At a train station in Bareilly, a dusty mid-sized city in the Indian state of Uttar Pradesh, teenage health workers wove through crowded platforms armed with small bottles of polio vaccination drops. They were looking for kids tiny enough to be under five years old, kids without the ink stain on their finger indicating they'd already been vaccinated. Watching the moms in January convinced me that India's decades-long campaign against polio is working. Moms don't let strangers, even ones with official-looking bright yellow aprons, give their kids medicine unless they know it's both important and legitimate. And now that it's been six years since India's last reported cases of poliovirus, which can lead to crippling deformities and paralysis, they know that these oral drops are vital without the pro-vaccination pamphlets or Bollywood actors in television ads saying so.
India announced that it had officially eradicated polio back in 2014 after a 20-year campaign that cost at least $200 million every year it was in effect. The Pulse Polio program was an unexpected success given the country's population of 1.2 billion and rocky public health record. It was carried out by the government, nonprofit groups, and agencies like the World Health Organization and United Nations, with an effective combination of injectable and oral vaccines. India's results helped the global number of polio cases drop from 350,000 in 1988 to just 74 in 2015.But years after the last case of polio stopped spreading locally, India still has to channel millions of dollars and dispatch more than 2 million health workers annually to keep the virus at bay. While most of the world has now successfully eradicated polio, the virus continues to spread in three countries: Nigeria, Pakistan, and Afghanistan, the latter two of which border India. Political boundaries can't stop a highly infectious virus, and Pakistan has exported its polio cases to other countries throughout the past decade.
The last countries with polio have some important commonalities: They are rankled by terrorism that threatens health workers and makes it difficult to disseminate vaccines. But the root of this is often based in something else entirely: conspiracy theories that have grown out of stark mistrust in power.
This misinformation is a kind of virus in itself. Fighting dangerous conspiracy theories, as India has found, is its own important battle, as important and challenging as actually stamping out the poliovirus for good.While the governments of Pakistan, Afghanistan, and Nigeria have committed to the distribution of polio vaccines, they can't control the underground networks created by Al Qaeda, the Taliban, Boko Haram, and Islamic State, or ISIS.Last April, militants killed seven Pakistani policemen who were guarding public health workers in Karachi. Later in 2016, the World Health Organization reported that two cases of polio had been found in Nigeria, in a part of the state isolated from the rest of the country by the terrorist group Boko Haram. In Afghanistan, militants blocked tens of thousands of children from being vaccinated."In all of these cases, the security, violence, and inability to access the populations that need the vaccination have interrupted these efforts," said Josh Michaud, a director of global health policy at the Kaiser Family Foundation, a nonprofit research organization.
Part of this resistance is grounded in the US-led assassination of Osama bin Laden, who was found, in part, due to a 2011 Hepatitis B immunization campaign orchestrated by the CIA. Since the Taliban and Islamic State figured out the role of this strategic faux-health campaign, they have been waging a war against health workers, including those dispatched to disseminate the polio vaccine in rural areas. Meanwhile, the Pakistani doctor who helped the CIA is still in jail.
Health groups have made many attempts to reach out to the Taliban. In December 2015, a liaison from the insurgent group actually agreed to work with WHO officials in Afghanistan to help vaccinate the children in impacted areas there. "I am 100 percent happy to work alongside WHO and the government to fight polio, a disease affecting children in our isolated areas," Obaidullah Elaj, a Taliban doctor, told Bloomberg.But just months later, militants attacked health workers again, and since, several new cases of polio have emerged.Other conspiracy theories protecting the poliovirus have to do with the vaccine itself. As with antivaxxers in North America and Europe, misconceptions are often spread in local communities in Pakistan and Afghanistan, where health education is weak. In Pakistan's Swat Valley, home to many rural and isolated villages, some families worried that the polio vaccine was a secretive method of forced birth control. Others mistakenly believed the oral drops contain materials made of out of pigs, forbidden in Islam, the dominant religion in both countries.India doesn't grapple with ISIS or the Taliban the same way as its neighbors in the Middle East. But when it comes to fighting misconceptions and conspiracy theories, the polio program has faced similar hurdles in this populous country where every state can feel like a different country, with a different language and culture.
