It is 32 years since the World Health Organization vowed to eradicate polio, launching the Global Polio Eradication Initiative with the objective of wiping the crippling disease from the face of the Earth by 2000. Two decades on, the disease that at its height in the 1950s killed half a million people globally every year, most of them children under five, and left countless millions of others paralyzed is a shadow of its former self. That, however, really isn’t close to good enough, because it isn’t money holding back a complete victory, but something much more fundamental.
In 1988 there were 350,000 cases of polio worldwide. In 2019, following three decades of collaboration and more than $10 billion invested in the world’s largest private-public health partnership to date, there were just 125 recorded cases of naturally occurring polio (also known as wild polio) virus. But there is a stumbling block to the final eradication of this cruel disease and if is not removed, it could allow polio to return with a vengeance.
No public health program can succeed without the cooperation of the public. That cooperation is based on trust and it is clear that polio’s resistance is rooted in the bitter history of a people conditioned by millennia of outsider interference to trust no one.
All of the remaining cases of wild polio are either in Pakistan or Afghanistan, concentrated mainly in the remote border regions between the two. The majority of cases are in Pakistan’s province of Khyber Pakhtunkhwa, the northwest frontier region through which traders and invaders bound for the gateway Khyber Pass have travelled and rampaged since Alexander the Great passed this way in the 3rd century BCE. Since then, from the Persians and the Mongols to the British, the Taliban and the Americans, strangers have brought nothing but grief to this remote yet pivotal region. So why should the well-meaning outsiders who each season do their best, but fail to inoculate a critical mass of children expect to be greeted with anything but suspicion?
It is easy to blame ignorant susceptibility on the powerful rhetoric of extremist preachers or the threats of militant groups for the reluctance of entire communities to have their children vaccinated. But the ease with which rumors circulate – for example, that the vaccine used by foreign-funded NGOs is designed not to protect children but to sterilize them – speaks of a fertile ground of suspicion. In Khyber Pakhtunkhwa, the conspiracy theories come not from the internet but from memory – and some memories are extremely fresh.
After US Navy SEALs tracked down Osama bin Laden in his Abbottabad hideout in May 2011, it emerged that the CIA had mounted a fake hepatitis B vaccination program to gather confirmatory DNA identification from family members in the Al-Qaeda leader’s compound. As the outraged InterAction coalition of American NGOs noted later, using humanitarian activity as a cover “casts doubt on the intentions and integrity of all humanitarian actors in Pakistan, thereby undermining the international humanitarian community’s efforts to eradicate polio.”
Last year, Pakistan’s polio campaign was derailed by as many as 700,000 refusals to have children vaccinated, mainly in Khyber Pakhtunkhwa. The results are clear enough: 125 cases of paralysis in Pakistan and Afghanistan in 2019, up from just 33 in 2018. But the potential consequences are far worse.
Paralysis affects only one infected person in 200, so those 125 cases represent a contagious population of at least 25,000 individuals. Each one of these is capable of passing on the virus, which is easily transmitted via food or water through poor hygiene and inadequate sanitation.The threat that poses goes far beyond the communities in Pakistan and Afghanistan to the entire region and the wider world. “As long as a single child remains infected, children in all countries are at risk,” is the warning from the WHO. Failure to eradicate the disease from its last remaining strongholds “could result in as many as 200,000 new cases every year, within 10 years, all over the world.”
The outbreaks in Pakistan have already spread beyond the northwest. In 2019 four cases were identified in Lahore, near the border with India, which for now remains polio-free. Another six cases cropped up around Karachi, 1,000 km from the northwest frontier and one of the region’s busiest ports, with connections to many parts of the world, including the Gulf.
Determined vaccination campaigns in the Gulf states saw polio eradicated first in Kuwait, in 1985, followed by Qatar (1990), the UAE (1992), Bahrain and Oman (1993) and Saudi Arabia (1995). But the ongoing presence of polio in Pakistan and the large numbers of Pakistanis who either reside in or travel regularly to the Gulf states, means the disease could return to any of these countries.
In November, world leaders gathered in Abu Dhabi for the Reaching the Last Mile Forum, pledging a total of $2.6 billion towards the Global Polio Eradication Initiative’s Polio Endgame Strategy, which envisages a world free of polio by 2023. Contributing governments and institutions took their lead from Sheikh Mohamed bin Zayed, the crown prince of Abu Dhabi, who hosted the event and gave $160 million.
More important than money, however, is the role the UAE is taking in tackling polio in Pakistan’s hardest-to-reach and deeply suspicious communities, for whom the Emirates is a nation of kindred souls, sharing a region, a religion and a history of mutual interest. Since 2014, the Emirates Polio Campaign, working closely with the UAE Pakistan Assistance Program, has delivered more than 430 million polio vaccines to some of the most remote areas of Pakistan, along with food aid, water treatment plants and infrastructure projects designed to connect communities to the opportunities of the modern world.
In the process, it is also delivering the one essential ingredient without which the Polio Endgame Strategy will become yet another missed deadline: trust.
Jonathan Gornall is a British journalist, formerly with The Times, who has lived and worked in the Middle East and is now based in the UK.