Use of vaccinators in Osama hunt harmed war on polio

Did the killing of Osama bin Laden have an unintended victim: the global drive to eradicate polio? In Pakistan, where polio has never been eliminated, the CIA’s decision to send a vaccination team into the bin Laden compound to gather information and DNA samples clearly hurt the national polio drive. The question is: How badly?

After the ruse by Dr Shakil Afridi was revealed by a British newspaper a year ago, angry villagers, especially in the lawless tribal areas on the Afghan border, chased off legitimate vaccinators, accusing them of being spies.

And then, late last month, Taliban commanders in two districts banned polio vaccination teams, saying they could not operate until the United States ended its drone strikes. One cited Afridi, who is serving a 33-year sentence imposed by a tribal court, as an example of how the CIA could use the campaign to cover espionage.

“It was a setback, no doubt,” conceded Dr Elias Durry, the World Health Organisation’s polio coordinator for Pakistan. “But unless it spreads or is a very longtime affair, the programme is not going to be seriously affected.”

He and other leaders of the global war on polio say they have recovered from worse setbacks. The two districts, North and South Waziristan, are in sparsely populated mountains where transmission is less intense than in urban slums. Only about 278,000 children younger than 5 – the vaccine target population – live there. By contrast, in northern Nigeria, where polio is being beaten after years of public resistance to the vaccine campaign, children number in the millions.

Also, Durry said, vaccinators reached 225,000 Waziristan youngsters in early June, before the ban. All will need several doses to be fully protected, but each dose buys time.
And, said Dr Bruce Aylward, the WHO’s chief of polio eradication, vaccination teams are posted at highway checkpoints, train stations and bus stations. They give drops to all the children they find.

The truth probably won’t emerge until the summer spike of polio cases tapers off in the fall. The virus likes hot weather, and the summer monsoons flood the sewage-choked gutters where it lurks.

Paralysed children may also be found in neighbouring countries with better surveillance, as they have been before just over the China and Tajikistan borders. Genetic testing will show whether the strains are Pakistan-based.

By contrast, if the eradicators are winning, local paralysis cases will slowly shrink to zero, as they have in India, a former epicentre which has not had a case in almost a year and a half. And the virus will no longer be found in sewage samples from Pakistani cities, as it is now.

Local anger was at its height last July, when The Guardian exposed the CIA connection. It was confirmed by defence secretary Leon E Panetta in January. Public outrage flared again in May after Afridi was sentenced. A coalition of aid groups protested to David Petraeus, the director of Central Intelligence.

“There could hardly have been a more stupid venture, and there was bound to be a backlash, especially for polio,” said Dr Zulfiqar A. Bhutta, a vaccine specialist at Aga Khan University in Pakistan. Bhutta, who also heads the government’s research ethics committee, said both Afridi and the CIA could be “sued or worse.” To establish their credibility, Afridi’s teams vaccinated whole neighbourhoods in Abbottabad without permission.

The setback was just one more in the endless war on polio, which was supposed to have been over by 2000. The fight is against the last 1 per cent of cases. Paralysis cases worldwide have shrunk from 350,000 in the 1980s to about 600 now. Victory gets tantalisingly close, and then recedes, forcing health authorities to appeal for another $1 billion, as they did recently in Geneva. Nigeria had only 62 cases last year; Pakistan had 198. For every known case, there are about 200 carriers with no symptoms, experts believe. Thus far in Pakistan this year, only 22 confirmed cases have been found. But the virus is still in sewage samples, meaning people are still shedding it.

Paradoxically, Afridi was not offering polio vaccine, but hepatitis B vaccine. Exactly why has not been elucidated, but there is a possible explanation: Hepatitis vaccine is injected, while polio vaccine is oral drops. If the objective was to gather DNA – which Afridi’s team apparently failed to do – it would be easy to aspirate a little blood into each needle. Also, “hepatitis B could be kept under the radar,” Bhutta said. “For polio, there are too many players and agencies,” he said.

But polio is the vaccine with a long history of controversy among Muslims in many countries, so Pakistanis who were not familiar with the difference turned on polio vaccinators.

Rumours about polio vaccine abound: that it is a western plot to sterilise girls, that it is unclean under Islamic law, that it contains the AIDS virus. The WHO and the UN Fund for Children, which oversee the campaign, have asked Islamic scholars, including top Saudi clerics, to issue fatwas saying the vaccine is safe and should be given.
Five years ago in Afghanistan, when Taliban sympathisers beat vaccinators, Unicef and the WHO successfully appealed to the Taliban leader Mullah Muhammad Omar for letters of protection their teams could carry. Now they are trying to open talks with the local commanders in Pakistan.

Drone strikes

“They know we don’t have any control over drone strikes,” Aylward said. “And I’ve yet to meet a parent who prefers a paralysed kid. The Taliban commanders face these same issues – but they have grievances that need to be addressed.” Vaccination would be more welcome if other services were added, like care to prevent deaths in childbirth, Bhutta said.

Pakistan’s polio failures started long before a Navy SEAL team killed Bin Laden. A “mafia” of local leaders was pocketing gasoline money, putting children on the payroll, fielding ghost teams and faking statistics, Durry said. More than 300,000 children lived in areas considered too dangerous to enter.

Then, in early 2011, stung by India’s success and with the WHO threatening to issue travel warnings, the prime minister rolled out a new plan. Officials were ordered to recruit mothers as vaccinators, and stipends for them went up. Fundamentalist imams were lobbied to endorse the vaccine. “Knock on wood, the programme is functioning well,” Durry said.

Some observers remain skeptical. Aamir Latif, Karachi bureau chief of the national Online News, said resistance remained strong in some tribal areas. Heidi Larson, an anthropologist at the London School of Hygiene and Tropical Medicine who has produced a “vaccine confidence index” said trust dropped precipitously after the Guardian article. Unicef said its own surveys of 200,000 Pakistani households showed no such declines.
Vaccine refusals, they said, went up in only one province, Baluchistan, and then only after the drive got much more aggressive. “Mothers were saying, ‘My child got drops too many times,”’ said Dr Julie Hall, leader of Unicef’s polio programme.

While the CIA ruse hurt, Bhutta said, he still believes that Pakistan will eliminate polio. “Tragic as it is, I’m confident resistance will die down,” he said. “The rational religious establishment is engaged now, and the lunatic fringe is just the lunatic fringe.”