What polio can learn from leprosy

Pakistan’s contrasting experiences with polio and leprosy show that technical interventions alone cannot achieve disease elimination. Sustained community trust, long-term partnerships with local civil-society organizations, integration with broader health needs, and institutional continuity should complement vaccination, surveillance, and outbreak response in the final stages of polio eradication.

Pakistan presents a global health paradox. Few disease elimination or eradication programs have received as much international financing and political attention as the fight against polio. Yet Pakistan remains one of the last countries in which wild poliovirus (WPV) transmission has never been interrupted. In the same country, a far smaller leprosy program, sustained largely by civil-society organizations, with a fraction of the resources and none of the political visibility, has cut the number of newly diagnosed leprosy cases by more than three-quarters since the start of this century [1,2].

Polio and leprosy are not epidemiologically equivalent. Polio is an acute viral infection prevented through population immunity; leprosy is a chronic bacterial disease requiring early diagnosis, multidrug therapy, and disability prevention. Their trajectories cannot be compared as a natural experiment. Nevertheless, their contrasting institutional histories raise an important question: what can Pakistan’s intensively financed polio eradication program learn from one of its least financed disease-control programs?

The global polio campaign has achieved extraordinary success, reducing wild poliovirus cases by more than 99% [3]. Yet persistent transmission of WPV in Pakistan shows that technical effectiveness alone is insufficient. Insecurity and cross-border transmission with Afghanistan matter, but so does distrust. Pashto-speaking communities, around 15% of Pakistan’s population, accounted for 81% of wild poliovirus type 1 cases over the past decade [4]. Repeated campaigns can reach households without the institutions behind them becoming trusted.

In marginalized communities, families may reasonably ask why the health system returns reliably with polio vaccine but remains absent when they need clean water, maternal care, nutrition, or treatment for a sick child. Vaccine hesitancy is often framed as a knowledge deficit to be corrected through communication. However, vaccine resistance can also reflect broader judgments about the trustworthiness and responsiveness of institutions, including whether communities feel heard and their concerns are taken seriously [5]. Trust cannot be delivered in vaccination rounds.

Pakistan’s leprosy experience offers a different model. For decades, organizations such as the Marie Adelaide Leprosy Centre (https://malc.org.pk/) and Aid to Leprosy Patients (https://alp.com.pk/) have worked alongside government services to maintain early diagnosis and treatment despite declining political commitment [1, 2]. They did more than distribute multidrug therapy. They built long-term relationships with patients and families, conducted community-based active case finding, managed complications, addressed stigma and disability, and remained accessible after treatment ended [2]. Their legitimacy was accumulated through continuity and care.

Three lessons merit consideration. First, trust should be treated as infrastructure [6]. Like surveillance systems, cold chains, and trained personnel, trust must be built before crises and maintained between campaigns [6]. Second, local civil-society organizations should be financed as institutions, not used mainly as short-term delivery channels. Contracts that fund only mobilization or message dissemination rarely sustain the organizational memory, local leadership, and broader services through which trust develops. Third, disease eradication or elimination programs should respond to needs communities themselves consider urgent. This does not mean diluting the focus on poliovirus. High-quality vaccination, surveillance, and rapid response remain essential. But in persistently underserved areas, polio activities should connect families with routine immunization, primary care, nutrition, and other services, not as temporary incentives, but as evidence of a different relationship between communities and the health system [4].

This approach would also help polio campaigns leave a durable legacy. Community engagement should not be treated as a temporary instrument for securing acceptance of the next vaccination round. It should strengthen institutions that communities can continue to use and hold accountable after transmission has been interrupted. Measuring doses delivered and households reached is necessary, but programs should also assess whether referral pathways function, whether local organizations remain capable, and whether communities perceive services as responsive to their priorities.

The comparison also carries a warning for leprosy. Low national incidence can create complacency, erode clinical expertise, weaken surveillance, and prompt premature donor withdrawal, even though child cases, geographic clusters, and diagnostic delays continue to indicate ongoing transmission [1, 2, 7]. Pakistan’s zero-leprosy roadmap therefore combines trusted civil-society networks with active case finding, contact screening, post-exposure prophylaxis, and digital surveillance [2]. The lesson is not to choose trust over technology, but to make trust the social infrastructure through which technology works.

The last mile of elimination or eradication may depend less on how often a programme can knock on a family’s door than on whether the institution standing outside has earned the right to be trusted.

Practical recommendations for polio eradication programme

The experience of leprosy elimination in Pakistan suggests four practical considerations for polio eradication programme. First, treat trust as programme infrastructure by investing in sustained community relationships between vaccination rounds, rather than rebuilding engagement during each campaign. Second, strengthen and finance trusted local organizations as long-term partners, including their institutional capacity, rather than engaging them primarily for short-term mobilization or message delivery. Third, link polio activities with broader community health priorities, using referral pathways and connections to routine immunization, primary care, nutrition, maternal and child health, and other locally relevant services. Finally, expand programme monitoring beyond vaccination outputs to include indicators of community trust, functioning referral pathways, institutional continuity, and perceived responsiveness to community priorities. These measures would complement, not replace, high-quality vaccination, surveillance, and outbreak response, while helping to build the durable relationships required for eradication and its aftermath.

Author contributions

A.F. conceptualized the Comment, reviewed the relevant literature, and wrote and revised the manuscript.

Funding

Not applicable.

Data availability

No datasets were generated or analysed during the current study.

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Competing interests

A.F. is a member of the Editorial Board of BMC Global and Public Health. The author declares no other competing interests.