Pakistan, the country that almost ended polio 30 years in a row

Four-year-old Shahmeer* in Sindh’s Sujawal had been receiving his hifazati teekay on time for pneumonia, diarrhoea, measles, typhoid, poliovirus. Every box on his vaccination card was marked complete. Yet, on March 5, he became Pakistan’s first reported polio case of 2026.

Shahmeer showed no visible symptoms — he went out to play as usual, did not complain of joint pain, and showed no signs of paralysis. This is because he had contracted non-paralytic polio, which is a form of the disease that goes unnoticed, sometimes showing up only as a mild flu, but still capable of spreading the virus. The virus in his gut was genetically linked to a positive environmental sample from Hyderabad, lab analysis showed, pointing to ongoing transmission in Sindh.

In many ways, Shahmeer’s case reflects Pakistan’s dilemma today: the country may be close to eradication, but the virus has not been eliminated. It has simply become harder to detect and, therefore, harder to wipe out.

Right now, Pakistan is in what is called “the last mile,” or its most challenging phase, says the prime minister’s focal person, Ayesha Raza Farooq. It has reached this point thrice in the last decade: in 2017, when eight cases were reported, in 2021, when only one case was recorded, and in 2023, when six cases were reported. But each time, progress was derailed by a surge in cases. By the end of 2025, the tally was 31.

Three months into this year, only one case has been reported, and a majority of samples from sewage have been clear of the virus. This has given Unicef Sindh’s team lead Azeem Khawaja the hope that we will reach zero cases by the end of 2026. “Sustaining them there is the big question,” he added. Pakistan must have no cases for at least three years in a row to be declared polio-free. No virus can be detected in humans, the environment, or laboratory samples.

The last mile means Pakistan will have to vaccinate 95 per cent of its children. It aims for over 45 million children each campaign but manages about 43 million every time. That two million or so is the last mile.

During the February and April campaigns this year, 950,000 and 300,000 children were not vaccinated, respectively. Typically, between 800,000 and a million children are missed in each nationwide drive.

Behind these numbers are the doors that never open, the children who are not home, and the parents who keep turning polio workers away.

Familiarity that coexists with suspicion

At seven o’clock on a December morning, Sindhi Para in Karachi’s Dalmia, UC-7 of Gulshan Town, had barely risen for the day. Deep in the coil of the basti’s narrow alleys, mothers speed-walked to school, their children straggling behind. Not much else was stirring, except for the sweeper’s long-handled broom.

A medical centre sat at the edge of the alley leading to Sindhi Para, where dozens of women were gathered under an old tree. Its entrance was littered with run-down furniture yet to be discarded. Inside, the buzzing of a pedestal fan greeted visitors before the fading paint on the walls.

The women, most of them clad in burqas and joggers, queued in the courtyard. Their eyes darted from their phone screens to the office, where their supervisor sat. Finally, his voice rang loud. Names were called, data sheets were handed over, and an announcement was made: “What is our goal? Not a single child is to be missed.” The polio teams fanned out.

Before she led her team into the assigned neighbourhood, Samina adjusted the strap of her blue vaccine carrier box and stepped into the first house on her list. A toddler ran past her. “Ali hasn’t gone to school yet?” she asked. His mother laughed and called him back. As soon as he entered, Bilqis squeezed the two precious drops into the child’s open maw and dragged a pen across his cuticle. Parmeela chalked up cryptic symbols at the gate: EPI St. 4, H. 9. 1/1 + 0 T+2, AFP 0, ZD 0 ←. Before leaving, Samina double-checked: “Any newborns? Any visiting children? Any cases of paralysis?”

Then they inched forward to the next gate.

“Arey Samina, I was only wondering when you will come over,” an elderly woman at the door said. “Come on in, ladies.” Samina led the way in, and for the next 20 minutes, the women chatted over a cup of tea, swiftly switching from Urdu to Sindhi. The conversation jumped from the new family that recently moved upstairs from Balochistan’s Hub to the upcoming wedding, and inflation. Before they said goodbye, the lady health workers took turns to use the bathroom, Samina refilled her water bottle as Bilqis squeezed the dropper over the open mouth of the newest member of the family.

Parmeela herded the women upstairs to meet the newcomers. A woman, with a toddler cradled on her hip, answered the door. As Samina greeted them, Parmeela and Bilqis’ eyebrows shot up. “We didn’t know you could speak Balochi that well,” they later said to tease her.

