In this second of two case studies exploring why polio vaccination varies between apparently quite similar districts in Afghanistan, we look at two neighbouring district in Helmand province, Nawa, with its rare incidences of polio since 2001, and Nad Ali, which has seen one of the highest numbers of polio cases in the country. A constellation of factors has made Nawa easier for vaccinators and Nad Ali more difficult. Nawa has been largely stable and government-controlled over many years, while Nad Ali has suffered waves of violence. People in Nawa have had better access to education and health services and are a more stable population, more tribally homogenous and more pro-government. The Taleban ban on door-to-door vaccinations in the province since 2018 has also affected Nad Ali severely and to a far greater extent, because the Taleban have controlled more territory there, that is, reports AAN’s Fazl Muzhary, until a major offensive in November 2020 brought most of Nawa’s population also under Taleban control and their children out of reach of vaccinators. The series editor is Kate Clark.An Afghan volunteer drops polio vaccine into a child's mouth in Helmand’s provincial capital Lashkargah Photo: Abdul Malik/AFP, 2008
This research series is funded by the Bill and Melinda Gates Foundation. The first part in the series considered two districts in Kandahar and also included a general introduction to polio in Afghanistan.
In this research, we wanted to compare polio vaccination in two districts under Taleban control or influence which have similar security and socio-economic conditions. Neighbouring Nad Ali and Nawa both border the district of Helmand’s provincial capital, Lashkargah. Nad Ali’s district centre (bearing the same name) is about 12 kilometres to the west of Lashkargah and Nawa, with its district centre, Khalaj, is about 16 kilometres to the south of Lashkargah. A Ministry of Rural Rehabilitation and Development (MRRD) official told AAN they estimate that 55,860 people are living in Nad Ali and 60,750 in Nawa. Although higher estimates have been given, they are generally in proportion, ie indicating the two districts have roughly the same size of population. Nad Ali, however, is far bigger in terms of land area. Both districts have green areas (shne simi) – old, established irrigated land – and desert areas (dashti simi) – which are newly populated by people moving to take advantage of tube-well technology to water the land and grow crops. However, there is a higher proportion of green areas in Nawa than in Nad Ali. Both districts are largely agricultural with people cultivating cotton, wheat, maize, bean, mung beans, sesame, caraway and vegetables. Nad Ali is famous for poppy, which is mostly grown in the desert areas. Poppy is also cultivated in Nawa, although it is better-known for its melons and watermelons.
Both districts are currently under the almost complete control of the Taleban; the exception in both are the district centres. For Nawa, the takeover was recent – in November 2020. Since early February 2021, after the research for this report was conducted, Nawa has been wracked by severe fighting between the Taleban and government forces, who have been using air power to try to open an alternative supply road to the district centre as the main connecting road is in Taleban hands. Nad Ali, at the moment, is in a similar situation, where the Taleban control the main road to the district centre and the Afghan government supplies their beleaguered forces in the district centre, via helicopters. Since the research for this report was completed, there has been some fighting in the eastern part of Nad Ali, such as in the Chanjir area, which also saw air strikes, and Taleban attacks and the capture of the Nawabad area, which is near the district headquarters However, given the Taleban and ANSF focus on Nawa, it has tended to see most of the recent fighting in Helmand province.
As can be seen in Table 1, Nad Ali has reported 27 positive polio cases since 2001, making it the worst district in the country in total. While the bulk of these cases are not recent (almost all were between 2005 and 2013, with a marked peak in 2011), last year, after a five-year gap, polio re-emerged in the district with one confirmed case. By contrast, Nawa has seen just three cases since 2001 and none since 2011.
For this report, AAN used a method of combining desk research and semi-structured interviews with key informants. The research relied on AAN’s broad network of key contacts, to ensure that information collected is of a necessary depth. The safety of interviewees is a priority: conducting research by phone or WhatsApp, rather than in person, and anonymisation of interviewees enables people to speak comfortably, even on what may be sensitive topics.
We interviewed six key informants, all male, three from each district. They comprised two health workers, one of whom previously worked as a District Polio Officer, a district governor, a teacher and two tribal elders. All of them are living both in their respective districts and in Lashkargah, travelling between both as work and family life requires, because their land and farms are in the districts while their families are living in the provincial capital for security reasons. This is typical for a large part of both districts’ populations who live near the provincial capital, where there is work (for those without land) and comparative safety.
