Afghanistan Analysts Network – English

Economy, Development, Environment

Why does the Incidence of Polio Vary? A comparative study of two districts of Kandahar (Part 1)

Ali Mohammad Sabawoon 23 min

Afghanistan and neighbouring Pakistan are now the only two countries in the world still suffering from polio, an infectious viral disease that strikes children, causing temporary or permanent paralysis and, in some cases death. Despite the availability of a vaccine since the 1960s and national vaccination since 1978, polio remains a persistent challenge in Afghanistan. Last year, the number of polio cases in Afghanistan went up alarmingly: 56 positive cases countrywide in 2020, mostly in the southern provinces, compared to 29 cases in 2019. The major reason for that was Covid-19 which hampered the polio vaccination campaign. Beyond this, however, there is always variation between districts both in the success of vaccination and the number of polio cases. We wanted to try to understand this variation. In the first of two case studies, AAN’s Ali Mohammad Sabawoon presents a comparative study of two districts in Kandahar province, Arghandab, which has always had few polio cases, and Shah Wali Kot, which has always had more, with an introduction by Jelena Bjelica. The series editor is Kate Clark.

An Afghan health worker administers the polio vaccine to a child in Arghandab district of Kandahar province in August 2018. Photo: Javed Tanveer/AFP

This research series is funded by the Bill and Melinda Gates Foundation.

Introduction to the series

2020 was a particularly bad year for polio in Afghanistan, as Table 1 shows. 56 polio cases were reported with 66 per cent of them in the south – in the provinces of Kandahar, Uruzgan, Zabul and Helmand. The major new driver of infections in 2020 was the pause in vaccinations, ordered in March by the World Health Organisation (WHO), which was concerned that vaccinators, going door-to-door, might unwittingly be contributing to the spread of Covid-19. That order was lifted over the summer, but it meant several months lost. Geographical variation is also stark; the prominence of the south and indeed particular districts in the south in the polio statistics is clear.[1]An analysis of the WHO dataset of polio cases in Afghanistan segregated by province, district and date, which AAN received from the organisation, shows that the poliovirus has most often been … Continue reading The aim of this research was to carry out granular research as to the reasons for this variation. Providing context to the case studies, this introduction provides information on how polio vaccination is carried out in Afghanistan and lays out some of the broader trends in polio incidence.

How Afghan children are vaccinated

Attempts to comprehensively immunise all Afghan children is done via two routes. From 2001, there has been routine immunisation. It is aimed at new-borns and infants up to 18 months-old and is delivered in health facilities, by vaccinators going door-to-door, and in mobile health clinics, which travel to different locations and set up temporary facilities, for example in a mosque, or other public building. There is also what is called scheduled immunisation, in 1997 and then yearly since 1999; this involves ‘national immunisation days’, nationwide campaigns to give supplemental doses of the polio vaccine to all under-fives in the country. The aim of these campaigns, which usually last several days, is to reach as large a population as possible and create an immunological barrier against the spread of wild poliovirus and risk of outbreaks. Tens of thousands of polio workers go door-to-door, making sure every child under five, “including new-borns, sleeping, sick, and visiting children,” receives the polio vaccine.

Table 1: Positive polio cases in Afghanistan 2001-2020. Graph by AAN from WHO data

As table 1 shows, the high number of polio cases seen in 2020 was not without precedent. According to WHO statistics, 2011 was even worse, with 80 cases. Between 2001 and 2005, the number of polio cases in Afghanistan were generally much lower. Numbers began to creep up in 2006, and then shot up in 2011 when 80 cases were reported, 62 of them in southern Afghanistan. Hamed Karzai, then president of Afghanistan, blamed the Taleban, urging the insurgents to allow vaccinators to immunise against polio, saying, “Those who stand in the way of vaccinators are the true enemies of our children’s future.” However, the Taleban denied blocking the campaign. Afghan health officials blamed Pakistan for the spread of polio. In 2011, the number of polio cases in the more populous Pakistan had also risen sharply, doubling from the previous year, from 80 to 192, respectively (see a New York Times report here). The border is porous and the arrival of people from across the Durand line uncontrolled, but this was hardly Pakistan’s responsibility alone. This was also the time of ‘the surge’ when, between 2009 and 2012, US troops increased to more than one hundred thousand, with fighting concentrated very much in the south; vaccination drives may have been compromised by conflict and internal displacement. Numbers of positive polio cases did fall back, to 13 and 14 in 2016 and 2017, before appeared to be on the rise again, even before the high number in 2020.

