EFTA00586403.pdf

Strictly Confidential: IPI Mission Report 15 May 2013 POLIO ERADICATION IN PAKISTAN: PROBLEM AREAS & POSSIBLE SOLUTIONS Afghanistan MINIUM PANCY Batochistan Tap4 'Stan WALM, A110 /14,01.. A.•O1..Y w.X.0.10 Panjab ,11.1M r' AM Northern Areas hattSIOI District Map of NWFP & FATA (2004) Ilse klub. tutew.y • Tom. • tiller triaqi Ales Pie"Inclally A•Saltleiod TIiJ Arc., lk.gan•ennon,lin siPanun atm" • P• *mull intwair, Sunlit •FATA Note: This is not a comprehensive report on polio eradication in Pakistan, nor a technical assessment The mission was undertaken to acquire an on-the-ground picture from the affected communities and prepare a Roadmap with ideas on how to fill in the gaps and weaknesses. What may be of interest are the nuances which have emerged from the direct talks with the interlocutors from the tribal areas, as well as ideas on how to use the limited opportunities which present themselves. EFTA00586403 Executive Summary: National and international organizations have, since decades, been involved in the eradication of polio and other diseases in Pakistan. However, the recent informal mission and meetings confirmed that the Gates Foundation played a key role in polio eradication acquiring the status of "highest national priority." Further, the Gates Foundation provided the impetus in the setting up of the Prime Minister's Polio Monitoring and Coordination Cell and the National Emergency Action Plan (NEAP). NEAP, too, was the brainchild of the Gates Foundation. It is well-conceived, with appropriate structures at the national, provincial, Agency and district levels. Owing to the generosity of the Gates Foundation and the example it set for other international donors, the polio eradication programme in Pakistan faces no dearth of funding. As a result, Pakistan was close to complete polio eradication, when a combination of external circumstances (conflict, terrorism, drones, anti-US sentiment, ban on anti-polio drops) as well management issues (relating to corruption, accountability, too exclusive a focus on polio eradication to the detriment of routine immunization, poor infrastructure etc.) created again an increase in the number of polio cases. The vast majority of remaining polio cases today are found in the Federally Administered Tribal Areas (FATA), where two of its seven tribal agencies (North Waziristan Agency (NWA) and South Waziristan Agency (SWA) ) are particularly hard-hit, with cases reported in Balochistan and Sindh Provinces, invariably all with a Pashtun connection. The"good" Taliban in North Waziristan Agency issued a ban in June 2012 which the "good" Taliban in South Waziristan Agency observe as well. The "bad" Taliban, i.e. the Hakimullah Mehsud-led Tehreek e Taliban Pakistan (TTP) have not issued a ban! The information acquired leads to the conclusion that religion-based refusal is a very small part of the problem; the rest is pressure tactics not only by the Taliban but also by local communities to achieve other ends; one-upmanship; poor follow-up & monitoring; the security situation (i.e. the one-day polio eradication campaign with anti-polio drops cannot be carried out if the Pak Govt is carrying out a military operation in the area); problems relating to the anti-polio campaign visavis the other routine immunizations; and the corruption resulting from the vast amount of money and jobs involved. Inaccessibility, too, is not a major problem, since the same remote locations were covered in the past, when polio cases did go down dramatically, hence is used more often as an excuse now. It is also likely that the very low number of polio cases recorded a few years ago stemmed more from under-reporting, in particular by families in remote locations or without the means to visit a health facility. For every polio case reported, FATA health professionals estimate that that at least three to four cases go unreported. This type of mis- or under-reporting in developing countries is a phenomenon well-known to UN social development agencies. Security continues to be an issue, but not an insurmountable one. Although there was a great deal of pre-election turbulence, including bombing and suicide attacks, and despite the TTP threat of having teams of suicide bombers standing by to disrupt the elections, these took place fairly smoothly on 11 May 2013, including a record-breaking turn-out in FATA as well. Women voted in unprecedented numbers in many of FATA's seven tribal Agencies. EFTA00586404 Next steps: A new Govt will not be formed until mid-June at the earliest. Thereafter, IPI should undertake a second mission to Pakistan, to explore further some of the points in the body of the preliminary mission report, viz.: (i) de-link polio eradication from all other issues; (ii) examine whether "Days of TranqUilitr and "Safe Passage" (originally introduced by UNICEF precisely to enable child immunization, and now used in Afghanistan with the approval of the Afghan Taliban) could be introduced in the two FATA Agencies where the ban is in effect as well as in trouble zones in other FATA agencies; (ii) follow-up on the modalities being developed regarding the United Arab Emirates (UAE) grant of US$ 110 million for polio eradication in FATA over three years; it appears that this project will be supervised by the Pakistan Army's Surgeon-General, with the Army responsible for both disbursing the funds and monitoring implementation. This modus operandi, while not ideal, may well provide solutions to the problems of corruption and mis-management which have engulfed polio eradication in Pakistan. Army involvement should also take care of the security angle. (iii) discuss further with FATA health officials in Peshawar their plans to combat corruption, improve accountability, and the re-introduction of incentives for reporting polio cases; (iv) follow-up on the Govt's plan to give the polio eradication campaign (PEC) a lower profile, to ensure that this is not detrimental to polio eradication; (v) encourage the Govt health authorities not to neglect routine immunizations, as the exclusive focus on polio eradication has not only had an unintended negative effect but has also upset the