Additionally, the author spoke to serving health, education and MRRD officials and former District Polio Officers concerning particular statistics, in order to get and verify various figures and iron out discrepancies. He also drew on information gathered in visits to these districts in 2013, 2014 and 2015. The bulk of the interviews for the research were conducted in February, with follow-up interviews in March and April.
The report first gives background to the two districts in turn before looking at the differences in their polio campaigns
An introduction to Nad Ali
The people of Nad Ali can be divided according to the type of land where they live. Some live in the shne simi (green areas), which is old, established, irrigated land. From 2010 until the recent fighting at the end of 2020, the Afghan government controlled most of these green areas, but now almost all of the villages are under Taleban’s control. People also live in the dashti simi (desert areas), which comprises the vast majority of the territory of Nad Ali. These areas have only been populated since the start of the second millennium, by people who migrated there from other parts of Helmand, including Nad Ali district. They have drilled tube wells, using the water to irrigate the land and growing crops – greening the desert.
The MRRD estimates that there are 55,860 people living in Nad Ali district in 9,310 households. An MRRD official in Lashkargah said there were 250 villages in the district, of which 117 are ‘unregistered villages’, in the desert areas. Registration is important, as with it, comes schools, health facilities, programmes resulting from the Citizens Charter and other services (read this previous AAN dispatch for more details (here).
Nad Ali is the second most heterogeneous district in the province with the largest group, Kharoti Pashtuns, only comprising about a third of the population and with more than 20 other tribes and non-Pashtun groups also featuring (see page 8 of this paper drawing on field research from the 1970s). Moreover, many families have only lived in the district for a matter of decades. They are settlers –naqilin – who moved there after US irrigation projects in the 1950s and 1960s turned desert land to arable. It means that even in the green areas, the population is, by Afghan standards, relatively uncohesive.
Security and governance
Starting from 2006, Nad Ali has experienced waves of violence. After severe fighting in 2007, the Taleban were able to gain a foothold in the district (see media reports here and here), after which neighbouring Marja fell to them in September 2008. In 2009, joint ‘clear, hold and build operations’ by US and British forces began with the aim of driving the Taleban out of Nad Ali. In 2010, the Commander of ISAF (COMISAF), General Stanley McChrystal ordered a heavily-publicised joint operation involving 15,000 forces Afghan and foreign troops, code-named Operation Moshtarak, to push the Taleban out of the districts of Marja, Nad Ali and the rural areas around Lashkargah. The Taleban lost their grip on the majority of the areas of Nad Ali they had controlled, including almost all of the green areas of Nad Ali; by 2012, 80 per cent of the district was under government control. Local self-defence forces, called uprising groups, were formed by the government in order to hold the areas and these were later upgraded to Afghan Local Police (ALP), (see here).
This situation prevailed up to March 2016 (see this AAN report) when Nad Ali once again started experiencing Taleban attacks and the capture of territory. Since 2017, government control has been limited to the district headquarters. Various government attempts to recapture the lost areas have failed (see this AAN report). In November 2020, local sources said, the Taleban took control of all the villages surrounding the district headquarters, where the Afghan security forces are now under siege. This fighting also resulted in the closure of a healthcare centre in the Chanjir area of the district. Generally, over the years, it can be said that the safest places in the district have been the government-controlled district centre and the desert areas, that have been under complete control of Taleban and which are far away from traditional population centres and rarely fought over.
Currently, tribal elders and other residents told AAN that provincial government officials in Lashkargah cannot even reach the district centre by road; instead, it is supplied by helicopter only. Our interviewees said there were only Afghan National Police (ANP), Afghan National Army (ANA) and a group of militia fighters known as sangurian in the district centre – and confined to it – and with no civilian administration at all. When the author asked district governor Ayub Omar Omari for comment on this in February 2021, he said he did not want to talk about military affairs.
Every village in the green areas has a village council registered with the Citizens Charter programme. Each council has 25-30 members of whom four are key: the head, deputy, secretary and the treasurer. Each also has committees for procurement, health, youth, agriculture, poverty reduction, education, environment and community project monitoring. The MRRD official quoted the Citizen Charter report giving the aims of the programme as to reduce poverty, provide short-term work opportunities, let people know about the local government system, implement different projects and build capacity in the community, particularly those who are members of the councils. The MRRD official said that, in the past, there was also district community council, but it was deactivated after the village councils set up as part of the Citizen Charter were established.
