Wave of boycotts hinder polio eradication campaign in Pakistan

For villages seeking jobs, electrification, water and healthcare, holding the polio effort hostage has become a tool for leverage

When polio vaccinators turned up at Zeeshan Ali’s village to administer drops to babies and toddlers, the teams were met with defiance and demands.
Mr Ali and his fellow Kuki Khel tribesmen refused to let their children take the drops until government administrators first met their own requests.
The villagers’ disobedience earlier this month was not prompted by the conspiracy theories that have dogged efforts to eradicate the poliovirus in Pakistan’s rugged borderlands.
Instead, it was the latest example of polio boycotts which have become a growing problem for the international campaign to stamp out the crippling childhood poliovirus.
For residents of this corner of northwest Pakistan, the $1.1bn per year global eradication programme has become the ultimate bargaining chip in their dealings with what they consider a distant and neglectful government.
For villages seeking jobs, electrification, water, paved roads, healthcare or any other government service, boycotts have emerged as a tool for leverage, by holding the polio eradication effort hostage.
They know that Pakistan is one of only two countries where the disease is still endemic and that the country is under international pressure from frustrated donors to finish the job.
Their message to officialdom is often blunt: You never do anything for us, and then turn up every six weeks demanding our children take polio drops. Well you must give us something in return.
The phenomenon has grown into a significant obstacle for the eradication programme in Pakistan, which had recently gone more than a year without a case, only to see numbers flare again.
In Mr Ali’s village, the polio boycott was used as a pressure point to get assurances that families displaced from their homes during the country’s bloody war against its own homegrown Taliban militants would be helped to move back.
Elsewhere, demands have been for jobs, economic investment, access to electricity or water, or immunisations against diseases the locals consider a greater threat than polio.
Mr Ali told the Telegraph: “We have been asking the government to take steps for the return of about 3,000 families displaced by war in 2012, but there is no success.
“Then, we started a boycott against polio immunisation and announced that parents will have to pay 10,000 rupees (£27) penalty if they allowed drops to their kids.”
He said: “The polio boycott worked, as the government gave us surety of repatriation of displaced people within two months, due to which we allowed vaccination.”
He denies he is acting callously, or ignoring the risks to children.
He said: “We do care for our children, but we also know that the government concedes to our demands only when we stay away from polio drops.
“The government is under global pressure for polio inoculation.”
A report last year by the global eradication campaign’s international monitoring board of experts said there had been 218 active boycotts in Pakistan’s Khyber Pakhtunkhwa province in January 2023 alone. The board said the statistic was “staggering”. Three-quarters were resolved, but at the cost of significant time and effort.
Analysis found nearly a third of boycotts were linked to concerns about jobs and another 16 per cent were triggered by grievances about lack of basic necessities such as health care, electricity and water supply.
About two-fifths “were associated with multiple demands, ranging from land disputes to the lack of mobile phone networks, illustrating a complex web of challenges faced by these communities”.
Local commissioner Syed Motasim Billah Shah told the Telegraph he had been called on to deal with a boycott earlier this month in Kohat district.
He said: “The people shouldn’t link polio vaccination with demands like electricity and gas supply and construction of roads because such an attitude compromises the health of their children and their future.”
He said he had argued with parents that society as a whole must protect children from lifelong disability.
The boycotts come on top of stubborn misinformation that polio drops are harmful, or a Western plot to sterilise Muslims.
In places, the reception for polio workers is so hostile that they fake vaccination records to save themselves trouble.
“We cannot walk freely during the house-to-house campaign due to threats by militants,” explains Muhammad Raees, a vaccinator in North Waziristan.
“In most cases, our workers mark the fingers of children without vaccinating them. In this way, they claim vaccination in papers and escape the parents’ wrath.”
Polio workers are also still coming under attack from militants.
Gunmen on motorcycles earlier this month shot a polio worker and a police guard escorting him during a vaccination campaign in Bajaur district. So far this year, 17 health workers have been killed and 39 wounded, according to a United Nations security report.
Dr Abdul Sattar, who has worked on the polio campaign, said: “We continue to address the misconceptions regarding the efficacy of vaccines.
“But the people are under the misconception that huge money is spent on polio and some money could be allocated for water and sanitation and other problems they face,” he said.
The boycotts and continuing violence come amid frustration that the eradication effort in Pakistan appears to have gone into reverse.
Two years ago, the country of more than 230m seemed on the verge of defeating the virus and went for more than a year without detecting a case, its longest stretch ever.
Since then, it has returned, even appearing in the capital, Islamabad, for the first time in 16 years. Pakistan reported its 18th case of 2024 last week.
Globally, while the eradication campaign has still cut cases by more than 99 per cent since it began more than three decades ago, the remaining handful of cases have proven stubborn to stop and indeed have begun to rise in recent years.
Part of that comeback has been due to a fateful decision taken nearly a decade ago to streamline vaccines.
Until that point polio drops had included weakened virus from all three strains found in the wild, types 1 to 3, giving protection across the board.
But with type 2 apparently vanquished at that point, in April 2016, the world began using pared back drops which did not protect against type 2.
The reasoning at the time was that this would stop rare cases of so-called vaccine derived polio from the type 2 virus now it had been stamped out.
Harmless weakened virus from vaccine immunises children who take drops, and also passes through their gut into the environment.
However in rare cases, as it spreads, it can mutate back to a harmful version and paralyse those who have not been given drops.
Vaccine-associated paralysis is estimated to occur only once in every 2.7 million doses administered, but the risk is there.
By fading out type-2 virus from the vaccine, type-2 virus could be removed from the environment and vaccine-derived cases would end.
Stocks of vaccine specially targeted against only type-2 were laid in, just in case.
Yet tragically, if the science may have been sound, the implementation was bungled. When type-2 outbreaks did emerge as expected, the response was sluggish and they spread.
Vaccine derived type-2 polio has continued to circulate after the vaccine switch and has paralysed more than 3,300 children since.
A report commissioned into what happened, called the switch in vaccine “an unqualified failure”.
For the global programme to get back on track, it must not only deal with these outbreaks, but must somehow also deal with the boycotts, suspicion and misinformation which are still rife in Pakistan.
Salman Shah, 51, one defiant father, said “We are concerned about the health of our children but it doesn’t mean that we administer them polio drops to render them impotent and infertile.”
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