target communities; (vi) discuss the important issue of a less than optimal cold chain (the process whereby vaccines must be kept at a required temperature at all stages of their transport and storage, from manufacturing to the end recipient of the vaccination) at the field level; provision by the Govt of electricity would help; (vii) explore if the Pak Army and JUI-F, a religion-based Islamist party with a large following in FATA, can get the "good" Taliban leader Gul Bahadur in North Waziristan Agency to lift his ban (Gul Bahadur was earlier associated with JUI-F); thereafter the Mullah Nazir Group in South Waziristan Agency will automatically lift its ban; finally, the TTP could be approached to ask them to remove their reservations on polio eradication (although it has now become clear that TTP would like to open a dialogue on polio eradication more to acquire legitimacy and to introduce other issues); (viii) also attempt to get the Pak Army to get Mullah Omar, head of the Afghan Taliban, to issue an appeal to the TTP to support polio eradication; (ix) an opportunity could be provided by the new Provincial Govt in Khyber Pakhtunkhwa Province (KP); EFTA00586405 (x) get a video interview done with TTP Spokesperson Ehsanullah Ehsan on polio eradication. The situation, while difficult, is not hopeless, and the last inch can indeed be run and won! List of main abbreviations in the Executive Summary and body of report: CMCC: civil-military coordination committee DDM: direct disbursement mechanism of salaries FATA: Federally Administered Tribal Areas IDPs: internally displaced persons JUI-F: Jamiat Ulema Islam (Fazlullah), a religion-based Islamist party KP: Khyber Pakhtunkhwa Province (earlier called the North West Frontier Province), which borders FATA NEAP: National Emergenvy Action Plan PE: polio eradication PEC: polio eradication campaign TTP: Tehreek e Taliban Pakistan, a loose grouping of the so-called "bad" Taliban, which owes allegiance to Mullah Omar, head of the Taliban in Afghanistan; the "good" Taliban are not part of TTP, although they, too, are close to Mullah Omar UNICEF: United Nations Children's Fund WHO: World Health Organization. EFTA00586406 Introduction: Thanks to a very successful global campaign over the past decade, polio has been successfully eradicated in 99.9% of the world; however, it remains endemic in only three countries -- Afghanistan, Nigeria and Pakistan. In Pakistan, the vast majority of remaining polio cases are found in the Federally Administered Tribal Areas (FATA), where two of its seven tribal agencies (North Waziristan Agency and South Waziristan Agency ) are particularly hard-hit, with cases reported in Balochistan and Sindh Provinces, invariably all with a Pashtun connection. Owing to porous borders and close kinship ties, there is the danger of polio spreading to and from Afghanistan, and possibly beyond. Hence eradicating polio globally and permanently has come down to the ability to reach those reservoirs of children in a handful of unstable, isolated and inaccessible areas and communities. Wiping out polio under these conditions requires more specific and tailored approaches from the global campaign which has worked in the vast majority of countries, including in the rest of Pakistan. This is an internal IPI mission report, based on an informal visit to Pakistan over five days, between 27 April and I May and focusing on the north-west of the country, the source of the problems. Meetings were held with a variety of sources to enable a snapshot of the present state of play. These contacts/discussions included non-official sources and official health sources in Peshawar, the seat of both the tribal FATA Secretariat as well as the Provincial Govt, and official sources in the national capital Islamabad -- including by coincidence Dr Waqar Ajmal, the Pakistani technical focal point for polio at the Gates Foundation, who is based in Seattle but was visiting Pakistan. Background: Intensive informal meetings were held bilaterally or in small groups with a variety of representatives from FATA's seven tribal agencies (Bajaur, Khyber; Kurram; Mohmand; North Waziristan; Orakzai; South Waziristan) and some adjacent semi-settled areas (Kohat, Swat and Shangla). The interlocutors were from leading tribes in each FATA Agency, and by profession mainly development workers, social workers, journalists and small enterpreneurs. They live in their ancestral villages and small towns, and manage to be mobile, travelling with great difficulty to nearby urban areas for work or other reasons. A number are internally- displaced persons (IDPs). The tribal interlocutors were selected on the basis of their ability to provide authentic and accurate on-the-ground information on polio issues in their respective tribal Agency. Note: Similarities in the problems voiced by different tribal interlocutors were less of a surprise than were the modest "success stories," which provide reason to hope that the last inch can indeed be run and won! Federally Administered Tribal Areas (FATA): EFTA00586407 Straddling the wild and difficult terrain between Pakistan and Afghanistan (only one of FATA's seven tribal Agencies does not share a border with Afghanistan), FATA is overwhelmingly Pashtun (most have family ties in Afghanistan), fiercely independent, very conservative, has a rampant gun culture, and follows a fundamentalist version of Islam. Smuggling is a time-honoured profession. The laws governing the rest of Pakistan have no jurisdiction in FATA, to which a separate set of rules and regulations going back to British times are applied. FATA has been largely left out of the infrastructure development seen in the adjoining Khyber Pakhtunkhwa Province (one of Pakistan's four provinces) or in the rest of Pakistan. The problems in FATA, other than conflict, insurgency, terrorism and illegal activities, stem from lack of development; poverty; inadequate basic services; poor or absent secondary or tertiary health facilities; few jobs or legal means of earning an adequate livelihood; difficult terrain hence difficult access; very low rates of education and in particular very low female literacy. A native