Monish Gulati
A police escort was killed and another wounded when militants
attacked a team of polio vaccinators on the outskirts of Peshawar on 30
November.1 Earlier on 23 November, militants in Pakistan
kidnapped eleven teachers involved in a polio vaccination campaign for
school children at a private school in the Bara area of the Khyber
tribal agency. The militants took the teachers to an area controlled by
Taliban-affiliated Lashkar-e-Islam group.2 These incidents
are amongst a string of senseless attacks carried out over the last few
years by the Pakistani Taliban (or the Tehrik-i-Taliban Pakistan-TTP) on
health workers working under Pakistan’s polio immunisation programme.
This article looks at the impact of these actions of the TTP on
Pakistan’s efforts to rid itself of polio, particularly after medical
evidence has indicated that Pakistan may have contributed to the spread
of the disease to Syria, and implications this holds for India.
A strain of the virus that originated in Pakistan has caused polio
and crippled at least 13 children in Deir al-Zor, Syria, where an
outbreak was detected in October. Genetic sequencing has confirmed the
origin of the virus strain found in Syrian children. According to the
Assistant Director-General for Polio, Emergencies and Country
Collaboration at the World Health Organisation (WHO), the virus has
travelled over land to Syria3 and is spreading across the
Middle East. Emergency plans are being implemented to vaccinate more
than 20 million children in the region.4 Closely related
strains of the wild polio virus of Pakistani origin have also been
detected in sewage samples in Israel, the West Bank and Gaza Strip since
February 2013. The vaccinations are to be carried out in Egypt, Iraq,
Jordan, Lebanon, the Gaza Strip, West Bank, Syria, and Turkey.5
Pakistan
Pakistan is one of three nations in the world (others being
Afghanistan and Nigeria) where polio remains endemic. Efforts to stamp
out polio in Pakistan through an oral immunisation programme have been
on since 1994. The programme had begun to yield results; in 2011 there
were 198 new recorded cases of polio in Pakistan, while in 2012, there
were just 58. However, the official number of polio cases detected so
far this year, have risen to 72. Most of the polio cases have been
detected in Pakistan's tribal regions; 19 cases from North Waziristan,
17 from Khyber, 9 from Khyber Pakhtunkhwa province, 6 each from Bannu
and Punjab, and 4 from Sindh have been reported so far this year.6
The Pakistani polio programme was initially targeted by the clergy
and the Taliban who declared the vaccination as a Western ploy to render
Muslims sterile by alluding to the fact that it was receiving foreign
financial assistance. However, there was little improvement in the
situation even after the funding of the programme was taken over by the
Pakistani government with the assistance of the Bill and Melinda Gates
Foundation (B&MGF), which had pledged to pay the seven per cent
annual interest on the $227 million loan the Islamic Development Bank
had provided to Pakistan for polio immunisation.
Another misconception is that the polio vaccine contains materials forbidden by Islam, such as alcohol and pig’s blood.7
The misconceptions are worse among the Pashtun population. Officials
associated with the programme, however, blame it on the country’s
failure to ensure quality polio vaccination, preventing immunisation
refusal and the inability to reach all children under five years of age.8
Since July last year, 24 health workers and policemen providing
protection to these health workers have been killed and 14 others
injured in 24 targeted attacks on vaccinators in different parts of the
country by the Taliban.9 The most recent attack having taken
place on the outskirts of Peshawar when two people were killed and 13
wounded in a bombing that targeted polio workers.10 Attacks
on health workers have not been restricted to the north of the country;
in December 2012, gunmen killed four women working on a government polio
vaccination campaign in Karachi.
Other Factors
Besides vaccination refusal, denial of access to certain restive
areas is a major cause for the rise in polio cases. According to
reports, the authorities in FATA were unable to vaccinate around 900,000
targeted children either due to the TTP’s ban on vaccination in North
and South Waziristan agencies last year or due to military action
against militants in other agencies.