Education and health sectors
All schools and healthcare centres in Nad Ali district are active, both those in government and Taleban-controlled areas. They are scattered throughout the green areas. The desert areas are deprived entirely of such government services.
Nad Ali district has 28 schools: seven high schools, seven middle schools and 14 primary schools for boys and girls. Two of the primary schools are for girls only, nine for boys only, and in three, boys attend in the morning and girls in the afternoon. The head of Helmand’s education department, Daud Sapari, said they have 15,338 pupils who are taught by 127 teachers. The district education director, Muhammad Naem said they had two female teachers on staff and a further 17 other female teachers who work based on temporary contracts, better known as ajir.
Nad Ali has eight healthcare centres, with 67 staff in total, 12 women and 55 men. An employee of the Bangladesh Rural Advancement Committee (BRAC), which is the main implementing NGO in the health sector in Helmand, Dr Sapari, said the only private healthcare in Nad Ali district are some personal ‘diagnostic centres’, where individual doctors rent a room in the bazaar, treating ‘walk-in’ patients and prescribing medicines. The state-provided health services, run by BRAC, are organised as follows:
Community Health Centre (CHC) in the district town, which is now moved to Zarghun village: two doctors, one male and one female, two midwives, two nurses both male, one psychosocial counsellor, one administrator, one pharmacist, one laboratory operator, one driver, one food distributor, two vaccinators, both male, and two security guards.
Three Basic Health Centres in Loy Manda, Sayedabad and Chanjir, each with: one nurse, one midwife, one guard, one cleaner, one food distributor, two vaccinators, male and female, one Community Health Supervisor (CHS) and one nutrition counsellor.
Four Sub-Centres in Naqilabad, Barigul bazaar, Hewad bazaar and in the Khoman area, each with one Community Health Supervisor, one nurse, one midwife, two vaccinators, both male, one guard. Naqilabad also has a food distributor and a nutrition counsellor.
Those living in the dashti simi are clearly deprived of education, health and development services. Yet even in the shne simi, services may not be what they are on paper. A tribal elder in the district “completely rejected” BRAC’s reporting that there was a female doctor at the Community Health Centre: “There is not a single female doctor in the entire district,” he said (see also this AAN report).
Number of polio cases
Nad Ali has had 27 positive polio cases since 2001, the worst total in the country. However, the bulk of those cases were between 2006 and 2012, with a peak of 8 cases recorded in 2011 (see table 2 below). After that, cases fell back and there have been none since 2014, except for last year, when one case was registered.
An introduction to Nawa
MRRD estimates the population of Nawa at 60,750, living in around 10,750 households. The district has 215 villages, including 45 newly-developed in the district’s two desert areas, Trikh Nawar, in the west of the district and the other, bordering Garmsir district, in the south. Like Nad Ali, migrants have settled in the desert areas, drawn by the possibility of farming their own land, but they generally moved from other parts of Nawa, not other parts of Helmand province, meaning even the desert areas’ population is more stable than Nad Ali’s. There is also far more tribal and ethnic homogeneity. Nawa people are mainly Barakzai Pashtuns, reflected also in the district’s full name, Nawa-ye Barakzai. The other two major tribes represented are the Popalzai, mostly in the south and west of the district, and Nurzai, who are a majority in the south.
Nawa, like Nad Ali, had a community council in the past, but it was dissolved after the Citizen Charter councils were created. Right now, there are 170 village councils, present only in the green areas, mainly located on the west bank of the Helmand river, that work under the umbrella of the provincial MRRD department. This means, as in the case of Nad Ali, that the villages in the desert areas are deprived of these councils and their linkages with government and NGOs, their services and projects. Also, as in Nawa district, all schools and healthcare centres are open and are scattered entirely in the green areas, with one exception, a health sub-centre in Trikh Nawar.
