Since the launch of the Global Polio Eradication Initiative (GPEI) in 1988, the global incidence of poliomyelitis (polio) fell by more than 99 percent, and two of the three wild poliovirus (WPV) serotypes (types 2 and 3) were eradicated. After being endemic in over 125 countries at the time of GPEI’s launch, Pakistan and Afghanistan remain the only polio reservoirs of the type 1 strain today.
In 2024 alone, Pakistan reported 70 WPV1 cases, while Afghanistan, as per the most up-to-date open source information, recorded approximately 25 cases. This is a sharp increase compared to 2023, when the combined tally for both countries stood at only 12, with six reported in each country. It is then no coincidence that both Afghanistan and Pakistan are under the sway of firebrand Islamists, who have actively sought to disrupt anti-polio initiatives, and concurrently, have wrestled with dramatic internal upheavals.
This begs a pivotal question: can Pakistan and Afghanistan continue to collaborate on eradicating polio, even as their relations have soured, best evidenced by the cross-border air strike Pakistan launched into Afghanistan in late December 2024?
Polio and Terrorism: A Dangerous Spread
In 2024, Pakistan witnessed an array of attacks on polio vaccination teams and their police escorts amid a sudden spike in polio cases across the country. With the Tehreek-e-Taliban Pakistan (TTP) on an upward trajectory since the Afghan Taliban’s ascent to power, the group has launched more and more attacks – including against polio vaccination teams, a common target since the TTP’s inception.
Such resistance to vaccination stems from a flurry of propaganda floating around in Pakistan, particularly in its tribal belt abutting Afghanistan. The TTP, in this case, can be regarded both as a victim of this misinformation and also an active perpetuator of it. Some of the most widely held misconceptions include: vaccination is a Western machination to sterilize Muslim children; immunization cannot be given before the occurrence of a disease as it is deemed un-Islamic; polio drops cause early maturity in girls; and the notion of vaccination being Jewish-American propaganda.
Beyond these beliefs, the bogus Hepatitis B vaccination program run by the United States’ Central Intelligence Agency (CIA) to track down Osama bin Laden, then hiding in Pakistan’s Abbottabad, created a trust deficit between locals and vaccinators, which endures to date. This ruse, whose impact on the discovery of bin Laden remains unclear, was facilitated by a Pakistani physician, Shakil Afridi. It is imperative to note here that Afridi, convicted of treason for assisting the CIA, is still languishing in jail, bearing the consequences of the United States’ Global War on Terror and risking being forgotten despite the heavy price he paid. The sham vaccination program further vindicated militants’ concerns that polio eradication efforts were, indeed, a means for intelligence gathering, based on which they sought to disrupt vaccination campaigns.
The fear that this ruse generated extends beyond Pakistan, spreading its tentacles in Afghanistan as well. For example, after allowing house-to-house (door-to-door) vaccination in early 2024, the Taliban reportedly banned it in September 2024, possibly due to fears that it could reveal the location of the Taliban leaders, making them prone to foreign threats. It was in any case already banned in the southern province of Kandahar, where the top nucleus of the Afghan Taliban resides. It is thus no coincidence that Kandahar plays host to a majority of Afghanistan’s polio cases. In fact, even before the Taliban stormed back to power in August 2021, they had banned door-to-door drives in areas under their control.
It is thought that the Taliban do not want to ban vaccination drives outright but only aim to modify their modality, preferring vaccination at local mosques instead, where families would be required to bring their children. This will severely hinder the vaccination process for every child, as site-to-site or mosque-to-mosque strategies are less effective than the gold standard of house-to-house campaigns – more so in Afghanistan, when the Taliban have implemented sweeping restrictions on women’s public movements. Research has shown that the inclusion of women in vaccination teams has previously led to a reduction in vaccination refusals. However, with the recent ban on women receiving medical training (one of the last fields in which women were permitted to work and study), the future of Afghanistan’s health care infrastructure hangs in the balance.
Lessons From Nigeria
While the situation seems bleak, there is cause for hope.
Until 2019, Nigeria was among the three polio-endemic countries, and was plagued by similar conditions as the Af-Pak region, such as anti-polio propaganda, the threat of Islamist militant groups (Boko Haram in this case), and other traditional barriers like a lack of sanitation and clean water. Subsequently, in a landmark achievement in 2020, the African continent in toto was declared as wild poliovirus free.
Nigeria was able to eliminate wild polio, thanks partly to the cooperation of influential religious leaders. Including the Sultan of Sokoto, the spiritual leader of Nigeria’s Muslim community, these revered figures delivered sermons in favor of vaccinations. Since such leaders and religion at large are woven into the socio-cultural fabric of Afghanistan and Pakistan, religious representatives carry far more leverage than government officials, and as such, could be integrated into the governments’ efforts to eradicate polio. Besides, many of these religious figures maintain cross-border ties and influence that could further aid eradication efforts.
