Security Apprehensions with Polio Eradication Process: A Study of Katlang, District Mardan, Khyber Pakhtunkhwa


Authors: Muhammad Zahid, Arshad K. Bangash & Syed Rashid Ali

Security Apprehensions with Polio Eradication Process: A Study of Katlang, District Mardan, Khyber Pakhtunkhwa

Abstract

The study aims to investigate security threats to polio workers and its link with polio eradication process in Katlang, District Mardan of Khyber Pakhtunkhwa, Pakistan. The study population is consisting upon 200 employees of Health department Khyber Pakhtunkhwa, UNICEF and WHO. Sample size was calculated through Sekaran’s Magic table. Proportionate allocation sampling technique was used for distribution of sample size among the selected categories of the respondents. The data was collected through questionnaire. Data was analyzed and presented at univariate and bivariate levels, while using Chi Square test statistics to ascertain association between dependent and independent variables. Among the associated factors: accessibility, monitoring problems in insecure areas, attacks on polio workers, insufficient security provision and feelings of insecurity among polio workers were significantly associated with polio eradication process. Anti-vaccination rumours and misconception about polio needs to be dispelled through active involvements of religious and political leaders.

Keywords: Polio Eradication, Immunization Days, Security, FATA, Militancy

Introduction

Poliomyelitis (infantile paralysis) is an infectious and viral disease that mainly attacks on central nervous system of human beings. In the beginning patients usually show symptoms of a mild and non-paralytic infection; however, with the passage of time it can result in paralysis. Children below five years are the main victims of polio virus that ultimately cause the death of infected children (Mushtaq et al., 2010). Owing to the gravity and severity of the disease, different initiatives were taken in order to cope with the problem and to make the world polio free. Among these initiatives, The Global Polio Eradication Initiative (GPEI) started by the World Health Organization (WHO) in 1988 is credited for saving the life of 2,50,000 children (Baig, 2004). In addition, five millions of children were saved from polio that would have been paralyzed, if not vaccinated. Moreover, efforts of WHO and global partners restricted polio-virus only to Pakistan, Afghanistan and Nigeria (Fetene and Sherani, 2013; Khan and Qazi, 2013).

Various parts of Khyber Pakhtunkhwa (KP) and Federally Administered Tribal Areas (FATA) are still facing the curse of polio virus. Such virus is mainly found in Bajur Agency, Khyber Agency, Mohmand Agency, and Swat. These areas are continuously under terrorist attacks and military operations, which renders them difficult regions for polio eradication campaign. The killing of polio workers in these areas also caused a lot of damage to the cause and halted the campaign. The difficult geography, growing talibanization and conservative political and religious approach in masses of the area are like adding insult to the injury. In addition, the concept that health campaigns, similar to that of polio eradication campaigns, are being used to locate the terrorists and their training centers, has created an aversion among masses towards such campaigns and has produced a lot of reaction. KP is the most affected province in Pakistan at present owing to a high number of killings of polio workers and deteriorated law and order situations. As a result, many children have missed their routine vaccination in recent times.  

Polio Statistics in Pakistan

Pakistani government is sagaciously working to curb poliovirus. However, in addition to other reasons, security threats are impeding the polio eradication process. The given table shows number of registered cases in each province for the last 07 years.

Table 1: Province-wise Number of Polio Registered Cases

Province

2010

2011

2012

2013

2014

2015

2016

2017

Punjab

7

9

2

7

5

2

0

1

Sindh

27

33

4

10

30

12

8

0

KP

24

23

27

11

68

17

8

0

FATA

74

59

20

65

179

16

2

0

Balochistan

12

73

4

0

25

7

2

1

Gilgit-Baltistan

0

1

1

0

0

0

0

1

Azaj Jammu & Kashmir

0

0

0

0

0

0

0

0

Total

144

198

58

93

306

54

20

3

Source: http://www.endpolio.com.pk/polioin-pakistan/polio-cases-inprovinces

 

The prevalence of polio brings questions in mind that why polio is endemic in Pakistan, Afghanistan and Nigeria. Apparently, the easiest reply to this question could be partial success in implementation of vaccination strategies/coverage; but the reasons could be many in number and much more complex in nature than it looks. Along with managerial hurdles, religious controversy and security factors are also impeding polio eradication process in Pakistan. Currently, the worse security circumstances and increase in militancy in certain parts of KP have negatively affected polio eradication process. It is also observed that threats, abduction and killing of polio workers also made immunization activities troublesome (Khan, 2010). Moreover, it is almost impossible to carry out and monitor polio eradication activities in war hit areas  which in return serve as an obstacle in the way of polio free KP (Chang et al.,2012; Fetene and Sherani, 2013).

