EFTA00975983.pdf

From: Terje Rod-Larsen fr" To: ' ' Gleevacation@gmail.com> Subject: Fw: Polio Update Pakistan Date: Thu, 07 Nov 2013 15:08:34 +0000 From: Nasra Hassan [mallto: Sent: Thursday, November 07, 2013 08:32 PM To: Terje Rod-Larsen; Andrea Pfanzelter; Walter Kemp Subject: Polio Update Pakistan Terje, IPI is undertaking daily monitoring & is in regular contact with interlocutors. Here is a brief update on the present situation, which shows some improvement over the past summer months — however, the droning to death of Pak Taliban's topmost leader on I Nov 2013 will bring consequences (including on the polio eradication programme PEP) on which I will send you a separate update in due course: I. Increase in cases: both in the tribal belt as well as in adjacent settled areas, in some towns and slums — especially among tribal families displaced by conflict (thus missing out on vaccination) — but also a few cases sneaking into previously "clean" areas. Parental refusal rates, especially in remote scattered communities, have also increased over 2012. 2. Some success/softening in Taliban position: Despite those increases, and after strenuous efforts by IPI and others, and completely under the radar, there has been a "softening" in the Taliban position, i.e. they are not making pronouncements against polio vaccination and are often looking the other way, though they do refer to "spies" entering sensitive Taliban havens under the guise of anti-polio health workers (there is some truth to this, a charge also levied against NOOs, details later). There is confirmation of families carrying drops to banned areas but often without the required temperature storage. NB: Although Balochistan Province health authorities announced on World Polio Day that there have so far been no recorded cases — 4 in 2012 vs. 73 in 2011 -- a bit of scepticism over the steep drop is in order, as this province has pockets of insurgency, terrorism, Afghan refugee camps and "catchment" areas & cross border traffic. It covers Pakistan's largest land area and has its smallest population, concentrated in a few towns and thinly-spread over the rest. So how come? There are transit teams to cover kids in vehicles, but this alone does not explain a seeming, though very welcome success! However, WHO this summer reported 2 cases with genetic similarity to a strain that was globally wiped out. Noted here not as a technical issue but as an example of mis- reporting. 3. Attacks on health teams: have also decreased (to repeat, not all were aimed at the anti-polio programme but had other reasons, such as targeting of the police, security or pro-govt militia personnel accompanying the health workers, especially the last-mentioned). 4. Pak Army role: In addition, the Pakistan Army has been helping PEP but keeping this strictly under wraps, with no info appearing in the press, so as not to give the Pakistan Taliban any reason to undertake media-tique retaliatory action. 5. Taliban ban: The FATA Health Secretariat (covering the tribal areas) is encouraging aifiga (group of tribal elders and other influentials) in North Waziristan to get the "good" Taliban to rescind their ban. 6. Support by senior politicians: including the Prime Minister, have made official statements underlining the importance of PEP, especially in connection with World Polio Day — these are valuable in keeping the official EFTA00975983 health structures focussed on polio, but have little effect on the Pak Taliban. 7. Govt talks with Taliban: despite media reports to the contrary, and despite what the Prime Minister has stated, these talks have not yet begun, although there are a number of parallel processes underway — now a complete (temporary) stop follows the assassination of the Taliban leader. 8. Continuing problems: (i) Corruption: eg. in Sind province, a health team refused to administer drops until their 3- month backlog of salaries was paid. "Ghost" kids, teams (latter also called "dummy teams"), vehicles continue. Similar in education services, eg. "ghost schools", also called "shadow sch000ls" exist but are better known and documented because these are permanent structures. (ii) Mis-reporting/under-reporting: figures of children covered continue to be too positive & self-serving; different health structures give differing figures. (iii) Expired/poor quality vaccines: these rumours refuse to go away, and disgruntled health staff have leaked this info. (iv) Inaccessibility: although this is a really major problem, it is invariably under-played and contributes a great deal to children being missed. (v) Routine immunization: still suffers from lack of attention & resources (which continue to be focused on polio). (vi) Parental refusal: now cropping up in locations outside the Taliban area of influence as well; many of these refusals are in remote areas where the public info campaign does not reach (no electricity, so no TV/radio etc.). (vii) Transit as: to cover kids in vehicles, sounds simple and should work but small problems eg. lack of intra-departmental lack of coordination & cooperation get in the way. (viii) Mobility & volatility: Because of a great deal of intra-Pak and cross-border mobility by affected groups such as Afghan refugees, internally-displaced families, and migrant labour, vaccination coverage can be volatile and change quickly from one season to the next. (ix) Flaws in PEP: criticism is beginning to be voiced publicly by health staff in provinces/areas other than the Taliban-controlled areas, i.e. in Punjab and elsewhere — this can have a positive outcome in that "militant violence" and "security" cannot be used as sole excuses! 9. Measures: Examples of additional concrete measures, in addition to those outlined in the May 2013 internal mission Report: (i) Community involvement/responsibilityi (ii) Passport & ID issuance/renewal: make polio vaccination of children a required document. (iii) Ditto visas: should not be difficult to get Western & other countries, esp. the Gulf, to introduce, especially for Hajj & Umra. NB: In some cases eg. tribal areas, this will not work as, but should be feasible in other areas. 10. Syria/Pakistan angle: Syria has been free of the polio virus since 1999, but in recent months cases have been reported in north-east Syria with WHO stating that there is laboratory proof that viruses isolated in Palestine & Egypt originated from Pakistan. While a genetic analysis of the Syrian polio virus is not yet complete and while it is probable, it cannot yet be stated with certainty that the transmission came from Pakistan. If this turns out indeed to be the case, as is likely, it will be (as in sw China) another case of polio transmission & re-transmission caught up in the morass of jihadist militancy & movements. 11. Afghanistan & border areas: With elections & troop withdrawals both scheduled for 2014 and increasing Afghan Taliban militant activity, it is likely that the national polio eradication programme will suffer. Eg. abduction of polio workers has been reported this year. So far the official support by Mullah Omar for polio vaccination (with the condition that it be coordinated with them in areas under their influence and a "safe passage" letter obtained and that no "foreigners" be involved) has been instrumental in good anti-polio coverage -- although Afghanistan, too, suffers from many of the problems found in Pakistan (corruption, mis/under- EFTA00975984 reporting etc). However, as of 2014, various parallel events & developments are likely to have a negative effect on PEP: (a) the attention of the Karzai regime is already focused more on its own continued survival; (b) attention & resources diverted to political, financial and security issues considered more essential at this stage than PEP; (c) power struggles not only between the Afghan Taliban and other armed groups, but also among the latter. 12. Next steps: IPI visit being planned for 25 November 2013, and further to the May "next steps", inter alia : (i) to follow-up on issues outlined in May internal mission report as well as in this interim Update; (ii) analyse impact of events & developments between May and now; (iii) review and examine outcomes of first visit visit & contacts established; (iv) get update on security issues which affect PEP; (v) set up additional, new parallel "channels"; and (vi) initiate preliminary research on Afghanistan. End. EFTA00975985