Education and health sectors
Nawa district has 35 schools, comprised of ten high schools, four middle schools and 21 primary schools. The head of Helmand’s education department, Daud Sapari, said they had 19,788 pupils, taught by 223 teachers, 222 men and one woman. According to district education director, Syed Ahmad Ulfat, there is some primary education for girls; two of the primary schools are girls-only, while in five other schools, boys and girls attend classes together. The district has ten healthcare centres, with 93 staff, of whom 22 are women. According to BRAC, there is one private clinic, located in the Dubela area which is part of the green area, with an unknown number of staff, and several personal diagnostic centres for general check-ups. State-provided health services, run by BRAC, are organised as follows:
One Community Health Centre (CHC): two doctors, one male and one female, two midwives, two nurses both male, one psychosocial counsellor, one administrator, one pharmacist, one laboratory operator, one food distributor, two vaccinators, both male, one Community Health Supervisor (CHS), one nutrition counsellor, one driver, two guards and two cleaners, one male and one female.
Five Basic Health Centres, in Ainak, Basulan, Punjab 2, Surkhuduz and Kharaba, each with: one nurse, one midwife, one guard, one cleaner, one food distributor, two vaccinators, male and female, one Community Health Supervisor (CHS) and one nutrition counsellor.
Four Sub-centres, in Guhargin, Fazldin Mamuriat, Trikh Nawar and Landai Shakh, each with: one nurse, one midwife, one guard, one food distributor, two vaccinators, male and female and one nutrition counsellor.
With regard to service provision in general, services in Nawa may, like Nad Ali, not be as described on paper. Again, the reported existence of a female doctor is disputed by our interviewees.
Governance and security
Nawa district had been under firm government control for most of the last two decades. Key to that are stable social dynamics because of its tribally relatively homogenous population, and the fact that, as an elder told AAN: “The people in Nawa have been, for most of the time, pro-government.” Washington Post reporter Rajiv Chandrasekaran wrote for NBCNEWs (here), “The three principal tribes in the area largely get along.” There was fighting in Nawa in the desert areas and in the outskirts of the district centre, around 2006-07, but the Taleban were badly defeated by US Marines who were then permanently deployed to the district in the summer of 2008 until they left as part of the transition of security provision from ISAF to the ANSF. The exception is the desert area, Trikh Nawar, which has been mostly either contested or under Taleban control since the author visited in 2013.
US interest in Nawa was also expressed in financial support. Chandrasekaran, in his book, Little America: the War Within the War for Afghanistan, has described US Aid for International Development (USAID)spending 30 million USD within a year of the arrival of the marines, turning Nawa into a “boomtown.” The author, visiting Nawa on multiple occasions, found the district remained relatively prosperous and peaceful until October 2016. At that time, the Taleban stormed Nawa district headquarters and took control of most of the district, including the district centre, for nine months. The government attacked Taleban positions in July 2017, but because Nawa was important strategically for the Taleban as it lies on the path to the provincial capital, Lashkargah, they fought hard to keep it. They managed to retain control of most of the villages even though they lost the district centre (see this media report). In October 2020, the Taleban launched attacks on various government posts, aiming at recapturing the areas they had lost in 2017. According to one key informant, a former health worker with BRAC, the Taleban regained and have kept control of the vast majority of Nawa since October 2020. Since then, the government’s presence has been confined to the district headquarters. The main road that connects the district centre with Lashkargah has been closed for traffic since 2017. A government land operation supported by airstrikes in early February 2021 to open an alternative road to the district headquarters failed.
Number of polio cases
Nawa has had only three cases of polio in the last 20 years, one each in 2007, 2010 and 2011, almost one tenth of Nad Ali’s recorded cases.
Summary of differences between the two districts
In summary, one can say that while the populations of Nad Ali and Nawa are roughly the same, Nawa is far smaller, 2,505 km2, compared to Nad Ali’s 4,564 km2 and so is more densely populated. Nawa has a far higher proportion of registered villages, five-sixths of the total, compared to about half in Nad Ali, meaning it is better served by government and NGOs. Nawa does have a larger population than Nad Ali, but it has, proportionately, a larger number of clinics and schools. There are more pupils in school, more teachers and smaller average class sizes. It has a little less provision for girls’ education, but absolute numbers of schools for girls and female teachers in both districts are low. Nawa’s population is also more stable and tribally more homogenous. It has suffered from less fighting over the years and longer periods of stable government control, although currently, like Nad Ali, it is almost completely controlled by the Taleban.
