The Shots Heard Around the World

From global-health success story to nightmare: How a worldwide effort to eradicate polio went from Jonas Salk to Islamic terrorist.

Laurie Garrett
By , a columnist at Foreign Policy and former senior fellow for global health at the Council on Foreign Relations.
Photo: RIZWAN TABASSUM/AFP/Getty Images; Chart: Global Polio Eradication Initiative
Photo: RIZWAN TABASSUM/AFP/Getty Images; Chart: Global Polio Eradication Initiative
Photo: RIZWAN TABASSUM/AFP/Getty Images; Chart: Global Polio Eradication Initiative

New shots are jeopardizing humanity's battle to eradicate polio, and they don't include syringes or vaccines. Rather, they're the gunshots of Islamic terrorists.

New shots are jeopardizing humanity’s battle to eradicate polio, and they don’t include syringes or vaccines. Rather, they’re the gunshots of Islamic terrorists.

The fight to eliminate polio is now imperiled, according to the World Health Organization (WHO), by “insecurity, targeted attacks on health workers and/or a ban by local authorities on polio immunization,” and violence in the Middle East. In a March 2014 report, the organization warned that the virus, which existed in only three countries at the dawn of 2012, is now returning to places from which it had been eradicated, and “risk of further international spread remains high, particularly in central Africa (especially from Cameroon), the Middle East, and the Horn of Africa.”

The collective forces of global health are watching their efforts backtrack, thanks to warfare and to the growing belief within Islamist circles that the polio-eradication effort is a secret CIA plot, designed to harm or contaminate Muslim children. Amid assassinations and bombings of vaccination sites, chiefly in Pakistan and Nigeria, the death toll for healthcare workers now exceeds the number of children dying of polio, and could soon surpass the tally of new virus-paralyzed youngsters worldwide.

What was once a triumphant example of humanity and solidarity has transformed into something deeply dangerous.

In 1988, Rotary Club International combined forces with UNICEF in an effort to eradicate polio from the planet by the year 2000. In just 12 years the global effort reduced the estimated number of polio cases from 400,000 in 1980 to just over 7,000 cases in 1999. As the clock ticked toward the millennium, the then-new Bill & Melinda Gates Foundation threw considerable financial weight behind the effort, which has now immunized 2.5 billion children and youth in 200 countries, corralling a force of more than 200 million volunteers, at a combined cost of $8.6 billion.

But 2000 came and went with polio still in circulation in several countries, chiefly Pakistan, Nigeria, Afghanistan, and India. In 2003 — when just 784 polio cases were reported worldwide — a handful of imams in Nigeria’s northern Kano state, which is overwhelmingly Muslim-populated, concluded that the vaccine contained American-made sterilizing agents that would render their daughters incapable of bearing children. Some were also convinced that the HIV virus was deliberately added into the vaccine.

Among the imams were well-read scholars who drew their conclusions after perusing websites similar to those former South African President Thabo Mbeki used back in the day. Mbeki concluded that AIDS did not exist and that Western pharmaceutical companies invented false HIV claims in order to compel drug sales across Africa. A Harvard study found that the former president’s AIDS denialism and refusal to allow treatment for his people cost more than 300,000 South African lives.

The polio-is-a-CIA-plot idea spawned in northern Nigeria spread to Afghanistan and Pakistan, where some Taliban members added vaccination to their list of complaints against American military forces. By 2006, the polio caseload had risen to more than 2,020 children.

In 2007, a chief surgeon and head of polio eradication in northern Pakistan, Abdul Ghani Khan, was assassinated in a Taliban bombing attack. His murder followed a fatwa issued by Mullah Fazlullah, the leader of the Taliban in Swat, declaring war on all who vaccinated children against polio. Since 2003, public health leaders and Muslim scholars have struggled in northern Nigeria, Pakistan, and Afghanistan to convince the public that their local imams and Islamist leaders are wrong, the vaccine is safe, and the alternative of widespread child paralysis is unconscionable.