conservatism and Talibanization affect public information campaigns - TV satellite dishes are opposed, as are cellphones with camera. For its own protection, each family generally provides one male member to the Taliban or to whichever militant group holds power in the locality. Sources of income include smuggling of drugs, arms, consumer goods; kidnapping and extortion; legal and illegal transport of goods to and from Afghanistan; and migrant labour in the Gulf -- hence local sources of income such as from a polio eradication campaign (PEC) are popular and a source of patronage. FATA is the highest-risk zone for polio transmission in Pakistan; 79-80% of polio cases are related to the Pashtun community in FATA or KP. Polio cases in FATA peaked in 2010, at 74; in 2011, there were 59, and in 2012 there were 20. Winter is low season, transmission season is May to Oct/Nov. Snapshot of Pakistan's existing polio eradication (PE) system: (i) In 1994, when the Polio Eradication Initiative was launched, 24,000 polio cases were reported, which came down to the lowest level in 2005 and in 2007 figures still remained low. Indeed, polio was almost on the verge of eradication. The PE programme was technically good, despite management weaknesses, but in the face of additional challenges (Talibanization, conflict along the western border, spread of the Taliban into Swat etc), an upward spiral began. Between 2009-2010, the numbers of cases were in the 90s and 100s; in 2011, 198 cases created an outcry at the international level. The Govt realized that the problems relating to management, corruption, and accountability needed to be dealt with. (ii) Prime Minister's Polio Monitoring & Coordination Cell & NEAP: polio eradication has been assigned the highest priority by the Govt of Pakistan -- in fact it was declared a national emergency, with a National Emergency Action Plan (NEAP) introduced in January 2011, giving PE the highest level of priority. The NEAP 2011 target was a December 2011 stop in cases; NEAP 2012 was an augmented NEAP, with all district administrations made responsible via the Deputy Commissioners and Political Agents. In 2012, the cases came down to 58, PE acquired momentum and eradication was almost in sight. NEAP 2013 has a few additional changes: (a) integrating operational and communications plans into one EFTA00586408 whole; (b) stopping polio transmission by June 2013; and (c) and tracking missed-out children before the next PEC. (iii) NEAP is well conceived; it has a very good data-base; originally, the Govt had a fairly good and wide-spread information campaign, with announcements on TV, radio, print media, wall chalkings (graffiti) banners etc.; this info campaign has been made low-key in the face of threats by the militants. (iv) there are ca. 15-20 PECs per annum; each child costs Rs. 20 per PEC (ca. Rs 30 million); ideally each child should be vaccinated at birth, 1 month, 6 months, 12 months; (v) PEC cycle (each covers ca. 15-20 days): 15 days before a PEC, the Union Council Polio Eradication Committee UPAC prepares micro-plans: covering children up to five yrs, in- flows & out-flows of children etc.; 10 days before a PEC each UPAC meets; there is a CMCC (civil-military coordination committee); training of the area in-charge; acquisition of vaccines, cold chain, transport; 3-day door-to-door visits; 4th & 5th day follow-up; 6th day post-PEC monitoring by WHO — after which a new cycle starts. (vi) UNICEF pays 170 staff in all FATA Agencies for social mobilization only on the polio issue (UNICEF had hired the National Reconstruction & Development Foundation (NRDF), an NGO with a set-up in each Agency and the Frontier Regions, through which clerics were paid to support PEC & issue fatwas, but apparently funding became an issue in 2012. (vii) Direct disbursement mechanism (DDM): to deal with corruption and siphoning off of funds, a new system (originally started in Nigeria) has been introduced omitting the middlemen, with 70%-80% of the "end workers" receiving payment due directly into their bank accounts. (viii) Refusals in ICP: 17,000 refusals out of 5.2 million target children under 5 years, but after the anti-polio worker shootings, the refusal rate is now ca. 28,000-29,000. (ix) Sindh: cases recorded are among Pashtun children in Karachi (if they are permanent residents in Karachi, they are not mapped in KP records); of the two cases reported recently in Karachi, one family was originally from Swat, settled in Karachi, father has polio; the second was recorded in Dadu. In 2012, there were three cases in KP, among Pastuns who, after 10 years in Karachi, had shifted back to KP and two of the children had never been vaccinated in Karachi; (x) Balochistan: "Quetta Bloc" = Pashtun areas in Quetta, Pishin, Qila Abdullah. (xi) Wild polio virus: According to its genetic lineage, there are three types of polio virus; Type II has been eradicaled globally, Type I and Type III are still around; in Asia Type III is found, of which two cases were reported in Khyber Agency; the rest are Type I. (xii) China recorded a few cases of Type I among children in the Xinkiang province with Uighur Muslim majority and a probable transmission link to Afghanistan/Pakistan -- the Chinese authorities immediately administered anti-polio drops to all! Pixels of polio eradication (PE) issues: PE worked fairly well for years, despite inherent difficulties and weaknesses. The following points were conveyed by the interlocutors as representative of the views held in their areas and have been compressed and aggregated under categories: "Polio has become as important as the nuclear bomb"... there is almost as much attention and money assigned to PEC as to our nuclear assets!... people involved in polio eradication have become millionnaires... people have a regular source of income as long as there is polio... if the Govt does not care about people's basic needs, it should not worry about polio either!" As interlocutors made these analogies and statements, all heads nodded vigorously in agreement. EFTA00586409 High-profile PEC: many Govt health officials agree on the negative effects as unintended consequences of a