Factors affecting polio immunisation in the two districts 1: The Taleban ban on door-to-door vaccinations and insecurity
Our interviewees in Nad Ali were unanimous in blaming the conflict as the primary driver behind the large number of polio cases over the last two decades. One polio vaccinator summed this up: “When there’s fighting, survival is the priority for people, not polio vaccination.” By contrast, Nawa has seen much less fighting over the years and far more long-term stability, both good for promoting polio vaccinations. In Nad Ali, acute outbreaks of fighting have disrupted polio vaccination campaigns on multiple occasions, reducing access to health facilities or closing them entirely and also making travel difficult for patients and vaccinators. Conflict also forces people to flee their homes: “When there was fighting in Nawzad district,” said one interviewee, “it forced people to take refuge” in a place where vaccination campaigns have been difficult to deploy, “the deserts of Nad Ali.” By contrast, the first conflict-related displacement of local people recorded in Nawa district since 2001 was not until 2017, see for example this household (assessment). Even then, the number of IDPs was low, with only 17 families displaced. The other major factor currently affecting vaccination is the Taleban ban since 2018 on door-to-door vaccinations. Before then, it should be noted, the Taleban had not made anti-vaccination statements or instituted bans.
In both districts, the last immunisations took place in early 2020 before the World Health Organisation (WHO) stopped operations countrywide in March 2020 over concerns that vaccinators going door-to-door might unwittingly help spread Covid-19. Before then, all key informants in Nad Ali said they had seen vaccinators only in the green areas that were then controlled by the government, where polio vaccinations there were regularly carried out. They had seen none in the Taleban-controlled areas. This split in vaccination coverage is not new. The former District Polio Officer interviewed by AAN said that as early as 2018 after the Taleban had increased territorial control in Nad Ali, “They told their fighters that door-to-door polio vaccination was banned, without giving any reason.” Although the ban is on door-to-door delivery only, other factors, primarily the conflict, have made it difficult for parents to get their children to clinics or mobile vaccination teams to get to children.
Interviewees reported that another type of vaccination delivery – mobile teams of vaccinators – had used to operate in Nad Ali, but their numbers were first reduced and then they ceased to operate all together, as the Taleban fought to take over areas and insecurity made it unsafe for the teams to visit an ever-expanding area. The international NGO official interviewed said his organisation used to have ten mobile teams of vaccinators who would set up a temporary road-side post and vaccinate children travelling to the district centre and to the provincial capital. They would vaccinate not only children under five, but also older ones, up to the age of eight. Those children would have their fingers inked with a marker. Although these teams focused on all children irrespective of whether their home area was controlled by the Taleban or the government, their coverage was limited only to those travelling into the district centre or to Lashkargah. In effect, they could only reach children living in the government-controlled areas because children in Taleban-controlled areas tend not to travel, because of the possibility of fighting. Even if adults travel, they prefer to leave their children at home, in case of they run into IEDs, or fighting between the Taleban and Afghan security forces.
Those mobile teams stopped working entirely in Nad Ali in late 2020, as the fighting spread to areas that had previously been controlled by the government. Currently, the international NGO official said, there are supposed to be four mobile teams operating in government-controlled areas that continue to vaccinate children traveling to the district centre. However, all the key informants told AAN they had not seen any mobile vaccination teams either. Moreover, even if these mobile teams are still operating, it would still only be in the green areas, meaning the people in the desert areas are deprived of their services, unless they go to Lashkargah with their children and happen to encounter the mobile teams on the way.
The third type of vaccination delivery, where people bring their children to healthcare centres was only ever operational in the formal areas of Nad Ali where the clinics are located. But fighting has had an impact there. The Basic Health Centre in Chanjir has been closed since the fighting in November 2020, the former District Polio Officer said. At that time, the only Community Health Centre (CHC) located in the district centre was also closed as the fighting came nearer. Ultimately, it has been moved to Zarghun village, which is located to the northeast and is now under Taleban control. However, this location is too remote and dangerous for many people to get to. Also, a bridge on the way to Zarghun was destroyed during the November fighting, cutting many people off from the clinic. Whether people in Nad Ali ever wanted to bring their children to clinics for vaccination is another issue, looked at in more detail below.
