The Struggle for Polio Eradication in Pakistan and Afghanistan
For the past decade, Sughra Ayaz has been traveling door to door in southeastern Pakistan, urging parents to allow their children to be vaccinated against polio as part of a global initiative aimed at eliminating this paralytic disease. She listens to the concerns and fears of families. Some are practical – they prioritize basic needs like food and water over vaccines. Others are based on misinformation – some believe the oral vaccine sterilizes their children.
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Amid widespread misinformation and pressure to succeed, Ayaz has heard reports that some campaign managers have instructed workers to falsify vaccination records. Additionally, she notes that the vaccines, which require refrigeration, are not always stored properly.
“In many places, our work is not done with honesty,” Ayaz said.
The World Health Organization (WHO) and its partners launched a polio eradication campaign in 1988 with the goal of eliminating the disease, a feat previously achieved only with smallpox in 1980. While there were moments of progress, including a low of five cases reported in 2021 in Pakistan and Afghanistan, the number of cases has since risen, reaching 99 last year. Officials have missed several self-imposed eradication deadlines.
Afghanistan and Pakistan remain the only countries where polio transmission has never been interrupted. The global campaign has focused most of its attention and funding on these two nations for the past decade.
However, the Global Polio Eradication Initiative (GPEI) has faced challenges due to mismanagement and what insiders describe as an adherence to an outdated strategy and a problematic oral vaccine. According to workers, experts, and internal materials obtained by The Associated Press, officials have falsified vaccination records, selected unqualified individuals to administer vaccines, failed to deploy teams during mass campaigns, and dismissed concerns about the oral vaccine, leading to outbreaks.
In Afghanistan and Pakistan, where mistrust of vaccines is widespread and healthcare systems are weak, local workers like Ayaz have long raised concerns about issues within the campaign. However, these problems, along with concerns from staff and outside health officials, have remained unaddressed, according to insiders.
Officials highlight the successes of the campaign, such as vaccinating 3 billion children and preventing 20 million cases of paralysis. They also acknowledge challenges, including difficult-to-reach remote villages, cultural and religious opposition to vaccination, and the deaths of hundreds of polio workers and security personnel due to their association with a Western-led initiative.
Dr. Jamal Ahmed, WHO’s polio director, defended the progress in Pakistan and Afghanistan, citing tailored responses in resistant areas. He emphasized the importance of protecting children, stating, “Let’s not overdramatize the challenges, because that leads to children getting paralyzed.”
Ahmed believes authorities will end the spread of polio in the next 12 to 18 months, with the latest eradication goal set for 2029. This year, the campaign aims to vaccinate 45 million children in Pakistan and 11 million in Afghanistan. Children typically need four doses of two drops each to be considered fully immunized.
Dr. Zulfiqar Bhutta, who has served on advisory groups for WHO and the Gates Foundation, said campaign officials should listen to criticisms of their tactics. He warned that continuing with the same strategies could lead to similar outcomes.
Internal WHO reports show years of problems on polio vaccination teams. As early as 2017, local workers alerted senior managers to significant issues. These included falsified vaccination records, untrained relatives being chosen as vaccinators, and improper vaccine administration. Reports noted that vaccinators often lacked knowledge of vaccine management, with some failing to keep doses properly cold. There was also evidence of sloppy or falsified reporting, with workers noting more used vaccine vials than were actually supplied.
In Kandahar, Afghanistan, local government authorities interfered in choosing vaccinators, resulting in the selection of underage and illiterate volunteers. Vaccination teams worked hurriedly without proper monitoring or supervision. In Nawzad, Afghanistan, a team covered only half of the intended area, leaving 250 households untouched.
Vaccine workers and health officials in both countries confirmed the issues in the documents and told AP it’s challenging for campaign leadership to understand the difficulties on the ground. Door-to-door efforts face cultural barriers, unfounded stories about vaccines, and the region’s poverty and transience.
Some workers find families have moved, and occasionally, encounters can be abusive. “Most of the time when we go to vaccinate and knock on the door, the head of the house or the man is not at home,” said one worker, speaking on condition of anonymity. “Many people find it offensive that a stranger knocks on the door and talks to a woman.”
Critics point to the continued use of the oral polio vaccine. Before the first polio vaccine was developed in 1955, the disease was among the world’s most feared, paralyzing hundreds of thousands of children annually. WHO says that as long as a single child remains infected, kids everywhere are at risk.
Eradication demands near-perfection – zero polio cases and immunizing more than 95% of children. However, public health leaders and former WHO staffers say campaign efforts are far from perfect, and many question the oral vaccine. The oral vaccine, proven to be safe and effective, has been given to more than 3 billion children. But there are rare side effects: scientists estimate that for every 2.7 million first doses given, one child will be paralyzed by the live polio virus in the vaccine.