high-profile and almost exclusive focus on polio: (a) recognizing its importance to the Govt, and the world, the militants and even others exploit this weakness and use it as a bargaining chip (they are well aware that the Govt can do little against the drone attacks): no water, PEC stop; no electricity, PEC stop; release our comrades from prison, or PEC stop (even criminal gangs are using this tactic). Solutions: (a) use the service delivery mechanism created for PE also for routine vaccinations and the expanded programme of immunization (EPI); (b) continue PEC but with a lower profile; (c) strengthen normal health care and routine immunizations; and improve the EPI programme, which has suffered from an exclusive attention to polio; fixed sites; outreach which is not vigorous; and no longer house-to-house visits. Social issues: Tribal communities, fed up with socio-economic disadvantages and difficult living conditions, voice the view that poverty will kill them anyway, so what if a child gets polio; the (male) child will not be able to earn a living anyway so what if he is crippled; they often use a stop on PEC as pressure to acquire other essential services such as electricity or water in return for supporting PE; there remains widespread suspicion of UN, NGOs, including local NGOs who receive external funding. Health issues: (i) there are far worse diseases, which kill, while polio only cripples, so why is not as much being done against these diseases? (ii) maternal and infant morbidity and mortality are major problems but are largely ignored in favour of PE; (iii) PE competes with routine vaccinations and wins; (iv) expired vaccines; (v) some families may refuse to administer vaccines to an only son; (vi) suspicion of the quality of govt-issued anti-polio drops (many medical staff get the vaccines from overseas, either Saudi Arabia or the US, for their own children); (vii) get the vaccine ingredients tested by doctors acceptable to the conservatives (to prove that the ingredients are not harmful). (viii) a few cases of children getting polio despite PEC (probably skipped, or cold chain broke) has created fear. Religious and related issues: Refusal is minimal on religious grounds as a result of effective PEC; it is more a complex of reasons as noted under the different sub-headings in this section: (i) religious leaders are not being involved in the right manner (WHO & UNICEF have financed a project through the National Reconstruction & Development Foundation to involve FATA clerics in supporting PE, though many interlocutors criticized the selection process); (ii) the selection process of clerics is important, as there are different religious currents such as Deobandi or Ahle Hadith or Tablighi, which hold sway in different parts of FATA; EFTA00586410 (iii) some clerics harbour doubts about the ingredients in anti-polio vaccines (i.e. it is disguised birth control, affects virility, creates sterility and infertility, either as unintended consequences or as part of a western conspiracy against jihad and Muslims); (iv) PE has become a jihad issue linked to family planning: bara khandan, jihad asaan ("big families help jihad"); (v) after the Osama bin Laden raid in Abbotabad in May 2011, many clerics no longer speak out in favour of PEC; (vi) a "war" of the Fatwas, pro and contra; (vi) for all Haj pilgrims, anti-polio vaccination is essential — those ostensibly opposing anti- polio drops for their children take it themselves!; (viii) earlier, the imams used the Friday khutba (sermon) but many have stopped for a mix of reasons; (ix) symptoms of polio are ascribed to jinn, or that the tribulation is from Allah, as everythjing, good and bad, is from Him; (x) Tribals from SWA and NWA who have fled their homes and crossed over into a safer location, do bring their children for the drops, despite the prevailing ban on PEC in these two tribal Agencies; (xi) There is no Taliban ban on PE in Afghanistan (see below) although the Taliban in Pakistan and the Taliban in Afghanistan enjoy close links. Awareness issues: (i) a continuing lack of awareness in some Agencies (earlier gains made as a result of Govt public information campaigns have decreased in certain areas); (ii) the earlier awareness programmes via the Govt's public information campaigs were good, but ever since these were stopped or made low-key as a result of TTP pressure and security concerns, awareness has also receded; re-start public information campaigns; the FATA Health Secretariat has a media directorate which runs two radio channels; exact PEC dates are not announced so as not to alert the militants; the campaign against PEC appears to be more effective than the PEC!; earlier, PEC was advertized and disseminated on TV but since the use of satellite dishes was stopped (TTP criticize TV shows as unlslamic except religious shows), this medium remains unused in FATA (although satellite dishes can be found in many hujras, guesthouses belonging to tribal chiefs and important community leaders); (iii) involve the media (a number of international agencies and other donors have held workshops); use social media; internet radio etc; (iv) set up a committee in each village, made up of elders, imams, teachers etc. to support PEC (process of selection is important); (v) local legitimacy: use tribal jirgas; get Maliks (hereditary tribal chiefs), fungi holders (local elders other than Maliks), and other such persons who command authority, to administer drops (a rep. from another Agency disagreed, preferring those with spiritual authority); (vi) Surveyst_There are numerous surveys on all types of social issues, including polio; since 9/11, Pakistan has been surveyed to death! All reps made fun of survey sponsors, at their "stupid" questions, and categorically stated that the majority of questionnaires were filled out by a few persons (surveys are well-financed but require a great deal of effort especially in remote areas) and that depending on the theme, those surveyed deliberately gave wrong information or provided answers which would please the sponsor -- probably some applicability to polio as well. Political issues: EFTA00586411 There is no concerted