Right now, in Nawa, as most of the areas are under Taleban control after the fighting of autumn 2020, door-to-door vaccination is banned. According to the BRAC official, villagers used to mostly have their children vaccinated at healthcare centres, but that has now become difficult for them because the continuing fighting makes travel difficult. The official from the international NGO said there were currently no mobile teams operating in Nawa because the road from the provincial capital was blocked. People are able to travel to Lashkargah on an alternative, but more complicated route, involving a river crossing due to lack of a proper bridge, and could get their children vaccinated there, but this would require effort and persistence.
Factors making vaccination campaigns easier or harder
There are other factors affecting the variation in vaccination take-up in the two districts, beyond the effect of the conflict and the Taleban ban, although some are consequences of these two.
Although our interviewees could provide no figures, all said coverage in Nawa had been good before the recent Taleban takeover, with most children being vaccinated and that people in Nawa, as the international NGO officer put it, “respect vaccinators.” The population has had better relations with the government and more contact with NGOs and service providers, with better access to health facilities and education than in Nad Ali, all likely to create a more positive environment for vaccinators. Those better relations are partly because more of Nawa’s territory has been under stable government control for longer, but it is also a question of settlement patterns. The proportion of registered villages in Nawa is far higher than in Nad Ali, about five-sixths of the total, compared with about a half in Nad Ali. Moreover, even in the Trikh Nawar desert area of Nawa, there is at least one health sub-centre, providing rudimentary serves. In other words, even if there was no Taleban presence and no fighting skewing access, more people in Nawa would have access to government and government services.
Geography also makes a difference to door-to-door campaigns, when they are allowed. In the desert areas, people often build their houses very far from each other, rather in the more typical clusters of villages and hamlets. This means that door-to-door vaccinations, when they can take place, simply take more time and are more trouble than in the more densely-populated green areas. This issue was highlighted by an official involved in the polio campaigns in Nad Ali who told AAN that, because of the long distance between settlements, at times, vaccination might not actually happen at all. Frustrated by long walking distances, vaccinators might not put enough effort into visiting every home. Another interviewee said: “Vaccinators did not carry out actual door-to-door vaccinations and instead poured the vaccine somewhere else and reported to the officials that they had vaccinated children.” He suspected that the majority of the vaccinators did not ever go to the desert areas of his district.
The divide between the haves and the have-nots is acute in Nad Ali; lack of government or NGO-run health facilities and other services in the desert areas drives mistrust of government/NGO-organised vaccinators, said our interviewee. One thought the inadequacy of education facilities there also fed directly into poor vaccination uptake: “As the people are uneducated, they are not psychologically ready to vaccinate their children,” he said. “They mistrust the polio vaccine, believing it would result in mischievous children who do not respect their elders.” He thought one result was that there are relatively high numbers of ‘refusal families’ in Nad Ali district, those who actively do not want their children to be vaccinated. He said numbers were especially high in the desert areas where there is not only a mix of people who have migrated there from all over, driven by conflict or attracted by the promise of farmland, but also they also tend to be more conservative. Perhaps this also makes people less able to place their trust in outsiders coming and wanting to vaccinate their children.
By contrast, given Nawa’s high proportion of densely-populated and better accessible green areas, its relatively tribally homogenous, long settled, and generally pro-government population, it is easy to see why polio vaccination has generally fared better there. Even in Nawa, however, there are constraints and a possible gap between what is reported and what actually happens.
For example, BRAC told AAN that people in Nawa, before the recent trouble, would bring their children to health centres for vaccination. However, our key informants said this rarely happened. The former District Polio Officer told AAN that women hesitate to take their children for vaccination to the mainly male-staffed district health centres. In terms of staffing, there should always be a female vaccinator and midwife in all health centres. Vaccination is carried out by vaccinators, not doctors or nurses, so mothers bringing their children for vaccination should always be able to deal with a female health worker. However, as women usually visit health facilities for reasons other than to get their children immunised, if a health facility does not have female nurses or doctors, they are less likely to go. In all of Nawa district, there are no female nurses and only the one female doctor in the community health centre, whose existence our interviewees disputed. Nad Ali faces the same dearth of female health professionals, with the added problem that both of the vaccinators in its community health centre are male. The district governor also said the treatment offered in the districts’ health centres was of poor quality and other interviewees said this meant local people generally prefer to go to private clinics in Lashkargah, instead of the state-run facilities, if they can.
