti-polio ambassador in July to break the ethnic group’s resistance to eradication efforts. Pakhtun families, especially those damaged by war, tend to view any outside help with more suspicion than do others. They often also avoid health workers for fear of upsetting the local Taliban.
‘The killing of polio workers is outrageous,’ says Imran Khan. ‘What kind of twisted mindset would target those fighting disease. Condemn these sick criminals.’
“Polio is not a priority for them,” Dr. Zulfiqar A. Bhutta, a vaccine specialist at Aga Khan University in Karachi, tells Newsweek of the Pakhtuns, “these people have seen nothing but conflict since 1979.” They are more concerned, he says, about basic civic facilities, and drone strikes. “Their priorities and those of the government just do not match.” The refusal of Pakhtun families to have their children immunized is putting others at real risk. These children are quickly becoming the main carriers for the disease. Already this year, sewage samples from cities like Hyderabad and Rawalpindi that had previously been declared polio-free showed that the virus was back.
“Certain elements we refer to as the Taliban, though it’s a very general term, feel threatened by the presence of people going around vaccinating children in their areas,” says WHO’s Dr. Guido Sabatinelli. He says that in Afghanistan—along with Pakistan one of only three countries where polio still exists. Nigeria is the third—the Taliban are “absolutely in favor” of the anti-polio campaign. But the propaganda against polio vaccination is just as vicious there. Early this month in Kapisa province, gunmen pumped six bullets into a teenage immunization-program volunteer, killing her. A Taliban spokesman denied responsibility. In many other areas, the insurgents prevent anti-polio teams from accessing at-risk children.
Disruption of the immunization campaign in Pakistan puts other countries in danger as well. “Unfortunately, this is something we may have to face,” Bhutto Zardari tells Newsweek. “If Pakistan is not free of polio, if we are unable to reach every single child, polio can go beyond our borders.” The Global Polio Eradication Initiative says polio spread internationally last year from Nigeria and Pakistan. Officials from WHO have previously warned that Pakistanis could face restrictions on travel abroad to keep the disease from spreading. Saudi Arabia already requires proof of oral polio vaccination from pilgrims coming to Mecca. Dr. Hussein A. Gezairy, an adviser to the World Health Organization, on his visit to Pakistan in September said all Haj pilgrims from the three countries where polio still exists would be immunized upon arrival in the Saudi kingdom. He also appealed to Pakistan’s militants to allow vaccinations.
“The entire Muslim world has eradicated this disease except for these three countries,” says Bhutto Zardari. “Saudi Arabia can play a key role in calling for a polio-free Muslim ummah,” she says, suggesting that the kingdom’s immunization-for-Haj condition may prove useful. “If one of the most important Muslim countries in the world, Saudi Arabia, has been able to eradicate polio with the same vaccine we use, why can’t we?”
Religion can help combat the ignorance, to some extent. Khan’s National Research & Development Fund has almost two dozen fatwas in support of the anti-polio campaign, including one issued in July from the Grand Imam of Cairo’s Islamic Research Academy of Al-Azhar. “As this disease endangers the lives of our children, causes paralysis of limbs and renders children physically disabled, and as we are ordered to avert harm, [we appeal] to all parents not to listen to rulings that ban vaccination against this noxious disease,” reads Dr. Ahmed al-Tayyib’s edict, which also cites the following Quranic verse: “Allah, exalted be Him, says losers indeed are those who kill their children foolishly without knowledge.” Khan’s organization also uses scripture in support of its work—“Saving a life is saving humanity: Al Quran,” its website prominently displays.
For some, religion, or the misrepresentation of it by rabid clerics, is not the stumbling block. “What good are fatwas if the government doesn’t provide security?” asks Maulana Tahir Ashrafi, chief of the All-Pakistan Ulema Council. It is impractical, impossible, for the state to provide protection to its entire army of unarmed anti-polio health workers. “I don’t see religion as the problem,” WHO’s Dr. Elias Durray tells Newsweek. “Muslim countries around the world [which have eradicated polio] are a good example of this.” Thanks to these anti-polio fatwas, however, fewer parents have been refusing oral drops for their children on so-called religious grounds. But even fatwas from such luminaries as Cairo’s Grand Imam can’t make any difference with people like the Quetta imam who reportedly used his Friday sermon to express joy that his son had been diagnosed with polio. The imam said his religious obligations had been fulfilled since the Quran, he alleged, shuns polio vaccinations.
As if this self-destructive and utterly specious narrative wasn’t enough, there’s the compounding fallout from the Raymond Davis and Dr. Shakeel Afridi affairs. Since CIA operative Davis shot and killed two Pakistanis on a Lahore road—in apparent self-defense—in January 2011, there has been much hysterical handwringing over U.S. spies operating in Pakistan under the garb of selfless humanitarianism. Dr. Afridi’s hepatitis—not polio—vaccination ruse to successfully pinpoint the whereabouts of the world’s most famous fugitive, Osama bin Laden, didn’t help either. To the satisfaction of the Pakistani street, Afridi has been jailed for aiding and abetting the CIA and U.S. government. Never mind that bin Laden was an enemy of Pakistan too.