effort to convince militant groups to allow PE; the deliberate use of a PEC ban or stop as quid pro quo -- as pressure tactics by militants to get comrades or relatives freed from prison; Corruption issues (money, goods, services, jobs): Polio eradication is very lucrative: (i) suspicions against the health authorities as PECs are very lucrative (one health worker receives Rs. 1,500 per one-day campaign, the supervisor gets Rs 2,900; some health staff make up to Rs 36,000 per PEC; (ii) "ghost" polio worker teams, eg. lower actual numbers are lower, the difference is pocketed, ditto numbers of transport vehicles; sometimes the "ghost" teams are at multiple levels, eg. health workers paid by the Govt, hospital teams, plus checkpost volunteers, hence "ghost" teams or "ghost" staff at each stage (eg. funds for two staff are used to employ one person only, the second stipend is pocketed); (iii) there are "ghost" children, eg. one vial costs Rs. 1,000 at the subsidized rate (actual cost is higher), the vial covers up to 20 recipients, but is actually given to 14 or 15 children only — i.e. larger amounts of vaccine are recorded than are strictly necessary; (iv) some health teams do not get paid for months, eg. in one Agency, health workers have not yet been paid for the past eight PECs; (v) many foreign-funded projects aimed at raising awareness of social issues including PE were criticized as being part of the chain of corruption; (vi) the corruption is widespread and not restricted to PE, eg. a FATA rep. recalled that as a student he had received a scholarship of Rs. 15,000 pm for 2 years, but he used to get half only; (vii) PEC jobs are given on the basis of patronage and safarish (connections); Egs: a political leader in a FATA Agency stopped opposing PEC after an NGO gave him water-pumps which cost Its 5,000 each; and solar-powered deep freezers provided by WHO are often kept by govt staff in their homes for private use in areas where there is no electricity; (viii) Too much khanapuri (simply ticking off boxes, often resulting in inaccurate reporting on forms). Funding issues: There is no lack of funds either from the national exchequer or from external donors. The UAE Govt has pledged US$ 110 million to cover all PECs in FATA over the next three years. The Memorandum of Understanding (MoU) has still to be signed and the precise modalities are being worked out, including the visits of teams from UAE. The Govt health authorities understandably want non-FATA adjacent areas to be included to prevent cross-infection -- this point is still being negotiated. The UAE grant is considered important not only because of the funds, but because it is the first major involvement of a Muslim Arab country with the hoped-for concomitant effect of stilling suspicion in FATA and KP. Note: There is agreement at the highest Pak Army levels that the UAE-funded polio eradication programme will be placed under the supervision of the Pak Army's highest medical authority, the Surgeon-General. The Army will be involved in disbursing the UAE funds and monitoring their use; the local health workers will be under Army supervision. EFTA00586412 PEC-related issues: (i) poor delivery system in many tribal areas: eg. a health worker hands over an anti-polio kit to a young boy and sends him off to administer the drops to children in his village or hamlet; (ii) breaks in the cold chain (also reported by field-level staff interviewed separately); (iii) poor monitoring system or follow-up; (iv) under-reporting and mis-reporting of polio cases (see Note below): (v) skewed financial benefits, eg. a medical technician in a hospital receives a salary of Rs. 18,000, and gets in addition Rs 30,000 for a PEC -- this increases suspicion among a conservative constituency that money, not health care, is behind the PEC; (vi) in addition, some medical technicians who were not selected for the PEC, turned anti- PEC; (vii) this double-dipping needs to be controlled and better thought-out, i.e. what started out as an incentive is now leading to problems; (viii) inadequate system of reporting abuse, i.e. those to whom abuses should be reported are often part of the system of abuse; (ix) structural and systemic reforms are required (beyond the scope of this Report); (x) short-term, medium-term, and long-term solutions required: in the short-term, improve all basic health services, especially routine vaccinations, with door-to-door delivery; in the medium-term, fight corruption and establish justice; in the longer-term, improve infrastructure and invest in development; (viii) young women in health teams arouse the ire and opposition of conservative communities and bring PEC a bad name; (xi) teams sometimes skip remote, inaccessible locations; (xii) forms are filled out in numbers exceeding those actually vaccinated; (xiii) poor accountability; (xiv) some of the "refuseniks" (as they were referred to!) are elected officials; (xv) pressure on junior field staff not to report "missed out" children; they cannot complain because of intra-family or inter-tribal considerations and snitching could lead to a blood fued. Note: Under-reporting and mis-reporting of polio cases: Reported by almost all interlocutors, but conceded by only two Govt health sources, one spoke directly and openly, the second was more indirect and hesitant to concede; this could be a partial explanation of the very low recorded figures in past years. The under-reporting arises less from unintentional or intentional fudging by field staff, and more from the fact that families are either located in a very remote area, or lack the knowledge or resources to bring the affected child to a health facility. This is comparable to similar mis- or under-reporting in the developing countries, a phenomenon well-known to UN social development agencies in many social sectors. A public health specialist advised that even now, for every one reported case of polio, at least three to four go unreported, and that with one polio case, ca. 200 households around are in danger of infection. Surveillance is carried out by WHO staff. FATA health authorities used to have a surveillance project under which a cash incentive