Vector Volume 11 Issue 2 - 2017

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Polio vs Politics: The Case of Pakistan [Feature Article] Jeanine Hourani Jeanine has just completed her first year of the Master of Public Health at the University of Melbourne, having come from an Immunology & Microbiology background. She is particularly interested in refugee and migrant health as well as the effect of warfare on Public Health. Her previous work includes ‘As Syria Bleeds’ which explores the effect of the Syrian Crisis on the health system. Polio is a highly infectious disease caused by poliovirus which predominantly infects young children by invading the nervous system and can result in paralysis. [1] Polio reached epidemic proportions in the early 1900s but was brought under control after the introduction of effective vaccines in the 1950s and 1960s.[1] Despite the progress that has been made, as long as a single child remains infected with poliovirus, children in all countries are at risk of contracting the disease.[2] This is because poliovirus can easily be imported into poliofree countries and subsequently spread, potentially resulting in as many as 200,000 new cases every year. There is no cure for polio, it can only be prevented by the polio vaccine which, if administered correctly, can protect a child for life.[2] As such, vaccination programs are key to achieving global polio eradication. War and civil unrest have a destructive effect on population health. In particular, conflict increases the prevalence of vaccine preventable diseases and decreases the success of vaccination programs.[3] For instance, Pakistan is one of the few countries in the world where polio is still endemic [1, 4, 5] and this is largely due to its geopolitical and socioeconomic challenges. [6] In 2006, Taliban insurgency intensified in Pakistan and the resulting political insecurity has been directly associated with the rise in polio transmission.[7] Failure to achieve polio eradication in Pakistan demonstrates the importance of non-health sector issues, such as barriers to access in war and conflict zones [6]. Conflict and insecurity in Pakistan is clustered in Khyber Pakhtunkhwa (KP) and Federally Administered Tribal Areas (FATA) which are home base to the Taliban and al-Qaeda.[5, 7, 8] The conflict and insecurity in KP and FATA has led to a dramatic rise of reported paralytic polio cases in Pakistan with more than 85% of the global polio cases coming from these regions.[7, 9] The establishment of KP and FATA as major polio reservoirs is undeniably linked to active conflict and insecurity in these regions.[7-10] It is clear that global health programs can no longer isolate themselves from economic, security, and political interests. Polio eradication in Pakistan jeopardises worldwide efforts aimed at eradicating polio.[6] In 2013, polio strains originating in Pakistan were detected in sewage samples in Egypt, Israel, the West Bank, the Gaza Strip, Syria, and Iraq.[1, 7] The first subsequent polio case occurred in Syria in October 2013, resulting in 35 children being paralysed by November.[1] The first Iraqi polio case was confirmed in March 2014.[1] Polio has spread from Pakistan in South Asia to countries in the Middle East that have been polio-free for decades, unraveling progress that has been made on a global scale [1, 7] and confirming that polio eradication is no longer solely Pakistan’s problem, but a global one. Fueling this problem is the United States’ involvement in Pakistan. In 2011, the CIA attempted to obtain DNA samples from the children in KP as part of the search for Osama bin Laden. In order to do this, the CIA conducted a fake vaccination program against hepatitis B, leading to an erosion of public trust in immunisation.[1, 7-9] The use of aid workers for intelligence purposes and the use of health initiatives to advance security and 15
