Why Pakistan struggles with violence, mistrust in its polio fight

The unfortunate incidents reported on September 12, 2024 point out to the growing violence against health workers, particularly those involved in Pakistan’s polio eradication efforts. A policeman was killed in Bannu and a female polio worker was raped in southern Pakistan. These are not isolated incidents. They represent the escalating violence and mistrust that threatens public health initiatives in the country.

Rising threat to polio workers

Pakistan’s struggle with polio is intrinsically linked to violence against healthcare workers. In Khyber Pakhtunkhwa, the epicentre of many attacks, militants have repeatedly targeted polio vaccination teams, falsely portraying the campaign as a Western conspiracy to sterilise Muslim children. These myths have endured for over a decade influencing public perceptions and making vaccination efforts a perilous task for health workers.

The tragic attack in Bannu, where a policeman guarding polio workers was killed, is reminiscent of numerous other attacks. Just a day prior, gunmen killed two others—a polio worker and a police escort. The constant threat of violence has led to a climate of fear among health workers. The militant group Islamic State (IS) claimed responsibility for a roadside bombing in South Waziristan on September 9, which targeted officers protecting a polio team, injuring six officers and three civilians. The recurrence of such incidents reveals that violent actors are intensifying their assaults on vaccination teams.

The rape of a female polio worker in Sindh further exemplifies the vulnerability of healthcare workers. Women have played a crucial role in Pakistan’s polio eradication campaign as they are often able to access households that male workers cannot. However, the assault in Jacobabad highlights how even these female workers, essential to the programme, are at risk. Sexual violence against female healthcare workers is rare but represents an especially heinous dimension of the threats they face.

Persistence of polio

Despite decades of efforts, Pakistan remains one of only two countries where polio is endemic, the other being Afghanistan. In 2024 alone, Pakistan has reported 17 new cases of wild poliovirus (WPV1), with the first case in Islamabad in 16 years serving as a sobering reminder that the disease still lurks, even in areas long thought to be polio-free .

One of the most critical factors contributing to the persistence of polio in Pakistan is the low vaccination rate in regions like North Waziristan, a former Taliban stronghold. This area, along with Balochistan, has witnessed a resurgence of polio cases due to both direct violence against health workers and widespread misinformation. Local populations, heavily influenced by religious extremists, resist vaccinations often out of fear of retribution from militants or based on unfounded conspiracy theories .

Compounding these issues are the systemic challenges within the public health infrastructure. The National Emergency Operations Centre and government officials have been working to expand outreach efforts. A recent large-scale vaccination campaign launched in September 2024 aimed to reach 33 million children across 115 districts. However, despite such efforts, environmental samples still show the presence of the poliovirus indicating gaps in coverage and a need for more effective strategies.

Mistrust, conspiracy theories and the legacy of Osama bin Laden

One of the most damaging episodes in the history of polio eradication in Pakistan is the fallout from the CIA’s fake vaccination campaign during the hunt for Osama bin Laden. In 2011, the American intelligence agency ran a phony vaccination drive to gather DNA samples from Bin Laden’s family. Although the operation was successful in confirming the Al Qaeda leader’s presence in Abbottabad, it had far-reaching consequences for Pakistan’s health campaigns. The event fuelled conspiracy theories that the polio vaccine was a tool for Western intelligence agencies leading to widespread mistrust of vaccination campaigns.

The aftershocks of this event still resonate today. Militants exploit these fears, framing polio campaigns as foreign plots and in some cases, community members are pressured into avoiding vaccines to protect themselves from potential violence. In extreme cases, parents forge fake vaccination records to avoid both the wrath of militants and government-imposed restrictions. This dynamic has stymied the eradication efforts, particularly in conservative rural areas like Khyber Pakhtunkhwa and Balochistan.

Role of local leaders and cultural dynamics

While international agencies have provided crucial funding and expertise, their dominant presence in Pakistan’s polio eradication programme has often been met with suspicion. The absence of local leadership in such a culturally sensitive initiative has exacerbated the perception that the programme is imposed from the outside. The imbalance between international and local input has made it harder to gain community trust. As Rana Jawad Asghar noted in The Lancet, the programme must be adapted to local realities with more significant involvement of Pakistani public health experts and community leaders to ensure its success.

In regions like North Waziristan, where polio vaccination rates are dismally low, local public health officials who understand the socio-cultural dynamics have successfully initiated programmes that are better accepted by the community. By providing epidemiological training to local health workers, initiatives such as the National Stop the Transmission of Polio programme have helped bridge the gap between communities and vaccination efforts.

Violence and its implications on public health

The broader issue of violence against healthcare workers in Pakistan goes beyond polio campaigns. According to the Safeguarding Health in Conflict Coalition (SHCC), incidents of violence or obstruction against healthcare workers more than doubled between 2021 and 2022. These violent attacks not only claim lives but also disrupt essential health services. In 2022, eight security personnel assigned to protect healthcare workers were killed and 15 were injured in the line of duty contributing to a culture of fear among vaccinators.

Polio workers often refuse to work in high-risk areas without security escorts, but even then, attacks continue. This has had a devastating impact on the vaccination campaign’s efficacy. In several instances, fear of attacks has led to the suspension of vaccination drives, leaving children vulnerable to preventable diseases like polio.

Dealing with dual threats of violence and misinformation

To combat the twin threats of violence and misinformation, Pakistan’s polio eradication efforts must undergo significant reforms. First, the government must enhance its security measures for healthcare workers. While military escorts are a common practice, they are not foolproof. A more sustainable approach would involve engaging local communities, particularly tribal elders and religious leaders, to foster trust and provide safe passage for health workers. This community-centric model has shown promise in areas like North Waziristan.

Second, there must be a concerted effort to counter misinformation. The government and non-governmental organisations must leverage media campaigns, religious endorsements and educational programmes to dispel myths about the polio vaccine. These initiatives should be tailored to address the specific concerns of rural populations such as fears of Western conspiracies or religious objections to vaccination.

Finally, the international community, while continuing to provide technical and financial support, must take a backseat in strategy formulation allowing local health experts to take the lead. By empowering local leaders and integrating their knowledge into public health campaigns, the programme can gain greater acceptance within communities.

Pakistan’s fight against polio is not just a battle against a disease. It is a struggle for trust, safety and the well-being of future generations.