2022 Quetta Suicide Attack
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Pakistan Pakistan, officially the Islamic Republic of Pakistan, is a country in South Asia. It is the List of countries and dependencies by population, fifth-most populous country, with a population of over 241.5 million, having the Islam by country# ...
is one of the two remaining countries in the world where
poliomyelitis Poliomyelitis ( ), commonly shortened to polio, is an infectious disease caused by the poliovirus. Approximately 75% of cases are asymptomatic; mild symptoms which can occur include sore throat and fever; in a proportion of cases more severe ...
(polio) is still categorized as an
endemic Endemism is the state of a species being found only in a single defined geographic location, such as an island, state, nation, country or other defined zone; organisms that are indigenous to a place are not endemic to it if they are also foun ...
viral infection, the other one being
Afghanistan Afghanistan, officially the Islamic Emirate of Afghanistan, is a landlocked country located at the crossroads of Central Asia and South Asia. It is bordered by Pakistan to the Durand Line, east and south, Iran to the Afghanistan–Iran borde ...
. While it has yet to fully eradicate polio, there has been a major downwards trend in the number of reported cases per year; the total count of wild poliovirus cases in Pakistan in 2019 was down to 147, compared to 84 in 2020, 1 in 2021, 20 in 2022, 6 in 2023 and 41 as of October 2024. Though the polio immunization campaign in the country started in 1974, the efforts for eradication officially started in 1994. The infection remains endemic despite over 100 rounds of vaccination being carried out in the past decade. Pakistan had the world's highest number of polio cases in 2014.


Pakistan Polio Eradication Programme

Since 1994, the Pakistan Polio Eradication Programme has been fighting to end the crippling poliovirus from the country. The initiative is driven by up to 339,521 trained and dedicated polio workers, the largest surveillance network in the world, quality data collection and analysis, behavioral change communication, state of the art laboratories, and some of the best epidemiologists and public health experts in Pakistan and the world.


Eradication efforts in the 20th century

The Expanded Programme of Immunization (EPI) was begun in Pakistan by the
World Health Organization The World Health Organization (WHO) is a list of specialized agencies of the United Nations, specialized agency of the United Nations which coordinates responses to international public health issues and emergencies. It is headquartered in Gen ...
(WHO) in the 1970s to combat deaths from six vaccine-preventable diseases. In 1980, the EPI had vaccinated just 2% of the population against polio; by 1990, the coverage had increased to 54%. In a 1994 interview, CDC officials predicted total polio eradication in Pakistan within two to three years; by 1995, the WHO projected total eradication by the year 2000, a target that the organization reaffirmed in 1998. However, despite donor attention, the rate of vaccinations sagged. By 1991, only 83 percent of Pakistani children had been vaccinated. Research by the
Center for Disease Control The Centers for Disease Control and Prevention (CDC) is the national public health agency of the United States. It is a United States federal agency under the Department of Health and Human Services (HHS), and is headquartered in Atlanta, ...
(CDC) in April 1998 cited a failure to vaccinate, vaccine failure, and inadequate immunization strategies as causes for the continued incidences of polio in this time. Reasons for under-vaccination included the population being uninformed, considering vaccination unimportant, and having to travel long distances to vaccination sites. In response to these challenges, organizations including the WHO,
United Nations Children's Fund UNICEF ( ), originally the United Nations International Children's Emergency Fund, officially United Nations Children's Fund since 1953, is an agency of the United Nations responsible for providing humanitarian and developmental aid to childre ...
(UNICEF), CDC, Rotary International, and the Bill and Melinda Gates Foundation pulled together to develop and fund intensive eradication campaigns, including door-to-door vaccinations.