Many Pakistanis have viewed polio vaccination campaigns with
suspicion after the CIA's use of a fake vaccination program in 2011 to
collect DNA samples from residents of Osama bin Laden's compound to
verify his location. The policy gave credence to the conspiracy theories
in circulation. Last year, a Taliban commander in northwest Pakistan
announced a ban on polio vaccines for children in the region as long as
the US continues its campaign of drone strikes in the region. The TTP
also believes that western powers are using polio vaccination programmes
as a cover for espionage. 11
However, many experts believe TTP’s strategy goes deeper. “It’s
another way of trying to control the population through fear”. The
difference in perception between the Afghan Taliban and the TTP on such
issues gives credence to this notion. Mullah Omar had issued a statement
that called for a change in the Taliban attitude, particularly towards
women’s rights and education. In May 2013, the Afghan Taliban endorsed
polio vaccination saying, “According to the latest international
medicine science, the polio disease can only be cured by preventive
measures i.e. the anti-polio drops and the vaccination of children
against this disease. The Islamic Emirate of Afghanistan supports and
lends a hand to all those programs which works for the health care of
the helpless people of our country.”12 Mullah Omar has allowed polio immunisation in Taliban dominated areas of Afghanistan since 2007.13
The Afghan Taliban proceeded to warn organisations not to attack
polio immunisation teams. The Taliban ‘advisory’ was applicable to all
its affiliates including the TTP. However the TTP continued with its
targeting of Pakistani health workers carrying out polio-immunisation;
drawing international condemnation. These acts, amongst others including
kidnapping and extortion, were reported to have deeply strained the
relations between the TTP and Mullah Omar.
Gender Aspect
It has been suggested that there is a gendered aspect to TTP’s
actions based on the recent history of militant violence being directed
against “lady health workers”, a body of more than 100,000 women who
deliver door-to-door healthcare.14 The lady health worker
programme was initiated by Benazir Bhutto in 1994, and for many women
and girls in remote areas, they provide the only direct access to
healthcare. A 2012 study published in the British Medical Journal looked
at how the Taliban threatened and attacked female health workers in
Swat during their brief period of control of the area. Lady health
workers were socially ostracised after public vilification by the TTP.
The study also found that many Lady health workers stopped working or
left the area due to the threat to their lives.
Afghanistan
According to the Global Polio Eradication Initiative, Afghanistan is
one of three countries in the world where polio remains endemic. There
have been 8 confirmed cases of polio in 2013 (as of October) and 37
reported cases in 2012, which were confined to the southern provinces,
specifically within thirteen districts in the provinces of Helmand,
Kandahar, and Uruzgan. However, the eight cases of polio confirmed in
2013 are located in the eastern provinces of Nangarhar and Kunar. Same
has been confirmed by WHO, which said that polio has been eradicated
across the country except Kunar and Nangarhar provinces (which are
adjoining FATA).15
India
WHO removed India from the list of polio-endemic countries in March
2012 after India successfully completed an entire year without an
incidence of polio. However, India will have to remain polio free for
two more years before it is declared polio-free by the WHO.16
India is alive to the possibility of the polio virus entering the
country through transnational movement of people, particularly from
Pakistan and Afghanistan. The Central government has alerted all the
States bordering the neighbouring countries to strengthen surveillance.
Special booths have been established on the Wagah border and Attari and
Munabao train stations to ensure that all children under the age of 5
coming from across the border are given polio drops.
In 2012, after WHO removed India from the list of polio-endemic
countries, Dr. Zulfiqar A. Bhutta, a vaccine expert at Aga Khan
University’s medical school in Karachi, stated “[n]othing wounded our
pride as much as that”. Following the WHO announcement, Pakistan’s
government went on an emergency footing. A cabinet-level “polio cell” 17
was created and various mullahs were drafted to endorse the vaccination
campaign in order to dispel persistent rumours and to give moral
legitimacy to the program. The mullahs subsequently issued 24 fatwas in
favour of vaccination and the same was disseminated to the public
through the health care workers.