 

Earlier studies regarding security factors were carried out in FATA. A lesser number of studies on said subject were carried out in settled areas of province. Therefore, the present empirical study is designed with a more focused approach to analyze the security factors that hinder polio eradication process in settled areas. In more scientific way, it could be stated that the study aims to delineate association of security factors with polio eradication process in settled areas of KP. The coming section compiles the relevant literature on the issue with focuses on security factors in the polio eradication process at KP.

Literature review

Law and order affects the overall activities and polio campaigns are not an exception. The present condition of security, growth of militancy and radicalism in KP and FATA confined execution of the polio eradication project. It is accounted for that security situation of certain operation hit areas of Pakistan obstructs polio inoculation (Mahmood and Aftab, 2013). Conflict and insecurity in KP and FATA resulted in alarmingly high polio cases.  As much as 407 polio cases were reported in 2013 and 2014 (Husain et al., 2016).

Militant groups obstructed vaccination process in 2012 thus declaring it un-Islamic. Worse law and order in FATA resulted in non-coverage of more than 350,000 children for a period more than 2 years (Alexander et al., 2014). Attacks on polio workers since 2012 left a number of polio workers shot dead and obstructing the national immunization and other health related activities in the mentioned areas. After military operations, polio eradication activities were resumed. Polio workers were accompanied by security personals but they are still under attack by militant groups in certain areas (Husain et al., 2016). Continuous attacks and sense of insecurity compelled workers to quit their jobs and discouraged others to join such jobs. Due to these factors, FATA are lacking appropriate number of polio workers (Khan & Qazi, 2013).

Militant groups see polio employee as a soft target and utilize various strategies like physical assaults, killing and threatening; that has pushed the polio eradication initiative to almost a failure. They assaulted and coerced polio groups to stop them from joining polio campaigns. These attempts of firing, kidnapping and killing of polio workers produced a sense of insecurity among workers and hence refused to work (Khan and Qazi, 2013). Studies also highlighted security personals do not come in time as well as their number is also insufficient. Then again, frail security arrangements from security agencies make it hard to oversee and check polio workers’ operation in the field (Fetene and Sherani, 2013).

Another associated factor with military operation is internal displacement of millions of people and circulation of polio virus to other parts of country. Acute Flaccid Paralysis (AFP) and environmental surveillance data indicate that current wild polio-virus transmission originates from these regions in FATA and KP with a significantly higher prevalence among temporary displaced persons (IDPs) settled elsewhere in the country (Husain et al., 2016).

Aims and Objectives of the Study

The study aims to investigate security threats to polio workers and its link with polio eradication process in Katlang, District Mardan of Khyber Pakhtunkhwa, Pakistan.

Methodology of Study

The study was carried out in Tehsil Katlang of District Mardan, KP with the sole aim to explore the potential security threats that obstruct the activities of polio workers in the area under study. The total population of the study universe was 434 as per data provided by District Health Office, Mardan. From the total population, a sample size of 200 was selected using Morgan formula (Sekaran, 1992). The detail of research participants is provided in Table 2 below.

 

Table 2: Sample Distributions

Category

Total Employees

Sample

Lady Health Worker

230

106

Lady Health Supervisor

11

5

Expanded program on immunization Technician

17

8

In charge Basic Health Unit

10

5

Area in charge

42

19

Social Worker

100

45

Tehsil Temporary Monitor

15

7

Union Council Polio Worker

9

5

G.TOTAL

434

200

 

A comprehensive questionnaire was developed with the help of researchers’ observation and literature review. The first draft of the questionnaire was discussed with the experts of the field for its content validity which was improved accordingly. The data was collected through the improved questionnaire which was put into SPSS for analyses purpose. In order to find out association between the variables i.e. Security threats (independent variable) and polio eradication process (dependent variable), Chi Square test statistics was applied.

