KARACHI, Pakistan — On the second story of a rough concrete house in the narrow alleyway of one of Karachi’s innumerable informal settlements, Fatima slammed her front door. Through its iron bars, two Sindh government health officials pleaded with the young mother to allow her two-year-old son to receive oral polio vaccination drops. She had been told the drops would sterilize her son, she said. Also, her husband was not at home, and she first needed his permission, Fatima added. The toddler stood silently at his mother’s side.
Fatima is one of a rapidly dwindling number of parents in Karachi, and Pakistan more broadly, who refuse to vaccinate their children against polio. Two years ago, Pakistan’s inability to eradicate the disease — along with just Afghanistan and Nigeria — left it on the verge of international pariah status. Countries threatened travel bans for Pakistani citizens after poliovirus derived from Karachi was linked to an outbreak in Syria and the virus’s presence in Israel.
Now, the country is on the verge of eradication, and officials orchestrating what they hope is the final stretch are determined to not let anything get in the way.
The hard-won successes are the culmination of a complete revamp in strategy, predicated by improvements in security. Since 2014, operations against extremist and criminal groups drastically reduced violence in key locations such as Karachi. Meanwhile, the federal government created a new bureaucratic management structure for polio that is empowered to hold district-level officials accountable, with increased transparency and oversight. Scientifically sound data collection and sharing systems were put in place with the help of international partners. For the first time, the federal government was able to enlist senior clerics from every main Islamic sect and institution in Pakistan to fully back the vaccination campaign. Female vaccination teams were better trained and better paid, and were, importantly, recruited from the neighborhoods where they would work.
In 2017, only five cases have been detected nationally, with one in Karachi — down from 306 nationwide in 2014. The current nationwide monthly vaccination campaign began in September and will run through May, when temperatures are relatively lower and the vaccine is more effective. The goal is to inoculate 38 million children — a Herculean effort that will involve a quarter million vaccination and security personnel.
Back at Fatima’s doorstop, the officials didn’t back down. Perhaps in normal circumstances, the government and its international partners may have moved on; 100 percent coverage is impossible, and not necessary to eradicate the virus. But this small neighborhood abuts a canal that serves as an open sewage system drain and a garbage dump. This is one of two areas of Karachi where the virus has been found in recent environmental tests. And the water regularly overflows into the cinderblock dwellings that line it. Even one unvaccinated child in this area was unacceptable for the Sindh Emergency Operations Center that runs the vaccination campaign in Karachi.
The vaccinators, themselves local residents, knew that Fatima’s husband Sultan was home. They called the district-level police official overseeing security for the polio campaign. Within minutes, four officers armed with pistols and Kalashnikovs arrived. They insisted that Sultan come out, and one of the officers grabbed him by his shirt and pulled him down the short flight of stairs.
As the police officers pushed the man to the nearby commercial area where their vehicle was parked, dozens of men from the area quickly gathered around. Sultan’s neighbors, led by his barefoot, bearded uncle, began to demand that he comply. “If you don’t do this, our children will suffer!” one man pleaded. Before the crowd had time to disperse, the health official, standing nearby, received a call from his police counterpart. Sultan had agreed.
In 2014, the tactics and strategy now being deployed to eradicate polio would have been impossible. Then, many residents of Karachi lived under the shadow of ethnic criminal gangs and their political patrons. In Pashtun-majority communities, the Pakistani Taliban and associated militant groups held coercive sway. Militant groups also held territory in the Federally Administered Tribal Areas on the border with Afghanistan, another polio stronghold.
At the time, police in Karachi were losing over 100 officers yearly and were overwhelmed by the scale of violence. They could barely spare personnel to provide security for the monthly vaccination drives, which in turn only took place sporadically. The areas where the virus was endemic were also the most violent and inaccessible.
That year, the cases spiked to over 300 across the country, with Karachi seeing 23 confirmed cases. For each visible case, 200 more children are thought to be infected and carrying polio unknowingly.
Resistance to the polio campaigns thrived in that contested security dynamic. The vaccinations were led by the World Health Organization and UNICEF — easy targets for right-wing Islamist “culture wars” against perceived western influence. Islamist newspapers such as the Daily Ummat regularly carried specious stories about the vaccine.
The revelation that the CIA had posed as vaccinators to collect intelligence on Osama bin Laden in 2011 only hardened resistance. More than 70 polio vaccinators and security personnel have been killed across Pakistan since then.