of Rs. 5,000 was given for every polio case reported and are now planning to re-introduce this to encourage reporting. Security issues: Although there are genuine security issues, security considerations are sometimes invoked unnecessarily. EFTA00586413 (i) there have been no attacks on PEC workers in FATA, only threats so far; TTP strongly denies it is behind the attacks in KP, Sindh and Punjab provinces - it is clear, however, that anti-State elements are using these attacks to hit the Govt where it hurts; (ii) PEC has become a security issue eg. in some areas in KP; a health team is protected by three khasssadars (tribal levies) who in fact may be the target of the attacks; (iii) the Dr Shakil Afridi phenomenon with the fake hepatitis campaign in Abbotabad (he did actually cover Bajaur Agency) has multiplied suspicion and played into the hands of the "western conspiracy" theorists as well as strengthened the position of those who link PEC to espionage; (iv) militants and drones are not as important to PEC as they are made out to be -- earlier, the same militants had no issues with PEC; (v) there are allegations of deliberate attempts to show PEC as high-risk, and drama created around the issue. (vi) road construction labourers working on a highway from Bannu to Ghulam Khan in North Waziristan Agency (on the border with Khost in Afghanistan) are protected by the Pak Army, so query as to why health workers cannot be similarly protected. The Tehreek e Taliban Pakistan (TTP) position differs from their Taliban brethren in Afghanistan. The hardened position of TTP on PE is related to their desire not to be seen as less "Islamic" than the other hard-liners: "We have not banned polio drops, but we need a dialogue that it is not anti-Islam!? Essentially, the TTP wants a platform or dialogue, and the leghitimacy that would flow from such a dialogue; in addition, the dialogue would immediately be used to insert other demands. The TTP insists it has not attacked any health workers, but does say: (a) the drones kill us, the UN does nothing, but wants our cooperation in polio eradication? We don't want the UN's sympathy!; and (b) if the vaccine ingredients can be proved to be in compliance with Islam, we will administer the drops ourselves! Pakistan-Afghanistan cross-border infection and re-infection via transit of children: There are over 500 informal crossings along the long porous border; six transit points are permanently staffed, with additional transit points between FATA and the settled areas, where anti-polio drops are available until sunset daily. "Catching" the children at these transit points is particularly important owing to the constant movement of families and because children may well miss out PEC in both their home locations as well as elsewhere and thus be a source of infection and re-infection. Main FATA transit points along the Pakistan-Afghan border: SWA: Angoor Adda; NWA: Ghulam Khan and Datta Khel; Khyber: Torkham (with PE), Tirah (Tabai); Shalman (Ghakhi); Mohmand: no crossing point; Bajaur: of the four, Latai, Kagga, Ghakhi Pass and Nowa Pass, only Latai and Kagga are used; Orakzai: the only Agency without a border with Afghanistan, hence people use Bajaur crossing points; Kurram: border checkpoints in Upper Kurram (Kharlachi and Gawai) and in Lower Kurram (Shaheedan Dand, Charguti, Shabak, Ahmad Shin, Batti). Afghanistan: EFTA00586414 PECs are functioning very well, with the Afghan Taliban cooperating with the Afghan Govt, with "Days of Tranquility" and "Safe Passage;" in fact the Afghan Taliban assist the Afghan health workers to carry out their work by issuing a letter "authorizing" this prior to each PEC; in 2013, two new cases have so far been recorded in the area bordering Pakistan — after the Pak Army military operation in Swat in 2009, militants fled into adjacent Kunar Province in Afghanistan). The Afghanistan Govt gives anti-polio drops to children who cross over from Pakistan, but there are children who miss out on PEC on both sides of the Durand Line, the unofficial de facto border between Pakistan and Afghanistan. Security issues at present: According to a very senior defence official, the turbulence and bomb attacks are mainly related to the elections & are politician-oriented, i.e. not too many law enforcement agencies or personnel are being targetted; the TTP issued end April 2013 a statement against democracy and declared open season on secular parties; Post-elections: the new Govt, whatever the composition, will try to introduce a fresh approach, which cannot be predicted at this stage -- maybe negotiations or military operations — hence for some time to come, the security situation may worsen. Afghanistan post-2014: If the US withdrawal leaves behind an unstable environment, and depending on who comes in after Karzai, and if there is no agreement with the Afghan Taliban, there will be civil war. Even with an orderly withdrawal, there will still be a dip in the security situation, with each power source positioning itself. How soon Afghanistan can get out of this dip depends on who is in power in Kabul. This dip/civil war will, in any case, spill over into Pakistan, where the power struggle will breed further instability and unleash negative forces. In KP and FATA, the TTP will try an upsurge, and try to expand in Pakistan; The Pak Army's 11 Corps, responsible for KP, FATA and the border areas: there is close liaison with FATA health authorities, and no PEC is allowed if a military operation is ongoing. EFTA00586415 Annex (informal sampling front each FATA Agency and some semi-settled areas on the basis of meetings with tribals from these areas): North Waziristan Agency (NWA) borders Afghanistan: In NWA and SWA, the Govt is trying to embed PEC in larger health programmes via health campaigns, with Pak Army support; each PEC misses out ca. 250,000 kids in NWA & SWA. The last polio eradication campagin (PEC) with door-to-door visits was in June 2012, which stopped after a ban was imposed by the so-called "good" Taliban leader Gul Bahadur, who announced that no PEC team would be allowed in until the drones were stopped. He charged that while polio could affect a