There is also geographical variation to polio incidence. Since 2001, the poliovirus has most often been detected in the southern and, to a lesser extent, the eastern region of Afghanistan. In AAN’s first report on polio in 2019 (see AAN’s report here), we looked at how cases in the south are mainly found in Kandahar province, with spillover transmission observed into other southern provinces, especially Helmand and Uruzgan. In the eastern region, the epidemic is part of what is called the ‘northern corridor transmission zone’ extending from Nangrahar, Kunar and Nuristan into Khyber Pakhtunkhwa and the Federally Administrated Tribal Areas in Pakistan (the one case in Kapisa would also probably be placed at the westernmost end of this corridor). There were also smaller numbers of positive polio cases between 2001 and 2018 further north, for example, in Kunduz and Balkh provinces. Herat province in the west of the country had also seen small numbers of positive polio cases, as has Farah, which neighbours both Herat and Helmand.

The reasons why polio is still endemic in Afghanistan and also why incidence varies can be attributed to two underlying factors: varying access for vaccinators and a highly mobile population. The Swedish Committee for Afghanistan’s health officer, interviewed by AAN in 2018, said that, in general access had been better before 2010 and since then, had shrunk under pressure of the conflict. War, also of course, drives displacement, with the worst-hit families often having to leave their homes multiple times.

Although the Taleban are often blamed for blocking vaccinations, the situation on the ground is more nuanced. The movement was pro-polio vaccination until 2018, although as with many issues, local commanders might take different decisions – for example, in Kunduz, the local Taleban Committee for the Prevention of Vice and Promotion of Virtue introduced a ban on door-to-door vaccinations between March 2016 and February 2017. Since 2018, however, the Taleban have been more suspicious of vaccinators. In May to December 2018, they imposed a total ban on all vaccination in four provinces – Helmand, Kandahar, Ghazni and Uruzgan, leading UNICEF believes to 3.4 million children missed out on vaccination that year (see UNICEF report here). Also from May 2018, the Taleban specifically banned door-to-door vaccinations nationally, affecting all areas under their control. Taleban spokesman Zabihullah Mujahed, interviewed by AAN in 2019, accused the immunisation staff of doubling as ‘spies’, helping with pinpointing targets for airstrikes. He said the bans were ordered by the movement’s health commission, approved by the Emirate’s leadership and were motivated solely by security.

In April 2019, again, the Taleban said it had temporarily stopped the International Committee of the Red Cross (ICRC) and the WHO from carrying out relief work in the areas it controlled in Afghanistan and had revoked security guarantees for their staff. The Taleban said in a statement that they had found WHO staff involved in “some suspicious activities” during vaccination campaigns and that the ICRC had failed to practically implement pledges given to the Taleban. This ban lasted for five months and UNICEF estimated it exposed nearly 10 million children to the poliovirus.[2]There were also some instances of the Islamic State in Khorasan Province (ISKP) banning vaccinations in the limited amount of territory under their control: see this AAN report here.

Talking to the Taleban and trying to persuade them to give access to vaccinators in areas under their control is undertaken by the UN Humanitarian Coordinator, UNICEF, WHO and other humanitarian actors in Doha and on the ground in Afghanistan.

It is worth stressing that communities themselves only very rarely block vaccination, although there was one such instance featuring in one of the case studies from Kandahar. Individual families, however, may be wary of allowing their children to be vaccinated; known as ‘refusal families’, they may be motivated by fears that the vaccine is harmful to the health of their children, or mean when they are grown up, they are infertile or only have daughters.

One issue beyond the scope of this research is what could be done nationally to improve access to children. Head of the national emergency operating centre at the Ministry of Public Health and senior adviser to the Minister of Public Health, Muhammad Khakerah Rashidi, has raised this issue, however, in the medical journal, The Lancet, in January 2021 and called for some hard thinking about how to do better:

“We have issues with access and this lack of access has been underestimated by the polio programme. For more than two and a half years some areas have had no access [to vaccines] but the strategy is the same,” he said.

