Government Policy, Community Engagement, Political Instability, Vaccination, Infectious Diseases

Civil Unrest and the Global Polio Eradication Efforts

~Written by  Kate Lee - MPH Epidemiology, Vanderbilt University Medical Center (Contact:

Vaccine-preventable illnesses are an ongoing global health issue. Just in the United States alone there have been outbreaks of measles and pertussis (whooping cough) from parents refusing to vaccinate their children. In 2013, California had over 9,000 people infected with pertussis. As of September 2014, the United States had almost 600 measles cases. For every 1,000 children getting infected with measles, 1 to 2 will die. There will be continuous outbreaks of diseases once thought to have been controlled or eradicated if parents do not adhere to the immunization schedule for their children. This is, however, an argument for another day.

Despite all of this, the United States no longer has ongoing transmission of one of the more debilitating illnesses that affected a lot of children in its peak during the 1950s: polio. This is, of course, due to vaccination campaigns. Since the launch of global polio eradication efforts in 1988, polio incidence has dropped to more than 99%. What can be said of these efforts in parts of the world that are not as stable economically, politically, or socially? In early 2014 India celebrated its third year without wild-type polio. In 2013, the African continent had 274 cases of polio but only 22 in 2014. Overall in 2014, there were 350 cases of polio, down from 416 in 2013 in the African continent. Ongoing poliovirus transmission occurs in three endemic countries: Nigeria, Afghanistan, and Pakistan. Although poor sanitation is a risk factor for polio, prevention of vaccination is the biggest risk one that these countries face.

Mistrust, misconceptions, and religious reasons all feed into public notions of vaccination. Political unrest may be one of the most important obstacles in the global campaign to end polio. Boko Haram insurgency has led to civil unrest in areas of northern Nigeria where ongoing polio transmission occurs. There has been a decline in polio cases in Afghanistan since the Taliban has allowed vaccination in recent years, but that has not been the case for Pakistan. The Pakistani Taliban and other Islamist groups have led killings of health care workers in an anti-immunization campaign. These militant groups threaten not only health care workers that administer the vaccines to the communities, but also the parents who offer vaccination for their children. Since the Pakistani Taliban ban on immunizations in 2012, more than 60 polio workers have been killed. The result of this has been Pakistan counting its 260th case of polio as of November 2014.

Sadly, the political unrest feeds into public mistrust, resulting in a cycle that perpetuates civil instability and polio transmission, leaving the $10 million global eradication effort hanging in the balance. Some health authorities are questioning if the polio campaign is worth it. Lives are lost, health resources are wasted, and new strategies must be reached to continue the immunization effort in Pakistan. Many individuals wonder why polio should be a priority when the country is undergoing so many more problems. There are a variety of other infectious diseases that place the population at risk due to poor sanitation and malnutrition. Outside of health, the threat of the Taliban hangs over the heads of the population. But, why would the Taliban target immunization campaigns? Part of the answer lies in negotiating leverage to stop drone strikes from the United States. The other part of the answer is rooted in a CIA campaign in 2012 to hide Osama bin Laden intelligence operations through the guise of immunization campaigns. Polio in Pakistan is not the first disease to be heavily affected by political unrest and exploited by militant groups, and it sadly may not be the last. What is extremely crucial to understand is that health and politics are not mutually exclusive.

This theme of political cooperation is constant throughout every public health issue. The global effort to erase polio is not an exception. Militant groups, however, now present an added obstacle in achieving social and political stability so that health care workers can conduct their tasks peacefully. Families and vaccinators should not have to fear that their lives are at risk for undertaking public health activities. Rethinking the immunization strategy in Pakistan is necessary. Improvement of basic health services and sanitation are starting points not just for polio, but a multitude of other infectious diseases. These campaigns are important, but take time and money to come to fruition, two resources that are becoming scarcer in a very unstable country.