few, the drones killed hundreds of innocent people, including women and children. "More dangerous than polio are spies!" Earlier, when PEC was carried out regularly, children used to run after the PE health teams with their mouths open for the drops! Even today, no girls school has been shut down, TTP send their younger girls to these schools, young women attend the women's college in a burqa. However, this too has become a point of counter-pressure. Eg. if the Pak Army does not remove a particular barrier, the militants will not allow girls to go to college (which is located beyond the barrier)! Some families visit the local district hospital and secretly get anti-polio drops, but it is reported that these are often expired and of poor quality. Families which leave NWA take their children for anti-polio drops, either at checkpoints during a PEC, or elsewhere. The PEC teams are often made up of young local boys who are poorly trained. There are "ghost" health centres without proper staff; curfews and checkpoints make life even more difficult than does militancy. WHO-donated solar powered deep freezers to store vaccines are often taken home by some Govt staff. A Hotline has been set up by the Health Dept but many do not know about it. The security situation is very bad, NWA is subject to heavy drone attacks, the movement of even NWA residents is very difficult, there are multiple checkpoints, at each checkpoint, all males are required to disembark, stand in line to get their ID papers and permits checked, then with hands raised and shirttails in their mouths, with naked upper body, they are made to walk through the checkpoint — to prove they are not wearing explosives belts; even young male children must follow this procedure. NWA has many crossing points to/from Afghanistan, controlled by the TTP; mainly women and children cross over. Note: In early May 2013, NWA's first polio case was detected, as well as two in Khyber Agency; two other cases in KP are in the pipeline as testing takes seven days. South Waziristan Agency (SWA), borders Afghanistan: In NWA and SWA, the Govt is trying to embed PEC in larger health programmes via health campaigns, with Pak Army support; each PEC misses out ca. 250,000 kids in NWA & SWA. Mullah Nazir, the "good Taliban" leader in SWA (droned in January 2013) followed Gul Bahadur's suit, accusing the US of deploying spies; he announced that anyone caught EFTA00586416 administering polio vaccines would be punished (the SWA rep. stated, however, that Mullah Nazir's own family are getting anti-polio drops). While PEC takes place in the 53 villages under Govt control, to which IDPs have returned, ca. 25,000 children are not receiving anti- polio drops. Other reasons are weak polio team set-ups and a poor delivery system. SWA is subjected to regular drone attacks as well as Pak military operations. IDPS from SWA often take refuge in adjacent Tank and Dera Ismail Khan, so a concerted effort should be made to include these IDP children in PEC, although Govt officials said that this is being done. Khyber Agency, borders Afghanistan: Khyber has three sub-divisions: Landi Kotal, Jamrud (on the border with Afghanistan, with Torkham being a major transit point, including for NATO supplies) and Bara. The rep. from Khyber reported very good awareness of PEC. Earlier, health workers went door-to-door for routine vaccinations, now the focus is on polio to the detriment of the other diseases. PEC was originally introduced as part of more comprehensive health care, In Bara, there are military operations with curfews, as well as inter-tribal conflict, which affects PEC. When Bara was under the control of a pro-Govt militant jihadi group (Amr bil Maruf wa Nahi Anil Munkar -- "enjoining good and forbidding evil"), PEC was allowed. In areas controlled by pro-Govt tribes (eg. the Aka Khel pro-Govt "peace militia" ), there have been a few PECs, but not regularly. Six months ago, when the Tirah area (see Note 1 below) was under the control of the pro- Govt group called Ansar ul Islam, PECs took place. At present, Tirah is under the control of Lashkar e Islam which has allied itself with the TTP, so a PEC is virtually impossible. However, as long as there was no military operation, Lashkar e Islam did not impose a ban nor did it attack health workers; the I man- I woman PE team composition was severely criticized. Note 1: The Tirah Valley has an extremely strategic location, as it passes through Kurram, Khyber and Orakzai Agencies in FATA/Pakistan, with Ton Bora in Afghanistan a few kilometres on the other side. The Tirah Valley is a major drugs and arms smuggling throughway. Note 2: In early May 2013, NWA's first polio case was detected, as well as two in Khyber Agency; two other cases in KP are in the pipeline as testing takes seven days. Bajaur Agency, borders Afghanistan: Small land area but a large population; of its seven counties, five are enveloped in militancy (Lower Mamun, Upper Mamun, Charmang, Chamarkand and Salarzai). Pre-militancy, there were no reported cases of polio. A political leader stopped opposing PEC after an NGO gave him water-pumps which cost Rs 5,000 each. On the rumour of anti-polio vaccines affecting fertility, the rep. from Bajaur gave his own example: he has a daughter who was vaccinated and she has borne seven healthy children! Mohmand Agency, borders Afghanistan: Between ca. 2000-2008, the children received anti-polio drops; then the situation changed, clerics began to speak out against the vaccine as part of anti-US sentiment, although there have been comparatively few drone attacks in this Agency. Since home health teams have stopped, some families take their children to Govt health centres to get anti-polio drops. Earlier, PEC was made up of a National Immunization Day in the entire region; plus "sweeps" EFTA00586417 which were home-to-home visits at the district level. Now, the Govt has stopped announcing the PEC date so as not to alert the militants, hence many parents have no way of knowing when the PEC is to take place. Kurram, borders Afghanistan: Has ca. 20-25 tribal groups, including an area with mainly shia tribal communities; there is no polio ban; the