Where this research might help to give context to the question of how to improve access is in its granularity. We have conducted research with the aim of pinpointing the reasons for variation in the success in vaccinating children against polio in two districts in each of two of the southern provinces, Helmand and Kandahar. All districts were under Taleban control or influence and each pair had similar security and socio-economic circumstances, but differing records on polio. This first report looks at two districts in northern Kandahar, both of which during the period of research were under almost complete Taleban control: Shah Wali Kot, which has had polio cases most years since 2001, and Arghandab, which has seen very few. Our second report will look at Nawa and Nad Ali in Helmand province.

Methodology

For this series, AAN combined 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.

The districts featuring in this report, Shah Wali Kot and Arghandab, neighbour each other and are both found in the north of the province. Both are very populous, with some residents commuting to Kandahar City for work or trade. Shah Wali Kot has been subject to far greater conflict than Arghandab over the last 20 years. Arghandab has been very near falling into Taleban hands several times and at the time of the research was under almost complete Taleban control. That changed on 9 April when government forces recaptured the district (see BBC report here, also confirmed by one of our interviewees). In general, though, it has had a long period of government control since 2009. Both districts remain contested. Arghandab has seen more development, in terms of project implementation by NGOs, than Shah Wali Kot. The differing incidence in polio is sharp, as can be seen in Table 2. Since 2001, Shah Wali Kot has seen 26 polio cases, one of the highest counts for any district in the country. Since 2006, cases have been recorded in all but three years. By contrast, Arghandab has only seen six cases since 2001 and none since 2014.

In each district, we interviewed a health worker, a youth activist and a member of the Parmakhtaiyi Shura, the District Development Association (DDA). Each is from their respective districts but commute to the districts for only part of each week, spending the rest of the week in Kandahar City, where their families live. This is a normal pattern for many people from these districts. We also interviewed an activist promoting education in Kandahar and nationwide to confirm some information about education in both districts, three government health officials and one United Nations polio immunisation worker to confirm some of the data regarding health and polio. All our interviewees were male.

Map 1: Shah Wali Kot District, Kandahar, by Samir Hamidi, 2021

A brief introduction to Shah Wali Kot district

Shah Wali Kot district is located 50 kilometres north of Kandahar City and straddles the Kandahar-Uruzgan highway. The total population, according to residents, is about 220,000, living in 518 villages. The residents of this district are all Pashtuns. The dominant tribe of the district is Popalzai, but there are also Barakzai, Atsakzai, Andar and others. The district has a Parmakhtiayi Shura (District Development Association) and a youth association. According to our interviewees in Shah Wali Kot, the residents of the district mostly depend on agriculture. The most common fruits grown are figs, pomegranates and a little almond. They also grow wheat, cumin, maize and poppy. The reservoir waters villages near the Dala Band (Dala Dam). Rivers and canals flowing towards, and downstream of, the dam water the fields and orchards in these villages. The Bori Rud (Bori River) also flows through the district, again providing irrigation water. Barmas (deep wells) powered by solar energy water desert lands far from the rivers. This post-2001 innovation has brought new settlers to the desert areas. Although new settlers, they are recognised and served by government and NGOs.[3]This is in contrast to the settlers of desert areas in the two districts of Helmand featuring in our next case study. Their villages are not recognised and they do not have schools, clinics or other … Continue reading

Fazal Muhammad Gharib Shah, district governor of Shah Wali Kot, said there were 895 Afghan National Security Forces (ANSF) deployed to the district: 175 Afghan National Police (ANP), 350 regular Afghan National Army (ANA) and 370 ANA Territorial Force (ANA-TF). After Afghan Local Police (ALP) were disbanded at the end of last year, said district governor Fazal Muhammad Gharib Shah, some of its members were, or will be, recruited into the ANA-TF, and some have moved with their families to Kandahar City because of security threats.

The district governor claimed that ten per cent of the district is under government control, with the rest controlled by the Taleban. Not so, said another official: “Frankly speaking, we control only the district centre.” A measure of what government control means on the ground confirms the latter estimate. The district governor and other district officials gave interviews sitting in Kandahar City; all said they could not travel easily to the Shah Wali Kot district centre and have to travel either in convoys or by air.

