Pakistani threat to India: polio
India is looking forward to its new status as a polio-free country. Having already been declared a non-endemic country in 2012 by the World Health Organisation (WHO), the agency is expected to confirm India as polio-free in February, once the final set of samples have been tested.
India has been struggling with the disease for decades, and the eradication of polio in the country is a huge achievement. However, polio is on the rise again in Pakistan, and despite India’s best efforts it may not be possible to prevent it crossing the border.
Pakistan (one of the three remaining polio-endemic countries along with Afghanistan and Nigeria) has also been working to counter polio, but efforts are hampered by violence and mistrust. The most recent high-profile event to impact upon Pakistan’s anti-polio drive occurred on 22 January when a bomb attached to a bicycle hit a police patrol on its way to guard a polio vaccination team in north-western Pakistan; six policemen and a boy were killed. The day before, there was an attack targeting heath workers in which four gunmen opened fire on a medical team in the southern city of Karachi. On this occasion three health workers (one man and two women) were killed.
The killings occurred just days after Pakistani authorities began a nationwide drive that was intended to help eradicate polio once and for all. Unfortunately, one of the biggest challenges the government faces is that militants want to terrorise the polio immunisation teams and force them to abandon their campaign.
At the time of writing no specific group has claimed responsibility for the 21 and 22 January attacks, but in the past the Pakistani Taliban have opposed anti-polio inoculations and blocked programmes in the restive north-western tribal region of Waziristan.
In 2012, for example, the WHO suspended its polio eradication campaign in Pakistan after the Taliban killed two of its workers in the north-western city of Charsadda. The WHO, which partnered with the Pakistani government, said that the decision to suspend the programme was made because of the “very precarious” security situation in the country.
Although Pakistan has managed to reduce its polio incidence rates over the last few decades it has not achieved what India has managed and eliminated it completely. Admittedly, the need for action in India was far more acute; one need only look at the data to see the crisis that India was facing (see Chart 1). Also, the effects of India’s efforts to eradicate the disease were not uniform. But the fact that Pakistan still has a persistent polio problem means India could still find itself at risk.
The lack of proper access to anti-polio vaccinations in Pakistan has led to a rise in cases. Having achieved a significant reduction in cases in the first few years of this century (199 cases in 2000 down to just 32 in 2007, according to WHO data), polio incidence shot back up in 2008 and has remained high ever since (a slight drop over the last two years notwithstanding) (see Chart 2).
Source for charts: our own presentation of WHO data
The WHO recently described the capital of Pakistan’s north-western Khyber Pakhtunkhwa province, Peshawar, as “the world's largest pool of polio virus”, and the fear that it could spread to regions that have lower disease incidence, or have eliminated the disease in the past, are well founded. In 2003 the northern Nigerian state of Kano banned polio vaccination because of fears that it caused infertility and spread HIV. Within 18 months the disease had reappeared in 12 African countries in which it had previously been eradicated.
More recently, polio has reappeared in Syria, and it was proved to have been brought in by an Islamist militant who travelled from Pakistan to fight. By November, 12 Syrian children were known to have been infected. In fact, none of Somalia, Kenya, Ethiopia, Cameroon and Syria had recorded any incidence of polio in 2012, but all saw cases emerge in 2013.
In January 2012, 21 children in a Chinese province were affected by polio, and DNA analysis of the virus showed that the virus strain had been transmitted from Pakistan. In December 2012, the same virus was detected in Al Azhar University, Egypt. In March 2013, the virus was then recorded in Palestine, and three months later, the same strain was detected in Israel.
Islamist objections
Militant Islamist groups have a great deal of control in Pakistan’s north-western regions, and their influence has also grown substantially in the central and southern Pakistani cities, including Lahore and Karachi, over the past two or three years.
The militants’ attacks have made it extremely difficult for health workers to run vaccination campaigns. Health experts say that the failure of the polio eradication drive will be devastating for the country and its already weak economy. “If the polio virus spreads in the country, Pakistanis will be barred from travelling to other countries,” Sikandar Januja, an activist in Karachi, told German press organisation Deutsche Welle (DW). This is a threat that already could be coming to bear (see below).
Janjua said he had no doubt about who was carrying out attacks on the health workers: “The Islamists’ organisations, including the Taliban, al Qaeda and Jamaat-i-Islami, are killing polio workers. Probably, there are some key al Qaeda leaders hiding in Karachi and the Islamists fear that through polio eradication campaigns the CIA will find and kill them,” Janjua added.
Janjua was clearly alluding to the attack on Osama bin Laden’s compound in Abbottabad in 2011, in the run-up to which a fake hepatitis vaccination programme, operated by Pakistani doctor Shakil Afridi, was used as cover for intelligence gathering by the CIA.
In July 2012 Pakistani authorities had to postpone a similar anti-polio campaign in Waziristan after Taliban leader Hafiz Gul Bahadur banned inoculations, claiming the programme was being used for the same purpose as Dr. Afridi’s.
- Dr. Shakil Afridi
Dr. Shakil Afridi, who ran the fake hepatitis inoculation campaign in Abbottabad that the CIA used to gather intelligence on Osama bin Laden, is currently in a Pakistani prison facing treason and murder charges.
Shahnaz Wazir Ali, an advisor to the former Pakistani Prime Minister Raja Pervez Ashraf, told DW that Afridi’s actions had made it difficult for the authorities to conduct anti-polio campaigns. “People think that agents like Afridi work in polio immunisation teams, and that might put their lives at risk,” she said.
Ali pointed out that the campaign to eradicate polio was not anti-Islam as propagated by some groups, but activists claim that since the truth about the Abbottabad programme became known, inoculation campaigns the country over have lost their credibility.
India’s ongoing efforts
India is desperate to prevent polio-infected people from crossing the border from Pakistan, but the border is so long, and in some places porous, that its efforts may well be in vain. In December India announced that Pakistani travellers would not be allowed to enter India after January 30 if they have not been administered Oral Polio Vaccination (OPV) at least six weeks prior to their departure for India.
The written statement, issued by the government, read “All persons – adults and children – travelling to India from Pakistan after 30 January 2014 are required to obtain Oral Polio Vaccination (OPV) at least six week prior to their departure to India.” The deadline was later extended to 14 February.
In an earlier statement the High Commission had said, “The step was being taken to safeguard India’s polio-free status, attained after sustained efforts and investment.
“It is applicable to all travellers from all countries where polio disease is endemic or where cases of polio are reported,” the statement said. “It is also applicable to Indian nationals travelling to and from these countries.”
India has used the oral vaccine to eradicate polio, but sees a national campaign of inoculation by injection as the most effective long-term strategy. Dr. Santhosh Rajagopal, Surveillance Medical Officer for the WHO, has presented a strategy for ensuring the permanent eradication of polio in India.
“By 2018”, said Rajagopal, “we will be withdrawing oral polio vaccine in a phased manner and injectable polio vaccine would be introduced in India. There is a timetable to follow from 2013 to 2018.” National Immunisation Days would be observed for two more years to cover oral vaccine to children up to five years of age.
However, for this long-term strategy to be effective, polio must be prevented from re-entering from Pakistan, and at the moment that looks problematic. Even with India’s border controls, the fact that Pakistan appears to have exported polio to so many countries in the last few years, coupled with its rising incidence in the country, suggests that India could struggle to maintain its polio-free status. If polio is found to taking hold again, India might have no choice but to close the border.