21st century

In March 2001, about 27 million children were vaccinated across the country in the hope that Pakistan could be virus-free by the end of that year. As of 2004, when there were 30 million children in Pakistan under five, about 200,000 health workers were required for a vaccination campaign that was carried out eight times a year. A documentary, ''Polio True Stories'', was aired on several television channels to make people aware of the problems facing people affected by the disease. Opposition to the polio vaccination program by militant groups continues to thwart the success of eradication efforts. In 2014, the number of polio cases reached 306, the highest it has been since 2000. In August 2015, the country launched an injectable polio vaccine intended to treat four million children and bring Pakistan closer to its goal of eradication by 2016. While the new vaccine is pricier than the traditional oral
polio vaccine Polio vaccines are vaccines used to prevent poliomyelitis (polio). Two types are used: an inactivated vaccine, inactivated poliovirus given by injection (IPV) and a attenuated vaccine, weakened poliovirus given by mouth (OPV). The World Healt ...
(OPV) and requires that a doctor or nurse administer it, the injection needs only one dose, not repeated doses, to generate immunity. In April 2019, over 25,000 children were rushed to the hospital during a mass panic over the spread of false rumors that the polio vaccine causes fainting and vomiting. In June 2022, officials believed that a new outbreak was the cause of some health workers helping parents avoid vaccinations by falsely marking a child's fingers, indicating they have been vaccinated for polio when they have not.


Connection to the assassination of Osama bin Laden

Leading up to the early 2000s, Pakistani vaccination workers were making notable progress in eliminating the polio virus in the highly infected areas of Gadap, Quetta Block (Quetta, Pishin, Kila Abdullah Districts), FATA (Federally Administered Tribal Areas), Khyber Pakhtunkhwa, Peshawar and the neighboring areas of Mardan, Charsaddah, Nowshehra and Lakki Marwat. In 2011, the U.S.
Central Intelligence Agency The Central Intelligence Agency (CIA; ) is a civilian foreign intelligence service of the federal government of the United States tasked with advancing national security through collecting and analyzing intelligence from around the world and ...
(CIA) employed the services of Pakistani doctor,
Shakil Afridi Shakil Afridi (), or Shakeel Afridi, is a Pakistani physician who allegedly helped the CIA run a fake hepatitis vaccine program in Abbottabad, Khyber Pakhtunkhwa, Pakistan, in order to confirm Osama bin Laden's presence in the city by obtain ...
, and local health officials to stage a fake vaccination campaign in an attempt to confirm
Osama bin Laden Osama bin Laden (10 March 19572 May 2011) was a militant leader who was the founder and first general emir of al-Qaeda. Ideologically a pan-Islamist, Bin Laden participated in the Afghan ''mujahideen'' against the Soviet Union, and support ...
's location in Abbottabad. This ruse was organized in an effort to gain more knowledge on Bin Laden's whereabouts prior to
Operation Neptune Spear On 2 May 2011, the United States conducted Operation Neptune Spear, in which SEAL Team Six shot and killed Osama bin Laden at his " Waziristan Haveli" in Abbottabad, Pakistan. Bin Laden, who founded al-Qaeda and orchestrated the September ...
. While it is still unknown if Afridi was aware of the implications for his services in the campaign, the main goal of the CIA was to collect
DNA Deoxyribonucleic acid (; DNA) is a polymer composed of two polynucleotide chains that coil around each other to form a double helix. The polymer carries genetic instructions for the development, functioning, growth and reproduction of al ...
samples of
Osama bin Laden Osama bin Laden (10 March 19572 May 2011) was a militant leader who was the founder and first general emir of al-Qaeda. Ideologically a pan-Islamist, Bin Laden participated in the Afghan ''mujahideen'' against the Soviet Union, and support ...
's children from blood left on the needles used to deliver the
Hepatitis B Hepatitis B is an infectious disease caused by the '' hepatitis B virus'' (HBV) that affects the liver; it is a type of viral hepatitis. It can cause both acute and chronic infection. Many people have no symptoms during an initial infection. ...
vaccination. The CIA's false vaccination campaign has had severe lasting effects on the North West corner of Pakistan. Since 2012, at least 70 polio workers have been killed in Pakistan. Many of the attacks have been claimed by the
Pakistani Taliban The Pakistani Taliban, officially the Tehreek-i-Taliban-e-Pakistan (TTP), is an umbrella organization of various Islamist armed militant groups operating along the Afghan–Pakistani border. Formed in 2007 by Baitullah Mehsud, its current ...
, who forward claims that the vaccination campaigns are a facade for intelligence gathering. The fake Hepatitis B campaign has caused people to question the motivations behind all vaccination campaigns, leading to a spike in poliomyelitis cases from 198 in 2011 to 306 cases in 2014. Many citizens of both the US and various other nations have criticized the CIA's vaccination campaign for the effects that it has had on Pakistan's
public health Public health is "the science and art of preventing disease, prolonging life and promoting health through the organized efforts and informed choices of society, organizations, public and private, communities and individuals". Analyzing the de ...
.