Although the Taleban have never managed to take control of the entire district, they currently control all areas except the district centre. Shah Wali Kot has long been contested. According to our interviewees as early as 2004, three years after the Taleban regime collapsed, the movement had gained a stronghold in the Chinartu, Elbagh and Ardobagh valleys, located in the west of this district. Up until 2006, the activities of the Taleban increased and they captured more areas in the district. Shah Wali Kot is an important as a transit route for the Taleban travelling from Uruzgan to Zabul and from there to Pakistan. In 2007-10, the Taleban have been able to capture areas around the Dala Dam which is near Arghandab district. They increased their attacks on the Shah Wali Kot section of the Uruzgan-Kandahar highway, blocking it entirely after 2014 when Uruzgan police chief, Matiullah Khan, who had been protecting the highway, was assassinated. Eventually, the government was compelled to abandon this increasingly deadly road and make an alternate route in 2017. According to the interviewees the Taleban gained control of this new highway as well around three years ago and the government was able to use it comparatively safely for only a short time.

In January 2019, US and Afghan security forces launched a huge security operation in the Zangal area, around 12-kilometre from the district centre to the west of Shah Wali Kot, a Taleban stronghold where their criminal court operated from. The government said that in the last 20 years, this operation was the largest in the area (see Pajhwok report here).They did indeed clear the Taleban from Zangal, but in time, the Taleban took it back.

AAN’s interviewees said the Taleban have divided the parts of Shah Wali Kot which they control into two districts – Upper Shah Wali Kot and Lower Shah Wali Kot. It is a vast district and this bureaucratic division enables the Taleban to control it better and have good access to all parts. They have a mulki wulaswal (civil district governor) and nizami wulaswal (military district governor) for each part.

The Taleban collect an agricultural tax, which they call ushr – although the use of this religious term is questionable[4]Ushr is Arabic for a tenth and is collected on the harvest. In Sunni Islamic jurisprudence, the term is used for a ten per cent tax on the produce of cultivated land. The proceeds should be … Continue reading – in all parts of Shah Wali Kot under their control; rates vary, mainly according to crop and type of irrigation, eg irrigated or rainfed. The government also collects a tax on the harvest where it can, sometimes also calling it ushr and sometimes ‘tax’ (maliya). One of AAN’s interviewees said that government officials do not go into the district to collect this tax, but if crops are taken to the provincial centre to sell and when fuel is taken from the provincial or district centre to power generators for watering crops, officials do collect tax at check posts.

There are eight health facilities in Shah Wali Kot: two Comprehensive Health Centres (CHCs), two Basic Health Centres (BHC) and four Sub Health Centres (SHCs). Each Comprehensive Health Centre has a doctor, midwife, two vaccinators (one male and one female), one nutrition officer and two guards. The Basic Health Centres have a nurse, midwife, vaccinator and two guards. The Sub Health Centres have only a nurse. According to all AAN interviewees in Shah Wali Kot district, the Taleban neither ban health facilities in the district, nor do they interfere in medical activities. However, they do interfere in the recruitment of staff, demanding either their relatives or friends and supporters be hired as polio officers based in Kandahar City explained:

The government is one government and the Taleban is another. In the areas that each controls, the people recommended by them must be hired and the demands [each party] makes must be accepted. Otherwise, the health facilities would face problems.

The Taleban have also directly interfered in polio campaigns as will be seen below.

According to the government’s education officer for Shah Wali Kot district, Amir Muhammad, the district has 16 schools, all for boys. He said that only seven were currently open and have pupils studying, while the remaining nine are closed, either because of fighting or because of the winter season – Shah Wali Kot has a mixed climate; upland areas near Uruzgan and Zabul in the north and northeast are much cooler and schools in these areas may currently be closed. However, Amir Muhammad’s figures were contested by three AAN interviewees in the district who said all schools are currently closed except for Shah Wali Khan High School, which is located in a comparatively safer area, near the border of Arghandab district.  Moreover, schools in cooler provinces and areas of Afghanistan are now open, as they always do after 21 March, but not yet in the cooler areas of Shah Wali Kot.