“When you have been meandering these streets for years, it is easy to know everyone and for everyone to know you,” Samina explained. “This way, vaccinations become easier … and it also keeps up to date with what is happening in the neighbourhood.”

The familiarity, however, coexisted with suspicion. A woman once spat on Parmeela and screamed that she was poisoning her children. A man pulled a gun on Samina each time she came to his door. In some homes, fathers would turn Bilquis away but the mothers would sneak the children out for the drops when the men were not home. They would tell the women not to mark the child’s finger and just note the tally on their official sheet.

The women blamed rumours for this resistance: that the “vaccine causes infertility”, that it is “un-Islamic”, that it is “aimed at reducing the population of a particular ethnicity”.

For a period, police accompanied the teams. But that created even more scepticism and fear, said Parmeela. So now, a police van was parked a short distance from teams at all times, but the men were rarely ever involved. The instruction was to persist. If persuasion failed, report the refusal; if tensions escalated, involve the in-charge or the police.

Ninety-eight per cent of refusals come from 30 districts across Pakistan, according to National Emergency Operations Centre Coordinator Anwarul Haq. These include areas with a history of high polio incidence (Karachi, Peshawar, Quetta and south Khyber Pakhtunkhwa).

During the first campaign of 2026, Karachi alone reported 58pc of refusals, the largest share.

“People often ask, ‘Why just polio?’” Ayesha Raza said. “Why is this a priority when children are dying from other diseases?” People are simply frustrated, and so when teams knock on their doors, it agitates them. Why does the government care about polio but not water in their taps? Or treatment for illnesses they and their children actually have? Or other necessities?

Some families used this as a bargaining chip. We will only vaccinate our child if we are provided soap, they would tell the health workers. Others demanded a strip of paracetamol, a better road.

“Simply, there is a lack of trust in our health systems,” explained Unicef’s Azeem Khawaja. “Instead of strengthening the health system, we have invested in outreach, on which 70pc of the immunisation coverage is dependent. Shut down outreach, and you will see resistance multiply.” And this was because the healthcare system was dependent on the choice of the people. “When we take the polio vaccine to every door, it builds the expectation that all the other health services would also be provided at the doorstep. All of this determines the health-seeking behaviour of a community.

“Right now, we are stuck in a vicious cycle that needs to be broken,” Khawaja added.

In recent years, community mobilisers have been tasked with softening resistance. They engage big names from the community (social media influencers, politicians, clerics) to raise awareness and help negotiate difficult refusals. One such instance was witnessed by Dawn.

On a Saturday afternoon, a three-woman team at the Al-Rashid Nomad settlement in Karachi’s Gujro was on a hunt. They were in search of a woman who had a habit of disappearing with her children during every campaign, only to return once they left. When the team approached her makeshift camp on an empty plot allotted to the nomadic community visiting from other parts of Sindh, the situation escalated. Both she and the neighbours were being difficult.

“My daughter has a fever … I don’t want to administer polio drops to her,” one of the men said. Sakina Bibi, the senior-most polio worker, described how swelling in children’s legs was sometimes blamed on the vaccine and resulted in resistance, even though it was linked to heat and environmental conditions.

The missing woman’s camp, on the other hand, was empty as usual, but one of the locals recalled seeing her earlier in the day. When the team finally found her, the arguments grew louder and the crowd bigger. The commotion drew the attention of a policeman at a short distance, whose hands reached for his weapon. Ultimately, an influencer, the caretaker of the settlement, was called in. “The vaccine will not do any harm to your child … even my children have a finger marking,” he told the woman in Sindhi. Ten minutes later, the drops were administered.

In Karachi, Gujro is also known as a hotspot, hence, it is key to countering refusals. “Gujro is Karachi’s gateway. People come here from all parts of the country in search of jobs, and therefore we have a lot of population movement here,” explained Syed Qaim Akbar Nimai, coordinator of the Emergency Response Unit for Gujro. About 70pc to 80pc of the population here came from conflict-ridden areas such as Waziristan and other parts of Khyber Pakhtunkhwa, where vaccine administration was difficult.

“This is the biggest challenge we have, and Gujro is super high risk for this very reason: we can’t relax for a moment here because it’s a continuous cycle,” Nimai added. “If you go to the bus terminals, you will see how many people are coming to us every day, and they’re all unvaccinated.”

Tip of the iceberg and beyond

But even if they were vaccinated, there is contaminated drinking water and open sewers.