Impact
Given the current situation where Syrians refugees in neighboring
countries have topped two million and that the immunization level in
these areas is not reassuring, the risk of further spread of the wild
poliovirus across the region is considered to be high. A surveillance
alert has been issued to actively search for additional potential cases.
Lebanon, which hosts more than 800,000 Syrian refugees, is vaccinating
all children under five. In Europe, experts have warned that the Syrian
refugees could inadvertently bring polio virus to Europe.18 The issue has further complicated the humanitarian crisis arising out of the Syrian conflict.
Back in Pakistan, the government has included polio vaccination
programme on the agenda for the proposed dialogue with the Taliban
groups. Imran Khan’s new provincial government in KPK is planning to
give polio workers weapons licenses to carry their own guns.19
However, the issue remains complex not only because of the TTP and
insurgency in FATA but because of the fact that the polio virus is also
endemic to Afghanistan and that Pakistan hosts large number Afghan
refugees. This worsening situation in Pakistan has the capability to
negate the positive gains seen in Afghanistan as cross-border movements
in the region could see a resurge of polio in the region.
India on the other hand, besides escalation of terrorism post-2014,
would also be mindful of the polio virus as a destabilized region could
see refugee movements into the country at a time it would be celebrating
the success of its decades-long ‘Pulse-polio’ programme.
(The author is an independent analyst based in New Delhi)
Endnotes
- Polio cop, 3 soldiers killed in attacks, The Nation, December 01, 2013. http://www.nation.com.pk/pakistan-news-newspaper-daily-english-online/na...
- Jibran Ahmad. Pakistan militants kidnap 11 teachers in polio vaccination campaign, Reuters, November 23, 2013. http://news.yahoo.com/pakistan-militants-kidnap-11-teachers-polio-vaccin...
- Syed Fazl-e-Haider. The virus of extremism fuels the spread of polio in Pakistan, The National, November 2, 2013. http://www.thenational.ae/thenationalconversation/comment/the-virus-of-e...
- Stephanie Nebehay Polio strain in Syria originated in Pakistan, WHO confirms, Reuters, Nov. 11, 2013. http://www.nbcnews.com/health/polio-strain-syria-originated-pakistan-who...
- WHO: Pakistan Polio Strain In Syria, RFE/RL, November 12, 2013.
- Ashfaq Yusufzai. Polio incidence higher than last year, Dawn, November 13, 2013.
- Samira Shackle. The struggle for a Polio-free Pakistan, NewStatesman, June 252013. http://www.newstatesman.com/politics/2013/06/struggle-polio-free-pakistan
- Ser 6.
- Ser 3.
- 2 killed in blast targeting Pakistani polio workers, CNN, October 8, 2013. http://edition.cnn.com/2013/10/07/world/asia/pakistan-polio-workers-attack/
- Ser 3.
- Zubair Babakarkhail and Dean Nelson. Taliban renounces war on anti-polio workers, The Telegraph, May 13 2013. http://www.telegraph.co.uk/news/worldnews/asia/afghanistan/10053981/Tali...
- Yaroslav Trofimov. ‘Risky Ally in War on Polio: the Taliban,’ WSJ, January 15, 2010. http://online.wsj.com/news/articles/SB126298998237022117
- Ser 7.
- BBC Pashto, November 19, 2013.
- Aarti Dhar. India no more a polio-endemic country: WHO, The Hindu, February 25, 2012. http://www.thehindu.com/sci-tech/health/india-no-more-a-polioendemic-cou...
- Khoso directs revival of Polio Cell, Dawn, June 02, 2013.
- Owen Bennett. Europe at risk of polio outbreak as refugees flee Syria, Express, November 8, 2013. http://www.express.co.uk/news/world/441872/Europe-at-risk-of-polio-outbr...
- Ser 7.
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