In even rarer instances, the live virus can mutate into a form capable of starting new outbreaks among unimmunized people where vaccination rates are low. Worldwide, several hundred vaccine-derived cases have been reported annually since at least 2021, with at least 98 this year.
Most public health experts agree the oral vaccine should be phased out as soon as possible. But they acknowledge there isn’t enough injectable vaccine – which uses no live virus and doesn’t come with the risks of the oral vaccine – to eliminate polio alone. The injectable vaccine is also more expensive and requires more training to administer.
More than two dozen current and former senior polio officials told AP the agencies involved haven’t been willing to consider revising their strategy to address some of the campaign’s problems.
Dr. Tom Frieden, a former director of the U.S. Centers for Disease Control and Prevention, said it would be impossible to eliminate polio without the oral vaccine. But he urged authorities to find ways to adapt, such as adopting new methods to identify polio cases more quickly. Since 2011, he and colleagues have issued regular reports about overall program failures.
“There’s no management,” he said, citing a lack of accountability.
Last year, former WHO scientist Dr. T. Jacob John twice emailed WHO Director-General Tedros Adhanom Ghebreyesus calling for a “major course correction.” John shared the emails with AP and said he’s received no response.
“WHO is persisting with polio control and creating polio with one hand and attempting to control it by the other,” John wrote.
In his response to AP, WHO polio director Ahmed said the oral vaccine is a “core pillar” of eradication strategy and that “almost every country that is polio-free today used (it) to achieve that milestone.”
“We need to step back and really care for the people,” he said. “The only way we can do that in large parts of the world is with oral polio vaccine.”
Ahmed also pointed to the success WHO and partners had eliminating polio from India, once considered a nearly impossible task. In the four years before polio was wiped out there, health workers delivered about 1 billion doses of the oral vaccine to more than 170 million children.
Today, nearly all of the world’s polio cases — mostly in Africa and the Middle East — are mutated viruses from the oral vaccine, except for Afghanistan and Pakistan.
Scott Barrett, a Columbia University professor, called for an inquiry into how things went so wrong — particularly with a failed effort in 2016, when authorities removed a strain from the oral vaccine. They miscalculated, leading to outbreaks in more than 40 countries that paralyzed more than 3,000 children, according to an expert report commissioned by WHO. Last year, a mutated virus traced to that effort paralyzed a baby in Gaza.
“Unless you have a public inquiry where all the evidence comes out and WHO makes serious changes, it will be very hard to trust them,” he said.
Mistrust of the polio eradication effort persists. With an annual budget of about $1 billion, the polio initiative is among the most expensive in all of public health. This year, the U.S. withdrew from WHO, and President Donald Trump has cut foreign aid. WHO officials have privately admitted that sustaining funding would be difficult without success.
Some say the money would be better spent on other health needs. “We have spent more than $1 billion (in external polio funding) in the last five years in Pakistan alone, and it didn’t buy us any progress,” said Roland Sutter, who formerly led polio research at WHO. “If this was a private company, we would demand results.”
Villagers, too, have protested the cost, staging hundreds of boycotts of immunization campaigns since 2023. Instead of polio vaccines, they ask for medicine, food and electricity.
In Karachi, locals told AP they didn’t understand the government’s fixation on polio and complained of other issues — dirty water, heroin addiction. Workers are accompanied by armed guards; Pakistani authorities say more than 200 workers and police assigned to protect them have been killed since the 1990s, mostly by militants.
The campaign also is up against a wave of misinformation, including that the vaccine is made from pig urine or will make children reach puberty early. Some blame an anti-vaccine sentiment growing in the U.S. and other countries that have largely funded eradication efforts and say it’s reaching even remote areas of Afghanistan and Pakistan.
In suburban southwest Pakistan, Saleem Khan, 58, said two grandchildren under 5 were vaccinated over his family’s objections. “It results in disability,” said Khan, without citing evidence for his belief. “They are vaccinated because officials reported our refusal to authorities and the police.”
Svea Closser, professor of international health at Johns Hopkins University, said Pakistan and Afghanistan were less resistant to immunization decades ago. Now, people are angry about the focus on polio and lack of help for diseases like measles or tuberculosis, she said, spurring conspiracy theories.
“Polio eradication has created a monster,” Closser said. It doesn’t help, she added, that in this region, public trust in vaccine campaigns was undermined when the CIA organized a fake hepatitis drive in 2011 in an attempt to get DNA and confirm the presence of Osama bin Laden or his family.
Workers see that continued mistrust every day.
In a mountainous region of southeastern Afghanistan where most people survive by growing wheat and raising cows and chickens, a mother of five said she’d prefer that her children be vaccinated against polio, but her husband and other male relatives have instructed their families to reject it. They believe the false rumors that it will compromise their children’s fertility.
“If I allow it,” the woman said, declining to be named over fears of family retribution, “I will be beaten and thrown out.”