 

Results and Discussions

  1. Socio-Demographic information of respondents

Table 3 below shows the socio-demographic information of respondents consisting upon gender, age, qualification, job experience, duty station, designation and employer’s details.

Table 3: Socio-Demographic Information of the Respondents

GENDER

FREQUENCY

PERCENTAGE

Female

140

70

Male

60

30

TOTAL

200

100

AGE

FREQUENCY

PERCENTAGE

20-25

21

10.5

26-30

58

29.0

31-35

64

32.0

36-40

29

14.5

41-45

12

6.0

46-50

9

4.5

51-55

3

1.5

56-60

4

2.0

TOTAL

200

100.0

EDUCATIONAL LEVEL

FREQUENCY

PERCENTAGE

Matriculation

77

38.5

F.A/F.Sc

54

27.0

B.A

33

16.5

M.A

22

11.0

MBBS

8

4.0

Others

6

3.0

TOTAL

200

100.0

JOB EXPERIENCE IN YEARS

FREQUENCY

PERCENTAGE

1-5 years

70

35

6-10

45

22.5

11-15

50

25

16-20

22

11

21-25

8

4

26-30

5

2.5

TOTAL

200

100

DESIGNATION

FREQUENCY

PERCENTAGE

Lady health workers

110

55

Lady health supervisor

8

4

EPI Technician

15

7.5

Area in-charge

20

10

In-charge BHU

8

4

Tehsil Temporary Monitor

5

2.5

Social Workers

34

17

TOTAL

200

100.0

DUTY STATION

FREQUENCY

PERCENTAGE

DheriLikpani

30

15

Alo

28

14

Shamozai

30

15.0

Katlang 1

35

17.5

Katlang 2

50

25

Babuzai

27

13.5

TOTAL

200

100

EMPLOYER OF THE RESPONDENTS

FREQUENCY

PERCENTAGE

Health department

172

86

PPHI

8

4

W.H.O

5

2.5

Other

15

7.5

TOTAL

200

100

Source: Field Survey, 2016

 

  1. Bi Variate Analysis of Security Factors and Polio Eradication Process

The present study restricted security factor  to certain statements like threats to polio workers, attacks on polio workers, presence of militants and criminals in the area, provision of security facilities, fear among polio workers, difficulty in monitoring and evaluation,  and refusal to duties due to worst law and order conditions. All these factors were cross-tabbed with polio eradication process in order to know its association.

Table 4 indicates the association of security factors with polio eradication process. It is important to know that why polio workers are threatened, attacked and killed.  In 2003, Nigerian religious scholars and political leaders raised questions on polio vaccination. As a result, mistrust was developed about polio eradication process. Polio vaccination was surrounded by various conspiracies. Voices against polio were so strong that polio campaign was halted and boycotted (Jegede, 2007). This mistrust and misconception was not limited to Nigeria but spread to other countries as well. In Pakistan certain religious and militant groups perceived polio vaccine as ploy of west and they declared it as an un-Islamic one (Khan &Qazi, 2013). The Pakistani Taliban reported that they oppose the polio immunization as an article of faith. This contention is emphatically bolstered by some Muslim religious leaders on religious grounds (Ansari, Khan, and Khan, 2007). Therefore, polio workers faced problems in FATA and Khyber KP. In the same context this study was conducted to know the link between security factors and polio eradication process.

The study results showed that threats to polio workers and polio eradication process was non-significantly (P=0.938) associated with each other. It can be assumed from these findings that mere threats by miscreants cannot impede the activities of polio workers. Moreover, improved security situation and coordination among various stakeholders reduced insecurity among polio workers. However, this might have been a result of the special attention given to the security of polio workers from the law enforcement agencies.

Moreover, results further show that physical attacks on polio workers were significantly (P=0.00) associated with polio eradication process. Polio workers face various problems including verbal threats, kidnapping and physical assaults from various anti-state elements and in such a situation no one prefers job over his or her life.  This fear of being attacked negatively affected the ongoing operations of polio workers and hence became a bottleneck in the way of polio free Pakistan. On the other hand improved law and order situation might have decreased effects of law and order on vaccination process. However, the overall situation of polio workers is not good at all; as still polio workers are being kidnapped and even killed. Various reports stated that since 2012, more than 100 polio workers have been killed. Current study confirms that attacks on polio workers negatively affect vaccination process. These results are also in line with findings of Fetene and Sherani (2013) and Naeem et al.( 2010). The cited studies  reported that threats and attacks on polio workers affects the overall activites of polio workers.

