Source article: http://www.nytimes.com/2014/09/02/health/how-fighting-in-pakistan-affects-war-against-polio.html?smid=tw-nytimeshealth

Fierce fighting in Pakistan is harming and helping the country’s drive to eradicate polio.

With cases steadily decreasing in Nigeria, the only other persistent global hot spot, Pakistan is becoming the virus’s last refuge; 117 cases of polio paralysis have been found this year, up from 25 by this time last year. And in three months of fighting between the armed forces and the Taliban, nearly a million people have been displaced, spreading the virus, according to Unicef.

But the military operations can be “a blessing in disguise,” in the words of the Federation of Islamic Medical Associations, which wants the disease eliminated.

Most cases are in the rural Waziristan region, where leaders of some Taliban factions have banned vaccinations since 2012. As refugees flee, they often encounter polio vaccinators, who have given two million doses at roadside posts in parts of Waziristan now controlled by the army and in cities to which people from the region have fled.

However, cases do appear elsewhere, including just across the Afghan border and in distant urban neighborhoods where people from Waziristan now live.

If the grip of Taliban leaders is broken, the giving of vaccinations may increase quickly. A Harvard-Unicef survey of parents in other areas where the Taliban is strong found that more than 80 percent thought offering vaccine in their neighborhoods was a “very good” or “somewhat good” idea.

In May, the World Health Organization declared a public health emergency when polio spread to Cameroon, Equatorial Guinea and Iraq. But unless new cases are being missed because of fighting in Iraq and Syria, those appear — like the 2013 outbreaks in Somalia and Kenya — to have been snuffed out by vaccinations.

The global effort to eradicate poliomyelitis has eliminated 99% of cases in its 26-year history. But the final 1% presents significant challenges. In the past 18 months, outbreaks in Africa and the Middle East make it clear that as long as the virus persists in the remaining endemic countries — Pakistan, Afghanistan and Nigeria — exports of the disease to other countries will continue.

The difficulties of the polio endgame have stoked cynicism among its critics, who point to previous missed deadlines. But this must not obscure the impressive gains that have been made, so much so that global eradication truly now seems within reach.

The last year has been difficult, with serious outbreaks in the Horn of Africa and the Middle East and a loss of ground in Pakistan. To turn the current situation around, a determined effort is needed to eradicate the virus from the endemic countries, and fast.

It is Pakistan that is now the heart of the struggle. Pakistan has already seen more than 100 cases this year, compared to only 8 in Afghanistan and 5 in Nigeria. The eradication effort in Pakistan — despite many shortcomings — has a good track record of successfully fighting sporadic flare-ups, and deserves much more credit than it has received. There is every reason to believe that the current spate of outbreaks will be contained.

Religious and medical communities, spearheaded by Pakistan Pediatric Association and Islamic Medical Association, have strongly backed Pakistan’s eradication effort. In the past few months, international Islamic scholars and bodies — including the Islamic Advisory Group on Polio Eradication and International Ulema Conference in Islamabad hosted by the Islamic Development Bank – have spoken out to condemn attacks on health workers, and to emphasize that polio vaccination is compatible with Islam, denouncing those who claim otherwise. Suspicion of vaccines will always be present, but religious leaders are now more vocal and rearranging their standpoint against a small fragment of hardliners.

Promisingly, according to new data, 95% of parents reached by health workers in the northwest tribal areas of Pakistan said yes to have their child vaccinated against polio.

Further, the military operation in North Waziristan has been a blessing in disguise. Although the population movement carries the risk of polio spread to new areas, it also opened up opportunities to provide health services for the first time to children from the Federally Administered Tribal Areas (FATA) through care for displaced families. As a result, as of July, over 1.5 million doses were administered to children under five years old during three rounds of house-to-house vaccination campaigns among the displaced and host communities. IMA in KPK in its capacity is assisting vaccination movement and its Mobile clinics will also reach the previously no-go zones for the sake of primary healthcare and vaccination.

The WHO declared polio an international public health emergency in May 2014, and called on the countries currently exporting poliovirus, including Pakistan, to ensure that residents and long-term visitors are vaccinated before traveling out of the country. Vaccinating international travelers – which will have questionable impact – must not detract from efforts to provide immediate health care to displaced families and others in high-risk parts of Pakistan. It is largely here, not at airports, that the final battle to eradicate polio will be won or lost.

Finally, the emphasis on polio, to the neglect of other health services, has fuelled false beliefs that polio immunization is an external initiative operating for outsiders’ benefit. Hardliners have used anti-Western sentiment as an excuse to repeatedly attack polio workers. Administering polio vaccines (with re-enforcement of usage of IPV) as part of a package of health services is a better way to engage local communities and religious leaders than through a narrow, polio-specific program.

Nigeria and Afghanistan have made remarkable progress in reaching difficult populations this way. Pakistan is increasingly pursuing this integrated approach. Local leaders in Peshawar launched the Sehat Ka Insaf campaign that provides polio vaccines as part of a package of nine child health services; its success has inspired similar efforts in Karachi and elsewhere.

This is our chance to eradicate polio from the globe forever. We cannot let it pass.