Polio Update - Bloomberg Business December 15, 2015

After the death of Osama bin Laden in 2011 by U.S. forces with the cooperation of a doctor in Pakistan, polio workers and doctors were seen as spies by the Taliban and became specific targets with more than 100 of them killed or wounded in Afghanistan, said Hedayatullah Stanekzai, a senior adviser with the country’s health ministry. Since 2012, 32 health care workers and other personnel involved in polio eradication have been killed in neighboring Pakistan, the WHO said this month.

That suspicion no longer exists in Afghanistan, said Elaj, the Taliban doctor.

The Taliban in Afghanistan released a statement in 2013 supporting all health programs in the country, including polio eradication. The cooperation is part of an effort to build trust among the general population, researchers said in a 2013 study on the challenge of violence in the final push to snuff out the disease, which has maimed and killed for much of human history.

No Spies

“We are not worried about the possibility of spies being among vaccinators because these are trusted people, introduced and hired on our recommendation,” Elaj said in a telephone interview from Kandahar. The following day, the medic appeared at a public health office in the city. A tall, bearded man, he wore a long tunic over trousers with a traditional blanket scroll tied to his body.

The “quality” of the Taliban’s polio campaign can’t be verified because there is no way to check that every vulnerable child is being vaccinated, the health ministry’s Stanekzai said.

That’s because the Taliban’s participation in the program, negotiated with public health officials and the International Committee of the Red Cross, comes with a condition: that their own people do the vaccinating in Taliban-controlled areas, said Mohammed Soghaier, a WHO doctor in an interview in his office in Kandahar.

Own Vaccinators

“Some areas are inaccessible except for Taliban, so we are requesting them to provide their own people or offer local people from these faraway areas to work with us,” Soghaier said. “Not one of these groups is against polio vaccination. They are cooperatives, they trust us.”

In the 1990s, the United Nations Security Council criticized the Taliban regime for abusing women and harboring members of al-Qaeda. The Taliban and other illegal armed groups in Afghanistan still threaten locals, foreigners and security forces operating in the country, the council said on Friday.

Still, polio won’t be eradicated without the Taliban’s help. There are about 500,000 children younger than 5 years in Afghanistan who aren’t fully immunized against the virus, a quarter of whom live in areas deemed inaccessible to vaccinators, according to the WHO. Decades of war, insurgencies and border skirmishes, combined with one of the weakest health systems in the world, have allowed the virus to persist.

“There is no clinic or hospital in the Taliban-controlled areas,” said Elaj, the Taliban doctor. “Health services are in devastating condition and people die from sickness at home or on the way to health facilities in the city.”

Two Taliban Groups

While Taliban groups in Afghanistan and Pakistan share the same name, operationally they have different goals and structures. The Afghan Taliban took power in the 1990s and received diplomatic backing from only two countries, Pakistan and Saudi Arabia, before the U.S. invasion in 2001. Top members received shelter in Pakistan for years, and the U.S. State Department now sees the group as being an “important partner” in a peaceful Afghan-led reconciliation process.

The Pakistani Taliban, on the other hand, is a collection of militant groups along the Afghan border that united in 2007 under the name Tehrik-e-Taliban Pakistan. The group, which the U.S. considers to be a terrorist organization, regularly attacks Pakistan government and military installations, and wants to impose its version of Sharia law in the country.

A spate of attacks this month show that parts of Afghanistan remain an active battle zone, even after gains made this year by the Afghan Taliban prompted the U.S. to reverse plans to withdraw most troops from the country by the end of 2016.

Taliban’s Birthplace

Kandahar, the Taliban’s birthplace, was at the center of a polio outbreak in 2011 that infected 80 people. Now, Afghanistan’s second-largest city and its province are free of the virus, an achievement gained with the cooperation of Taliban fighters, said Stanekzai, the health ministry adviser.

In male-dominated Kandahar, about 100 women dressed in blue burqas that cover their faces and bodies, move from house to house to find children to vaccinate.