Similarly, the presence of militants and criminals in the area was non-significantly (P=0.843) associated with polio eradication process. Result reveals that presence of militants or criminals in targeted area has no link with vaccination activities. It can be derived that in area under study criminals are not impediments to polio vaccination activities. This might be the reason that the study was conducted in settled area of Khyber Pakhtunkhwa, where proper security arrangements were made during the polio vaccination campaigns. Contrary to these results, it is also an evident fact that in different parts of the country the presence of criminal and militant groups adversely affected polio vaccination process.

Contrary to the above, a highly significant association (P=0.000) was found between accessibility of polio workers in worse security condition and polio eradication process. It is obvious that worse security conditions have immense effects on routine life; therefore polio eradication/vaccination is not an exception. Worse security situation makes certain areas inaccessible to polio workers. The reasons of worse security condition may be due to the presence of militants in the area, military operations and blood feuds in settled areas. Militants deem polio as un-Islamic and do not allow polio workers to perform their duties. This inaccessibility leads to non-coverage of children and hence non-eradication of polio. The findings of this study are in line with findings of Khan and Qazi (2013); and Mehmood and Aftab (2013),who  reported that worse law and order conditions restricts the activities of polio workers. Morover, polio workers may not be having that much conveyance  facilities that make them able to have an easy and frequent movement around the targeted terretory

Likewise, findings of the study exhibits that monitoring in worse security and polio eradication process, were found to be significantly associated (P=0.000) with each other. It is very difficult to  monitor the activities of polio eradication in security compromised areas. Usually, polio workers are monitored by representatives of World Health Organization (WHO)  and United Nation Children Emergency Fund (UNICEF). They usually travel in luxury cars that results in their high visibilty as well. In such a situation these monitoring teams are vulnerable to attacks of militant groups. It becomes difficult for them to monitor the activities of polio workers.  This finding is analogous with findings of Fetene and Sherani (2013) and Murakami et al., (2014) who reported that monitoring teams faces problems in security compromised areas. Furthermore, the forginer employees of WHO and UNIECF may not be willing to perform their duties in areas, where they think their lives are in danger.

Table 4 depicts that refusal to duties by polio workers and polio eradication process, were observed to have highly significant association (P=0.000). After attacks on polio workers in certain areas, polio workers refuse to continue their duties. Nothing is more important than life. Thus, it is very difficult to perform duties in life threatening conditions. It is evident that if employees do not work, department will be having shortage of trained workers; then it becomes impossible to be successful in polio eradication initiative. This could also be the reason that most of the polio workers are either engaged through daily wages or hired from other departments and there is lack of trained regular workers, who comes under the direct supervision of health institutions. Thus, such employees are not bound to efficiency and disciplinary rules of health department, in case they refuse to perform their duties during the vaccination days. The results are in line with the findings of Fetene and Sherani (2013) and Naeem et al.,(2011), who reported that refusal to duties has greatly affected polio combating activities and hence Pakistan awaits yet  to be declared as polio free country.

The tabulated data further suggested that the association between inadequate security and polio eradication process is observed to be significant (P=0.003). As discussed earlier polio workers needs proper security for their duties. Proper security will improve sense of security, protection and in turn will help them to perform their duties in an efficient manner. It is confirmed that adequate number of security personnel can play an important role in the success of polio eradication initiative. These results are in line with Mushtaq et al. (2010) and  Naeem et al.(2011) who reported that improved security situation results in better vaccine coverge.

Similarly, a highly significant association (P=0.000) contended between feeling of fear among polio workers and polio eradication process. Safety and protection of employees is one of the main duties of the employer and it is not possible to carry out such activities in life threatening situations. That is why majority of polio workers asserted that they refuse to continue their duty in such a situation. Moreover, respondents were not satisfied from security arrangements and affirmed that they feel insecure even in the presence of security personnel. This situation seems to be alarming that polio workers feel insecure in presence of police. It is, therefore, need of the day to enhance security arrangements for successful eradication of polio.  The results are in line with the findings of Khan and Qazi (2013) and Shah et al. (2011), who reported that sense of insecurity, prevailed among polio workers that affected their performance.