In 2008, the polio effort took on a more tightly targeted approach under a new WHO-led Global Polio Eradication Initiative (GPEI), which struggled to maintain international momentum and funding, to design sophisticated vaccination methods, and to counter mistaken beliefs about immunization safety. At that time, only four countries — Nigeria, India, Pakistan, and Afghanistan — had endemic polio, meaning the wild virus was still circulating in contaminated water supplies and between infected children. Fifteen other countries in 2008 had isolated polio cases, typically imported from those big four remaining endemic nations, or resulting from the very rare vaccine-induced disease. The eradication effort focused on the wild polio virus. 


There are two main types of polio vaccines. One type, a descendant of that originally invented by Jonas Salk in the 1950s, is made from killed viruses and is injected. The other, more commonly used today, is an oral vaccine that contains live viruses that have been crippled so that they cannot cause illness. Invented in the late 1950s by Albert Sabin, the oral vaccine takes care of two failures of the Salk approach. First, it doesn’t require needles, therefore poses no risk of needle-born contamination and sterilization problems. And second, unlike the Salk vaccine, which prevents viruses from causing disease in the individual, the Sabin product eliminates polio from the gastrointestinal tracts of children, thereby stopping fecal passage of the virus into sewage and water supplies. The problem, however, is that in rare cases some of the live viruses are not properly crippled, and may cause polio in the vaccinated child.

Death is rarely the result of a polio infection — less than one out of 3,000 infected children will suffocate as their capacity to breathe is paralyzed. But crippling, permanent paralysis occurs in about one out of 200 cases. As the overall numbers of polio-stricken kids have fallen, so have the horrors of paralysis and death.

Polio eradication witnessed astounding successes in previously desperate places: northern India, Southeast Asia, Ethiopia, and West Africa. In recent months, both India and all of Southeast Asia have been declared polio-free, having gone without wild polio cases for more than three years.

In 2013, for the first time in years, there were more polio cases outside the endemic countries than inside Pakistan, Afghanistan, and Nigeria: 240 versus 160 cases. The surge outside of the endemic areas was due to warfare that interrupted child vaccination in Somalia and Syria — and in both cases, genetic analysis revealed the new outbreaks were caused by strains of the virus identical to those circulating in Pakistan. It is not known precisely how the Pakistani virus reached Somalia and Syria. However, there is a possible link: The militaries that were present in both countries trained inside Pakistan.

As of March 26, a total of 47 polio cases have been reported in 2014 — all but six of them in the endemic countries, mostly Pakistan.

Today, far more polio vaccinators are dying than the toll of children killed or permanently paralyzed by the virus. At least 59 vaccinators and their security team members have been murdered over the past 20 months, primarily in Pakistan. GPEI has identified Pakistan’s Peshawar valley and abutting North Waziristan as the world’s “main ‘engine’ of poliovirus transmission.” Not coincidentally, these are strongholds of Taliban-aligned Islamists and the locations of most violent assaults on vaccinators.

The attacks and murders have targeted unarmed, usually female polio volunteers and health workers, or more recently their police or private security protectors.

In January 2014, three female polio workers were gunned down outside Karachi, prompting a mass walk-out by immunization employees locally, and then nationally. Shortly after, six polio security team members were felled in a bombing outside Charsadda, Pakistan. On February 11, a police officer was killed amid a hail of gunshots aimed at polio volunteers in northwest Pakistan. On March 2, a mass funeral was held in Khyber District, mourning 11 vaccinators, a police officer, and a child killed in a coordinated set of two bomb assaults. Salma Ghani, a 32-year-old female health worker, was kidnapped from her Peshawar home on March 24 by five unidentified men; her bullet-riddled body was found dumped on a roadside the following day. On March 27, in Balochistan, assailants opened fire on vaccinators from a speeding motorcycle, killing a police officer. It was perhaps coordinated with another, nearly simultaneous motorcycle attack in Larkana, which killed a police officer and a vaccination volunteer. A female polio worker in Bannu was killed on March 31, when gunmen opened fire as she left her home to start work with an anti-polio team.


The distinct escalation in assaults and killings of polio vaccinators can be traced directly to the May 2011 U.S. Special Forces assault on the Abbottabad compound inhabited by Osama bin Laden, his family, and al Qaeda elite. Three months after the raid, in which bin Laden was killed, the Guardian revealed that the CIA used a Pakistani doctor, Shakil Afridi, to carry out a fake hepatitis B vaccine effort in hopes of gaining DNA samples from the children living in the mysterious compound by injecting them and retaining the syringes. Afridi, who is now imprisoned in Pakistan as a traitor, never managed to gain entry to the compound.