percentage of girls attending school is the highest among FATA Agencies. Even in areas under the control of Fazal Saeed, who belongs to the "good" Taliban, PEC has continued. Of 13 BHUs, only two are closed (problem sites, one because of a bomb attack on a polio health worker in Ahmadzai Malikhel -- a shia area -- which was an accident as the landmine had been intended for someone else, and in Parachamkani, next to Ton Bora, where the problem is not one of security but one of remoteness, and lack of access (no roads or transport)). As a result of military operations in Khyber and Orakzai Agencies, IDPs have fled to camps in the Sadda county in Kurram Agency -- they cannot enter an IDP Camp until they have been given hepatitis tests and anti-polio drops. In the shia areas, PEC is 100% successful, partly because the shia have set up their own Pasdaran security system, receive funding from Iran, have functioning schools and health centres, and are well-organized. Note: The Deputy Commander of the TTP's Tariq Afridi Group gave drops to his children and when the news reached the higher echelons, their view was that he could give anti-polio drops in his area, but not to their tribes. Now, even that condition has been lifted and PEC is freely implemented. The "bad" Taliban have left the area, the "good" Taliban are found in some of the FR Kohat areas, but the ban does not apply here! Note: The Tirah Valley has an extremely strategic location, as it passes through Kurram, Khyber and Orakzai Agencies in FATA/Pakistan, with Torn Bora in Afghanistan a few kilometres on the other side. The Tirah Valley is a major drugs and arms smuggling throughway. Orakzai Agency, the only one which does not border Afghanistan: Although Orakzai does not share a border with Afghanistan, nonetheless it occupies a strategic position in the map of m,ilitancy as this Agency is a crucial link for militants moving among other FATA agencies, as well as a major transit route for the Pak Army. It borders Peshawar, the provincial capital as well as Kohat, an important garrison town. Orakzai was the original home of the TTP head Hakimullah Mehsud, before he moved to South Waziristan Agency to take over the leadership of the TTP after the death of his predecessor Baitullah Mehsud in a drone attack. Orakzai is divided into an Upper Sub-Division and a Lower Sub-division. In the Upper Sub-Division, the Pak Army has been carrying out military operations, including aerial operations, since a year. Almost 95% of the population of this area has fled, becoming IDPs elsewhere, especially in Hangu. This has opened a window of opportunity for the FATA health authorities, which have mapped and tracked these IDP children, and have given them anti-polio drops, covering ca. 95% of such children. In the central county of Orakzai (often referred to as Central Sub-Division), there are pockets of "missed" children, though their numbers are gradually going down. Note: The Tirah Valley has an extremely strategic location, as it passes through Kurram, Khyber and Orakzai Agencies in FATA/Pakistan, with Torn Bora in Afghanistan a few kilometres on the other side. The Tirah Valley is a major drugs and arms smuggling throughway. EFTA00586418 Khyber Pakhtun Ithwa (KP) Frontier Regions: Kohat Frontier Region: A semi-tribal buffer zone between Peshawar and Kohat, populated by the Afridi tribe; less corruption reported here than elsewhere; the polio situation is comparatively better than in the FATA areas, PEC involves the Education Dept including teachers. Three areas, bordering Orakzai and Khyber Agencies, were "red zones" because of military operations, where the Basic Health Units (BHUs) were closed -- these areas were recently cleared. The latest PEC was in April 2013, with almost 99% coverage. All areas of FR Kohat were accessible, there were many monitoring teams (perhaps deployed from other areas where they could not function?). In 2012, two polio cases were recorded, one a child who had fled from his original home, thus missing out PEC in both places, while the second was a case from a previous "red zone." Note: In FR Kohat, a verbal ban on anti-polio vaccination was introduced after 2009, with the head of the Tariq Afridi Group saying that if their Ameer said no, they would follow his instructions; he then showed a pamphlet issued by the Govt with a listing of the PE donors such as WHO, UNICEF etc — and pointed specifically to "USAID" and stated that that was why their Ameer had banned PEC. Semi-settled areas: These share some, but not all, of the characteristics of KP and FATA. Swat (home of Mullah Fazlullah/Mulla Radio): Despite the mountainous terrain, PEC was good, but after the militants took over in 2007- 2008, they opposed all NGOs. The Govt carried out a massive military operation in April- May 2009, pushing the militants out. There are no fatwas in Swat against PEC. Originally, Mullah Fazlullah who led a fundamentalist jihadi group called Tehreek e Nafaz e Shariat Muhammadi and later allied himself with the TTP, did not oppose PEC. He even threw out a challenge that his religious sermons (on his illegal FM channels) were more popular than the music channels. In Imam Dehri, the centre of Mullah Fazlullah's powerbase, there is a girls' school — the only condition he made was that girls in 6th class and above should wear the burqa. At present there is no overt militancy except target killings (such as the attempt against 14 year old Malala Yousufzai). Shangla (was also Mullah Radio territory): Of its population of 600,000, ca. 75% live in mountainous areas; of its 28 Union Councils, nine are considered high-risk for polio, all in Puran county which is under TTP control since the last four years; even in the areas not under the TTP, some communities refuse PEC on the grounds that until they receive other basic services such as electricity, roads, schools, the Govt can wait with its PEC! Corruption is considered Problem No.1, along with the timber and mineral mafia which exploit these valuable natural resources; labourers from Shangla work in mines in Balochistan, take their families along, thus the children miss out on PEC in both locations. EFTA00586419