In Gujro, barefoot children played around uncovered nullahs, their filth overflowing into the streets littered with garbage. And this contributed to the spread of polio. Positive environmental samples meant the virus was in circulation; someone was excreting the virus into the sewage system, whether a child or an adult. Look at it this way: children play outside, they come in contact with the virus, they go home and eat without washing their hands, the virus enters the gut. “This continues and sometimes it takes months before a diseased person appears in the community,” said Dr Ali Faisal, an associate professor at Aga Khan University, who specialises in paediatric infectious disease.

“In a city like Karachi where the population is dense and where WASH-related problems persist, positive environmental samples mean something big is going to happen because we are unable to see the cases,” he pointed out, adding that the transmission of polio was being underestimated because the virus was associated with paralysis. But paralysis was just the tip of the iceberg.

Strong environmental surveillance means detecting virus circulation before cases appear, and persistent sewage samples mean the virus still has human hosts, explained Professor Fatima Mir, also a paediatric infectious disease specialist at AKU. These hosts may be immune but they may also be vulnerable (missed children, migrant populations, people in areas with poor quality campaigns or underserved areas). So paralytic cases comprised only a small proportion of infections and reported cases may lag behind environmental detection due to surveillance weaknesses or actual immunity.

In Pakistan, the surveillance mechanism is two-pronged; environmental samples are collected from 127 drainage sites in 88 districts for testing at a WHO-credited laboratory in Islamabad. This is supported by 12,000 community-based surveillance facilities.

When the virus enters a child’s gut, samples should ideally be collected within 14 days, as the probability of detecting the virus is high in this window. Once this timeframe passes, samples of neighbours, friends and siblings are also taken up until 60 days, Dr Khawaja said.

Low case numbers, therefore, do not necessarily signal safety. They may instead reflect immunity levels that prevent visible disease, while transmission continues. “This is not a scientific failure,” Dr Mir said. “It is a failure of immunisation systems and trust.”

At the centre of this failure are children who never enter the system at all.

In polio programme language, they are referred to as zero-dose—children who have not received even a single dose of the vaccine, neither through routine immunisation nor supplementary campaigns. But on the ground, they are simply the ones who are missed: the child who were not home when the team arrived; the child whose parents refused; the child living in a settlement that exists beyond the state’s regular reach.

When such children contract the virus, it is not surprising. It is expected. “These are the children the virus finds,” Dr Mir explained. “Because they are completely unprotected.”

Pakistan’s immunisation challenge, she stressed, was not limited to polio campaigns. While door-to-door drives repeatedly boost immunity, routine vaccination—the backbone of any disease prevention system—remains uneven. Each month, a new group of children is born and enters the population, and when routine coverage is inconsistent, pockets of under-immunised children continue to build. This creates a revolving door of vulnerability.

“You may be doing campaigns again and again,” she said, “but if routine immunisation is weak, you are always playing catch-up.”

The gaps are not evenly distributed, instead, they are concentrated in urban slums, such as the Al-Rashid Nomad settlement, in mobile and migrant populations such as the highlanders of KP who come down to the plains in winter, in underserved rural districts such as katcha areas, and in areas where access is shaped by insecurity (North and South Waziristan, Bannu, Kurram and districts in south KP).

In these regions, even a small lapse in coverage is enough to sustain the transmission of the virus. And over time, these missed children accumulate until the system is once again confronted with the same question: if the vaccine exists, why are they still being missed?

“It’s not that we don’t know how to stop polio,” Dr Mir said. “It’s that we haven’t been able to do it everywhere, consistently.”

The consistency experts talk about is very much dependent on 400,000 and more frontline workers who are trekking the length and breadth of Pakistan. In the words of Ayesha Raza, the polio programme and its success depends on them. However, there seems to be little to keep them motivated.

After the recent pay cut, frontline workers in Karachi are now paid Rs12,000 for an eight-day campaign, while supervisors receive around Rs20,000. For many, this is their only source of income and it is barely enough. “I am not just earning for myself,” said Parmeela, a supervisor and the sole earner of her family. “I have my mother, and my dead brother’s son.” Samina echoed the same strain. When her husband lost his job during Covid-19, the responsibility of running the household fell entirely on her. “This Rs12,000 does not even include transport,” she said.

Some workers spend up to Rs500 a day just getting to and from their assigned areas. Many, like Samina and Parmeela, walk.

