Islamist insurgency and the war against polio: a cross-national analysis of the political determinants of polio

In 1988 the Global Poliomyelitis Eradication Initiative (GPEI) launched a global campaign
to eradicate poliovirus by the turn of the century through a programme of mass immunization.
Polio has not been eradicated, but the GPEI has achieved remarkable results: in 1988
there were more than 350,000 polio cases in over 125 countries, while in 2014 there
were 359 cases of wild polio in ten countries 1]–3]. Poliovirus has remained endemic in three countries: Nigeria, Pakistan, and Afghanistan.
In the past couple of years polio has spread from endemic countries to cause outbreaks
in previously polio free countries: from Nigeria to other countries in West Africa
and the Horn of Africa – there were 199 polio cases in Somalia in 2013–14 (the first
since 2007); and from Pakistan/Afghanistan to the Middle East – there were 38 cases
in Syria and Iraq in 2013–14 (the first since 1999 and 2000 respectively). In May
2014 the WHO declared the renewed spread of poliovirus to be an “extraordinary event”
and a “public health emergency of international concern” 4].

Empirical experience demonstrates that eradication is possible. India was until recently
the largest endemic reservoir of polio – in 2009 it accounted for almost half of the
world’s polio cases – and was considered to be the most difficult challenge for eradication
3], 5]. But India has not had a polio case since 2011 and in 2014 it was declared polio
free. This success was the result of two factors. First, new vaccines have been developed
against specific strains of the virus. These are particularly effective in areas where
sanitation is poor because bacteria that infect the gut interfere with the body’s
ability to mount an effective immune response to older vaccines. Second, a concerted
effort by the Indian government, in collaboration with the GPEI and other organizations,
deployed a large number of workers (more than 250,000 in the state of Uttar Pradesh
alone), and paid particular attention to vaccinating children from migratory populations
and in dangerous and remote areas 5]. The eradication of polio in India removed any doubts regarding the feasibility of
polio eradication. As Bruce Aylward, WHO Assistant Director-General for Polio, pointed
out, “Now that India has become polio-free, we have crossed… from our primary barrier
being technological or biological feasibility to one of political and societal will”
6].

The technical and biological factors that inhibit polio eradication are well understood.
The organisational factors are also understood 7]. The proximate cause of the persistence of polio in some areas and new outbreaks
in previously polio free areas is that too few children are vaccinated to stop the
spread of poliovirus 8], 9]. Yet the underlying political and societal factors that inhibit the effective implementation
of vaccination programmes have attracted little systematic analysis and do not even
feature in assessments of risks of outbreaks 10]. There is widespread agreement that civil war is associated with disease in general
11] and barriers to polio eradication in particular 1], 6], 12], 13]. Insurgency diverts resources away from healthcare and public health programmes,
disrupts healthcare infrastructure and the organisation of vaccination programmes,
and leads to forced migration, which spreads infectious disease and makes populations
hard to reach. Reports in newspapers and medical journals have suggested that Islamist
insurgents have a particularly negative effect on polio because they deliberately
undermine the efficacy of polio immunization campaigns by spreading misinformation
that they are a conspiracy to sterilize Muslim populations, which increases the likelihood
that parents will refuse vaccinations 8], and carrying out targeted violence and boycotts – often legitimised by these rumours
– that reduce the ability and willingness of polio workers to operate in particular
areas 12]. Some accounts argue that this reflects Islamists’ adherence to Islam and rejection
of non-Islamic influences, which makes them deeply antagonistic towards non-Muslims
and the West in particular 14]. More nuanced interpretations suggest that Islamist insurgents’ animus towards eradication
programs must be understood in the context of their interaction with domestic political
rivals and international actors 15], 16]. Islamic scholars note that there is no religious basis for opposition to polio immunisation
and suggest that the primary reason for failure of eradication is the presence of
conflict 17].