Recent government efforts

In 2015, the
Khyber Pakhtunkhwa Khyber Pakhtunkhwa (; ; , ; abbr. KP or KPK), formerly known as the North West Frontier Province (NWFP), is a Administrative units of Pakistan, province of Pakistan. Located in the Northern Pakistan, northwestern region of the country, Khyber ...
government had issued arrest warrants for 1,200 parents and guardians for refusing to administer vaccine to their children. 512 people were arrested on the charge but were later freed after signing an undertaking that they would not oppose vaccination. By 2015, new cases of polio had dropped by 70% as compared to 2014, due to increased vaccination in parts of the northwest Pakistan that had previously been under the control of militants. These areas were secured by Pakistani forces in the
Zarb-e-Azb Operation Zarb-e-Azb (Pashto/ ALA-LC: ; ) was a joint military offensive conducted by the Pakistan Armed Forces against various militant groups, including the Tehrik-i-Taliban Pakistan (TTP), the Islamic Movement of Uzbekistan, the East Tur ...
Campaign against Taliban militants. Previously, vaccination teams were forbidden by militants from vaccinating children in the area. Polio cases in Pakistan increased significantly in 2024 compared to the previous year, with increases in cases being reported across 71 districts. The majority of cases were reported in
Balochistan Balochistan ( ; , ), also spelled as Baluchistan or Baluchestan, is a historical region in West and South Asia, located in the Iranian plateau's far southeast and bordering the Indian Plate and the Arabian Sea coastline. This arid region o ...
, where on the border in Afghanistan cases had been surging as well. This was in part due to many children not receiving their scheduled polio vaccinations during the year, such as in September 2024 where a reported 1 million children missed vaccinations. Militant attacks on polio workers also increased during the year, with 27 attacks being reported in Khyber Pakhtunkhwa as of October 2024. Owing to this, on 28 October 2024 the Pakistani government launched an initiative to vaccinate 45 million children.


Current Statistics

20 cases of WPV were reported throughout 2022. In 2023, Only 6 cases of WPV were reported. As of October in 2024, this number had increased to 41 cases of WPV across 71 districts.


Factors affecting eradication

Some of the reasons which affect the eradication of polio are political unrest, poor
health Health has a variety of definitions, which have been used for different purposes over time. In general, it refers to physical and emotional well-being, especially that associated with normal functioning of the human body, absent of disease, p ...
infrastructure, and government negligence. The most afflicted areas are those where militants are present and the government lacks absolute control, such as the
Federally Administered Tribal Areas The Federally Administered Tribal Areas, commonly known as FATA, was a semi-autonomous tribal region in north-western Pakistan that existed from 1947 until being merged with the neighbouring province of Khyber Pakhtunkhwa in 2018 through the ...
. Transmission of the virus from such areas then leads to spread through other parts of the country.


Misinformation campaigns

Due to the fact that the vaccines are primarily produced in the western countries, militant groups like
Tehrik-i-Taliban The Pakistani Taliban, officially the Tehreek-i-Taliban-e-Pakistan (TTP), is an umbrella organization of various Islamist armed militant groups operating along the Afghan–Pakistani border. Formed in 2007 by Baitullah Mehsud, its current ...
propagandize that they have been made out of pig fat or contain alcohol, two things that are strictly forbidden in Islam. Some clerics have also denounced the vaccines. There is also a myth prevalent in many of the areas with low literacy rates that the immunization sterilizes the local population. Around early 2012, it was reported that some parents refused to get their children vaccinated in
Khyber Pakhtunkhwa Khyber Pakhtunkhwa (; ; , ; abbr. KP or KPK), formerly known as the North West Frontier Province (NWFP), is a Administrative units of Pakistan, province of Pakistan. Located in the Northern Pakistan, northwestern region of the country, Khyber ...
and
FATA The Federally Administered Tribal Areas, commonly known as FATA, was a autonomous administrative division, semi-autonomous tribal region in north-western Pakistan that existed from Independence Day (Pakistan), 1947 until being merged with the ...
on religious grounds but overall religious refusals in the rest of the country have "decreased manifold". Both major sides of the Afghani civil war now support the polio vaccination, and polio rates are steadily declining rapidly in Afghanistan, with only seven cases in 2015 (as of August 18, 2015). In
Pakistan Pakistan, officially the Islamic Republic of Pakistan, is a country in South Asia. It is the List of countries and dependencies by population, fifth-most populous country, with a population of over 241.5 million, having the Islam by country# ...
there were 29 cases in the same period, with organizational difficulties slowing immunization, but more than ten million children have been vaccinated in 2015. This is the last remaining region with active polio cases as of 2015.


