Dear Editor,

Childhood immunisation in Pakistan has advanced substantially over the past two decades. Sustained programmatic investment, most notably through the National Immunization Support Project has expanded routine coverage, and national full immunisation rates among children aged 12–23 months have risen accordingly [1]. Yet this progress remains uneven. The Pakistan Demographic and Health Survey 2017–18 found that only 66% of children aged 12–23 months were fully immunised [2], and coverage falls further in rural, low-income, and conflict-affected districts. In the Matiari district of Sindh, for example, Shahid et al. reported that just 48.4% of children under two had received all vaccines recommended under the Expanded Programme on Immunization (EPI), with rural coverage lagging well behind urban areas (62.9%) and geographical distance to services emerging as a significant predictor of delayed vaccination [3]. Such figures are illustrative rather than nationally representative, but they capture a consistent pattern: the burden of under-immunisation falls disproportionately on the most marginalised.

Under-immunisation in these settings is not attributable to vaccine hesitancy alone. Insecurity and targeted violence against vaccination teams, fragile health infrastructure, workforce shortages, and limited physical access all constrain coverage [3,4]. The COVID-19 pandemic compounded these barriers, disrupting routine immunisation and diverting frontline health workers, while heightened distress and altered risk perception independently shaped vaccine attitudes; in one national survey, 66.9% of respondents expressed some degree of hesitancy [5]. Against this backdrop, hesitancy is best understood as one determinant among several but a distinctly modifiable one, rooted in confidence, complacency, and convenience [6], and therefore squarely within the influence of the medical profession.

At its core, hesitancy in Pakistan reflects an erosion of trust. Misinformation amplified on social media magnifies fears about side effects, infertility, and religiously framed objections; in one recent study, 83.2% of parents had encountered negative messaging about the polio vaccine, even as television and clinicians remained their most trusted sources of information [7]. This mistrust has been deepened by the politicisation of immunisation. The 2011 disclosure that the Central Intelligence Agency had used a sham vaccination campaign to help locate Osama bin Laden lent credibility to circulating conspiracy theories and was followed by measurable declines in immunisation, with vaccination rates falling by an estimated 23–39% in districts most exposed to the ensuing anti-vaccine propaganda [8]. Reports of negative experiences and perceived coercion have arisen largely in the context of repeated, high-intensity polio eradication campaigns, particularly in communities already wary of state institutions [4]. Vaccine hesitancy in Pakistan is thus not merely an information deficit, but a symptom of strained relationships between citizens and the institutions meant to serve them.

This reframing carries a specific ethical charge for medical leadership, by which we mean not only individual clinicians but the councils, hospital administrations, and professional bodies that set the standards of the profession. Four obligations follow. Justice requires that health systems act to close, rather than tolerate, the coverage gap borne by marginalised children. Respect for persons demands honest, culturally attuned communication and genuine engagement with communities, rather than outreach experienced as coercive. Non-maleficence extends beyond the clinical encounter: because clinicians are among the most trusted sources of health information [9], misinformation originating from within the profession is uniquely harmful, lending false legitimacy to unfounded fears [10]. And fidelity to the public trust obliges leadership to safeguard the credibility of immunisation as a shared good. The distinctive contribution of this letter is to locate the response to hesitancy not solely in patient education, but in the professional accountability of medical leadership itself, including a duty to correct and, where necessary, sanction the propagation of falsehoods by clinicians.

Several measures follow directly. Training should equip health workers to communicate the benefits and risks of vaccination effectively and empathetically. Accurate materials in regional languages are needed wherever literacy is low. In insecure and rural areas, where distrust of government services runs deepest, partnership with community and religious leaders can help rebuild confidence and disseminate credible information. Vaccine-related misinformation should be monitored within routine public-health surveillance so that damaging narratives can be identified before they take hold [7]. Finally, medical councils and hospital administrations should uphold professional accountability, prioritising education and support, but ensuring that the repeated dissemination of misinformation by clinicians carries consequences [10].

Vaccine hesitancy in Pakistan is ultimately a test of institutional trust as much as a logistical challenge, and the profession’s response is a measure of its ethical commitments. Restoring confidence will require transparency, cultural humility, and leadership willing to hold its own members to account, so that every child’s right to protection from preventable harm is upheld not through campaigns alone, but by a profession that earns, and keeps, the public’s trust.

Declaration of generative AI and AI-assisted technologies use
During the preparation of this work, the authors used generative AI tools to assist with language refinement and structuring of the manuscript. After using these tools, the authors reviewed and edited the content as needed and take full responsibility for the content of the published article.