On Tuesday, public health officials reported three new cases of polio in Afghanistan's Kandahar province — the first in nearly two years to be recorded in the province, which, like the rest of the country, had recently made strides in fighting the disease.
Afghanistan is one of three countries in the world where the incurable but preventable disease remains endemic, particularly within Kandahar. The others are Nigeria and neighboring Pakistan, where the spread of the disease has recently reached record numbers largely because of an anti-immunization campaign that has resulted in the killing of dozens of health workers since 2012.
Earlier this month, Pakistan counted its 200th new case of polio this year — its highest in more than 12 years. The country has long battled the spread of the disease, managing to reduce the number of new cases to 28 in 2005. But resistance coordinated by the Pakistani Taliban and other Islamist groups — as well as, critics say, inaction by the government — has caused a recent spike that threatens to only get worse. Pakistan today accounts for 80 percent of all polio cases worldwide.
Afghan officials believe that migrants fleeing Pakistan's northern Waziristan region, where the government is battling Islamic extremists, are bringing polio across the border into Afghanistan's Khost province. According to the Global Polio Eradication Initiative, which monitors the disease worldwide, "North Waziristan is the district with the largest number of children being paralyzed by poliovirus in the world."
Before the latest cases in Kandahar, Afghanistan had registered seven new cases this year. Kandahar's public health department hasnoted that most children arriving from Waziristan haven't been vaccinated.
"Afghanistan is certainly vulnerable because of the close relationship between these countries, especially along their common border, which is one of the very poorest borders," Stephen Morse, a professor of epidemiology at the Mailman School of Public Health at Columbia University, told VICE News, noting that eradication initiatives there have been difficult but largely effective. "Afghanistan has been a huge challenge, and I'd hate to see that we'd have to do that over again."
Under international pressure, Pakistani authorities have carried out a number of vaccination initiatives, reaching 700,000 of the more than a million displaced residents in northwestern Pakistan this summer. Immunization campaigns across the country have reached 34.2 million children, or 95 percent of all children under the age of five.
But critics note that the numbers can be deceiving, and believe that Pakistan's government is not doing enough.
"The government has been putting out these figures, saying for instance, 'In this area we've covered 300,000 children,' " Benazir Shah, a Pakistani journalist who has covered the issue extensively, told VICE News. "But that doesn't really mean anything. How many children were in this area? We haven't had a census in Pakistan since 1998, so we don't really know. Unless you say, 'In this district we have covered every single child,' which is what polio is really about — reaching out to every single child — that just shows the lack of interest and the apathy of the government. There's very little drive."
The country's campaign for polio eradication has been very high profile — which helps explain why the effort has come under the attack of Islamic militants apart from other campaigns against hepatitis C and measles.
Launched by late Prime Minister Benazir Bhutto — whose daughter Aseefa was in 1994 the first Pakistani child to be vaccinated for the disease — the push for polio eradication has garnered much international interest.
It has also brought into the country large investments from various outside donors, including the Bill and Melinda Gates Foundation and the Islamic Development Bank. But the need for funds is still grave. The predominantly female vaccination workers who put their lives at risk to vaccinate children in hostile environments are typically paid 250 rupees a day — fewer than $3 — and sometimes even less. Some have refused to work in heavily at-risk areas, where the security situation is dire and government protection practically non-existent.
"It meant more to the previous government — there were more ads running, there was a lot more happening. The problem with this government is that they don't have the same drive, they don't consider it a priority," Shah said. "This government has always been considered pro-business, so that's something they're focusing on: the economy. Health is just not important."
"The problem with the previous government is that they didn't have access to the tribal areas, which this government does because of the ongoing military offensive right now in North Waziristan," she added, noting that the military campaign is a double-edged sword, as it also brings more resentment towards any government-sponsored initiative. "The polio campaign gives militants leverage, because it's a campaign that previous government have pushed for, that the international community is interested in. So they can kill a few workers or kidnap them and put out their demands. They'll kidnap workers and then say, 'Stop the airstrikes.' It works to their advantage."
Pakistan's Taliban leaders banned the immunization drive in June 2012, launching a campaign of violence against public health workers that has killed more than 60 people since December of that year.
Apart from the bloodshed, the campaign is principally one of misinformation, with some Taliban leaders claiming that the immunization drive is "a secret Jewish-American agenda to poison Pakistanis" and spreading rumors that the vaccinations are a secret sterilization plot, that they contain pig fat, and that healthcare workers are actually spies.
Suspicion about the medical teams traveling around the country wasn't helped by the fact that a Pakistani doctor named Shakil Afridi notoriously attempted to help the CIA track down Osama bin Laden by collecting DNA samples in Abbottabad under the guise of an immunization campaign — albeit for hepatitis B, not polio.
"There was similar resistance — to some extent even as violent — in northern Nigeria, in Kano state, a couple of years ago," Morse said. "Besides the objections people might have against the vaccine, there's usually a narrative that goes with it: that it is a plot. In Nigeria they said there was a plot to render Muslim women sterile."
In Pakistan, efforts to promote vaccinations through TV ads, for example, have also been somewhat misguided because they fail to reach communities — particularly some of the most vulnerable ones — with little access to such technology.
"Who's watching these ads?" Shah asked. "There's no assessment of how effective they are." But ignorance and misinformation is not the only problem, she added, or even the main one.
"It's not so much a Muslim, anti-West sentiment, it's more that for people it's also not a priority," said Shah, who has conducted many interviews with residents in the most at-risk areas. "They're saying, 'Listen, we don't have clean drinking water, we don't have food, we don't have jobs. Why should we care about polio?' There was a very, very small percentage of people that we spoke to that actually said, 'There might have pig fat in it, or it's a CIA operation.' Most of them just said, 'Why is it important to me?' "
Despite being on the rise, polio's impact remains relatively limited. The disease affects mostly young children; one in 200 infections leads to paralysis, and it is fatal in 5 to 10 percent of those cases. But in a country where poverty is also endemic and exacerbated by conflict, natural disasters, and the large-scale displacement caused by both, few think of polio as a priority.
Nevertheless, there have been encouraging efforts within the religious community to help eradicate the disease, including by issuing "anti-polio" fatwas calling bans on vaccination un-Islamic.
International pressure is also helping somewhat. In May, the World Health Organizationdeclaredpolio a "public health emergency of international concern," allowing it to recommend travel restrictions to prevent its spread. Saudi Arabia, which already required proof of polio vaccination from pilgrims traveling to Mecca, has begun vaccinating all visitors coming from Pakistan, Afghanistan and Nigeria directly upon their arrival in the kingdom.
Some countries now insist on having polio certification for the approval of visas. While this has led to a proliferation of forged vaccination certificates, it has also embarrassed Pakistani authorities into action.
The frequent updates on the numbers of people it has vaccinated are a reflection of this, Shah said.
"But they're stretched," she said. "There's this offensive in North Waziristan, these political rallies right in the heart of the capital, there's an economic crisis, the government is weak regionally…. There are a lot of other crises, and for the time being they're not really going to focus on polio."
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