The potential role of Saudi Arabia

Some researchers point to the unique role that Saudi Arabia is able to play in the affairs of the Muslim-majority Pakistan, both as the site of the annual Islamic pilgrimage (the
Hajj Hajj (; ; also spelled Hadj, Haj or Haji) is an annual Islamic pilgrimage to Mecca, Saudi Arabia, the holiest city for Muslims. Hajj is a mandatory religious duty for capable Muslims that must be carried out at least once in their lifetim ...
) and as the seat of formal Islamic authority, in terms of the ability to pass
fatawa A fatwa (; ; ; ) is a legal ruling on a point of Islamic law (sharia) given by a qualified Islamic jurist ('' faqih'') in response to a question posed by a private individual, judge or government. A jurist issuing fatwas is called a ''mufti'', ...
and shape public opinion. Given that over 10% (200,000) of the Hajj pilgrims are Pakistani, Saudi Arabia has a vested interest in eradication campaigns in Pakistan to prevent spread during Hajj. One possible avenue for the Muslim world to eliminate the polio threat is to have local mosques and community centres promote vaccination, emphasizing that the sanctity of life is foremost in Islam. If supported by national and international Muslim organisations, with the aid of world health agencies and Muslim public health scholars, this policy could reduce the extent of misinformation the Taliban is able to spread.


Poor health infrastructure

Pakistan's healthcare system is burdened by poor public-sector funding, an ill-regulated private sector, and a lack of governmental transparency, all of which contribute to limiting the quality of public health services. Though the Polio Eradication Initiative is well funded, it is delivered through the underfunded public infrastructure. Members of the Polio Eradication Committee in Pakistan have also expressed concerns regarding the accountability of the organizations backing the campaign. Since the number of cases began to rise following the raid on the
Osama bin Laden Osama bin Laden (10 March 19572 May 2011) was a militant leader who was the founder and first general emir of al-Qaeda. Ideologically a pan-Islamist, Bin Laden participated in the Afghan ''mujahideen'' against the Soviet Union, and support ...
compound, organizations including local health authorities, government workers, WHO, and UNICEF have been asserting blame rather than addressing the public health issues at hand. The public health system provides various avenues for institutionalized malpractice, wherein resources are leached. Staff misconduct is common, where staff members remain absent from duty, fail to run field operations, and divert vaccine for use in private facilities. This can result in the attachment of costs to services intended to be free.