foreign policy motives has undermined global healthcare initiatives aimed at polio eradication, jeopardising longterm global health goals.[7] Recent fatal attacks on polio vaccination workers in politically fragile parts of Pakistan pose a further threat to the global eradication of polio.[11] It is believed that the international attention paid to polio eradication may have led terrorist groups to believe that they can achieve some of their aims by interfering with its eradication. [11] As such, the Pakistani Taliban announced in June 2012 that it would place a ban on all vaccinations until the United States ended drone strikes.[9] Since then, the Taliban have orchestrated targeted attacks on immunisation teams that have tragically killed over 40 vaccinators.[1, 7] This includes the killing of Abdul Ghani (who was the head of the government’s vaccination campaign) by a road-side bomb after upon his return from a meeting with tribal elders to dispel rumours that vaccination is a U.S. conspiracy to sterilize their children. [5] To this day, vaccination program staff remain under threat of kidnappings, beatings, harassment, and even assassinations in conflict zones.[9] It is believed that the actions against polio workers may be driven by two objectives; to terrorise local populations and government workers, or to stop the house-to-house movement of polio workers who some terrorist groups suspect of carrying out US surveillance activity (brought about by the fake hepatitis B campaign).[11] Regardless of the reason, it is clear that polio eradication has evolved into a war tactic resulting in an environment of fear and anarchy. Global health initiatives are becoming increasingly intertwined with diplomatic, foreign policy, and security interests.[7] This is not limited to Pakistan: earlier this year, six Red Cross Aid workers were killed in Afghanistan [12], and healthcare in Syria has been transformed into a target of war.[13] It is clear that global health programs can no longer isolate themselves from economic, security, and political interests.[7] The recent portrayal of polio as the new battleground between Western forces and terrorist groups illustrates the importance of efforts to depoliticise polio activities.[11] We can no longer allow security or foreign policy motives to undermine polio eradication and thus compromise the wellbeing of the 7.5 billion people living on earth. Photo credit Sanofi Pasteur / Almeena Ahmed / Sanaullah Afridi, accessed from https://www.flickr.com/photos/sanofipasteur/29837040256/in/album-72157673062558422/ Conflicts of interest None declared Correspondance jeaninehourania@live.com.au References 1. Akil L, Ahmad HA. The recent outbreaks and reemergence of poliovirus in war and conflict-affected areas. Int J Infect Dis. 2016;49:40-6. 2. WHO. Does polio still exist? Is it curable? 2017 [Available from: http://www.who.int/features/qa/07/en/. 3. Glatman-Freedman A, Nichols K. The effect of social determinants on immunization programs. Hum Vaccin Immunother. 2012;8(3):293-301. 4. Afzal O, Rai MA. Battling polio in Pakistan: breaking new ground. Vaccine. 2009;27(40):5431. 5. Ahmad K. Pakistan struggles to eradicate polio. The Lancet Infectious Diseases. 2007;7(4):247. 6. Nishtar S. Pakistan, politics and polio. Bull World Health Organ. 2010;88(2):159-60. 7. Hussain SF, Boyle P, Patel P, Sullivan R. Eradicating polio in Pakistan: an analysis of the challenges and solutions to this security and health issue. Global Health. 2016;12(1):63. 8. Roberts L. Fighting Polio in Pakistan. Science. 2012;337. 9. Chang A, Chavez E, Hameed S, Lamb RD, Mixon K. Eradicating Polio in Afghanistan and Pakistan. A Report of the CSIS Global Health Policy Center. 2012. 10. Shah M, Khan MK, Shakeel S, Mahmood F, Sher Z, Sarwar MB, et al. Resistance of polio to its eradication in Pakistan. Virol J. 2011;8:457. 11. Abimbola S, Malik AU, Mansoor GF. The Final Push for Polio Eradication: Addressing the Challenge of Violence in Afghanistan, Pakistan, and Nigeria. PloS Med. 2013;10(10):1-4. 12. SBS. Opinion: Aid workers are not a target, and never should be 2017 [Available from: http://www.sbs.com.au/news/ article/2017/02/17/opinion-aid-workers-are-not-target-andnever-should-be. 13. The Guardian. Syria ‘the most dangerous place on earth for healthcare providers’ 2017 [Available from: https:// www.theguardian.com/world/2017/mar/15/syria-conflict-studycondemns-weaponisation-of-healthcare. Key Messages • The persistence of polio in Pakistan jeopardises worldwide efforts aimed at eradicating the disease. • Global health initiatives are becoming increasingly intertwined with the diplomatic, foreign policy, and security interests • With the portrayal of polio as a battleground between Western forces and terrorist groups, greater effort should be made to depoliticise polio activities 16
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