Table 4: Security Factors Associated with Polio Eradication Process

Factors

 

Attitude

Polio Eradication

Total

Statistics

Yes

No

Uncertain

Threats to polio workers affect the activities of polio workers

Yes

183(91.5%)

6(3%)

3(1.5%)

192(96%)

=.393

(.983)

No

6(3%)

0

0

6(3%)

Uncertain 

2(1%)

0

0

2(1%)

Attacks on polio workers affect the activities of polio workers

Yes

184

6

3

193

=27.954

(.000)

 

No

 

7

 

0

 

0

 

7

Militants show up in areas affect the activities of polio workers

Yes

136(68%)

4(2%)

3(1.5%)

143(71.5%)

=1.407

(.843)

No

52(26%)

2(1%)

0

54(27%)

Uncertain 

3(1.5%)

0

0

3(1.5%)

Presence of criminals in areas affects activities of polio workers

Yes

152(76%)

3(1.5%)

3(1.5%)

158((79%)

=8.725

(.068)

No

36(18%)

2(1%)

0

38(19%)

Uncertain 

3(1.5%)

1(0.5%)

0

4(2%)

Worse security conditions make certain areas inaccessible to polio workers

Yes

159(79.5%)

3(1.5%)

3(1.5%)

165(82.5%)

=17.616

(.001)

No

31(15.5%)

2(1%)

0

33(16.5%)

Uncertain 

1(0.5%)

1(0.5%)

0

2(1%)

Worse security conditions make monitoring difficult

Yes

149(74.5%)

3(1.5%)

1(0.5%)

153(76.5%)

=27.954

(.000)

No

39(19.5%)

1(0.5%)

2(1%)

42 (21%)

Uncertain 

3(1.5%)

2(1%)

0

5(2.5%)

After attack some workers refuse to

continue their duties

Yes

174(87%)

4(2%)

0

178(89%)

=31.028

(.000)

 

No

9(4.5%)

1(0.5%)

2(1%)

12(6%)

Uncertain 

7(3.5%)

1(0.5%)

1(0.5%)

9(4.5%)

inadequate security is provided to polio workers

Yes

130(65%)

2(1%)

3(1.5%)

135(67.5%)

=15.805

(.003)

No

55(27.5%)

2(1%)

0

57(28.5%)

Uncertain 

6(3%)    

2(1%)

0

8(4%0

Polio workers feel fear even in the presence of security personals

Yes

170(85%)

4(2%)

0

174(87%)

=33.118

(.000)

No

16(8%)

1(0.5%)

3(1.5%)

20(10%)

Uncertain 

5(2.5%)

1(0.5%)

0

6(3. %)

 

Conclusion and Recommendations

The study concluded that polio eradication initiative has been facing several hurdles in Pakistani society, followed by certain operational lapses in the vaccination program. Mistrust, anti-vaccination rumours and rise of militancy also slows down the journey towards polio free Pakistan. Militants’ attacks and killing of polio workers converted a health issue to security issue.  It is an observable phenomenon that success or failure of a program up to some extent relies upon security situation of the locality. In light of the study findings, the researchers concluded that polio eradication process in Pakistan is not successful due to deteriorated security conditions and other allied factors. These are no more the days when Polio workers carried out their activities safely and without any fear. Polio teams are vaccinating children with sense of insecurity. Now a Polio team is not allowed to work without adequate security even in the settled areas of the country. This sense of insecurity among the polio workers has slowed down the journey of polio eradication process in the country.  Although, the law and order situation of country is improving with time but special focus is still needed.

In light of the study results, coordinated efforts are needed by stakeholders to curb the curse of polio from Pakistan. Anti-vaccination rumours need to be dispelled so that resistance and attacks on polio workers could be avoided. The goal of polio free Pakistan does not look possible without overcoming security threats; therefore it is pertinent to properly address security measures. An appropriate and timely provision of security should be ensured to polio worker to mitigate their feelings of insecurity through better security arrangements that will enhance better and extended vaccine coverage and will be resulting in greater chances of polio free Pakistan.