The story does not shift much across the country. In Punjab, workers are paid the same amount for eight days. In Bannu, payments have dropped from over Rs10,000 to Rs8,200 for four to five days of work, plus training. In Quetta, a community health worker who once earned Rs32,000 now receives Rs12,000, often weeks after the campaign ends. “Our government is doing so much,” said Ayesha, a polio worker in Punjab. “Is it not our right that we get a scooty at least? Officers get medals because of us.”

Ayesha contracted polio herself when she was two.

“At that time, my parents did not even know what it was,” she recalled. She was bedridden for months before receiving treatment and a prosthetic shoe. As she grew older, finding a marriage proposal became difficult. She eventually married and, after nine years of waiting, had a daughter. “I have polio, but I will not let anyone else go through the same pain,” she said. “I don’t want my daughter or any child to live the life I have lived.”

For over a decade now, she has been part of the very campaigns that could have prevented her condition. Her routine mirrors that of thousands of others across the country. The day begins early: assembling at a designated centre, collecting vaccine carriers packed with ice to maintain temperatures between two and eight degrees Celsius, receiving microplans and maps. Then, hours of walking door to door and street to street marking fingers, recording data, persuading families, returning to missed households, and finally submitting tally sheets by evening.

The cold chain must be preserved. The vials must remain shaded. Every dose must be accounted for. And still, the work does not end with logistics.

When faced with refusals early in her career, Ayesha would point to herself. She would ask parents why two drops felt more dangerous than a lifetime of disability. “Polio drops have been given in Pakistan since 1988,” she would tell them. “Has the population reduced?”

Despite living just a 10-minute drive away from her assigned area in Tajpura, she walks most of the distance. She often falls. Winters bring pain and stiffness. There is no transport, and no medical facility for workers with disabilities. Yet she continues.

Officials acknowledge the strain. Ayesha Raza Farooq, the prime minister’s focal person, said the programme had to “rethink” its operations due to funding constraints.

“Earlier, workers were engaged for longer periods and paid per day,” she explained. “We reduced the number of working days to optimise campaigns without compromising quality.” The result, however, has been a direct cut in earnings.

“Yes, it has impacted everything to a certain degree,” she admitted, adding that the programme was trying to compensate with other benefits. On the ground, workers say they have yet to materialise.

In Khyber Pakhtunkhwa’s Bannu, the challenges extend beyond pay. Javeria Gul has been working as a vaccinator for over 13 years. She holds a master’s degree—one she says has “gathered dust” because she could never find stable employment. “I am in my 40s, unmarried, and people say I am a burden on my parents,” she said. “So I do this work to survive.”

Each campaign begins at a mission hospital, where teams gather before being deployed, often with security escorts. Bannu has seen frequent militant attacks. “Even though security is provided, everyone is scared,” she said. She remembers a man in Basti Muhallah who pulled out a gun and warned the team never to return. In such cases, religious leaders are brought in to negotiate. A week after a major attack in the area, Javeria and her team continued vaccinating children for four consecutive days. “Fear is there,” she said. “But so is the work.”

In Quetta’s Shahbaz Town, Anita, a widow and a schoolteacher, has been part of campaigns for over five years. She describes two kinds of refusals. “The chronic ones refuse every time,” she said. “The silent ones avoid us. They don’t argue; they just don’t bring the child.” Women, she added, often want to vaccinate but are held back by male family members. “Men get angry quickly,” she said. “Sometimes we skip the finger marking and just note it on the tally sheet.”

The area is constantly shifting—families arrive for work and leave within a few years, making it harder to build trust.

During the last campaign, a citywide strike forced Anita to walk nearly an hour just to reach her centre. “We are not given food or transport,” she said. “But we still go.”

In Sindhi Para, as the winter sun begins to dip, Samina pauses briefly for a namaz break inside a house. A message arrives on her phone, listing the codes of missed households. She adjusts her dupatta and steps back into the lane. There are still doors left to knock.

From February 2 to 8 this year, Pakistan ran its first nationwide polio campaign for 2026, vaccinating over 44.3 million children under the age of five. Across the border, Afghanistan launched a similar campaign in the same week. It was not a coincidence. It was by design.

Eradication efforts in both countries are synchronised, timelines aligned, teams mobilised in tandem, and vaccination drives rolled out simultaneously on either side of the Durand Line. The reasoning is simple: the virus does not recognise borders, and neither can the response.

Pakistan and Afghanistan remain the only two countries in the world where the wild poliovirus is endemic. Epidemiologically, they are treated as a single bloc, not only because of geography, but because of people.

