The murder of health workers in Pakistan means the last leg of efforts to eradicate the disease can't be business as usual, says Heidi Larson.
The tragic murders of nine anti-polio workers in Pakistan last month, followed by the New Year's Day killing of seven more local community development workers, was both a wake-up call to the global polio eradication effort in its current form, and a 'canary in the mine' regarding the deteriorating state of development and security in the country.
- Local and international failings are behind the recent murders of anti-polio workers
- Eradication should not be pushed as the priority above other development concerns in Pakistan
- Next steps in global effort should include assessment of local realities
The past month of public reporting and private discussions on what happened, why and what happens next have revealed a complex web of governance failings, inadequate development structures and a landscape of multiple security threats, both locally and internationally.
Some blame the deaths on the lack of local governance and inadequate security; some assume it is a repercussion of the CIA's widely criticised decision to use a fake vaccination campaign in its attempts to locate Osama bin Laden; and some point to the fundamentalist threats banning girls from going to school or work.
Others point to Pakistan's 18th Constitutional Amendment, approved in 2010, which devolved health from being managed at a federal level to being managed (or not) at a provincial level. Although this is not a bad idea in general, it needs human and financial resources to make it viable.
The weaknesses in Pakistan's health infrastructure have also been exposed by the dramatic rise in measles cases — 14,687 in 2012 compared with 3,890 in 2011 — which led to more than 300 preventable child deaths in 2012, up from 64 in 2011.
In light of these contextual challenges in the final stages of polio eradication, what needs to be done to maintain momentum, yet to be conscious of the realities that have put polio workers' lives at risk?
Despite the instincts of the global polio programme, efforts at eradication should not be pushed as the priority above all others in Pakistan. Doing so is perceived by some as insensitive to other pressing and life-threatening concerns facing the country.
Instead, efforts to eradicate polio need to engage with activities addressing other local priorities — not by temporarily adding other services to polio campaigns, but instead by supporting measures that contribute to long-term, sustainable development.
Lady health workers (LHWs), as local female health workers are called in Pakistan, have been a symbol of the role the polio programme has played in highlighting underlying weaknesses in the health system. These workers have used the polio platform to draw attention to, for instance, their inadequate wages and job uncertainty — concerns first raised more than five years ago.
Over the past few years, their frustration and anger have escalated, leading to boycotts calling for uninterrupted and fair wages, permanent jobs and, now, better security. In August 2011, they fasted to protest against not being paid. More recently they boycotted polio and measles campaigns to make their points.
The global spotlight on polio eradication has also meant it has, at times, become hostage to other underlying grievances.
Community leaders, for instance, have boycotted the initiative in Pakistan for various reasons, including for access to safe water and against power shortages.
Pakistan's Express Tribune covered one boycott in an article that quoted a tribal elder as saying: "Our children die of scorching heat and mosquito bites, what difference does it make if they die of polio? We will continue our boycott until the government fulfils our demand." 
Even a high-level meeting of environmentalists and health experts used polio as leverage for better sanitation.
"Pakistan's efforts for polio eradication and achieving sustainable development goals are bound to fail, if access to safe sanitation in the country is not improved," reported The News. 
The global polio eradication initiative always intended to also help strengthen broader immunisation and health systems. Debates continue on how much the human and financial resources invested in polio eradication are contributing or detracting from other health and development progress, while keeping the focus on eradication.
The November 2012 report of the International Monitoring Board for the Global Polio Eradication Initiative summed up the interface between the polio initiative and broader health and development issues. On the cover page, the subtitle lists a number of "essentials" for the polio virus to survive, including "political misalignment, weak local leadership, disengaged traditional and religious leaders, corruption and underfinanced programmes".
None of these are unique challenges to polio eradication, but tally with the broader challenges facing human development.
Polio eradication is indeed a priority for global health and, for Pakistan's leaders, failing to eliminate it would certainly compromise the country's already fragile regional and global positioning. Weak management has allowed the disease to spread to China, while posing a risk to India's efforts to stay polio-free.
But the reputational concerns of national leadership are not what drive the willingness of local-level polio efforts. The health and development concerns, as well as political dynamics, vary considerably at provincial — and even neighbourhood — levels, where health delivery, including polio vaccination, actually happens.
The tragic murders should be a wake-up call to the polio eradication effort. The last leg of eradication cannot be business as usual. Each step will need to carefully consider the local political, cultural and operational dynamics — and not the dynamics of the past year, but of the current week, and even each new day they operate in.
Heidi Larson is a senior lecturer and principal investigator on a Project to Support Public Confidence in Immunization at the London School of Hygiene & Tropical Medicine in London, United Kingdom. Heidi can be contacted at email@example.com
 Incessant power outages: Fed up with govt indifference, tribesmen boycott anti-polio drive (Express Tribune, 2012)
 Polio eradication not possible sans improving sanitation: experts (The News, 2012)