One Land, Two Rules (5): The polio vaccination gap
While researching the delivery of health, education and other services in districts affected by the insurgency, we found that three of our featured districts, in Helmand, Nangrahar and Kunduz provinces, had seen cases of polio leading to paralysis in the last five years. There is no cure for polio, but there is an effective vaccination, so why, more than forty years since polio vaccination began in Afghanistan, are some children still not being protected? AANâs Jelena Bjelica (with input from the AAN team*) finds some answers in the impact of the conflict, a mobile population, patchy and scarce health care, women being unable to take decisions on health care, and vaccination strategies that might need to be re-thought.
Service Delivery in Insurgent-Affected Areas is a joint research project by the Afghanistan Analysts Network (AAN) and the United States Institute of Peace (USIP).
Previous publications in the series include an introduction, with literature review and methodology, âOne Land, Two Rules (1): Service delivery in insurgent-affected areas, an introductionâ by Jelena Bjelica and Kate Clark; and three case studies: on Obeh district of Herat province by Said Reza Kazemi; Dasht-e Archi district in Kunduz province by Obaid Ali; and Achin district in Nangrahar province by Said Reza Kazemi and Rohullah Sorush.
In this dispatch, the author first looks at what polio is and how efforts to eradicate it began, in the United States in the 1950s and globally, including Afghanistan in the late 1970s. She plots how polio has declined since then, before looking at why it continues to circulate here. She assesses current strategies for reaching newborns and under-fives. She then looks at three case studies, districts where polio has resulted in paralysis in recent years: Achin district in Nangrahar province, Nad-e Ali in Helmand province and Dasht-e Archi in Kunduz province.
What is polio?
Polio, short for poliomyelitis, is an infectious disease that is caused and transmitted by the poliovirus. The name âpoliomyelitisâ is derived from the Greek for grey (polios) marrow (myelon) and refers to the tissue inside the spinal cord.
There are three types of poliovirus, all members of the enterovirus genus. (1) Poliovirus only infects humans. It is very contagious and spreads through person-to-person contact. The virus is most often spread by the faecal-oral route, ie it enters through the mouth and multiplies in the intestine. Infected individuals shed poliovirus into the environment for several weeks, where it can spread rapidly through a community, especially in areas of poor sanitation.
One of the severe symptoms of polio in childhood is paralysis, and the disease is therefore also known as âinfantile paralysisâ. Polio can interact with its host in two ways: as an infection that does not affect the central nervous system and only causes a minor illness with mild symptoms; or, as an infection affecting the central nervous system when it may cause paralysis and in some cases even result in death. In about 98 per cent of cases, polio is a mild illness, with no or only flu-like symptoms. In paralytic polio, the virus leaves the digestive tract, enters the bloodstream, and then attacks nerve cells. Fewer than two per cent of people who contract polio become paralysed, but they are disabled for life.
In the early 20th century, polio was one of the most feared diseases. In 1916, for example, New York experienced its first large epidemic, with more than 9,000 cases and 2,343 deaths. Nationwide in 1917 in America, there were 27,000 cases and 6,000 deaths. Polio struck in the warm summer months, sweeping through towns in successive epidemics every few years.
It was only in the mid-1950s that a preventive vaccine was found and tested. In 1952, Dr Jonas Salk began to develop the first effective vaccine against polio. Mass public vaccination programmes followed and had an immediate effect; in the US, cases fell from 35,000 in 1953 to 5,300 in 1957. In 1961, Albert Sabin pioneered the more easily administered oral polio vaccine (OPV). (See this BBC timeline on the history of polio and this timeline on the history of polio vaccine).
It took somewhat longer for polio to be dealt with as a major problem in developing countries. It was only in the 1970s that routine immunisation was introduced worldwide as part of national programmes. By 1988, polio had been eliminated from the US, UK, Australia and much of Europe, but remained prevalent in more than 125 countries. The same year, the World Health Organisation adopted a resolution to eradicate the disease completely by the year 2000. Since then, through the Global Polio Eradication Initiative, more than 2.5 billion children have been immunised against polio.
