Biological Attack

As the annual hajj came to its end in early October, and hundreds of thousands of pilgrims departed Saudi Arabia having honored the highest traditions of Islam, the kingdom cautiously breathed a sigh of relief: No epidemic erupted among the roughly 1.4 million visitors. But though it may have seemed that attentions were focused on concern over the possible spread of the Middle East respiratory syndrome MERS — a disease that has affected more than 135 people in eight countries, killing 45 percent of those infected — for months Saudi health authorities have been keeping a nervous eye on another disease, polio, which is spreading rapidly across the Middle East, most recently inside war-torn Syria.

Though Saudi Arabia has been polio-free for decades, its Ministry of the Hajj has always borne special responsibility for the health and safety of all religious pilgrims to the holy city of Mecca. In Muslim tradition Crown Prince Abdullah, himself, is the custodian of the Two Holy Mosques, accountable for any tragedies that befall sacred visitors.

Given the intense religious significance of Saudi Arabia’s responsibilities, all possible disease outbreaks among pilgrims are a concern for the government. But it has been a long time since the Ministry of the Hajj had to take a position that stands diametrically opposite to the stance held by some followers of the faith: when it came to polio, the Kingdom stood firmly against Muslim extremism. This year, the ministry insisted that all pilgrims be fully immunized against polio, and bring proof of vaccination as part of their visa application process. Given that Muslim extremists — the Taliban and some al-Qaeda adherents — oppose polio vaccination, and have executed immunizers, the Saudi position was gutsy.

Whether it was successful, however, we’ll have to wait and see. The hajj has ended, and hundreds of thousands of pilgrims are now returning to their homelands all over the world. Because the incubation time for polio can be as long as 35 days Saudi authorities will not be sure that their measures worked until mid-November.

Nonetheless, it’s clear that polio — which just two years ago was on the verge of eradication, with active cases confined to just three countries — is resurgent, and the news is grim.

For the first time in 16 years, wild polio viruses are spreading in war-torn Syria, causing paralysis in afflicted children. On Oct. 19, the regime’s Ministry of Public Health declared a polio emergency and the World Health Organization (WHO) confirmed a "hot outbreak" that is actively expanding around Damascus. In the last week, polio cases have been identified in Ethiopia, Somalia, and among about a dozen Somali refugees in Kenya. As of Oct. 16, the number of 2013 active polio cases found in the three "endemic nations" (Afghanistan, Pakistan, and Nigeria) are far outnumbered by the toll in new outbreaks outside those countries: 99 children have contracted the disease in endemic nations, versus 197 in outbreak areas like the Horn of Africa, which had been free of polio. And in mid-October the United Nations Security Council called upon Khartoum and Juba to carry out mass vaccination campaigns after three cases of polio were found in the new nation of South Sudan.

Polio is not a mysterious disease — how it is spread among people and the role vaccination can play in its prevention are well understood. The world has struggled for decades to eradicate polio — a global effort that has cost billions of dollars and millions of man hours. Billionaire philanthropist Bill Gates added his weight and wealth to the polio campaign a few years ago, noting this summer that, "We’re raising the money to get it done by 2018. When these problems leave the rich world, they’re out of sight, out of mind…. Polio is where we have a very concrete plan. It’s raising $5.5 billion — of which the [Bill & Melinda Gates] Foundation is going to give $1.8 billion. If we get credibility from the polio success, we can be more articulate about a malaria or measles elimination plan."

But politics and religion can foil even the best technology and financing.

Victory seemed near in 2011 when vaccination coverage reached levels sufficient in most of the world to stop spread of the virus (which typically occurs through fecal transmission from infected individuals into water supplies or via close contact with others). By early 2011, polio was confined to Pakistan, northern Nigeria, and Afghanistan — all areas in which distrust of government and Western health services in Muslim communities was high. Backed by the Rotary Club International, Gates, and the Global Alliance of Vaccine Initiatives (GAVI), health officials worked closely with leading imams worldwide to assuage fears about immunization and counter false claims that the vaccines would either sterilize children or give them AIDS. The WHO was finally full of optimism about the polio fight.

But that summer, the U.S. Central Intelligence Agency narrowed its 10-year search for Osama bin Laden to a compound in Abbottabad, Pakistan. In hopes of confirming bin Laden’s presence behind the compound’s fortifications, American recruited Pakistani physician Dr. Shakil Afridi to carry out a fake hepatitis B immunization effort in the area. The scheme called for Afridi to gain entry to the compound, needle-immunize the children inside, and bring the used syringes to CIA operatives for DNA identification of the youngsters. Afridi never managed to get permission from the compound’s sentries, and the effort failed.