Map 2: Arghandab district, Kandahar, by Samir Hamidi, 2021

A brief introduction to Arghandab district

Arghandab is also located north of Kandahar City. Its district centre is just ten kilometres away and connected by an asphalt road. It is famous for its agriculture and orchards, irrigated by water from the Arghandab River and Shah Wali Kot’s Dala Dam.

According to district governor Ahmad Sharif, the district’s population is about 192,000, living in 72 villages. In other words, it is smaller in area, has a smaller population and is nearer Kandahar City than Shah Wali Kot.

The district governor said there were 679 members of the ANSF in the district: 190 ANP, 129 ANA and 360 ALP. According to the district governor, although the ALP should have been dissolved, because of bad security conditions and at the request of tribal elders and district officials, at the time of the research, it remained active and there were no plans to remove it. (For more on the disbanding of the ALP, see this recent AAN report.)

Arghandab has largely been in government hands in the last twenty years, enjoying long periods of relative stability. The whole of the district was with the government until late 2007 when the Taleban launched attacks and overran the northern bank of the Arghandab River. The southern, including the district centre, remained under government control. With the help of the Canadian military, Afghan National Security Forces (ANSF) re-gained control of all the territory lost and the Taleban withdrew. Many Taleban fighters were killed. In mid-2008, the Taleban again launched an attack on Arghandab and captured a huge part of the district. They also attacked the Kandahar jail, helping all the prisoners escape on buses parked outside the jail, and there were rumours that they planned to attack Kandahar City itself. This author was in the city working for an international NGO when the whole city was closed and NGOs and UN agencies told their staff to go home at midday – Arghandab is, after all, only ten kilometres away. The foreign forces positioned tanks on roads and intersections in the city and Bismillah Muhammadi, then Chief of Army Staff, flew to Kandahar. The following day airstrikes killed many Taleban and pushed their forces back from the city, but they kept their wide presence in Arghandab. In 2009, Abdul Razeq was commander of border police for Spin Boldak, then Provincial Chief of Police, was tasked with clearing Kandahar province from the presence of the Taleban. Arghandab was among the districts from which the Taleban were driven (see AAN’s reports here and here)

Arghandab was then quiet from 2009 until November 2020 when the Taleban launched an offensive and overran around 90 per cent of the district. In February 2021, when the research for this report was carried out, the district governor claimed that 40 per cent of the district was under government control, by which he meant there were security posts there. However, all of AAN’s three interviewees estimated that the government then controlled only about 10 per cent of the district, which they understood as the areas officials could safely visit and operate in. District officials had continued to easily travel to the district centre from Kandahar City throughout, since the road remained safe and under government control. In February 2021, AAN’s interviewees said that most people from the northern part of the district who had fled the fighting were still displaced, living either in Kandahar City or other areas of the province. According to UNOCHA, 2,677 people were internally displaced from Arghandab district from January to March 2021.

In April 2021 (after the research for this report was carried out), government forces began a counter-offensive, with the help of US airstrikes. They announced that the government had cleared the entire district from the Taleban, but warned IDPs not to return until land mines had been cleared. On 10 May, residents told AAN that IDPs had started returning home.

Arghandab has six health facilities: two Comprehensive Health Centres (CHCs), two Basic Health Centres and two Sub Health Centres (SHCs), one of which is newly established, ie after the research for this report took place.

According to the education officer for Arghandab, Shah Wali Afghan, the district has 24 schools: nine primary, eight middle and seven high schools, with a total of 10,280 pupils. According to the AAN’s interviewees 10 of the schools are still closed.

Comparing the two districts, one can say that both are largely agricultural, but Arghandab is probably richer because of its better irrigation and greater proximity to markets in Kandahar City. Although both districts have seen conflict over the years, Shah Wali Kot has seen more fighting and more sustained Taleban rule of more of the district. Shah Wali Kot has eight and Arghandab has six clinics run by BARAN, the provincial health provider. However, our interviewees, especially the health workers, said there had been many more public outreach, hygiene and safe drinking water projects in Arghandab district than Shah Wali Kot, implemented by UNICEF, IOM and BARAN. For example, they said BARAN had provided health-related training to pupils in schools and to tribal elders and others in the community. It had also built toilets in schools. Over the last seven years, wells for drinking water had been dug and pumps installed by various national and international NGOs. Shah Wali Kot, by contrast, has seen no such projects.

