For a brief moment two years ago, Pakistan seemed finally on the verge of defeating polio. One of only two countries in the world where the virus remains endemic, Pakistan recorded no new infections for a little over a year starting in 2021 — the longest virus-free stretch the country had ever experienced.
But since then, polio has roared back, spreading beyond its traditional hot spots to areas once largely untouched by the virus.
Last week, health officials reported the first polio case in the capital, Islamabad, in 16 years. This month, environmental monitoring detected the polio virus in sewage samples from several major cities, including Peshawar and Karachi, Pakistan’s largest city, where millions live in crowded, unsanitary slums.
And the virus has spread to a new epicenter in Balochistan, an arid, restive province in the southwest hundreds of miles from the virus’s former focal point in northwestern Khyber-Pakhtunkhwa Province.
On Monday, Pakistan began a weeklong nationwide polio vaccination campaign involving 286,000 health workers — the largest public health surveillance network in the world — aimed at vaccinating 30 million children under 5. The campaign, taking place across 115 of the country’s more than 165 districts, is part of the government’s renewed billions-dollar effort to contain the spread of the virus.
“I am hopeful that polio will be eradicated in the coming years and months through coordinated efforts,” Shehbaz Sharif, the country’s prime minister, said on Monday. “Polio will be driven out from the borders of Pakistan, never to return.”
The resurgence of polio in Pakistan is part of a global comeback of the virus, a highly contagious and sometimes deadly illness that once paralyzed hundreds of thousands of children worldwide every year. After vaccines were introduced in 1955, the number of cases dropped around the globe by more than 99.9 percent.
But after health authorities decided in 2016 to pare down the oral polio vaccine, the virus roared back. Since then, cases of vaccine-derived Type 2 polio have increased tenfold. This month alone, at least eight countries were battling polio outbreaks.
In Pakistan, the health authorities face an array of challenges.
Not only is the country home to difficult terrain, nomadic populations and poor infrastructure where polio thrives, but misinformation is also rampant, which has led to widespread distrust of vaccines.
Conservative religious scholars and militant groups have falsely asserted that the vaccination campaign is a Western conspiracy to sterilize Muslims, or that the vaccines contain ingredients derived from pigs, which are forbidden in Islam. Such claims have prompted entire communities to refuse vaccination.
Another problem: militants who attack vaccinators. This year, 15 people, mostly police officers, have been killed and 37 injured during vaccination campaigns, according to officials.
“Police officers are always easy targets, but those protecting polio vaccination teams are even more vulnerable,” said Muhammad Jamil, a Peshawar police officer.
Authorities in neighboring Afghanistan (the only other country where polio is endemic) have reported 18 polio cases so far this year, according to the Global Polio Eradication Initiative. These cases are primarily concentrated in southern provinces like Kandahar and Helmand, regions that border Pakistan and where cross-border movement of population makes the risk of transmission particularly high.
Global health officials planned to coordinate the vaccination drive across both countries in September and October to ensure those in nomadic communities are not missed. But logistical issues delayed Afghanistan’s campaign.
Pakistani health workers have also reported facing pressure from parents and local leaders to falsely mark children’s fingers with indelible ink, indicating they’ve been vaccinated even if they haven’t — a practice that health officials say has significantly contributed to the virus resurgence. Many vaccinators also do not report when families refuse to be vaccinated, fearing backlash if authorities take action against resistant families or tribes, health officials said.
In Pakistan’s tribal areas, polio vaccination has been used as a bargaining chip for local leaders desperate for better government services in a region that the authorities have historically overlooked.
On Monday, some communities in Khyber Pakhtunkhwa Province announced that they refused to vaccinate their children unless their demands — including improved infrastructure and support for people returning to villages after they were displaced during military operations — were met.
Protester leaders ordered community members to comply with the boycott, threatening to fine any family who violates it.
“We may not know whether the vaccine harms our children or not,” said Malik Shamshad, a leader of one of the boycott campaigns. “But we know that the government comes under pressure and resolves our problems when we refuse to vaccinate the children.”
Still, many health workers remain undeterred. Early Monday in Peshawar, a bustling city near Pakistan’s border with Afghanistan, around three dozen health workers gathered at a government health facility to start the week’s vaccination drive. With colorful scarves over their heads and shoulders, the workers recited verses of the Quran while police officers stood nearby.
“We know it’s a long battle,” said Firdos, 33, a health worker who preferred to go only by her surname for fear of retaliation. “But for the sake of our children, we have to keep going.”
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