“There is constant movement between the two countries,” explained Dr Israarul Haq, spokesperson for the NEOC. “Families live on both sides, tribes span across borders, and people cross frequently for economic and social reasons. If people are moving, the virus is moving.” This movement sits at the centre of both the problem, and the strategy.

Coordination between the two countries has intensified. Emergency Operations Centres on both sides maintain dedicated desks for cross-border collaboration, aligning campaign schedules, sharing surveillance data, and jointly planning interventions in high-risk zones, particularly along the belt of more than 17 union councils stretching from Chitral in the north to Chagai in Balochistan.

“If we miss a child here, they may be vaccinated there, and vice versa,” Dr Haq said.

In 2025 alone, Pakistan conducted three national campaigns in coordination with Afghanistan. The process is supported by cross-border forums and the Technical Advisory Group (TAG), an independent body that guides polio eradication strategies in both countries. Beyond synchronisation, surveillance data is also shared. Every detected virus, whether from a child or an environmental sample, undergoes genetic sequencing, allowing health authorities to trace its origin.

“If a virus detected in Pakistan is linked to a strain circulating in Afghanistan, we highlight that,” Dr Haq explained. “And they do the same with us.”

The coordination, officials say, extends beyond formal systems. Technical teams remain in constant communication, adapting strategies in real time. At the community level, religious leaders, tribal elders, and influencers are engaged on both sides to counter refusals and build acceptance. But even with synchronised campaigns, the scale of movement presents a persistent challenge.

Pakistan’s programme classifies mobile and migrant populations as high-risk — people travelling for seasonal work, displacement, or economic survival. These populations are mapped, tracked, and targeted, but they remain difficult to fully reach. To bridge this gap, transit vaccination has been expanded. Teams are deployed at bus terminals, highways, railway stations, and border crossings, vaccinating children on the move.

In 2025, more than 14 million children were reached through these transit points, the PM’s focal person said. Yet, the limitations are clear.

“Transit vaccination is a complementary strategy,” said Ayesha Raza Farooq. “It cannot replace door-to-door campaigns. Not every vehicle stops. Not every child can be reached this way.”

And this is where synchronisation becomes critical. If a child slips through one campaign, the hope is that they will be vaccinated in another — across a district, a province, or a border. Still, the imbalance remains: movement is continuous; vaccination is periodic.

Despite years of progress, transmission has not been eliminated.

“We were very close to eradication in 2018 … again in 2021,” Ayesha recalled. “But these programmes require relentless effort. Even a small lapse can set us back.”

She pointed to two key reasons: complacency and gaps in essential immunisation. “Many of the children who test positive are zero-dose,” she said. These are children who have not received even a single routine vaccine. “For them, campaigns have to be longer and more consistent.”

And then there are the conditions that allow the virus to thrive.

Poor sanitation, unsafe water, and overcrowded urban settings continue to facilitate transmission. In cities like Karachi, where sewage and drinking water often intersect, the virus moves quietly, circulating in the environment long before it appears as a case.

Environmental surveillance reflects this. In Karachi, a significant proportion of sewage samples continue to test positive—a sign that the virus is still being excreted, still finding hosts, still moving.

The geography of transmission has narrowed, but it has not disappeared. In 2025, most cases were concentrated in southern Khyber Pakhtunkhwa, particularly in districts bordering Afghanistan. Karachi remains a key reservoir, shaped by high population density, migration, and persistent refusals. In Punjab, mobility continues to complicate coverage, with virus strains often linked to other regions.

“Circulation has now been pushed back to a few zones,” said National EOC Coordinator Muhammad Anwarul Haq. “But until it is completely eliminated, the risk remains.” And that is the paradox of the last mile: the closer eradication comes, the harder it becomes to sustain.

Low case numbers create the illusion of control. The virus becomes invisible. Public urgency fades. But in small pockets — hard-to-reach districts, underserved communities, mobile populations — transmission continues, quietly rebuilding.

“We cannot rely on force,” Ayesha said. “You may succeed once, but eradication requires repetition, trust, and consistency.” This marks a shift in strategy from enforcement to persuasion, from access to acceptance. At its core, the goal remains unchanged: to interrupt transmission completely.

Under what officials describe as the “Roadmap to Zero”, Pakistan aims to eliminate both human cases and environmental circulation of the virus. But eradication is not defined by a single year of success.

Pakistan has come close before. Now, with transmission largely contained, cross-border coordination strengthened, and strategies evolving, it stands once again at a familiar threshold. The goal is simple. Staying there is the real challenge.

*Name hidden to protect identity

© Dawn Prism