Beheading Risk

“Working within the city is safer for us than going out to the villages,” said Wajia, a 19-year-old student, as she administered a dose of vaccine to a child on a dusty, unpaved lane bordered by a fetid sewer. “The Taliban would have already beheaded me if I’d gone there to vaccinate their children.”

About 80 percent of the 10,000 people immunizing children in southern Afghanistan are Taliban-appointed, said Najibullah Zafarzay, a WHO health coordinator in Kandahar. Besides “well-trained” vaccinators, the Taliban’s polio teams include supervisors, coordinators and social mobilizers who raise awareness about the disease, he said.

Vaccinators, who are paid 300 Afghanis ($4.50) a day, go from house to house in hundreds of southern villages, delivering two drops of oral polio vaccine in the mouths of every baby younger than a year old -- or about 1.6 million infants, Zafarzay said. Children under 5 receive an inactivated polio virus shot in village health facilities.

Bill Gates

Eight to 12 vaccination rounds are planned for Afghanistan this year. Each will deploy some 54,000 vaccinators, target 9 million children, and cost international donors, which include the Bill and Melinda Gates Foundation, Rotary International and USAID, about $3.6 million, Stanekzai said. Active fighting and hostilities caused by the Islamic State threaten the security of polio workers and deprive about 120,000 children of vaccine, he said.

Immunization coverage averages about 60 percent nationally, but drops as low as 40 percent in some southern areas -- well below the 80 percent needed to stop transmission.

New Weapon

Polio paralyzed millions of people worldwide in the 20th century before vaccines became widely available from the mid-1950s. In 1952, almost 60,000 cases with more than 3,000 deaths were reported in the U.S. alone.

World leaders resolved in 1988 to wipe out polio, prompting the WHO, United Nations Children’s Fund, Rotary International and the Centers for Disease Control and Prevention to form the Global Polio Eradication Initiative. They expected to finish the job in 12 years -- the same time it took to stop smallpox.

Polio, though, is a more difficult virus to eradicate because fewer than 1 in 100 people who catch it show signs of illness or are aware of the infection, enabling the virus to spread undetected, usually when someone eats food or drinks water contaminated with the feces of an infected person.

The virus’s most stubborn stronghold is Pakistan’s Peshawar region. Bordering Afghanistan, it’s a vast interconnected area described as the “conveyor belt” of polio transmission because of the ease in which the virus has moved between both countries, creating a viral reservoir.

“The large population movements from Afghanistan and Pakistan pose an incredible risk of international spread of polio beyond those two countries,” said Annelies Wilder-Smith, a professor of infectious diseases at Singapore’s Nanyang Technological University, who has served on a WHO emergency committee for polio. “In the past years, great efforts have been undertaken to increase vaccination coverage, but still more needs to be done.”

Exported to Syria

Infected travelers from the two nations threaten to seed outbreaks in countries where protection from immunization is weak. In 2013, 35 children were paralyzed in Syria after a virus originating from Pakistan touched off the Mediterranean country’s first polio outbreak in 14 years.

If the virus isn’t stopped next year, with global eradication officially certified by 2019, governments and donors will be hobbled with about $800 million a year in costs associated with continued vaccination and surveillance, said Sona Bari, a spokeswoman for WHO’s polio program in Geneva.

Afghanistan now requires all travelers younger than 5 years entering the country from Pakistan to receive the polio vaccine. At certain border points between Afghanistan and Pakistan, all travelers under 10 are being immunized to protect refugee populations who have a history of missed vaccinations.

Dangerous Work

The constant flow of people across the border is a major challenge, said Soghaier, the WHO doctor in Kandahar. At police check points, teams vaccinate about 3,000 children a day.

It’s dangerous work. One member of the transit team was killed after a Taliban suicide attacker targeted police checkpoint in Helmand province, he said.

Soghaier says he tries not to allow politics to get in the way of achieving the common goal of eradicating polio. “By collaborating with different groups and parties, we are simply implementing the operational guidelines,” he said. “It doesn’t matter if a village is controlled by anti-government elements, the government, or the Islamic State -- this is a social issue and we are keeping our program neutral to save every vulnerable child.”