Initially sentenced to 33 years in prison for being a member of Lashkar-e-Islam, a militant group based in Pakistan's Khyber Agency tribal area, Shakil Afridi is better known for his alleged involvement in a fake hepatitis vaccination campaign in which DNA samples were collected to help the US track down former al Qaeda chief Osama bin Laden in 2011.

And while the Pakistani physician's jail sentence was cut to 23 years by a Peshawar court last year, his imprisonment continues to be an irritant in the complex ties between Islamabad and Washington, the latter of which has repeatedly call for the doctor's release.

In the latest turn of events, that same tribunal resumed an appeal hearing on Thursday, June 25. However, experts cast doubts about the authorities' intentions of releasing the convicted physician: "Afridi is seen by the Pakistani government as the treasonous accomplice - the local national who helped a foreign intelligence agency set the stage for a humiliating, unilateral raid onto Pakistani territory," Michael Kugelman a senior associate for South Asia at the Washington-based Woodrow Wilson Center for Scholars, told DW.

Many analysts believe that Afridi, in effect, is behind bars for having cooperated with a foreign intelligence agency and that the rather inconsistent and contradictory ways in which his case has been conducted is typical of how the Pakistani authorities deal with many cases of public policy.

"The government has been very opaque about Afridi's current status and condition, so it's ultimately hard to know what's really going on. Short of some sort of prison swap with the US - which is highly unlikely - we can assume Afridi will be behind bars for the foreseeable future," said Kugelman.

A mishandled case?

Still, many argue the case has been mishandled by the Pakistani authorities and there are many inconsistencies in the legal process.

Dr Farzana Shaikh, associate Fellow at the Asia Program of the UK-based think tank Chatham House, points out, for instance, that while Afridi's alleged offences were committed in Abbottabad, he was tried not in a criminal court governed by the Pakistan Penal Code but convicted in the tribal agency of Khyber under colonial-era tribal laws (the Frontier Crimes Regulations 1901), which deny defendants the right to legal representation and appeal.

Moreover, the analyst explained, there is confusion surrounding Afridi's re-trial and conviction, which was overturned in 2013. "Although Pakistan has now ordered a re-trial, it is still unclear whether Afridi will be tried under new laws that give him the right to full legal representation," Shaikh told DW.

Meanwhile, Afridi remains in custody, reportedly at a high security prison in Peshawar, with little immediate hope of a reprieve or prospects for a fair defense, especially after his former lawyer was shot dead in March this year.

'A devastating effect'

But perhaps even more importantly, the controversy surrounding the Afridi case and his alleged role in the killing of bin Laden created a lot of hitches for key vaccination programs, as Ayesha Raza Farooq, the Pakistani prime minister's focal person for polio eradication, told DW.

In the short term, families in parts of the country decided not to get vaccinated. In the mid-term, even as the shock of the Afridi revelations dissipated, there remained serious perceptional challenges which had to be addressed through an intensive advocacy strategy.

The situation caused alarm amongst the program's planners and policy makers. The result was troubling impacts for public health, as evidenced by the high number of new polio cases in Pakistan in late 2013 and 2014. In fact, a total of 359 new polio cases were identified worldwide last year. Of these, 306 or 85 percent were detected in Pakistan alone.

The Afridi case has had a "devastating effect" on Pakistan's polio vaccination program, triggering the country's most serious public health crisis, said analyst Shaikh.

"While it cannot be said that the fake vaccination program was solely responsible for precipitating the crisis it has certainly aggravated the problem and made it much harder for health authorities to stem public hostility to the program, especially in northwestern districts and Balochistan, where Islamist militant groups have a strong presence."

Mistrust

But what lies at the root of the problem? The Pakistanis' response to the Afridi case needs to be understood in a broader context. There has long been suspicion among some conservative, rurally-based Pakistanis who have long believed that vaccinations are some sort of nefarious Western conspiracy to bring harm, whether by making victims sterile or causing some other major problem.

This is, to be sure, not a perception held only by Pakistanis. Some Nigerians and Afghans harbor such views as well. Not coincidentally, these people belong to some of the only countries in the world where polio is still endemic.

Against this backdrop came the Afridi revelations, which confirmed to many Pakistanis their long-held suspicions that vaccinations (polio and others) were a "big fraud." "Even the most progressive and pro-West Pakistanis were furious about these revelations, because they knew it meant that despite the worthwhile end goal of tracking down a top global terrorist, the major public health crisis of polio would only worsen," said Kugelman.

"Mistrust dies hard, and in the case of Pakistan, revelations of fake vaccination campaigns simply harden these long-held perceptions," he added.

Suspicion and violence

But mistrust hasn't been the only consequence. Pakistan also toughened its policies towards international aid groups, accusing them of covering for spying operations. More recently, the Interior Ministry announced it would monitor these groups' activities after authorities sealed the offices and suspended the operations of Save the Children, which they accused of being connected to the May 2011 killing of bin Laden, a charge the charity has vehemently denied.

At the same time, the Taliban and other groups have violently opposed vaccination campaigns, arguing they are a cover for foreign intelligence agencies. For a number of years, the militants would attack health workers seeking to penetrate the most polio-ridden areas, which coincidentally have also been the most militant-infested.

As a result, almost 80 health workers have been killed nationwide since December 2012. In essence, Pakistan's polio crisis has been driven not just because of fear of vaccination, but also attacks on vaccinators.

Making progress

The good news is that the Pakistani military offensive launched in North Waziristan last year has eliminated, or at least displaced, many of the Taliban militants who would prey on health workers. This is an important reason behind the drop in the number of new polio cases in recent months.

"The key issue of inaccessibility, the single major impediment to fighting polio, has been effectively addressed by launching a military operation to flush out terrorists, initiating campaigns protected by the armed forces and establishing an effective security strategy that is in sync with operational strategy in sensitive areas," said Farooq, adding there is now a high acceptance of vaccination across Pakistan, including in the tribal and far-flung areas as evidenced by data.

The country's focal person for polio eradication said Pakistan has made significant progress over the past years, arguing, among other things, that the Wild Polio Virus type 3 (WPV3) has not been reported in Pakistan since April 2012. Moreover, compared to the same time period last year, the country has witnessed a 70 percent reduction in the number of registered cases in 2015 (25).

"Pakistan has been criticized for not going after all militants equally in its counter-terror campaign in the tribal areas, and this is likely a fair accusation. However, it has robustly gone after the anti-state militants who terrorize polio workers. The resulting decrease in polio cases makes for a success story that we should all be very happy about," said Kugelman.