Climate

Fecal-oral transmission is the most common source of transmission of the poliovirus in developing countries, including Pakistan. In addition to the poor health and water sanitation infrastructure, the transmission of the virus is also heightened because of the high population density and climate conditions. Studies have indicated that the polio vaccine has reduced per-dose efficacy in areas near the
Tropics The tropics are the regions of Earth surrounding the equator, where the sun may shine directly overhead. This contrasts with the temperate or polar regions of Earth, where the Sun can never be directly overhead. This is because of Earth's ax ...
, including Pakistan and its neighboring country India. As a consequence of the climate in South Asia, sometimes ten or more doses of the vaccine need to be administered, each a month apart, in order to ensure immunity. The month-long spacing can itself be a reason for families not to complete the vaccination schedule, because transportation could prove unreliable from month to month, and parents might be unable to take time off of work for risk of losing the day's income or losing their job entirely. The threat of natural disaster also plays a role in delaying total eradication of polio. For example, Pakistan is prone to earthquakes and heavy monsoon rains. In the
2010 Pakistan floods The floods in Pakistan began in late July 2010, resulting from heavy monsoon rains in the Khyber Pakhtunkhwa, Sindh, Punjab (Pakistani province), Punjab and, Balochistan, Pakistan, Balochistan regions of Pakistan, which affected the Indus Riv ...
, of the 20 million affected, a majority were in the lowest socioeconomic percentile. In addition to cases of
dengue fever Dengue fever is a mosquito-borne disease caused by dengue virus, prevalent in tropical and subtropical areas. Asymptomatic infections are uncommon, mild cases happen frequently; if symptoms appear, they typically begin 3 to 14 days after i ...
,
cholera Cholera () is an infection of the small intestine by some Strain (biology), strains of the Bacteria, bacterium ''Vibrio cholerae''. Symptoms may range from none, to mild, to severe. The classic symptom is large amounts of watery diarrhea last ...
, and
measles Measles (probably from Middle Dutch or Middle High German ''masel(e)'', meaning "blemish, blood blister") is a highly contagious, Vaccine-preventable diseases, vaccine-preventable infectious disease caused by Measles morbillivirus, measles v ...
, the WHO reported an upsurge in cases of polio. By November 2010, Pakistan accounted for about 62% of all polio cases from endemic countries, with most new cases being from areas affected by the floods.


Perceptions of Pakistani parents

Another reason for the resistance to the polio vaccine is one of mindset. There is a common perception that other issues are more pressing than vaccination. A manifestation of this is the policy perspective that, if the source of the virus is contaminated drinking water, efforts should be made to purify the water rather than focus on the treatment of disease caused by ingesting the water. Surveys of the Pakistani population show that a significant number feel that the allocation of funding to prevent the problem is more efficient than retroactive treatment once the problem (the spread of polio) has already happened. Additionally, it has been shown that low parental - specifically, maternal - literacy and knowledge regarding vaccines and immunization schedules, poor socioeconomic status, and residence in rural areas all are attributable to decreased rates of immunization completion. Parental
education Education is the transmission of knowledge and skills and the development of character traits. Formal education occurs within a structured institutional framework, such as public schools, following a curriculum. Non-formal education als ...
is one of the most important determiners of whether children will complete their vaccinations. In a study of two-parent households in Pakistan, it was shown that the father's knowledge about health most impacted immunization decisions, with an effect so large that some researchers contend improving education will improve health more so than even the provision of health services.


Militant opposition to vaccine distribution

On 13 January 2016, a
suicide bomber A suicide attack (also known by a wide variety of other names, see below) is a deliberate attack in which the perpetrators knowingly sacrifice their own lives as part of the attack. These attacks are a form of murder–suicide that is ofte ...
detonated himself near security personal vehicles close to a polio centre in a town near
Quetta Quetta is the capital and largest city of the Pakistani province of Balochistan. It is the ninth largest city in Pakistan, with an estimated population of over 1.6 million in 2024. It is situated in the south-west of the country, lying in a ...
, Balochistan. The bombing killed at least 15 people, including 13 policemen and one soldier, and wounding another 25. Both
Tehrik-i-Taliban Pakistan The Pakistani Taliban, officially the Tehreek-i-Taliban-e-Pakistan (TTP), is an umbrella organization of various Islamist armed militant groups operating along the Durand Line, Afghan–Pakistani border. Formed in 2007 by Baitullah Mehsud, i ...
and Jaishul Islam organizations claimed responsibility for the attack. In another attack on 30 November 2022, a suicide bombing of a
police The police are Law enforcement organization, a constituted body of Law enforcement officer, people empowered by a State (polity), state with the aim of Law enforcement, enforcing the law and protecting the Public order policing, public order ...
truck in Quetta killed 3 people and injured 27 others. The police were travelling to protect
polio Poliomyelitis ( ), commonly shortened to polio, is an infectious disease caused by the poliovirus. Approximately 75% of cases are asymptomatic; mild symptoms which can occur include sore throat and fever; in a proportion of cases more severe ...
vaccinators. On September 12, 2024, a polio worker and a policeman were killed by a gunman affiliated with Tehrik-i-Taliban Pakistan.