The World Health Organisation (WHO) certified the Americas as a polio-free region in 1994 and the European region in 2002. India reported the last positive case in January 2011 and was certified polio-free in 2014; China was certified polio-free in 2013. Since 2012, polio has remained officially endemic in only three countries â Afghanistan, Pakistan and Nigeria.
Although the global incidence of polio has decreased by 99 per cent since the start of the global vaccination campaign, tackling the last one per cent of polio cases has proved difficult, as the Global Polio Eradication Initiative reported on its website:
Conflict, political instability, hard-to-reach populations, and poor infrastructure continue to pose challenges to eradicating the disease. Each country offers a unique set of challenges which require local solutions.
In Afghanistan, between January 2001 and March 2019, there were 414 cases of individuals contracting polio and becoming paralysed.
Positive polio cases in Afghanistan: 1980 to 2018Â Â Â
Despite the ongoing conflict, the number of paralytic polio cases in Afghanistan has decreased over the last 40 years. The publicly available historical data on positive paralytic polio cases in Afghanistan that can be found on the website âOur World in Dataâ by Oxford University, shows that the number of positive polio cases dropped from almost 2,000 in the mid-1980s to four in the early 2000s. (See graph 1 below for an overview of positive cases between 1980 and 1990 and graph 2 for 2001 to 2018). Although the numbers fluctuate, positive polio cases in Afghanistan in the 2000s and 2010s have been as low, annually, as in the dozens and even fewer than ten. This compares positively to the number of cases in the 1980s, which ranged from several hundred to often more than a thousand, indicating a relatively effective immunisation campaign (more on this below).
Data on positive polio cases in Afghanistan for the first half of the 1990s is almost non-existent. There is only a figure for 1991 when two cases were documented. It is nevertheless interesting to note that an almost complete dataset exists for the period of Taleban rule. According to the WHO, 19 cases were documented in 1997; 59 in 1998; 150 in 1999, and 120 in 2000. The data for 1996 is missing; that year saw the increased conflict as the Taleban moved to consolidate their power. How reliable these datasets are, given the WHOâs limited access during the civil war and subsequent Taleban rule is another question. The presumption that the Soviet-backed regime in Afghanistan during the 1980s had accurately reported the health situation in the country is also suspect. As usual, caution is needed when using historical datasets for Afghanistan.
An analysis of the WHO dataset of positive polio cases in Afghanistan between 2001 and 2018 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. (See graph 2 for an overall number of positive polio cases between 2001 and 2018.) Â In the south, they were mainly in Kandahar province, with spill-over transmission observed into other southern provinces, mainly 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. There was also a smaller number of positive polio cases during this period further north, for example, in Kunduz and Balkh, as well as one case in Kapisa, the easternmost province of the central region. Herat province in the west of the country also had positive polio cases, as did Farah, which neighbours both Herat and Helmand.
Taking 2018 as an example, 21 children were paralysed by the poliovirus in Afghanistan. Despite this high number of cases, the transmission was geographically limited to the southern and eastern regions and reported from only six of Afghanistanâs 34 provinces. 15 of the cases were in the southern region â nine in Kandahar province and with spill-over transmission to Helmand and Uruzgan. In the southern region, a major issue is lack of access: more than 840,000 children have missed out on the vaccination since May 2018. Inaccessibility coupled with some communities refusing to allow vaccination (more on this below), particularly in and around Kandahar, is a major obstacle for polio eradication in the country. It also makes responding to detected polio transmission difficult. The six cases in the eastern region are in the northern corridor transmission zone.
What causes the poliovirus to spread?
The vital question for those trying to protect children against the poliovirus is what drives it to spread in Afghanistan? According to experts, it boils down to two factors: lack of access for vaccinators and a highly mobile population. The 2017 report of the Afghanistan Technical Advisory Group (TAG) on polio eradication, looking at the epidemiological evidence, said it showed that âthe vulnerability of pockets of unreached childrenâ and âthe role of population movementâ are the key factors for poliovirus transmission across Afghanistan. The number of positive polio cases in Pakistan plays an important role in the virus spread through population movement across the border.Â In 2017, this number declined to only eight, from 306 cases registered during 2014, 54 in 2015 and 20 in 2016.