After a systematic two-year government crackdown, however, terrorist attacks in Karachi are now rare, and violent crime has dropped. Former “no-go zones” feel like normal, functioning, working-class neighborhoods. The only polio vaccination-related violence in Karachi since 2014 was the killing of seven security personnel guarding polio workers during a vaccination drive in 2016.
The consolidation of security gains has been the single factor that unlocked the ability to make all the other gains. “We needed the security in order to break through to the community and get access for a sustained period,” said an official in Karachi, who declined to be named because they were not authorized to speak to media. “With that, the sensitization process was able to happen.”
Pushing the restart button
Apart from the unrelenting security environment, past vaccination campaigns were haphazard and riven with corruption and incompetence. Until 2015, female vaccinators recruited from local communities were paid a pittance, if they ever received payment at all, according to interviews with health workers and officials at the time.
The six district commissioners governing Karachi, meanwhile, had varying levels of interest and commitment to the campaigns. Some actively resisted directives from the federal authorities. Vaccination numbers were regularly inflated, and resources stolen. Such misbehavior faced no accountability or consequences. More than 80 percent of children under two were left unvaccinated.
In 2015, as the security operations were making gains, then-prime minister Nawaz Sharif led a rehaul of the process. He created a new body, the National Emergency Action Plan, with greater resources and power at the provincial levels. The campaign was coordinated with international implementing partners WHO and UNICEF, as well as the Bill & Melinda Gates Foundation, the U.S. Centers for Disease Control and Prevention, and the government of the United Arab Emirates.
Suddenly, provincial bureaucrats were accountable for vaccination. The government prioritized data collection of high-risk populations and environmental monitoring. Campaign officials engaged target communities to win their support.
Before this, “we did not have the kind of government ownership and community engagement effort that we see today,” said Rana Safdar, the national coordinator of the polio eradication campaign.
“The implementation part was largely left to the WHO and UNICEF, and as a result, the general public thought of it as a project or undertaking being run by the United Nations or somebody else’s agenda. So the major change that has happened is that now people have started to understand that this is something that is necessary for the health of our own children.”
Rolling out a new approach
NEAP’s first task was to create an effective bureaucratic structure that would allow for greater strategy coordination between the federal and provincial levels, as well as data sharing. Emergency Operations Centers were established in each province and in FATA to oversee the monthly vaccination drives, as well as the data collection and sharing, environmental monitoring, and security coordination.
These EOCs were mostly staffed by the partner organizations, but crucially, they were led by a government bureaucrat with the power to offer incentives or to discipline district commissioners if they failed to support the campaigns.
With the new system in place, NEAP set out to triage regions based on their risk, Safdar said. “We divided the country into four risk tiers, one to four … and then in terms of our response, we tried to match our efforts with the level of risk in that particular district.”
Building reliable databases of high-risk populations, and increasing the scope and quality of environmental monitoring to detect the virus were crucial, according to Safdar. Until this year, a census had not been carried out in Pakistan since 1998, and population data — including vaccination records — was in many cases too old to be of use.
Between the monthly vaccination drives, NEAP recruited tens of thousands of community health workers, including 7,000 in Karachi alone, to build a neighborhood-by-neighborhood data set of families and children. “Our data is more reliable than the census,” one health worker boasted.
Pakistan also now has the largest environmental coverage network in the world, with 53 sites across the country collecting samples from high-risk areas. Data informs the vaccination campaign in real time, said Safdar. There is greater focus now on reaching any missed children over the course of two weeks following the primary days of the monthly vaccination drive.
Perhaps NEAP’s most important innovation was to use a “bottom-up approach” that engaged with district- and union council-level officials and community leaders to formulate strategies tailored to the specific micro-dynamics of neighborhoods.
“Pakistan is a very diverse nation, in terms of geography, topography, demography, everything. And in order to implement a high-quality service delivery program, those dynamics need to be understood,” Safdar said. “We went down to explore what was actually causing such kinds of [vaccination] resistance.”
CHWs were the frontline of outreach. All women are recruited from the same neighborhoods where they work, giving them an advantage in accessing children. They often have intimate knowledge of the families and why they might be refusing vaccinations. CHWs can also more closely monitor the movement of children into and out of extended-family homes. They paid a salary of Rs20,000 per month — three or four times what they would normally be earning and bringing home to their families.