Other factors

Widespread
malnutrition Malnutrition occurs when an organism gets too few or too many nutrients, resulting in health problems. Specifically, it is a deficiency, excess, or imbalance of energy, protein and other nutrients which adversely affects the body's tissues a ...
in Pakistani children is a factor in lowered resistance to disabling diseases and reduced efficacy of the polio vaccine. In 2019 there were allegedly 'a dozen' cases of the most dangerous P2 strain from vaccine mismanagement.


Impact of polio in Pakistan

Polio has had drastic effects on the health of the population of Pakistan and on the nation's healthcare infrastructure and economy. The WHO estimates that 65–75% of polio cases in developing countries occur in children under 3 years of age, with 95% of all cases occurring in children under 5 years of age. Researchers at the School of Public Health at Johns Hopkins University quantified the
disease burden Disease burden is the impact of a health problem as measured by financial cost, mortality, morbidity, or other indicators. It is often quantified in terms of quality-adjusted life years (QALYs) or disability-adjusted life years (DALYs). Both ...
of various diseases in Pakistan; in the year 1990, a Pakistani person with polio averaged a loss of 1.13 healthy life years to the disease. The duration of disability of polio, averaged over 1000 people, was 81.84 years, the equivalent of diseases including
diphtheria Diphtheria is an infection caused by the bacteria, bacterium ''Corynebacterium diphtheriae''. Most infections are asymptomatic or have a mild Course (medicine), clinical course, but in some outbreaks, the mortality rate approaches 10%. Signs a ...
, childhood meningitis, and
measles Measles (probably from Middle Dutch or Middle High German ''masel(e)'', meaning "blemish, blood blister") is a highly contagious, Vaccine-preventable diseases, vaccine-preventable infectious disease caused by Measles morbillivirus, measles v ...
. There has been limited research into the impacts of polio in Pakistan in recent years, but a 1988 health survey found that the most common handicaps among individuals with polio were associated with mobility, occupation, and social integration. The survey found differences in participants based on whether they lived in a village or a slum area: there was a higher rate of disability in the village population, and higher frequencies of infectious, respiratory, and digestive diseases in the slum area. Both areas saw individuals with polio have a higher incidence of musculoskeletal system diseases, as well as infections of the ear, and respiratory tract. Given 1–2 years with occupational therapists, 80% of patients with handicaps showed improvement in function.


See also

*
Polio Poliomyelitis ( ), commonly shortened to polio, is an infectious disease caused by the poliovirus. Approximately 75% of cases are asymptomatic; mild symptoms which can occur include sore throat and fever; in a proportion of cases more severe ...
*
Eradication of polio Polio eradication, the goal of permanent global cessation of circulation of the poliovirus and hence elimination of the poliomyelitis (polio) it causes, is the aim of a multinational public health effort begun in 1988, led by the World Healt ...
*
Vaccination Vaccination is the administration of a vaccine to help the immune system develop immunity from a disease. Vaccines contain a microorganism or virus in a weakened, live or killed state, or proteins or toxins from the organism. In stimulating ...
*
Polio vaccine Polio vaccines are vaccines used to prevent poliomyelitis (polio). Two types are used: an inactivated vaccine, inactivated poliovirus given by injection (IPV) and a attenuated vaccine, weakened poliovirus given by mouth (OPV). The World Healt ...


References


Further reading

* Closser, Svea. ''Chasing Polio in Pakistan: Why the World's Largest Public Health Initiative May Fail.'' Vanderbilt University Press, 2010. . * "
Every Last Child ''Every Last Child'' (2014) is a Pakistani and UAE documentary film directed and produced by Tom Roberts and made under the Imagenation Abu Dhabi FZ banner. Roberts also wrote the story of the film. The film was released in three different langu ...
," documentary film, 2015.


External links


End Polio Pakistan


{{Eradication of infectious disease
Pakistan Pakistan, officially the Islamic Republic of Pakistan, is a country in South Asia. It is the List of countries and dependencies by population, fifth-most populous country, with a population of over 241.5 million, having the Islam by country# ...
Diseases and disorders in Pakistan Conspiracy theories in Pakistan fr:Éradication de la poliomyélite#Au Pakistan