Afghanistan and Pakistanâs eradication efforts are interlinked and the two countries are dependent on each otherâs success in eliminating polio â or held back by the otherâs failings. This is why the two countries established a daily communication channel on polio in 2016 (see here) and why Afghanistan established compulsory vaccination at border crossings with Pakistan for children under five years of age. However, poor access to health services at the sub-national level, a lack of professional health staff and in particular limited access for women to health services play an equally important role in the spread of the virus in Afghanistan.
Immunisation in Afghanistan
Routine immunisation against polio, launched under the name of âMass Immunisation Programme through the Ministry of Public Health (MoPH), has been mandatory since 1978 in Afghanistan. This followed the global trend of mandatory immunisation against polio introduced in the 1970s. This so-called âroutine immunisationâ against polio means that every newborn child should be given his or her first oral polio vaccine within their first 14 days of life, with four more vaccines to follow in the sixth, tenth and fourteenth weeks and a final one at nine months. However, the reach of mandatory routine immunisation, despite improvement over the years, has remained limited – because of the conflict and lack of access to health services.
According to publicly available WHO data, immunisation coverage among Afghan one-year-olds rose from three per cent in 1981 to 33 per cent in 1989. (A word of caution here: all percentages are estimates rather than hard statistics.) During the 1990s, it dropped back to an annual average of 25 per cent. The first supplemental immunisation activity, ie national immunisation days or polio vaccination campaigns aimed at children under the age of five, was launched in 1997. These campaigns, that usually last several days, have been conducted on a yearly basis since 1999. Their aim is to reach as large a population as possible and create an immunological barrier against the spread of wild poliovirus and risk of outbreaks. During these designated days, tens of thousands of polio workers go from door to door, making sure that every child under five, âincluding new-borns, sleeping, sick, and visiting children,â receives the polio vaccine. However, this approach has often been met with resistance and scepticism by local communities, especially since 2001, as will be explained in more detail in the following sections.
Nevertheless, the coverage of immunised children has increased over the years, from 24 per cent of one-year-olds in 2000 to 66 per cent in 2010. It rose further in 2011 and 2012, reaching 68 and 67 per cent, respectively. Progress was halted in 2014, the year when most foreign troops left Afghanistan and a presidential election was held, both events which lead to a general deterioration of security and consequently less access for vaccinators. The number of children immunised dropped to 50 per cent in 2014. In 2015, it increased again, to 60 per cent, and remained stable during both 2016 and 2017 (the latest available figures). This, however, is still too low: Afghanistanâs aim is to reach and immunise up to 80 per cent of newborns every year; this is the universally-accepted threshold for full immunisation.
Health sector shortfalls and some cultural considerations
Low routine immunisation coverage is one of the reasons the poliovirus continues to circulate in the country, said a 2011 UNAMA report. Even so, routine immunisation of all newborns, infants and pregnant mothers is only one of the strategies for polio eradication. Other strategies include: supplementary immunisation activities, surveillance, âmop-upâ campaigns, ie door-to-door immunisations that are carried out in specific areas where the virus is known or suspected to still be circulating and care for post-polio paralysis â part of the strategy because an infected person can spread the virus. Afghanistanâs health sector, however, is still not at the required level to systematically deliver basic routine immunisation.
Health expenditure in Afghanistan, although pretty high â 9.5 per cent of GDP according to the countryâs Central Statistics Office (2) â is heavily dependent on donors, with around 75 per cent financed by foreign aid (see page 10 of this report). It is thus mainly driven by donorsâ policies. For example, programmatic decisions as for major on-budget aid investment, such as the Afghan Reconstruction Trust Fund (ARTF, Â through which the Basic Package of Health Services (BPHS) (see also endnote 7) is entirely funded, although it is a fully âon-budgetâ programme,Â are still made by the World Bank (see this AAN analysis on aid and poverty in Afghanistan).