Shortly after the CIA ploy was disclosed, Orin Levine of the Gates Foundation and I warned in the Washington Post that any use of vaccination by intelligence operatives risked worsening conditions in the fight against polio. And David Ignatius wrote, “Afridi and his handlers should reckon with the moral consequences of what they did.”

As predicted, in 2012 several Taliban leaders and mullahs issued decrees, linking polio vaccination to U.S. military use of drones and accusing vaccinators of being CIA spies. They called for a jihad against immunizers. Maulvi Ibrahim Chisti of the Muzaffargarh district declared the anti-polio campaign “un-Islamic” and parents started refusing vaccines. By the end of the summer of 2012, hundreds of thousands of children across Pakistan were going without immunizations, not only for polio, but all of the key childhood diseases.

Matters worsened in early 2013 after DVDs of the movie Zero Dark Thirty turned up in the Pakistani black market. The Kathryn Bigelow film mistakenly depicted an Afridi character as a polio vaccinator.

As the pools of unvaccinated children grew, so, too, did the courage of the men and women carrying out polio work. It is hard not to describe these unarmed, poorly-paid, or volunteer workers — who, while dripping Sabin’s fluid into the mouths of babies, are well aware that they are being watched, their names noted, their addresses logged — as saints.

Meanwhile, the Pakistani polio strain has surfaced in Syria’s battlefields and, from there, has spread across the Middle East — from refugee camps to Palestinian outposts to the sewers of Israel. In its recent report the WHO said:

The major risks to eradication are: the bans on immunization campaigns in the North Waziristan agency in Pakistan and parts of southern and central Somalia; the continued targeting of vaccinators in Khyber Pakhtunkhwa province and Karachi in Pakistan; ongoing military operations in Khyber Agency (within the Federally Administered Tribal Areas) of Pakistan; insecurity in Eastern Region, Afghanistan, and Borno state, Nigeria; active conflict in the Syrian Arab Republic; and gaps in programme performance in Kano state, Nigeria, and in the outbreak response performance in Cameroon. These risks are compounded by gaps in polio surveillance and the continued threat of new international spread of wild poliovirus.

The tone of alarm in the WHO’s statement reflects the recent discovery of a six-month-old baby in Baghdad suffering from polio paralysis. It has been 14 years since polio has been seen in Iraq, and the Iraqi family had not traveled in known polio-hit areas. The child’s strain matched the one circulating in Syria.

Though still unconfirmed, there is a possible polio case in a Syrian refugee baby residing in Lebanon, and this has increased concern throughout the Middle East. More than 400,000 refugees and internally displaced people have fled Iraq’s Anbar Province, where conflict has rendered immunization especially dangerous. Fewer than 48 percent of the area’s children were vaccinated over the last two years, according to UNICEF. Better than 90 percent coverage is essential to creating “herd immunity,” bringing human-to-human spread of polio to a halt. The Iraqi government now talks about creating an immunization firewall across its northern border, blocking further spread of polio from Syria.

The vocabulary of warfare has been injected into the Middle East polio struggle. Because much of Syria is inaccessible to humanitarian workers, the exact extent of polio in the country is not known: 37 paralysis cases have been reported since the Syrian outbreak began sometime in October 2013.

Despite mass vaccination in 2013, environmental sampling in Israel, the West Bank, and Gaza continues to test positive for polio — the sources are unknown. A large population of Palestinians has been trapped inside Syria throughout the war, only receiving vaccines in February 2014, and it’s possible that refugees from this enclave have carried polio to nearby Palestinian territories.

The Global Polio Eradication Initiative has set new targets, new strategies, and new funding goals struggling to stay ahead of the virus — and Islamist zealots. It has done so before, of course, managing to conquer challenges but often twarted by political reality. In the end, polio will be eradicated when counterterrorism no longer includes fakery, and Islamists cease believing in jihad against health workers. 

Laurie Garrett is a columnist at Foreign Policy, a former senior fellow for global health at the Council on Foreign Relations, and a Pulitzer Prize-winning science writer. Twitter: @Laurie_Garrett

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