Chasing Polio in Pakistan: Why the World's Largest Public Health Initiative May Fail

5. Islamabad

123 ChAPter 5 Islamabad The commitment of the government has been absolute. —WHO international official, Technical Advisory Group meeting, April 2007 Let me also reinforce that from the government we have tremendous political leadership and commitment. . . . The PM and the First Lady have been leading polio campaigns. . . . The political leadership is absolutely clear. —Pakistani minister of health, Technical Advisory Group meeting, April 2007 The problem is that it’s supposed to be a government program, but it’s not. —WHO official, Islamabad Polio eradication in Pakistan was officially a government program with support from international organizations like WHO. In certain times and places, this was how things actually worked. Since hundreds of thousands of Pakistani government employees did the work of vaccinating children, polio eradication was a government program in a very real sense. As one WHO official noted, the progress made in greatly reducing the number of polio cases in Pakistan would never have been possible without government involvement. But in another sense, polio eradication was not a Pakistani government program; it was initiated, funded, and administered by international UN agencies and the governments of wealthy countries like the United States, the United Kingdom, and Japan. Pakistan took on polio eradication in response to international directives, not because it was an issue of national importance. For an eradication program, this internationally mandated approach was unavoidable; if polio is to disappear entirely, every country 124 Chasing Polio in Pakistan must simultaneously implement the recommendations of the Global Polio Eradication Initiative.1 Still, the official line was that polio eradication was a project of the government of Pakistan. The frequent repetition of the ideal—“polio eradication is a government program”—is an indicator of the fiction’s fragility. There was an ongoing , low-level struggle in Islamabad that centered around who should be responsible for administering polio eradication. In practice, UN agencies ran the project at the national level in Islamabad. They did so in large part reluctantly, as their attempts to get government employees to take on planning and administrative duties met with significant resistance. And yet, even as they hired large Islamabad- and field-based staffs to do the work that the Pakistani health system did not, UN agencies worked hard at maintaining the fiction of government ownership. The PowerPoints, reports, and letters that UN employees prepared were often printed on government letterhead and signed by the same government officials who represented the program at international meetings, though they usually had to be briefed beforehand by UN employees. UN employees resented this work: UN employee 1: The problem is ownership of the government—they are thinking that they are supporting us— UN employee 2: I just got call from [a government official] to put together a presentation on polio and write a speech for the minister. Well, whose program is it? UN employee 1: That’s how it runs. This gap between the ideal model according to UN officials and what people say actually happened is not unique to the Polio Eradication Initiative in Pakistan. On the contrary, it is a characteristic of almost all human societies. As a classic anthropology text notes: Two different levels of thinking may be broadly distinguished. First, there are people’s notions about what they actually do, the manner in which they conceive their own social system and the world they live in. And secondly, there are their beliefs about what they and other people ought to do, their legal and moral values or norms. . . . Since no mortals (so far as we know) suppose themselves to inhabit the best of all possible worlds, there are always some social relationships in which real and ideal, what is and what ought to be, are distinguished. Not all husbands, wives, neighbours, rulers, are perfect. (Beattie 1964,.37) Islamabad 125 Some societies have ideals driven by religious doctrine; the Polio Eradication Initiative has ideals driven by the WHO’s official policy. These extremely powerful ideals drive practice in important ways, but to equate them with practice would be a mistake. In societies with ideals of honesty, fidelity, and respect for private property, people still lie, cheat, and steal (though they may be punished for it). In societies with an ideal that national governments embrace international mandates, government officials drag their feet (not, as it turns out, a punishable offense—though some UN officials probably wish it were). Structural Power To grasp who creates the ideal...