Even given these constraints, the many factors explaining why vaccination has been easier over many years in Nawa than Nad Ali are clear. However, that begs a question which we have not managed to answer: Why has the incidence of polio has not been worse in Nad Ali in recent years? Looking at the situation, one would have expected more positive cases. To follow this up, we had hoped to look at events and better understand polio vaccination before 2017, especially what led to the peak in cases in 2011 and then the tailing off (now partly reversed by the one new case). However, tracing events and understanding historical dynamics has not been easy. Officials such as the district governor and the official at BRAC were new to their positions and did not know what had happened in the district previously. Local people’s memories of the last 20 years were also typically confusing and chaotic: what happened when has been lost in the slew of attacks, counter-attacks, displacements of people and movements of frontlines. Just one polio officer working in an international agency managed to provide some more coherent historical information.
The polio officer thought that just a year before the peak (2010), there had been access to all areas of Nad Ali district for vaccinators, despite the bouts of fighting from 2006 onwards. He dated problems with access related to security to the start of 2011 and Operation Moshtarak and the drive to get Taleban out of the district. In 2012, President Hamed Karzai ordered an emergency action plan which focused especially on the 13 highest-risk districts, which included Nad Ali. As a result of all these efforts, the “number of children [nationally] inaccessible declined from more than 80,000 at the end of 2011, to 15,000 by end of December 2012,” reported the 2012 Global Eradication Initiatives’ Annual Report, although it made no mention of Nad Ali specifically. From 2012 to 2016, the incidence of polio did start to tail off in Nad Ali and was not seen at all after 2014, until 2020. Without being able to access more detailed information about the vaccination campaigns before 2018, it is impossible to draw firm conclusions about what drove the rate of polio up or down before then. The question remains therefore: Given that the population of Nad Ali is in general difficult to vaccinate for geographic and social reasons, that waves of fighting have hampered access and that the Taleban, although not anti-vaccination before 2018, have since then, in areas under their control instituted either a total ban (for some months in 2018) or a ban on door-to-door vaccination delivery, why has there not been more incidents of polio in recent years?
Although Nad Ali and Nawa districts are similar to each other in many aspects, particularly in the size of their populations and their geographical features, they have strikingly different records on polio cases. The example of Nad Ali, which has been severely affected by conflict over many years, with most areas changing hands, sometimes several times, between the Taleban and the Afghan government, demonstrates how this can limit the reach of polio vaccination. The case of stable Nawa, with its much better access to government and public services, is a positive counter example, where far fewer positive polio cases have been reported. The case of Nawa’s ‘desert area’ of Trikh Nawar demonstrates that even in a less favourable environment and with poorer services, stability can contribute to polio control. Access for vaccinators and trust in the institutions implementing the immunisation are key; in this case, there is far more trust in government and in the vaccinators in Nawa. The concern now must be that polio is on the rise again in Nad Ali because of fighting and the Taleban ban, and that the situation in Nawa has been reversed, that the Taleban’s near takeover of the district in November and continued fighting will prevent most of that district’s children from being protected against the scourge of polio.
Edited by Kate Clark, Jelena Bjelica and Thomas Ruttig
 For example, the United Nations Office for the Coordination of Humanitarian Affairs (UNOCHA) in 2016/17 which reported 94,649 people living in Nad Ali and 96,479 in Nawa).
 The most recent update, from mid-May 2021, was that there was fighting not only near the district headquarters in Khalaj, but also in the Bolan area, which is very near the provincial capital Lashkargah and is also where roads to Nad Ali, Nawa and Lashkargah join. On 3 May, the Taleban spread warnings on social media that they had planted roadside bombs in Bolan and other parts of Nawa against government forces and people should avoid the roads leading to the provincial capital.
 In May to December 2018, the Taleban imposed a total ban on all vaccination in four provinces – Helmand, Kandahar, Ghazni and Uruzgan – and also from May 2018, a national ban on door-to-door vaccinations in areas under Taleban control, driven by fears, according to Taleban spokesman Zabihullah Mujahed, that immunisation staff were doubling as ‘spies’, helping with pinpointing targets for airstrikes. For more detail, see the introduction to the first report in this series dealing with polio in Kandahar and this earlier AAN analysis.
 He said the people did complain to him about this, but he said he was not part of the team monitoring the implementing NGO and could do nothing about it.
This article was last updated on 26 May 2021