When the CIA scheme was reported in July 2011 by the Guardian, it spurred outcry from public health leaders (myself included) regarding the peril posed by linking the agency’s efforts to already politically sensitive vaccination campaigns. Horribly, the backlash unfolded as we had predicted. Today, polio is spreading in Somalia and Pakistan in areas where Taliban and other Islamist extremist groups have managed to contort the entire CIA/hepatitis saga: Collusion in immunization efforts is, they claim, tantamount to supporting the CIA, U.S. drone attacks, and a laundry list of other perceived American sins against Islam. Never mind that the polio vaccine is oral, no needles are used, and the Afridi/CIA scheme was all about those needles — the "Big Lie" has spread. To date, extremists in Pakistan have waged countless attacks on polio immunization workers — most of them, unpaid female volunteers — and their security details, killing at least 20 of them since December 2012, and injuring many more in bomb, knifing, and gun assaults.

The Kingdom of Saudi Arabia this summer issued unique health requirements for umrah and hajj pilgrims hoping to avoid spread of disease, after the WHO in May called upon all travelers worldwide to get vaccinated. Among them was insistence on polio vaccination, including a requirement of valid certification from local health authorities. Which meant that those waging attacks on polio vaccinators (allegedly in the name of Islam), could not engage in the religion’s most holy ritual unless they could prove that they were fully immunized.

But the Islamic world now faces a genuine crisis with polio, as radical factions continue to attack vaccinators and decry immunization as a dangerous Western scheme. The full extent of the Somali outbreak is not known, as foreign health professionals now find the country too dangerous. Even the die-hard war zone physicians of Médecins Sans Frontières (MSF) gave up on Somalia in August citing the deteriorating security atmosphere. MSF workers have suffered stolen medical supplies, kidnappings, violence of all kinds, and other atrocities. The organization’s departure left Somalia’s health system in a shambles, undermining an already fragile network of public health clinics that had served as the primary centers of child vaccination. The United Nation’s child health program, UNICEF, distributes vaccine supplies to Somalia, but has pulled its personnel back to Kenya. (Somali refugees have carried the virus into Kenya and Ethiopia.) And since June, when al-Shabab attacked a U.N. complex in Mogadishu, there has been a steady outflow from the country of both humanitarian organizations and Somali refugees. Last month’s al-Shabab attack on a Nairobi shopping mall has further cemented belief that the nation’s security situation is unraveling, putting all forms of public health — including polio control — in a tailspin.

Across the Arab Spring regions of the Middle East, the public health situations have spiraled out of control, with outbreaks and failed vaccination efforts noted this year from Morocco to the Iranian borders, Alexandria to Lake Victoria.

And now, some seven million Syrians are now displaced, scattered across Syrian territory and neighboring nations of Turkey, Kurd-controlled Iraq, Lebanon, and Jordan. At least 1 million of them are children under 12 years of age, according to UNICEF. Inside Syria, the public health situation has deteriorated so markedly that the population is now beset by the return of most vaccine-preventable diseases, including measles, hepatitis B, whooping cough, and polio. More than a third of the nation’s hospitals have been bombed to smithereens, another 20 percent have sustained sufficient damage to render them useless, and some 15,000 health professionals have fled the nation. On Sept. 15, a group of doctors and Nobel laureates issued a plea to the world, saying Syria’s healthcare was "at the breaking point."

This month, Jordan will launch a costly national child immunization program to stop the spread of measles and polio from the encampments of Syrian refugees to the rest of the nation. Lebanon and Turkey are anxiously watching as the Syrian refugee populations within their borders swell to the point of bursting and illnesses spread. For Lebanon, the situation is especially dire: not only does the added Syrian population increase the country’s human population by 25 percent, but it brings with it many of the same factions and disputes that were behind Lebanon’s bloody civil war in the 1980s. And Israel, which has been conducting a mass immunization campaign, vaccinating approximately 850,000 children since August 2013 — when polio viruses were discovered in sewer systems located in several parts of the country — is far from completing its efforts on this front.

Indeed, the core of the polio crisis remains in radical Islamist areas of Pakistan and these attacks on immunizers have been brutal, security details have been unable to protect themselves, much less the healthcare workers, and there is discussion of issuing a global travel advisory regarding the dangers of contracting polio in the country.

The Kingdom of Saudi Arabia practices Sharia law, under Sunni Wahabbi interpretations. As the home of the Islamic world’s most sacred sites, and birthplace of the Prophet Mohammed, Saudi Arabia can set standards for Muslims worldwide. Having issued a decree over the summer calling upon all pilgrims to the hajj to demonstrate they had received valid polio immunization, authorities took an important step: Riyadh signaled that regardless of what shenanigans Afridi and the CIA were involved in two years ago, protecting children from permanent paralysis merits support for vaccination. We can only hope that the Saudi health decree will be heard and heeded across the Muslim world — before it is too late and polio spreads to under-vaccinated regions of Africa, Asia, perhaps even Europe. Given the shocking decline in child immunization compliance across much of Europe and the United Kingdom, driven by false claims that vaccines cause autism, many children may be especially vulnerable were polio to be reintroduced to the region.