Table 2: Positive polio cases in Shah Wali Kot and Arghandab districts of Kandahar province, 2001-2021. Graph by AAN based on the WHO dataset

An overall view of polio immunisation in Arghandab and Shah Wali Kot districts

The interviewees in Arghandab district were all aware of the latest polio campaign, which took place on 18 January 2021 and had seen the polio campaigners in their district. By contrast, in Shah Wali Kot, except for the health worker, the interviewees were not even aware that there had been a campaign because their district had been entirely inaccessible to vaccinators. Indeed, by late January, a polio official in Kandahar told AAN there had been no polio vaccinations carried out in Shah Wali Kot for just over three years (37 months). The polio communication manager for UNICEF in Kabul, Kamal Shah, confirmed that the inability of polio vaccinators to reach the district had allowed the poliovirus to continue to infect children. By contrast, Arghandab has seen sustained and ongoing door-to-door immunisation campaigns, over many years, according to health officials.

Given the Taleban’s strong hold on Shah Wali Kot, vaccinations there have been hit hard by the Taleban ban on door-to-door polio campaigns that began in May 2018 (see Azadi Radio Pashto report here). Even before that, though, there were problems, stemming from the conflict, corruption in the programme and less exposure to health and development programmes generally meaning parents were more likely to be suspicious of interventions by those seen as outsiders. Exacerbating these difficulties, interviewees reported, was that fighting had prevented monitors from travelling to Shah Wali Kot to observe the polio drives before 2017. Shah Wali Kot is still inaccessible for them. The monitors had therefore missed the major difficulties already assailing the vaccination campaign from all sides.

Here, the accounts given by our interviewees are somewhat confusing and contradictory, but all paint a picture of a vaccination programme targeted for corruption by people who had no regard for the health of their district’s children. Interviewees said that, in the years before 2017, both the Taleban and local government officials had insisted on their own people being hired, whether or not they were qualified. They also accused the Taleban specifically of taking money from each polio cluster. They said polio staff had been misusing resources set aside for the vaccination drives; they had subcontracted the campaigns, leading to fewer people being hired than budgeted. They skimmed off money intended for staff pay into their own pockets, destroyed the polio drops and filled in fake tally sheets. It may be, therefore, that polio campaigns in Shah Wali Kot were carried out more on paper than in reality.

Polio vaccinators, like other health staff have also found themselves directly falling foul of the conflict. In December 2017, a polio official in Kandahar told The New York Times that government forces had raided a health facility where polio staff also lived, believing staff were treating insurgents. They detained a polio worker. The Taleban, in response, the paper reported had blocked immunisation to 11 out of 28 polio zones whose opening they had early promised to allow. In 2017, the Taleban allowed vaccinators to visit only three out of the 28 zones in the district. After the above-mentioned incident, they rescinded their previous promise to allow immunisations in the other 11 zones. (A former UNICEF employee working in Kandahar confirmed this incident had taken place.)

By contrast, vaccinations in Arghandab have been far more consistently successful. AAN’s interviewees put this down to the relative lack of fighting in Arghandab district over the last 12 years. There have been some attacks from the Taleban during the last 12 years, they said, but they had been unable to control any of the main residential areas – until their offensive in November 2020. Even then, the youth activist said, children continued to be vaccinated: “After the Taleban captured around 90 per cent of the district, they warned the polio campaigners not to come to their areas for immunisation.” However, he said that very few people remained in those newly-captured areas. Most families had fled to Kandahar City or other safe areas and in those places their children were immunised. In the government-controlled areas, the interviewees also said that the polio vaccination campaign had been carried out in a good manner.

Interviewees in both districts pointed to the existence of some families who do not want their children to be immunised against poliovirus. In polio campaigners’ terminology, they are called ‘refusal families’. The interviewees relayed different suspicions and superstitions about the polio vaccine. Polio campaigners are sometimes accused of spying for the government or other states. For example, some people who refuse to let their children be immunised say the campaigners are spying for the infidels (kufar). [5]One incident not mentioned by interviewees as having an effect on vaccination hesitancy was the arrest, after Osama Bin Laden was killed in 2011, of Dr Shakel, the director of polio in Pakistan, on … Continue reading

How well do different types of vaccination campaign work?