The number of health workers is also too low. Nationwide, there are 2.3 physicians and five nurses and midwives per 10,000 people, 2011 WHO study found. The global average is 13 physicians and more than 20 nurses and midwives per 10,000 people. (3)
A minimum of 23 health workers per 10,000 people, according to 2006 WHO report, is required to achieve â80 per cent skilled coverage of births, one of the interventions considered by the Millennium Development Goals (MDG).âÂ In Afghanistan, only 50.5 per cent of births are attended by a skilled health worker, as the latest available WHO estimate for 2015 shows. This is important for two reasons: it is one factor behind the still-high maternal mortality rate, which was at 396 deaths per 100,000 live births in 2015, (4) and the high mortality rate of children under 5 years of age, which was 91 per 1000 live births in 2017 and; secondly, the presence of skilled personnel at birth means mothers can be informed in a timely manner about vaccination. The first polio vaccine can also be administered by health personnel. This may be why only 15 per cent of surveyed mothers that had newborns in 2015, a year when the first ever Afghanistan Demographic and Health Survey was carried out, reported that their children had been vaccinated against polio at birth. (5)
A journal article on routine immunisation coverage in Afghanistan, published in 2017 in BMC Public Health, an open access, peer-reviewed journal that focusses on the epidemiology of disease and the understanding of all aspects of public health found that, nationally, only 51 per cent of children participating in the survey had received all the vaccines included in Afghanistanâs routine immunisation schedule. (6) The survey found that 31 per cent of surveyed children had only been partially vaccinated and for the following reasons: the place to vaccinate child was too far (23 per cent), mother was not aware of the need to vaccinate (17 per cent), mother had no faith in vaccination (16 per cent), mother was too busy (15 per cent) and had fear of side effects (11 per cent). The remaining 18 per cent of mothers in the survey sample had never had their children vaccinated, mainly for the following reasons: place for vaccination being too far (40 per cent), no faith in immunisation (34 per cent), unaware of the need for vaccination (33 per cent), concerns about conflict-related security (21 per cent) and not being allowed to go to a clinic without a male family member (or mahrahm) (21 per cent).
Womenâs lack of access and lack of power to make health-related decisions are detrimental to their own health and make significant obstacles for them to get their children vaccinated. 2013 WHO study on gender-sensitive health service delivery said that:
For health-related decision-making, the findings were unanimous that women cannot take independent decisions on their own health and often need accompaniment for seeking health services. The heads of households (i.e. husband, father or brothers) are the ones who make those decisions for the women and this inhibits their timely access to health care services.
It is not only cultural norms that prevent women from accessing health services. The way health services are provided in the health sub-centres in villages is equally limiting. A 2017 study published in The Journal of Infectious DiseasesÂ found that, although the average availability of essential vaccines, such as OPV (Oral polio vaccine), BCG (Bacillus CalmetteâGuĂ©rin, against tuberculosis) and measles vaccines were generally high (above 90 per cent) at the various types of health facilities, in the health sub-centres (HSCs), it was typically below 80 per cent. (7) The study said:
Compared with other facility types, HSCs were less likely to have adequate stock of vaccines, essential cold-chain equipment, or proper documentation of vaccination activities [âŠ] Staffing inadequacies at the HSC level, which averaged 1 vaccinator compared with 2 for other types of facilities, may hamper the ability to deliver RI [routine immunization] services. Furthermore, unlike other facility types which had an average of 1 trained female vaccinator, most HSCs had none. This could hinder compliance with immunization, especially among women of childbearing age, given cultural sensitivities.
In 2018, as a result of all of these factors, according to UNICEF, only one in three children less than a year old received a vaccine through routine immunisation.
Supplementary immunisation activities, commonly known as âdoor-to-door campaignsâ have intensified over the years in the form of national and subnational immunisation days, ie short and intensive campaigns. Usually, there is more than one campaign a year (see, for example, details about the national immunisation campaign from July 2018 here; from August 2018 here: and from November 2018 here). These campaigns are intensive, massive and sometimes geographically defined, ie vaccinations are targeted at particular provinces or districts. They also come with pre-defined targets. In July 2018, for example, the target was 6.4 million children under five; in August 2018 it was 9.9 million and; in November 2018, 5.3 million.
