Polio eradication held hostage in Pakistan

In mid-June, after the fifth drone strike in two weeks, militant leader Hafiz Gul Bahadur of North Waziristan resorted to taking hostages. No Americans being readily available, Bahadur decided that the Western-funded effort to eradicate polio would suffice, declaring a ban on vaccinations until U.S. drone strikes cease. Militant leader Mullah Nazir of South Waziristan soon followed suit, announcing his own ban on June 26th.

From Bahadur’s perspective, there is something to the argument that drone strikes do more damage than polio. North Waziristan suffered from only 14 new polio cases last year, even as U.S. drone strikes killed over 250 of its residents, many of them armed militants allied with Bahadur. Of course, that these same militants are in fact largely responsible for both the mayhem and the public health crisis in Waziristan likely doesn’t enter into Bahadur’s calculations. As it stands, however, the polio vaccination campaign in the Federally Administered Tribal Areas (FATA) matters more to outsiders than it does to the tribal areas’ residents themselves, and as such it provides a tempting target for militant groups desperate for any kind of leverage over the United States.

Bahadur’s and Nazir’s bans fit into a broader pattern of Pakistani militants using intimidation and violence to halt polio vaccination campaigns in FATA. Militants have long spread rumors that the vaccines are part of a Western conspiracy to sterilize or poison Muslims, leading to high rates of vaccination refusal. Extremist groups have specifically targeted health workers for kidnapping or assassination, killing the head of the polio vaccination campaign in Bajaur in 2007.

The United States stands behind both drone strikes and health programs in FATA, blurring the lines between the two. This has always created tension, as seen in the debate over USAID’s on-again/off-again demand that its programs in FATA be overtly branded as "from the American people," even as those carrying out such programs are labeled as spies and targeted by militants. Suspicions of U.S.-funded health programs have been compounded by revelations that CIA informant Dr. Shakil Afridi attempted to collect information on Osama bin Laden’s family in Abbottabad under the guise of a vaccination campaign.

Pakistan’s remaining polio sanctuaries have become closely linked with anti-Western militancy and pose a growing challenge to the worldwide effort to eradicate polio. Globally, this effort has succeeded in reducing the annual incidence of polio from over 350,000 cases in 1988 to less than 700 in 2011. The eradication campaign has foundered with the increase in militancy in Pakistan, however, as polio cases there have risen each year since 2005. Last year Pakistan was responsible for more cases than any other country, most of which were concentrated in the Pashto-speaking areas along the Afghan border, including Waziristan.

Polio can easily spread from the tribal areas to elsewhere in the country. Labor migration and conflict have resulted in regular movement between Waziristan and Karachi, where polio has repeatedly surfaced. From the sprawling port city’s volatile slums the disease can spread onward, back to India, Bangladesh, and other countries which earlier rid themselves – at least temporarily – of polio. This potential danger was underscored in late 2011, when the World Health Organization traced China’s first polio outbreak in ten years back to Pakistan.

In addition to Pakistan, polio remains endemic only in Afghanistan and Nigeria. In all three countries it occurs nearly exclusively in Muslim areas home to anti-Western insurgencies. Polio persists here for two reasons: militants deny vaccination teams access to areas under their control and parents refuse to let their children be vaccinated. Both of these can be traced back to fears that vaccination is part of an anti-Muslim plot. These fears, however laughable they may appear to outsiders, need to be taken seriously.

The global campaign must be transformed into a Muslim-led effort if it is to eradicate polio from these remaining sanctuaries. Through no fault of their own, the World Health Organization’s director for Global Polio Eradication, Dr. Bruce Aylward, and representative in Pakistan, Dr. Guido Sabatinelli, are no longer the most effective choices for the campaign’s visible leadership. Polio has been eradicated in Muslim-majority countries as varied as Indonesia, Saudi Arabia, and Tajikistan, leaving behind a capable cadre of public health officials who could take over such posts.

Western funding and technical support will remain necessary, but it should be discretely channeled through the World Bank or World Health Organization. The United States in particular must publicly disassociate itself from the vaccination effort. The Organization of Islamic Cooperation needs to help provide funds for polio eradication, securing at least token donations from all its poorer member states and significant amounts from the wealthier members. Polio concerns all Muslim-majority countries; if eradication continues to falter it is only a matter of time before the annual Hajj pilgrimage, attracting hundreds of thousands of Muslims from across the world, becomes a site of polio transmission.

At the national level, Pakistan must continue its efforts to brand polio vaccination as Islamic. Some progress has already been made in securing the support of religious and nationalist leaders such as Imran Khan and Fazlur Rehman. International religious figures popular among FATA Pashtuns, including Dr. Zakir Naik of India and Imam Abdul Rehman al-Sudais of Saudi Arabia should also be encouraged to lend public support to Pakistan’s eradication efforts. If jihadist figures such as Hafiz Saeed of Lashkar-e-Taiba are willing to pose for photo-ops giving oral vaccination drops to three year olds, that too would be helpful.

For FATA residents to care about polio vaccination, this public relations campaign should be expanded to include health issues with a more immediate and devastating impact. In 2002, the World Health Organization found that tetanus was responsible for over a fifth of all infant mortality in FATA. Taking into account population and birth rate estimates, this suggests a rough figure of at least two thousand infants in FATA dying every year from tetanus alone, which is easily prevented with proper vaccinations for expecting mothers. The same militants who have banned the anti-polio campaign have also kept health workers from saving these and the thousands of other children who die from preventable diseases in FATA. The tribal areas’ residents should be enlisted in the effort to pressure militants to cease banning health programs as a weapon in their struggle against the Pakistani Government and the United States. To do this requires speaking to their concerns and assuaging their fears of foreign-funded vaccination campaigns.

Events along the remote Afghanistan-Pakistan border have a global impact for two reasons: terrorism and polio. Despite Bahadur’s and Nazir’s threats, U.S. drone strikes will continue in Waziristan, and perhaps the tribal areas will eventually fade as a center of anti-Western terrorism. In order for polio eradication to succeed, however, it must be separated from the United States and its drone strikes. It will be much easier to make the polio eradication campaign Islamic than it will be to erase anti-Western sentiment in FATA and other polio-endemic areas. Only by handing over the reins – and the credit – for polio eradication to Muslims, will Waziri, Pakistani, and American children together live in a polio-free world.

Sean Mann is currently in the Masters of Science in Foreign Service program at Georgetown University. He speaks Pashto, and recently spent a year conducting research on the border areas of Afghanistan and Pakistan.