After the Abbottabad operation, “people began saying strange things to us,” says Shazia Khan, a health worker in Mardan, who has devoted the past five years to the polio-eradication campaign. “Last when I knocked at one man’s door he actually asked me: ‘Are you looking for Al Qaeda in my home?’”
“The anti-polio campaign was already controversial in some parts of Afghanistan and Pakistan, but Dr. Afridi’s involvement in bin Laden’s death brought even more trouble,” says Dr. Jamshed, a Pakistani health official who, for the sake of his own safety, declined to use his full name. He says polio teams soon became unwelcome even in areas where the Pakistani Taliban had previously allowed them to work.
‘Polio has become a high-profile issue to Pakistan’s government, and extremists believe they can twist the government’s arm by attacking our workers,’ says Aseefa Bhutto Zardari.
Azhar-ul-Haq is fairly typical of parents in Pakistan who refuse to let their sons and daughters be immunized. “These dirty drops took the life of Osama bin Laden,” declares the 50-year-old father of eight. “We should not let anyone knock on our doors wanting to give polio vaccinations to our children.” He brags that he has never allowed his children to ingest what he calls the “non-halal” drops of oral vaccine—“And my kids are much stronger than the others.” Responding to reports that the Pakistani government is threatening to fine or imprison parents who refuse immunization, he says: “These are my kids; the government has no right.” He adds: “I and my father and my grandfather grew up without polio vaccinations. Allah will make sure my kids grow up the same way.” (It’s entirely possible that his children won’t become seriously ill. Polio is a stealthy infection, often producing no symptoms or perhaps a slight fever and a sore throat.)
Besides disinformation that polio drops could cause infertility or that the campaign is an unholy crusade by un-Islamic forces, conspiracy-prone refuseniks also believe the drops may contain pig fat. This, also, is untrue. In fact, according to Bhutto Zardari, Pakistan uses vaccine manufactured in Muslim-majority Indonesia. In Pakistan, where malaria and hepatitis campaigns run parallel to the war on polio, why is the latter almost always singled out for violence?
“Polio has become a high-profile issue to Pakistan’s government, and extremists believe they can twist the government’s arm by attacking our workers,” says Bhutto Zardari. Shahnaz Wazir Ali, adviser to the prime minister on polio eradication, concurs. “Militants politicize the virus because they know that the eradication of polio is important,” she told Newsweek. Polio prevention has been prioritized by successive governments in Islamabad since the campaign was first officially organized in 1993—by Bhutto Zardari’s late mother, Benazir—when there were some 30,000 reported cases. “Had there been a high-profile measles campaign, the extremists would have used that for leverage,” says Ali.
The anti-polio campaign is high profile enough to have drawn the attention of the world’s richest man. His Bill & Melinda Gates Foundation has pledged “more than $85 million” for Pakistan’s fight against the disease and $1 billion overall. Besides WHO and UNICEF, the country also gets help from foreign organizations like Rotary International and myriad nongovernmental organizations (which are generally viewed with suspicion by most Pakistanis, including politicians). Riyadh-based Islamic Development Bank is providing $227 million over three years to Pakistan for eradicating the “Muslim disease” of polio. If the Taliban wanted the world’s attention, with last week’s killings they got it. They can now use the threat of continued attacks to negotiate with the government, for, say, the release of their comrades from jail. At press time the militants had issued no demands tied to the polio murders, but Islamabad may have little choice when they do.
“What happened in Karachi and Peshawar is long-term bad news for the campaign against polio in Pakistan,” says Dr. Jamshed. These killings “mean even in the cities we will have trouble.” The prognosis is bleak, the health workers sitting ducks. “In many areas our volunteers are unwilling to work anymore. They have been warned by hardline mullahs and the Taliban not to participate in anti-polio programs. We were in the final stages of the effort to free Pakistan’s children from the virus. Now it’s looking like we will fail.”
Even though Pakistan failed to eradicate polio by the end of 2011, as it had hoped, it has made strides toward eradication. In September, health workers accessed the tribal Khyber agency for the first time since 2009 and administered drops to tens of thousands of children. Four nationwide vaccination drives took place this year—in July, September, October and December—and eight smaller ones targeting high-risk areas. Overall, some 34 million children have been vaccinated this year, according to official estimates. Pakistan also has 47 vaccination posts at entry and exit points in the tribal areas, 11 at the Pakistan-Afghanistan border (including at Spin Boldak which opened this year), and one each at the borders with China and India.
“Polio can be eradicated,” says adviser Ali, “If the world can make strides in controlling diseases like AIDS and hepatitis and since polio vaccines are available, why should a child be crippled for life?” WHO’s Dr. Durray is equally determined and says Pakistan could eradicate polio within next year. “The commitment of the Pakistani government is at its highest level right now,” he said, months prior to the attacks.
“Every day is a lost day for us. The virus does not wait for anyone,” says Ali. “Some people may have believed that killing polio workers could achieve the disgraceful aim of ending the campaign, but they are mistaken. We will not stop. We have to eliminate polio from Pakistan.” The next anti-polio drive—whenever that happens and whatever its cost in terms of security compromises—will be eerily low key. Pakistan is close to a final victory against the disease. To fail now would be sinful.
With Sami Yousafzai and Shehrbano Taseer. From our Jan. 4, 2013, issue.