The US government has told a group of local health educators that it will no longer use immunisation programs as a cover for espionage.
But the damage from previous such programs is difficult to undo, and distaste for the US, exacerbated by drone strikes, means the announcement has more symbolic value for Western audiences than impact on the ground. Luckily, local efforts and leadership in affected areas are making progress.
Three regions – Somalia, Nigeria and Pakistan – have armed groups openly hostile to public health efforts, especially immunisation. But only in the latter is this due to the CIA’s actions.
Radical groups in Pakistan
The most radical threat to public health by armed extremists is by anti-government elements in north-west Pakistan. Attacks on health workers and security personnel protecting them have led to more than 60 deaths over the past three years.
The escalation in assaults and murders of vaccinators can be traced directly to the May 2011 U.S. Special Forces assault on the Abbottabad compound inhabited by Osama bin Laden and his family. Three months after the raid, in which bin Laden was killed, the Guardian revealed the CIA had used a Pakistani doctor to carry out a fake hepatitis B vaccine effort to get DNA samples from children living in the compound.
Combined with anger about continuing drone attacks, this episode led to a ban by the Pakistan Taliban in July 2012 on all forms of immunisation in areas they control in the Federally Administered Tribal Areas (affecting mainly North and South Waziristan districts).
Around 350,000 children in contested areas are unable to access immunisation and other public health services. And there’s been a spike in paralytic polio cases in Pakistan this year, with 66 cases reported so far (compared with only 14 in the same period last year).
But this spike is merely the most visible impact of the Pakistan Taliban’s ban on vaccinations; polio surveillance is very effective compared with surveillance for other diseases.
Other negative health impacts include women health workers (the bedrock of Pakistan’s community health services) being unable to work for fear of violence. This means the coverage of health programs for women and children is now very low. And the government has closed 450 community health centres in FATA since 2010 due to the unwillingness of personnel (especially women) to work in the region.
What is being done?
Bans on vaccination and other public health programs are fuelled by a mix of political, tactical, and quasi-religious motives. The link made by the Pakistan Taliban between drone attacks and child immunisation programs, for instance, is spurious but holds the international health community to hostage.
Many in the global Islamic community have been active in countering claims that the polio vaccination, for instance, is “anti-Islam”. The Islamic Advisory Group on Polio, based at Al-Azhar University in Cairo, has been the most active.
At a meeting in Jeddah this year, the chairman emphatically denounced what he termed “fallacious and distorted fatwas (edicts) and claims” against polio vaccines and strongly condemned violent attacks against polio vaccinators. The IAG has developed pro-vaccination fatwas and disseminated them to local Islamic leaders in the hope of countering the radicals’ propaganda.
Another approach has been the use of innovative communication strategies to mobilise community demand for vaccination. Messages are being transmitted by respected community leaders, mullahs and teachers.
Local political leadership is vital because it can be transformative. In the state of Peshawar in Pakistan, where violence had disrupted many immunisation campaigns, Imran Khan’s government deployed 4,000 security personnel and banned motorcycles on 12 consecutive Sundays to vaccinate more than seven million children against nine diseases without any violent incidents.
Likewise, discrete negotiations between the governor of Kandahar province in Afghanistan with local Taliban leaders led to high vaccination rates and the elimination of polio from the province in late 2012.
The important lesson from Afghanistan is the importance of keeping polio prevention and other life-saving public health programs politically neutral.
While former president Hamid Karzai demanded high performance and accountability from provincial governors, he maintained a low public profile and avoided politicising the polio vaccination program.
The White House announcement will contribute to building that neutrality in challenging settings such as north-west Pakistan. What’s now needed is a concerted campaign by communications specialists and religious scholars to convince communities that vaccinating children is not just “a good idea” but an obligation.
Hostile militant groups elsewhere
In south and central Somalia, Al Shabaab has banned all humanitarian agencies, including Islamic Relief access to territories it controls, leading to the cessation of all child health programs.
More than 300,000 children were un-vaccinated for over three years, resulting in a 2013 polio outbreak that paralysed 194 children and spilt into the neighbouring countries of Ethiopia and Kenya. Al Shabaab’s ban on vaccination also led to widespread measles epidemics throughout the Horn of Africa.
In north-east Nigeria, the extreme militant group Boko Haram has attacked health facilities that provide immunisation and killed health workers, claiming that vaccination is a Western plot to sterilise girls and infect them with AIDS.
Nigeria has long been a stronghold of anti-vaccination propaganda. In 2003, the political and religious leaders of three northern states called on parents not to allow their children to be immunised. They argued vaccines could be contaminated with anti-fertility agents, HIV, and cancerous agents.
The result was thousands of children getting of new infections, and the outbreak of polio eventually spread abroad as far as Indonesia.