They gathered in a small room in one of this city’s worst slums, a dozen mothers sitting cross-legged with toddlers and newborns on their laps, listening to advice about polio prevention.
“Keep your children from playing in garbage cans and sewer drains,” said Saddaf Malik, a brightly dressed young woman from UNICEF.
Simple enough, but then came the questions, spiked with suspicion and indicative of why Pakistan remains one of three countries in the world where the paralyzing disease still thrives despite constant campaigns in recent years to defeat it.
Why, some mothers wondered, were the vaccination teams coming back once a month, instead of every three months, as they used to? Were the repeated doses meant to induce sterility in Muslims?
The polio fighters looked crestfallen. They thought this dangerous myth was dead in Lahore — a sprawling city with an estimated 1.5 million young children that logged just one polio case a year ago and none since.
“This is really alarming,” the district’s chief health officer, Muhammad Saeed Akhtar Ghumman, said in his office later when a UNICEF staffer reported the women’s concerns to him.
Troubling, too, was the confirmation of the polio virus in 16 of 28 sewage samples taken so far this year in Lahore, a marked increase over 2011. And three successive positive samples — in July, August and September — have raised worries about the virus’s “silent circulation,” as World Health Organization officials call it.
“We take it very seriously if there is even one positive sample,” said Ni’ma Abid, a WHO senior medical officer. “It means you have polio in the community.”
Still, overall trends in Pakistan, where nearly 30 million children have been vaccinated in recent years, are encouraging. In 1994, when the nation began to fully engage the scourge, polio killed or paralyzed at least 1,500 children, by conservative estimates.
Last year’s cases numbered 198 nationwide. This year’s tally is 54.
But the intractability of other social ills, including insurgency, poverty, illiteracy and inadequate sanitation, have conspired to ensure that the country remains years away from meeting its goal of polio eradication by the dawn of 2013.
Last week, a new setback emerged in Baluchistan, where doctors reported five cases of polio-crippled children in the restive province, which had seen only four cases this year.
The new cases are significant because they resulted from the vaccine itself. WHO officials called this extremely rare, but it can happen in places where the level of immunization is exceedingly low and the sanitation poor.
Polio drops contain a weakened polio virus that provides immunity. Once excreted, it has a slim potential to mutate into a strain that can cause paralysis.
The five cases of “vaccine-derived polio” — the first seen in Pakistan — could give skeptical parents another reason to refuse to vaccinate their children, some officials fear.
While refusals have been dropping nationwide, rumors abound that the drops contain religiously proscribed (“non-halal”) ingredients or are part of a Western plot to spread infertility and limit Muslim population growth.
A CIA-paid Pakistani doctor’s hepatitis immunization campaign, launched to try to collect Osama bin Laden’s DNA before his killing last year, also gave a boost to conspiracy theorists and religious leaders who advise parents not to vaccinate their children.
“The problem we already have is trust,” said one health official, speaking on the condition of anonymity because of the issue’s sensitivity. “The last thing we need right now is giving people another reason to distrust the vaccination campaigns.”
Despite significant progress elsewhere in Pakistan, polio has risen in the militancy-hit northwestern province of Khyber Pakhtunkhwa. In North Waziristan and South Waziristan, tribal areas where the Taliban this summer banned vaccinations in response to U.S. drone strikes, the inoculation teams have no access to 210,000 children. An additional 40,000 in risky frontier zones near the Afghan border also are out of reach.
One key to reducing outbreaks, U.N. health workers say, is to educate parents such as those at the session in Lahore this month. Those attending were ethnic Pashtuns, the descendents of Afghan refugees who came to Lahore in the 1980s, along with millions of others who swarmed across the border after the Soviets invaded Afghanistan.
Pashto speakers have accounted for 85 percent of the nation’s polio cases in the past three years, officials report. These include transients from the tribal region who relocate to enclaves here — and in other cities, such as Karachi — bringing the virus with them. (Afghanistan and Nigeria are the only other two countries where polio is endemic.)
In Lahore, UNICEF dispatches “social mobilizers” to comb flyblown streets and refugee hovels over and over, trying to account for what they term “missed children” — the still-unvaccinated ones who are potential polio time bombs.
To help find them, Mayor Noor-ul-Amin Mengal hired 34 Pashto-speaking college students to bridge communication gaps in a recent inoculation campaign. He said he also recruited 30 religious leaders to support the effort.
Is it working?
“Parents do not object to the drops,” said Amir Khan, 20, a teacher leading a class for Afghan children in a three-walled brick structure. He said all 40 of his pupils younger than 5 had been vaccinated.
Nearby, a frail, thin mother peeked from behind a worn tarp and nervously greeted the vaccinating team — two plump women in nicely pressed Pakistani-style chemises and a young man in Western office wear. They were checking on the 11 children under the age of 3 who lived in the refugee compound and would need follow-up doses.
The thin woman reported a new arrival, a 4-day-old baby. The mobilizers said they would be back to administer drops. She darted quickly back inside.
That morning, the team also visited a preschool drop-in center in search of five missed children. The staff provides free breakfast and said they sometimes give polio drops without parental permission. The five children weren’t to be found.
A few yards down the street, a little girl climbed into a garbage bin in search of nourishment. She found a wrapper containing a morsel, gnawed at it, then skittered off into an alley reeking of sewage.