References

 

Alexander, J. P., Zubair, M., Khan, M., Abid, N., &Durry, E. (2014). Progress and peril: poliomyelitis eradication efforts in Pakistan, 1994–2013. The Journal of infectious diseases, 210(1), 152-161.

Baig, A. (2004). Vaccination Coverage for Oral Polio Vaccination and Identifying the Determinants Associated with Popular Participation in Immunization Activities of the Polio Eradication Programme in Pakistan (Master dissertation, Centre for the Public Health). Retrieved July 12, 2017 from http://abrarbaig.tripod.com/masterthesis/Master_thesis.pdf

Chang, A., Chavez, E., Hameed, S., Lamb, R. D., &Mixon, K. (2013).Eradicating polio in Afghanistan and Pakistan. Center for Strategic and International Studies, Washington DC.Retrieved July 12, 2017 from http://csis.org/files/publication/120810_ Chang_EradicatingPolio_Web.pdf

Fetene, N. W. (2013). Determinant factors for implementing polio eradication activities under security compromised settings of Pakistan. Journal of Tropical Diseases & Public Health.http://dx.doi.org/10.4172/2329-891X.1000127

Hussain, S. F., Boyle, P., Patel, P., & Sullivan, R. (2016).Eradicating polio in Pakistan: an analysis of the challenges and solutions to this security and health issue. Globalization and health12(1), 63-95

Jegede, A. S. (2007). What led to the Nigerian boycott of the polio vaccination campaign?. PLoSmedicine4(3),73-80

 

Kazi, A. M., Khalid, M., &Kazi, A. N. (2014). Failure of polio eradication from Pakistan: Threat to world health. Journal of Pioneering Medical Sciences, 4(1), 8-9S.

 

Khan, S. A. (2010). Poliomyelitis in Socio-cultural Context--study from Province Punjab, Pakistan. Institute of Public Health and Clinical Nutrition, Faculty of Health Sciences, University of Eastern Finland. Retrieved July 12, 2017 from http://urn.fi/URN:ISBN:978-952-61-0180-4

Khan, T., &Qazi, J. (2013). Hurdles to the global antipolio campaign in Pakistan: an outline of the current status and future prospects to achieve a polio free world. J Epidemiol Community Health67(8), 696-702.

Mahmood, D., & Aftab, M. (2013). Failure of Polio Eradication in Pakistan. Escalating        Research Science Magazine, 2 (4), 3-6

Murakami, H., Kobayashi, M., Hachiya, M., Khan, Z. S., Hassan, S. Q., & Sakurada, S. (2014). Refusal of oral polio vaccine in northwestern Pakistan: a qualitative and quantitative study. Vaccine32(12), 1382-1387

Mushtaq, M. U., Shahid, U., Majrooh, M. A., Shad, M. A., Siddiqui, A. M., &Akram, J. (2010). From their own perspective-constraints in the Polio Eradication Initiative: perceptions of health workers and managers in a district of Pakistan's Punjab province. BMC international health and human rights10(1), 10-22.

Naeem, M., Adil, M., Abbas, S. H., Khan, M. Z. U. I., Naz, S. M., Khan, A., & Khan, M. U. (2011). Coverage and causes of missed oral polio vaccine in urban and rural areas of Peshawar. Journal of Ayub Medical College Abbottabad23(4), 98-102.

Shah, M., Khan, M. K., Shakeel, S., Mahmood, F., Sher, Z., Sarwar, M. B., &Sumrin, A. (2011). Resistance of polio to its eradication in Pakistan. Virology journal8(1), 422-57

 

 

About the Authors

Muhammad Zahid is a Lecturer at the Department of Sociology, Abdul Wali Khan University Mardan, Pakistan. He can be reached at mzahid@awkum.edu.pk

Dr. Arshad Khan Bangash is an Assistant Professor at the Department of Sociology and Gender Studies, Bacha Khan University, Charsadda, Pakistan. He can be reached at arshad.dwah@gmail.com

Dr.Syed Rashid Ali is an Associate Professor at the Department of Sociology, Abdul Wali Khan University Mardan, Pakistan. He can be reached at syedrashid@awkum.edu.pk