Until this week Nigeria had been applauded as a global health success story for polio eradication efforts. The West African country had gone two years without any new cases of polio, which meant only two countries were left to potentially eradicate polio from the planet altogether: Afghanistan and Pakistan.
Then news broke on Thursday that two cases of polio had been found in children living in the northern state of Borno, the birthplace of militant group Boko Haram. It was a setback for Nigeria's program, but also a stark and sobering reminder that public health efforts, even if backed by millions of dollars and years of planning, can be quickly undone by violence.
Nigeria had been a tough country to treat even before Boko Haram, said Josh Michaud, associate director for global health policy at the Kaiser Family Foundation, a nonprofit research and policy organization. Public health programs—backed by both the government and international aid groups—faced several obstacles, including a widespread anti-vaccination campaign that convinced many Nigerians that vaccines were dangerous. Even so, they were able to reduce polio from around 1200 cases in 2006, to no new cases in 2014.
"There has been a concerted effort by all parties," Michaud told me, referring to the collaboration between the government and international development agencies. "There was a dramatic turnaround in polio."
But Boko Haram, which has since aligned with the Islamic State, has proven a much more difficult hurdle. The group is responsible for killing more than 6,000 people and displacing up to 1.2 million more. And the group's attacks have taken a toll on health clinics and hospitals since it rose to prominence in 2009. Many of Borno's doctors and nurses have been forced to flee the region for safety. In 2013, the polio eradication effort took a direct hit when militants attacked some foreign doctors and staff administering vaccines, as Al Jazeera reported.
Warzones have always been a hotbed for disease and illness, but the terrorist factions that threaten us today impact global health in a whole different way. Many insurgent groups looking to challenge existing governments target basic internal infrastructure: hospitals, schools and roads. ISIS has also been tearing apart emergency hospitals run by outside groups like Médecins Sans Frontieres (Doctors Without Borders), leaving little hope for everyday people caught in unstable Middle Eastern countries.
"The three last countries with polio have similar reasons why," Michaud said. "In all of these cases the security, violence, inability to access the populations that need the vaccination have interrupted these efforts."
But he pointed out that there is a silver lining to this week's news. The fact that Nigerian officials and health workers could surveil Borno to find the cases was a win for the government, since they haven't had enough access to the area for several months. Each case of paralysis caused by polio usually means there are at least another hundred cases of polio without symptoms nearby, he said. So the government's gains in the region could mean the reintroduction of essential vaccinations to northern Nigeria in the near future.
Meanwhile, outside organizations working to fund and implement the polio program showed no signs of backing down. Nonprofit groups and aid agencies have spent $247.2 million in 2016 to fight polio with the Nigerian government, more than they have spent on any other country in the world. Their strategy will be essential to the global effort, given the mass displacement and millions of refugees fleeing the country, possibly without treatment or vaccination.
"No matter how hard-to-reach an area is due to geographic barriers or insecurity, the polio program reaches those kids to protect them from polio," said Jay Wenger, director of the polio program at the Bill & Melinda Gates Foundation, a major contributor to Nigeria's polio program.
"While the cases in Borno are a disappointment, we are confident that we will stop the outbreak like the program has done in all but three places on earth."