“This girl knows every house in her lane, she knows when a newborn is born, she knows who the refusal is and so on … and she’s got a registration book, which she keeps updating all month long as to who has gone and who has come and who has been vaccinated,” said the official in Karachi.
Margaret, a community health worker in the majority-Catholic Da Silva Town neighborhood of Karachi, recalled how it took time to build trust. She has been working for two years as a CHW, and initially, she encountered significant suspicion toward the vaccine. “At first it was difficult to live in the community. People would make fun of us, and hoot when they saw us,” she said.
If a child fell ill during the campaign from any common ailment, conspiracy theories about the vaccines would circulate and cause resistance, she said. One man said he would shoot her — if not for the fact that she was from the community. Families would question why supervisors and then independent monitors would visit after the vaccinations to check the quality of the campaign. “Before I would get angry, but from our training I know that you should always be calm and rational in order to explain to people,” she said.
Today, Margaret said, “the community is accepting us because they know this work is for the benefit of their children. Now if there is delay in the campaign, they ask why I’m not coming.”
Out of the 1,500 children in her area, Margaret said that the number of parents refusing to vaccinate has dropped from 90 to 20 since 2015.
Misconceptions propagated by religious leaders or other right-wing sources were a significant challenge to vaccination until 2014. Government efforts to recruit respected maulanas and clerics to support vaccination were spotty, primarily because of the threat from extremist groups.
Once the security environment improved, the Sindh province polio eradication officials have recruited 120 clerics in Karachi alone, representing every religion and sect in Pakistan. The clerics receive a stipend and logistical financial support, the official in Karachi said. In turn, vaccinators are now equipped with fatawa books and videos of fatawas on their mobile phones to show parents.
In Karachi, there were 80,000 recorded refusals in 2014; this year that figure has dropped to 15,000. Since 2015, the national refusal rate has stabilized at 0.1 percent of the 38 million children targeted for vaccination, according to government data.
Today in each priority neighborhood where there have been vaccine refusals, the EOC organizes regular community education and engagement sessions including appearances by these “influencers.” Routine immunization and health services are also offered at the sessions.
According to the senior polio official in Karachi, the largest proportion of refusals are now non-religious. Many parents become tired of the multiple visits per month by vaccinators — three rounds of vaccine for each child are required — and question why polio is given such importance while they do not have access to basic health services, regular garbage collection, proper drainage, electricity, and other basic infrastructure and services.
District commissioners, with more resources but also accountability, have been very creative and responsive. “The D.C. creates a sensitization team with the assistant commissioner, and they go to these areas and hold community engagement sessions,” the official said. “It’s effective because they end up giving them something — if there’s garbage, they pick it up. The D.C. can handle that.”
Temporary health camps are also set up during the campaigns. The access to a broader set of health services draw in mothers, who also then have their children vaccinated.
As a last resort, the district commissioner can also work with security forces to detain and arrest parents who still refuse to vaccinate, under a threat to public order law.
The right partners
Karachi is one of four tier-one locations in Pakistan that receive the greatest share of focus, along with the Quetta area in Balochistan, Peshawar, and FATA. Since 2014, the United Arab Emirates has played a significant role in advising on and providing funding for security in these four regions. A unit at the UAE embassy in Islamabad is dedicated to polio eradication efforts and works with the emergency operations centers in each province.
In Karachi, for example, an extra 5,000 police from the province participate in the vaccination campaigns each month. UAE assistance pays for their meals — and a significant boost to morale — as well as other logistical costs.
In FATA, the Pakistani state has only recently begun to try to incorporate the semi-autonomous area into the country politically and economically. After a decade of fighting militant groups there, state agencies are often seen as coercive at best, and oppressively violent at worst.
Among many FATA residents, the UAE is well known and liked, both because of strong ties to the Gulf through labor migration, and due to the UAE’s post-conflict reconstruction work in the tribal areas, including schools and housing for displaced populations. The country’s public support for the polio eradication campaign built on its previous work and helped change the perception that it is solely a western initiative, according to Safdar.
“We tried to use this acceptance of the UAE being a well-respected Muslim country in these difficult to reach populations. And so in a given number of agencies in FATA, we started utilizing their support not only in terms conducting the campaign, but also in terms of our social mobilization efforts,” Safdar said.
“This message that the activities are being supported by our brotherly Muslims country itself eased a lot of difficulties.”
Read more Devex coverage on global health.