There are different ways to get vaccine to children – or children to vaccine; they include children brought to clinics, vaccinators going door-to-door to people’s homes and mobile teams setting up temporary facilities in villages, typically during vaccination drives.

Door-to-door polio immunisation is familiar to each and every family in both districts and interviewees reported that people like this form of immunisation. However, in areas under Taleban control, it has been banned since May 2018. The most successful means of vaccination, however – and the interviewees were unanimous in this – were the mobile teams that visitvillages and provide vaccination alongside nutrition programmes. One of the youth activists explained:

The women usually bring their children to the polio immunisation to receive some food items for their children at the same time. If the nutrition programme wasn’t there, many women wouldn’y bring their children for immunisation.

As to taking children to clinics, this would typically be done by mothers who would be accompanied by their husbands or other mahrams, or possibly in groups of other women. These social restrictions always make it difficult for women to travel, in particular to distant health facilities. But for everyone in both districts, there are other problems with travel, as one of our Shah Wali Kot interviewees explained:

The main problem for people – apart from the fighting and landmines – is the lack of transport. People can’t get to the health facilities because they are too far away.

He explained further:

Around three years ago, the government – or maybe an NGO? – distributed Zarang ambulances (a moped-rickshaw ambulance) to the community to carry patients, especially women, who were unable to get to the health facilities. But all those ambulances were taken home by people who use them for their own business and don’t give them to patients.

The youth activist in Arghandab district said they had faced the same problem in his district: 30 Zarang ambulances were distributed, but were only used to help patients for a few days:

Our district covers a vast area and has a large population, but the current health facilities aren’t enough even for half of the population. The main barrier for all our patients to have access to health facilities is lack of transport.

Problems with transport mean that getting vaccinators to children, especially those in more remote areas, are always more likely to succeed than requiring children to be brought to clinics.

Interviewees spoke about both sticks and carrots. Families could be encouraged to get their children vaccinated by linking vaccination to services for which there is clear demand, for example, nutrition programmes. Interviews also considered that ways to force families to get their children protected might also be useful. One of the health shura members said they wanted the district government to refuse to issue ID cards (tazkiras) to families known not to have immunised their children against poliovirus. UNICEF’s communication manager for polio in Kabul also favoured elders using similar leverage in getting vaccinations done. When a wakil-e guzar (community head) in a provincial centre refuses to countersign people’s legal documents if they had not vaccinated their children, he said, this produced “good results.” However, he said he had not heard of similar actions at the district level. One can imagine such coercive methods would need to be managed delicately, given the risk of alienating communities or families if the approach was badly received.

The importance of having local vaccinators

The general health staff in clinics in both districts include people from other districts in Kandahar province and other provinces, with staff generally commuting back to Kandahar City, where their families live, on a weekly basis, and people are happy with that. However, polio staff are different. Interviewees in both districts said that polio immunisers must be local. According to UNICEF official interviewed in this report, UNICEF rules also mandate this. There are both advantages to having local staff and potential problems when they are not local.

Interviewees gave multiple reasons why it was so much better to have local vaccinators. Polio campaigners and mobilisers working in their own villages are more effective because they care more. They will not trample on local sensitivities – which strangers can – and are generally more acceptable in communities which dislike ‘strangers’ in their midst. Local people have a better chance, at least, in negotiating with Taleban, who are also likely to be local men, to allow immunisation in their areas; interviewees said this was because to some extent, the ‘deal’ between the community and the Taleban was one of give and take.

On the specific issue of trying to get refusal families to allow their children to be vaccinated, interviewees felt that locals could be particularly helpful. First of all, they are working to protect their own community and would be less likely to waste or throw away polio vaccine doses. However, one of the local shuras members felt they could help with the campaign if the shura knew which families were reluctant to get their children vaccinated. “We told the polio campaigners several times to share information about [these families],” he said “so that we can encourage them in different ways to get their children immunised, but they haven’t done this.” One of the youth activists in Arghandab district alleged that the polio workers do not want to share the list of refusal families because of financial concerns. He said the workers talk to the families and agree to colour their children’s nails, which is how children who have been immunised are identified, but they do not give the dose. “We have watched videos,” said the activist, “showing polio mobilisers pouring polio vaccination drops either into running water or onto the soil.” He speculated that campaigners are afraid that if they do not colour the children’s nails, their supervisors might deduct money from their salaries or fire them.