In the past, Pakistan’s Council of Islamic Ideology had ratified fatwas (an opinion or decree given by an Islamic religious leader) endorsing polio vaccination. Similarly, the late influential cleric Maulana Sami-ul-Haq, who governed the Dar-ul-Uloom Haqqania seminary – a place infamously dubbed the “university of jihad” for nurturing the Taliban’s top brass (Taliban founder Mullah Omar himself had received an honorary doctorate from this seminary) – had ratified similar fatwas.
There is, however, no unified doctrine among such religious institutions and figures, and to complicate matters further, they often retract or dilute their fatwas. For instance, in 2014, Sami-ul-Haq was reportedly against the government advertising his fatwa, believing that the publication’s timing risked jeopardizing the ongoing dialogue process with the Taliban.
The Need to Cooperate
A Pakistani official previously lamented that the polio virus would eventually spread across both countries Afghanistan and Pakistan if vaccination campaigns are not executed “regularly and in a synchronized manner.” Given their geographical proximity, it is not entirely preposterous to imagine a day when a densely populated country like India (declared polio-free in 2014) or another neighboring country, could report a case or detect polio in environmental samples, thus auguring ill for the region. This is notwithstanding the restricted movement between regional countries and Afghanistan and Pakistan.
The COVID-19 pandemic served as a stark reminder that so long as there is one body playing host to a virus anywhere in the world, national boundaries offer little protection. No one is safe until everyone is safe. The fact that even a highly isolated country like North Korea was not completely impervious to the pandemic vindicates this concern. Complacency thus is not an option – neither for Afghanistan and Pakistan, nor for the neighboring countries in South Asia.
With the onset of winter, considered the low-transmission season for polio, Afghanistan and Pakistan have an opportunity to work hand-in-hand to ramp up vaccination efforts. Besides the positive effect on polio eradication, it could perhaps act as a “cooperation multiplier,” expanding pre-existing cooperation between the two countries, especially at a time when their relations appear to have taken a hit over the TTP issue.
Arguably, one of the chief reasons for increased polio cases in Afghanistan can actually be attributed to the souring of Af-Pak relations. When the then-Pakistani administration in October 2023 decided to expel over a million undocumented Afghan refugees, the majority ensconced themselves in southern and eastern Afghanistan, regions near the Pakistani border that have reported the most polio cases.
Fortunately, though, over polio, both countries seem willing to cooperate, as Pakistan’s National Emergency Actions Plans (NEAPs) for Polio Eradication evince. From NEAP 2020 to the newly approved NEAP 2024-25, a special emphasis has been placed on Af-Pak coordination, including the provision of vaccination at border crossing points (Torkham and Friendship Gate), coordination between rapid response units (RRUs) of both countries, and synchronized vaccination drives. The launch of fresh vaccination drives in both countries in late October 2024 best symbolizes such cooperation.
However, the enduring absence of any policy to protect polio workers, including security personnel, in Pakistan’s NEAPs for Polio Eradication paints a rather ominous picture. Neither NEAP 2020 nor the NEAP 2024-25 appears to have incorporated such a policy. This, coupled with the overall worsening security situation, underscores the need for Pakistan to buttress its civilian law enforcement agencies, in particular the police force, considering they are now the first line of defense by dint of accompanying polio workers to shelter them from militant attacks.
More broadly, reversing the grave security situation in Pakistan would have a positive impact on the fight against polio. Studies have shown that polio has higher chances of resurging in areas prone to conflict and instability – take, for example, the discovery of polio cases in the Gaza strip. This would then explain the rise in polio cases not only across Pakistan, but particularly in Balochistan, a region wrestling with a tempestuous ethno-nationalist insurgency. While correlation does not imply causation, a disaggregated evaluation reveals that 27 out of the 70 polio cases in Pakistan emerged from Balochistan, the highest tally of any province.
Lastly, given the Taliban are no longer an insurgent group but constitute a government machinery, they have governance-based reasons to double down on vaccination efforts – and direct their ideological twin, the TTP, not to attack polio vaccination teams. While this may be idealistic, considering their reluctance thus far to rein in the TTP, a massive polio outbreak on top of Afghanistan’s existing health crises could undermine the Taliban’s ability to govern. At the end of the day, despite possessing a repressive tool-kit at their disposal to crush any dissent or opposition, the Taliban, much to their dismay, remain mortal human beings, equally vulnerable to the very maladies afflicting the population they rule over.