Walking through a puzzle of alleyways in Bareilly, I made my way to the Dargah-e-Ala Hazrat, the tomb for 19th century jurist Ahmed Raza Khan, an expert in Islamic law who gained a strong following throughout his life. The community that flourished around the dargah is conservative and pious. Every day the five prayers central to the Islamic faith blast through loudspeakers into the bustling neighborhood.When polio workers from the government and nonprofit groups started to pour through communities like this one back in 1995, they confronted backlash. Families were scared of the vaccine, convinced it was government conspiracy and a form of birth control, possibly to curb the Muslim population, said Shami Mohammed, the local polio program liaison for UNICEF, a United Nations agency focused on children's health and education.Their fears, he said, stemmed from a crisis that dates back 40 years. In 1975, then-Prime Minister Indira Gandhi declared a state of emergency, a 21-month-long period of severe law enforcement meant to crack down on dissent. As part of an effort to control the population, Gandhi ordered government workers to perform vasectomies, often by force. An estimated 6.2 million men, some not even married, were sterilized across the country, the BBC reported.Many people in India's conservative Muslim communities, who have often faced discrimination in a Hindu-majority country, were traumatized. While Islam does not necessarily prohibit or restrict birth control, it is still a cultural and religious preference to have large families, and approaches to family planning vary.
Polio workers inherited this widespread resistance, but they had no intention of stopping their important work, said Mohammed. Instead, workers from the nonprofit Rotary International and UNICEF reached out to revered Muslim leaders near the dargah. "We went to talk to the leaders at the dargah, help them understand with all the documents that none of the rumors were real," Mohammed told me.
In the early 1990s, polio workers approached Shahbuddin Razvi, a mawlana (or religious leader) in the area. When I met Razvi, a solidly built man who was wearing a buttoned-up black tunic and a small skullcap called a taquiya, he told me the workers brought research and data to him, some from Islamic medical associations, to prove that the vaccinations were safe.As we sipped tea in a small room in the back of the dargah, Razvi said he was quickly convinced. He started traveling across the district and neighboring state of Uttarakhand with Rotary and UNICEF volunteers. He met with imams, religious leaders who lead prayers in mosques, and would help them understand why the vaccine was important. Sometimes he would administer the vaccine to children in his own family to show others it was safe.In his own community in Bareilly, Razvi started to give talks on polio during jummah, the Friday prayer central to the Islamic faith, similar to Sunday church for Christians. Here, he had hundreds of people in one place, and he could openly talk about issues of health and sanitation. (Poliovirus is spread through contact with infected fecal matter.)
"There is a hadith [rule] in my religion that is a strong recommendation. You have to wash yourself five times a day, before and after you pray. A practicing Muslim would follow that," he said. "And they would be healthy."This kind of intense community outreach worked. Polio workers were able to cross cultural boundaries, dispelling myths and building trust in communities that had no faith in their government. Fighting polio became almost like a program of social inclusion, cutting through India's socioeconomic hierarchies.
At the Bareilly train station that day, I came upon a 22-year-old woman named Veera, struggling up some steps with a travel bag, and her son, Mayank. When Veera was younger, the polio vaccination program was weak. Her telltale limp will be a lifelong reminder of the poliovirus that she contracted, and the public health system that failed her. The fresh ink stain on her 4-year-old son's finger, meanwhile, was a sign of change and progress.To watch India's immunization program in action is to watch an army of people of every age and background quickly dispatched across the country. They set up booths at traffic lights and neighborhood milk stands. I followed clusters of women as they went door to door in every village on designated immunization days, marking doors with chalk to signal they've been there. They checked tiny fingers. They said "polio" over and over again, cementing it as a household word.
"We say every 250th person in India is involved in polio vaccinations," said Ajay Panwar, director of the regional World Health Organization immunization program in Bareilly.Those efforts end exactly at the border, where the country has set up polio vaccination booths for the people crossing over from Pakistan. And until the virus is wiped out from Afghanistan and Pakistan, India has to stay just as vigilant as when it plagued its own citizens."As India itself was one of the last countries to eliminate polio from inside its borders, it remains particularly vulnerable to reintroduction," Michaud said. "Any country where there is a drop in population immunity—a gap in the armor—could be the site of a reintroduction."But India's fight against the virus has also dealt the world a lesson: Public health programs work best when they include education and inclusion. It's a lesson that applies in the US, where some parents still refuse to vaccinate their children against preventable diseases, and in Pakistan, where health workers with vaccines will not live long enough to reach another child.If the three remaining countries with polio are able to wield education as an antidote to rampant conspiracy theories, it will do more than wipe polio off the face of this Earth—it would make a huge dent in terrorism too.The reporting for this story was supported by Rotary International.