One interviewee underlined the necessity of having local vaccinators by referring to an event three years ago in Arghandab which led the community to ban polio immunisation during two sub-national campaigns, for around four months. AAN was told the full story, but because of local sensitivities, agreed not to publish it. One of the interviewees explained in general what had happened:

We’d been continuously asking those in charge of the polio campaign to run the immunisation through the local people, the villagers themselves. But they didn’t accept our proposal. Because the campaigners were not local, something unfavourable happened. As a result, the local people stopped the immunisation in their area for two periods of polio immunisation.

Worth mentioning is one factor that appears not to be significant in affecting take-up of the polio vaccination. All interviewees praised BARAN, which is contracted to run 102 government clinics in Kandahar province, and provides excellent support to the community, as one explained: “If there was no BARAN, the health services would come to halt. If the government ran these activities, there would be a huge amount of corruption.” Although BARAN does not run the polio campaigns, if its health provision was unpopular that might have had a knock-on effect on how people viewed vaccinations. Another way to look at this is that when or if immunisation is part of a broader health package that local people value, it may be more successful. As a broader point, there also appears to have been a marginal positive effect on people’s greater acceptance of vaccination in Arghandab because this district has received more public outreach, hygiene and safe drinking water projects over the years.

Conclusion

Summing up the main differences between Arghandab and Shah Wali Kot, it can be said that conflict is the primary driver of difference, but that this is not entirely straightforward. One can imagine that if locals were insistent their children be vaccinated or the Taleban saw it as a priority, the conflict could better be managed and vaccinations carried out more successfully. Yet the conflict spawns many problems – with monitoring, travel for residents, and health workers’ safety, including polio vaccinators. In Shah Wali Kot, it has meant there are fewer health programmes of the sort which ‘prepare the ground’ in a general way for people to trust their children to polio vaccinators. Also noteworthy is that in places where people are suspicious of outsiders, if local people do not run the programme, it can create fertile grounds for suspicion; even in a district like Arghandab, not having local staff caused bad enough problems to close the programme down temporarily. The Shah Wali Kot vaccination programme has also been hit by corruption linked to the warring sides, further denting the prospects of the district’s children being protected from a terrible disease. Add to all this Taleban bans and restrictions and it is not surprising that far more children in Shah Wali Kot have been left vulnerable to the poliovirus by failed vaccination campaigns.

Edited by Kate Clark and Jelena Bjelica


References

References
1 An analysis of the WHO dataset of polio cases in Afghanistan segregated by province, district and date, which AAN received from the organisation, shows that the poliovirus has most often been detected in the eastern and especially the southern regions in Afghanistan. For more see this AAN report here.
2 There were also some instances of the Islamic State in Khorasan Province (ISKP) banning vaccinations in the limited amount of territory under their control: see this AAN report here.
3 This is in contrast to the settlers of desert areas in the two districts of Helmand featuring in our next case study. Their villages are not recognised and they do not have schools, clinics or other services; this is a factor in promoting the success or otherwise of polio vaccination.
4 Ushr is Arabic for a tenth and is collected on the harvest. In Sunni Islamic jurisprudence, the term is used for a ten per cent tax on the produce of cultivated land. The proceeds should be given to eight categories of people: the destitute, the poor, ushr and zakat (alms) collectors, those enthusiastic for Islam, prisoners, the indebted, wayfarers and passengers who may be rich at home, but needy away. The Taleban do not use the proceeds for these people or for social goods like education or healthcare, but rather for running their organisation and military campaigns. For more on this, see here.
5 One incident not mentioned by interviewees as having an effect on vaccination hesitancy was the arrest, after Osama Bin Laden was killed in 2011, of Dr Shakel, the director of polio in Pakistan, on suspicion of having spied for the American government.

Tags:

Taleban service-delivery in the Taleban controlled area Healthcare Health polio Ministry of Public Health

Authors:

Ali Mohammad Sabawoon

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