Global poliomyelitis eradication is almost within reach—this disease persists only in Nigeria, Afghanistan, and Pakistan, which are countries with substantial Muslim populations.1 Today this ambitious goal is threatened, partly by misinformed and politicised religious views that not only seed suspicion about polio vaccination but recently led to murder of polio workers. In Pakistan, 16 workers engaged in a polio vaccination campaign have been killed since December, 2012, halting vaccination in many parts of the country and placing Pakistan’s 2012 gains in poliomyelitis eradication at risk.2 Copycat attacks followed in Kano, Nigeria, and were thought to be the work of extremist group Boko Haram.3 Although Pakistan’s Government, civil society, and religious factions have condemned the killings, action is urgently needed to dispel public misperceptions and deter ongoing violence.
Saudi Arabia and its health authorities are uniquely placed to bring about change in Pakistan for two reasons. First, as the site of Mecca and Medina and host to the Hajj, Saudi Arabia wields enormous influence in Muslim Pakistan. Second, Saudi Arabia has experience of introducing new public health recommendations and strengthening public health outreach by legitimising new public health measures with both formal Islamic authority, in the form of fatwas, and informally, through public opinion.4
Saudi theocrats and public health officials are experienced in effective public health messaging in the diverse Muslim public space. Despite a widely held perception of narrow interpretations of Islamic tradition, Saudi Arabia’s advanced medical academe and traditional religious theocracy have forged imaginative partnerships to solve public health challenges so that advanced therapies—whether living or cadaveric organ harvesting, genetic counselling, care of terminally ill patients, or therapeutic abortion—are available in Saudi society.5 A nexus of science, medicine, and religion has enabled a smooth introduction of advances in every aspect of health care into Saudi Arabia’s medical system, which successfully operates in a conservative Muslim society. This collaborative approach is one Pakistan must emulate to the benefit of its imperilled polio programme.
Pakistan’s Taliban views vaccination programmes as not being Islamic and a western innovation to be repudiated, at the peril of the murder of health workers and the inexorable rise of poliomyelitis.6 Saudi Arabia’s clerics have shown the opposite view through their willing and engaged acceptance of diverse forms of advanced medicine—eg, the use of alcohol-based hand hygiene agents, and use of porcine medicinal products if no alternative is available.
Pakistan could benefit from such a collaborative approach, and Saudi public health officials are ready to engage international Islamic organisations to issue religious edicts lending vital legitimacy to Pakistan’s programme for eradication of poliomyelitis. Similar partnerships have been deployed between local religious clerics and public health officials in Nigeria,7where polio vaccination campaigns were once boycotted, and Indonesia,8 which has also legitimised health programmes with the help of religious theocracy.
Saudi Arabia has a strong national interest in controlling the spread of the poliovirus in Pakistan. Every year, over the past decade, more than 10% of all pilgrims, nearly 200 000 Muslims, travelling to Hajj were Pakistanis (figure). Only Indonesia sent more pilgrims to the Hajj, and Pakistan is predicted to surpass Indonesia in population size by 2020.9 Host to pilgrims from more than 187 nations10 arriving in Saudi Arabia, the massive influx of Pakistan’s pilgrims can be a risk for new polio outbreaks in the Hajj cohort, the domestic population, and, through returning pilgrims, globally. Such an outcome could set the global polio eradication programme back by decades. The existence of poliomyelitis in Pakistan already poses a regional risk, as recently described in Afghanistan and China.
Saudi Arabia has enforced strict public health interventions for the millions of people who travel to Mecca each year, linking the issue of a visa to documented vaccinations, deploying thermal cameras to quarantine pilgrims with fever, and denying entry to people who might pose public health risks.12 Currently, Saudi Arabia recommends the administration of two doses of oral polio vaccine to all pilgrims coming from countries with active circulation of poliovirus. Saudi Arabia requires one dose 6 weeks before arrival (tied to Hajj visa issue) and a second dose on arrival. During Hajj 2012, nearly 500 000 doses of oral polio vaccine were administered at Saudi Arabia’s expense to pilgrims coming from countries with poliovirus circulation.13
Saudi authorities have a lead time of about 9 months before the Hajj season begins, allowing swift and specific planning for each Hajj. Saudi Arabia’s legitimacy in managing Hajj-related health is demonstrable. During Hajj 2012, the Saudi Ministry of Health banned all Muslim pilgrims from Uganda and the Democratic Republic of Congo, because of reports of Ebola outbreaks, to safeguard pilgrims. Although this decision could have been contested as not Islamic if not sanctioned by religious authorities, and Saudi authorities vilified for denying the divine rights of African Muslims, the ban was peacefully enforced and accepted because of the religious legitimacy afforded by clerics.12 Similarly, Saudi clerics have supported public health rulings deterring certain Muslims from Hajj during the recent influenza A H1N1 pandemic, which was a particular threat for pregnant women, elderly people, and those with comorbidities—a sensitive matter because all Muslims should attend the Hajj while they are able bodied.13, 14
Saudi Arabia’s experience has benefited from the Mecca-based World Muslim League’s ratification of medical recommendations, facilitating their wider adoption in Saudi Arabia and beyond. This unified approach avoids the opposition seen by extremist groups claiming to act in the name of Islam, despite motives clearly anathema to Islam. Saudi Arabia’s experience can inform the debate about eradication of poliomyelitis in Pakistan with similar approaches to management of public opinion through officially sanctioned public health and religious messaging, supported by the international religious theocracy and by the Saudi monarch, the apical authority for Islam in Saudi Arabia.
Although counteraction of the Taliban with a fundamentally Islamic position might seem inflammatory, this approach is rooted in Islamic teachings guaranteeing the sanctity of human life above all religious rites. Enlisting local mosques and community centres to promote polio vaccination as sanctioned by Islam to preserve life could lend Pakistan’s polio programme immeasurable authority. These measures, if ratified by national and international Muslim organisations, when supported by the world’s health agencies and leading public health academics of Muslim heritage, provide the authority needed.
Pakistan’s demoralised public health workers must be supported by a robust international approach that combines both traditional diplomatic and imaginative political responses to draw on the powerful authority of the international Muslim community, including the Organization of the Islamic Conference, the International Fatwa Body in Mecca, and Al Azhar in Egypt. Only then can we relegitimise infection control authorities and engender confidence in both public health officials and the vulnerable Pakistani population.
The Muslim world is responding emphatically. Sheikh Mohammed bin Zayed Bin Sultan Al Nahyan of Abu Dhabi is partnering with the Bill & Melinda Gates Foundation in a US$100 million commitment to the Global Polio Eradication Initiatives and Endgame Strategic Plan 2013—18 to be announced at the Global Vaccine Summit, Abu Dhabi, during World Vaccination Week (April 24—30). Such endorsement emphasises the recognition of poliomyelitis eradication as both a prime challenge and an extraordinary opportunity for the Muslim world. The Taliban’s intimidation must be excoriated by the Muslim community, for Pakistan has a truly critical role in global poliomyelitis eradication, which, with definitive Muslim intervention, will finally be relegated to history.