The pandemic and polio are colliding in Pakistan.
It's definitely harder for the country to keep up its efforts to wipe out this highly contagious disease. (Pakistan is one of the few pockets in the world where it's still circulating.) But the lessons learned from its polio effort are proving helpful for the coronavirus vaccination campaign.
First, a bit of background is in order.
The pandemic isn't the only obstacle to the polio effort. Four years ago, Pakistan was celebrated for coming close to eradicating the disease. Then came a viral video that upended the efforts.
In April 2019, a private school teacher made several videos claiming children were sickened by the polio vaccine.
In one video, the teacher Nazar Muhammad gestures to boys sitting on a hospital gurney. "They are all laying unconscious, look!" he shouts.
That video was clearly bogus: even as Muhammad speaks, the children are sitting. He then orders them to lie down, presumably to look unconscious, and they do.
The obvious fakery made no difference: The videos, which he filmed near the northwestern city of Peshawar, spread quickly as local journalists picked up the claims as fact and broadcast them across the country.
"It spread like fire," says Rana Safdar, coordinator of Pakistan's National Emergency Operations Centre for Polio Eradication. "People started even making public announcements in the mosques, that unfortunately children are falling ill, so please don't get your children vaccinated."
A mob torched a health clinic. Gunmen killed a security officer guarding polio workers. Parents of some 25,000 vaccinated children rushed them to hospitals, fearing they'd been sickened. And the numbers of parents refusing the vaccine soared, says Safdar.
"We missed almost 2.5 to 3 million children in that nationwide campaign," he says.
Back on track
Since then, the government has been trying to get its polio campaign back on track.
"Our road has been really, really bumpy," says Safdar. "We started our battle afresh."
Safdar says the incident spotlighted how little defense they had against disinformation on social media. Facebook noticed as well.
"What we saw in April was really something that we hadn't seen before," says Sarim Aziz, Facebook's head of public policy for South Asia. "What we realized in Pakistan, that this is not just your average vaccine hesitancy issue, it's that this is a national emergency."
Aziz says following the explosive viral video, Facebook began removing misinformation which she described as having the potential to cause "real-world harm." They included accusations of health workers being spies – which can trigger deadly attacks.
Facebook also amplified verified information about vaccines, including from the U.N. and the Pakistani government, making their pages the first to come up in searches about vaccine on the platform. Safdar says they set up their own social media monitoring department, staffed with a handful of Pakistanis.
A pandemic pause
But just months later, the pandemic began, and vaccination campaigns were paused for four months. That "allowed the polio virus to to expand freely," says Dr. Hamid Jafari, director of polio eradication for the World Health Organization's Eastern Mediterranean region.
From just seven cases in 2017, the number of cases steadily increased to 167 cases in 2020. Mass polio vaccination drives resumed in July last year, and in January, Pakistan held its first mass drive of 2021, employing some 285,000 health workers to reach 40 million children under five years old.
Among the vaccinators was Zeenat Parveen, assigned with reaching children in alleyways in Rawalpindi, a city near the Pakistani capital.
She jostled alongside a hawker selling vegetables and wove her way between children playing in the alley. A blue cooler, filled with vaccine vials, hung off her shoulder with a long strap. "I've been vaccinating kids here for three days," she tells NPR. "Now, I'm checking to see if I've missed any."
She knocks on a door, but there's no response. She barges in through flimsy metal doors, and laughs. "I'm from here," she says to me. "It's okay."
She chats with the parents and gestures to a boy loitering on a stairwell. "Sher-Ali!" she calls out, "come here!" She checks his pinky fingernail: there's an ink mark there, indicting he's been vaccinated. Outside, Parveen scribbles on the door with chalk. It reads: four kids; vaccinated in January. Most doors in Pakistan are marked with similar information.
Refusals are quite rare now.
Most parents refusing the vaccine largely believe it is a Western conspiracy to make Muslim children infertile, says Jafari of WHO.
"It has really gotten hold," says Fatima Akram Hayat, a health advisor to the Pakistani government. The sentiment is strongest in areas where people are forgotten by authorities, where they largely don't have any other health services – and yet polio vaccination workers repeatedly come to their door.
Those who refuse the vaccine believe the government does not care at all about them, she says. They wonder: "So why are these workers coming into my village and vaccinating my child?"
Polio eradication workers acknowledge they have to improve basic health services in those areas if they are to succeed in overcoming vaccine resistance. "There is a huge amount of focus on improving routine immunization coverage," says Safdar, and improving "our basic health delivery," to deal with malnourishment, clean water and sanitation.
Drawing on the polio experience
With Pakistan's COVID-19 vaccine rollout expected to start this month, the country's well-established polio eradication infrastructure, from its army of health workers, to its detailed surveillance mapping of virus outbreaks, has already helped with monitoring and curbing the spread of COVID-19.
It "has played a tremendous role in the COVID pandemic response," says Jafari. "Pakistan would be well positioned, given its polio assets, to help plan for the rollout of the vaccine."
Jafari says tens of thousands of health workers know how to do mass vaccinations. They know nearly every house in Pakistan. They know how to keep track of vaccine refusals.
But Hayat, the health advisor, says if conspiracy theories about the COVID-19 vaccine take hold, they're in trouble. "Our strategy right now is to work on it before that happens," she says.
Already, there's a worrying sign: a recent poll says nearly 50% of over 1,000 Pakistanis surveyed don't want to get vaccinated. Most are concerned about potential side effects, not conspiracy theories, but it means health officials already have a steep hill to climb.
"It's like a game of Jenga," Hayat says. "Everything might be going well. And then there's one thing that happens or one conspiracy theory that takes hold or one thing we do wrong – and it can all come crumbling down."