Inside the world’s largest polio reservoir

Peshawar, Pakistan – Almost 60 years after Jonas Salk developed a vaccine for the polio virus, the crippling disease remains endemic in just three countries: Afghanistan, Pakistan, and Nigeria.

Of those, only Pakistan saw an increase in the number of cases reported last year, from 58 cases in 2012 to 93 in 2013. More than 90 percent of these were found to be genetically linked to a strain of the virus emanating from the northwestern city of Peshawar.

According to a statement released by the World Health Organization (WHO), all environmental sewage samples collected over the past six months in Peshawar have tested positive for the presence of poliovirus, making the urban centre of approximately four million the world’s “largest poliovirus reservoir”, or source of infection.

‘Uninterrupted virus circulation’

Peshawar is the capital of Khyber Pakhtunkhwa (KPK) province, and one of the oldest cities in the region. Its proximity to the Pakistan-Afghanistan border has made it a hub for Afghan refugees, despite its small size and limited resources. This, along with the fact that many militant groups are suspected of basing their operations in Peshawar, has given the city an outsized geopolitical significance.

Although the city is a bustling, ethnically diverse centre of business, it’s also wracked by violence: attacks in Peshawar have claimed the lives of 29 people already in 2014. Shia Muslims and Christians are often specifically targeted. 

“The centre [of Peshawar] has been a persistent reservoir leading to continued and uninterrupted virus circulation that poses tremendous challenges for those working to eradicate polio,” said Dr Elias Durry, the head of the WHO’s Global Polio Eradication Initiative.

Growing polio reservoirs in other parts of Pakistan, such as Karachi, the Quetta block, and the Federally Administered Tribal Areas, further complicate the problem. Genetic sequencing shows that the recent polio outbreak in Syria that paralysed 13 children is linked to Pakistan. And of the 14 cases of polio recorded in nearby eastern Afghanistan last year, all were linked to cross-border transmission.

Peshawar is “a feeder and amplifier of the poliovirus that circulates to other parts of the country and endangers lives”, says the WHO’s Durry. Most cases of polio in Pakistan are registered in the Federally Administered Tribal Areas, which is close to Peshawar. The city’s high population density – and the fact that many people in the region are on the move due to security concerns – exacerbate the problem.

Ambitious campaign

In response, the KPK government recently launched a series of one-day vaccination drives. The campaign, named Sehat ka Insaf [“Health for All”], aims to administer vaccines for nine paediatric diseases, including polio, to 800,000 children in the province. Initially expected to launch on January 26, the campaign was delayed due to security concerns and because of a boycott by health workers, who say they have not been paid for four months.

Free health kits including soap, blankets, towels and water containers were also distributed to help improve general hygiene standards.

Initial data obtained from the Peshawar district’s Control Room, which monitors and collects data on the vaccination campaign, found that last Sunday’s drive in Peshawar vaccinated 360,715 children. While these are preliminary figures, open to scrutiny and revision, supporters of Pakistan Tehreek-e-Insaf (PTI), the political party that leads KPK’s government, expect the total number of children vaccinated in the whole province to exceed 500,000.

However, Peshawar Lady Health Supervisor Ayesha Khan argues that the figures cited are exaggerated and unattainable, given the performance of young PTI health volunteers. “My teams in the field were told to stay away while the volunteers took charge,” she told Al Jazeera. “I came back 30 minutes later and the volunteers were sitting with vials of the vaccine still lying in their bags.”

Stories of mismanagement and lack of interest are rampant. Khan stresses that polio eradication is not simply about administering vaccines, but also about raising awareness within families – which requires the health workers involved to be knowledgeable. Khan expressed dismay at what she said were the volunteers’ lack of information and their propensity to hoist PTI party flags during the drive, rather than administer vaccines.

“You cannot do four days’ worth of work in 15 minutes,” she says. “They are not sincere, and I am sure that once results emerge, the coverage rate will be far below 50 percent.”

This sentiment is echoed by an official working for the Prime Minister’s Monitoring and Coordination Cell for Polio, who spoke to Al Jazeera on condition of anonymity. He was critical of what he called “political point scoring”.

“If the KPK government takes ownership [of the vaccination drive],” the official says, “that is acceptable and, in fact, encouraging for the polio programme. But the campaign should not be designed to promote a specific party.”

Security measures

Vaccination campaigns in Peshawar had been halted since December due to security concerns. Since July 2012, 39 polio workers and security personnel have been killed in attacks led by the Pakistani Taliban, which often claims that polio vaccinators are foreign agents or part of a “Jewish conspiracy”. Some Pakistanis are distrustful of vaccination campaigns after learning that a putative hepatitis vaccination programme in Pakistan was actually run by the CIA in an attempt to find Osama Bin Laden.

Of the health workers killed, 24 were in KPK, including eight from Peshawar. In such a hostile environment, polio campaigns need to be carefully planned, rigorous and consistent.

Younas Zaheer is the general secretary for the PTI in Peshawar and the media spokesperson for the “Health for All” plan.

“The PTI government is very serious about this initiative and considers it a duty to the future of this country,” he said. “This campaign has been thoroughly planned to reduce risks.”

The programme will conduct one-day campaigns on 12 consecutive Sundays to ensure effectiveness. Zaheer claims that last Sunday, 5,000 PTI volunteers administered the vaccine to more than 400,000 children below the age of five. With medical camps set up in various Peshawar neighbourhoods, the plan is expected to extend to other parts of the province after its first three months.

To prevent attacks, health workers have been banned from riding two to a motorcycle, and mobile phone services have been suspended on days when the campaign takes place. Unlike previous arrangements in which security forces escorted vaccinators, more than 4,000 police officers have been deployed to cordon off entire areas of Peshawar to ensure a secure environment.

“From the chairman to our volunteers, PTI is focused and determined to eliminate polio and show the world that we are committed to the cause – despite death threats,” Zaheer told Al Jazeera. “We don’t want our country to be degraded in the world, and we don’t want our children to be paralysed.”

Though the campaign has faced criticism, many of those working to address the polio crisis have high expectations of the KPK government’s campaign. Draining Peshawar’s polio reservoir would be a great relief for many living elsewhere in Pakistan – and around the world.

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