Pakistan's tragic battle with polio
Pakistan is facing international travel restrictions because of an uncontrolled outbreak of polio. But unless vaccinators gain unfettered access to North Waziristan, where the Taliban are in control and have banned the vaccine, it will be hard to stem the spread of the disease, reports Kim Ghattas.
In a Peshawar hospital, two-year-old Gul [his name has been changed for safety reasons] is getting a check-up. He screams when his legs are squeezed together; they fall limp when released. Gul has been diagnosed with polio. He's one of the latest victims of the crippling disease that is spreading fast in the tribal areas in north-west Pakistan.
Gul is from near the border with Afghanistan. The Pakistani Taliban insurgency there has hampered access for health workers and the polio campaign never reached his small village.
But the tragedy of Gul's case is that his family did everything it could to keep him healthy, including risking their life by defying the militants and smuggling the vaccine into their village. The militants say vaccinations are a cover for espionage and part of a Western conspiracy against Muslims.
Out of fear of reprisals, Gul's father and uncle don't want to identify their family or village by name. The father, a manual worker, makes about 300 rupees (approximately $3) a day and only speaks Pashto, the language of the tribal areas. The 16-year-old uncle has had some basic education and can say a few words in English. But they knew they needed the vaccine to keep the 15 children in the extended family healthy because one of the older children contracted polio five years ago.
"I was afraid but wanted to vaccinate our children at any cost," says the uncle.
For two years, terrified but determined, he travelled to the largest nearby town to pick up a small bottle of the oral polio vaccine. He hid the small bottle of drops in a water cooler inside a school bag and travelled back and forth by taxi instead of bus to remain as inconspicuous as possible.
The fare for the trip - 1,000 rupees - is the equivalent of three days' wages. Full immunity can require up to 10 doses, especially in poor rural areas where other health issues can undermine the efficacy of the vaccine. The uncle managed to do four runs. But by the end of last year, the family says fighting in the area made it hard to reach the hospital to get more doses. Gul and one other child contracted the disease in early May. Health experts also caution that the potency of the vaccine can be undermined if the cold chain is broken when moving the vaccine. It was hard to ascertain whether the uncle had managed to keep it at a constant temperature while travelling.
"We blame the government mostly and those people who don't understand the importance of the vaccine," said Gul's father, not even daring to mention the Taliban by name. "But the government abandoned us in the tribal areas a long time ago - we have nothing there."
There have been 67 new cases of polio in Pakistan so far this year, compared with eight during the same period last year. More than 90% of cases were reported in the tribal areas, roughly 70% of them in North Waziristan, where there have been no vaccinations for two years. High season for the spread of disease is around the corner and the World Health Organisation expects the numbers to keep growing.
More than 60 polio vaccinators and police guards protecting them have been shot dead by militants over the last two years. To push into the tribal areas, the government has ordered the army to help protect the health workers.
One of the recent vaccination campaigns under army protection took place in Khyber. More are to follow across the tribal areas surrounding North Waziristan. The government is also asking the army to enforce vaccination on anyone leaving the tribal areas at transit points along the borders with the rest of the country. Adults need to be vaccinated too with the oral drops because they can be healthy but still carry the disease in their gut and transmit it.
The goal appears to be to contain the disease within North Waziristan until access can be negotiated or enforced.
Peace talks with the militants have stalled but earlier this month the ministry of interior said polio would be on the agenda of talks for the next round.
Professor Ibrahim Khan, a religious leader who represents the militants in the indirect negotiations with the government, told the BBC that until that announcement, the government had not brought up the polio issue with the Taliban.
"If peace negotiations succeed, we will be able to provide vaccines to the children of North Waziristan," said Prof Khan. "The solution to our problems lies in the negotiation process."
The health of thousands of children is now caught up in politics. The army is also losing patience with peace talks and has stepped up military strikes against militant hideouts in North Waziristan.
When I asked Interior Minister Chaudry Nisar recently what the strategy was to get the vaccine to tens of thousands of children inside North Waziristan, he told me he needed a few more days before being able to say - an astounding answer for a crisis that started two years ago.
But there is finally a sense of urgency in Pakistan, mainly because of the international travel restrictions which will become mandatory on 1 June.
The restrictions mean that a disease that was only a problem for the poor has now become a concern - and an embarrassment - for all Pakistanis.
Anyone leaving Pakistan, even if previously vaccinated, will need a dose of the oral vaccine before they do so. International health organisations in Pakistan estimate they will need four million doses in the next four months. The restrictions will help stop the spread of polio outside Pakistan - but in North Waziristan a generation of children is still waiting for the life-saving drops.