The first major conflict between Islamists – albeit non-violent Islamists – and polio
campaigns occurred in 2003, when the leaders of several northern-Nigerian states banned
vaccination programmes following rumours that they were a Western conspiracy to render
Muslim children infertile 9], 16], 18]. The boycott lasted a year and was a major setback for polio eradication. It resulted
in a global polio outbreak that affected 20 countries, accounted for 80 % of the world’s
polio cases at the time, and cost more than US$500 million to control 18]. In Pakistan, resistance to polio campaigns began a few years later: in 2007 militants
banned vaccination programmes in the North West Frontier Province due to similar fears
19]. The boycott was accompanied by targeted violence against polio workers – most notably
the assassination of the head of the government’s vaccination campaign in Bajaur Agency
in 2007. Some observers argue that Islamist insurgents in Pakistan have become increasingly
hostile to polio vaccinations in the past couple of years. These accounts stress the
CIA’s use of a fake hepatitis immunisation programme to collect DNA from Osama bin
Laden’s family members before his assassination in 2011. This seemingly vindicated
insurgents’ suspicions that immunization drives are a cover for espionage activities
6], 9], 20]. In addition, the increased use of drone strikes in northwest Pakistan by the United
States is said to have amplified Islamist insurgents’ enmity to polio vaccination
campaigns because the insurgents suspect that polio workers were carrying out surveillance
in order to identify targets for drone strikes 2], 6], 21], 22]. As a result an influential leader of the Pakistani Taliban in North Waziristan banned
polio vaccination programmes in areas under his control in summer 2012 20], 21]. This is said to have led to a steep increase in the number of polio cases in the
area 20], 21]. It should be noted, however, that other influential Islamist clerics in Pakistan
opposed the ban, issuing Fatwas that encouraging parents to immunize their children
against polio and other diseases 23]. In addition, Boko Haram has reportedly carried out several similar attacks on polio
workers in northern Nigeria 9], 24]. There have also been alleged attacks in Afghanistan, although these are much less
frequent 25]. It should be noted, however, that when the Taliban were in power between 1995 and
2001 they fully supported the GPEI. They continue to support polio campaigns but the
diffusion of ideas from Pakistan means that some insurgents are hostile to vaccination
programmes and many parents refuse to vaccinate their children 9], 26], 27].

Based on the analysis outlined above we generate three testable hypotheses. The first
relates to the widely held conviction that civil war in general increases the likelihood
that a country will be affected by polio. It is argued that the violence and disruption
of armed conflict undermines the ability of polio workers to carry out mass vaccination
programmes, as well as causing a more general public health crisis.

Hypothesis 1: Countries affected by non-Islamist insurgency will have a higher number
of polio cases.

The second hypothesis considers the more contentious argument that Islamist insurgency
in particular increases the likelihood that a country will be affected by polio. It
is argued that Islamist insurgents deliberately undermine the effectiveness of polio
immunization campaigns by spreading misinformation and carrying out targeted violence
and boycotts.

Hypothesis 2: Countries affected by Islamist insurgency will have a higher number
of polio cases.

Thirdly, some observers argue that Islamist insurgents’ animosity towards polio vaccination
programmes is the logical result of Islamic theology. If this is the case we would
expect the hostility to be more or less constant to reflect the fact that the theological
tenets of Islam have not changed over the past decade or so. Alternatively, others
stress the role of political dynamics. It seems apparent that some Islamist insurgents
have come to realize that interrupting polio campaigns is a useful strategy because
it generates international attention for the insurgents and enables them to force
concessions from their opponents. Moreover, it is argued that Islamist insurgents’
enmity towards polio vaccination programmes has intensified in recent years in response
to the counterinsurgency strategies used against them. The increased use of drone
attacks and the CIA’s use of a fake immunisation program in the assassination of Osama
bin Laden seemingly vindicated Islamist insurgents’ suspicions that immunization drives
are a cover for espionage activities. This is said to have seriously compromised the
GPEI’s activities.

Hypothesis 3: The effect of Islamist insurgency on the incidence of polio will be
stronger after the assassination of Osama bin Laden in 2011.