However, this âtargeted outcomeâ approach also has a downside. In the past, it repeatedly resulted in dishonest services, as AAN heard from two different sources in international organisations involved in the vaccination campaign. In some instances, the vaccinators simply dumped vaccines in the garbage, but counted them as administered, in order to reach their quota. In another case, according to the sources, the vaccinators took responsibility for areas they felt were too dangerous to work in, but did not report this lack of coverage back. This was also possible because there were no means to verify the number of vaccinated children. According to the director of the National Emergency Operation Center, Dr Maiwand Ahmadzai, they managed to overcome these limitations on monitoring in 2016. Through a presidential decree, a call centre was established which used GPS tracking of phone calls. Through this call centre, Dr Ahmadzai said, almost 95 per cent of physically-inaccessible areas could be communicated with and monitored. This, however, happened without sufficient consideration that the tracking method might amount to a violation of privacy or safeguards for the data collected not being used for other purposes.
The campaigns also often cause political tensions. Although organisers regularly highlight their neutrality, see for example in the 2019 National Emergency Action Plan for Polio Eradication, which says that the goal is to âmaintain dialogue with AGEs [anti-government elements, ie the insurgents] at local, provincial and higher level on programme neutrality for polio and supporting activitiesâ (see here), this is often disputed by the Taleban. Their spokesman, Zabihullah Mujahed, told AAN via WhatsApp that the polio vaccination had most recently been misused in Helmand, Kandahar, Ghazni, Uruzgan and all other areas where fighting was intense. âThe enemy was misusing vaccinators for collecting intelligence data,â he said, adding that:
Several people were arrested, who had entered Taleban-controlled areas, calling themselves vaccinators, but actually collecting intelligence data.Â Such had been appointed to identify the houses [and] residential areas of Taleban commanders and leaders. The vaccinators would leave chips [GPS tracking devices] in houses, so that the government would identify that house and locate it for targeting. This clearly shows that the enemy was seriously misusing the polio vaccination drive.
The director of the National Emergency Operation Center, Dr Maiwand Ahmadzai, said it was not easy for them to deal with these issues:
I have only a few people that I can send to these [contested or controlled] areas and who are technically able and trustworthy to us and to the Taleban [âŠ] and there are more than 50 districts that are in need of these kinds of people.
Mistrust has led to low levels of immunisation acceptance in some communities, (8) although acceptance has improved over time. The governmentâs National Emergency Action Plan 2019, for example, foresees a publication of the qualitative analysis aimed at understanding why people might refuse the vaccine. The government also plans to engage with media and social media to address rumours undermining the drive to vaccinate.
Nevertheless, the political tensions surrounding vaccinations still most often result in bans, which can be imposed by a local insurgency commander or at the regional level, as was the case in 2018 in Helmand, Kandahar, Ghazni and Uruzgan provinces (more on this below).
Three district case studies
1. Achin, Nangrahar province
Achin is a long-embattled district with complicated conflicts (see this AAN report). As of early 2019, most of the district was under government control. But, before that, in the 2015-18 period, the Islamic State Khorasan Province (ISKP), the Islamic Stateâs Afghan-Pakistani franchise, also known as Daesh â controlled most of it. The ISKP still continues to operate from mountain strongholds in the southern parts of the district. Before ISKP, between 2009 and 2015, the Taleban were in control of much of Achin. These power shifts, messy and often brutal, have resulted in the frequent internal displacement of people (see here and here) and a lack of access to health providers. Additionally, most health facilities have been damaged in the fighting. Even though, as of early 2019, health service delivery had only been hindered in ISKP-ruled areas, there are more general problems. For example, there are no female doctors in the district.
According to the WHO database on polio cases in Afghanistan, six positive polio cases were recorded in Achin between January 2001 and March 2019: one in 2012, one in 2014 and four in 2015, ie two were during Taleban rule and four during the shift in power in 2015 when ISKP captured Achin and turned the Mamand Valley into their local headquarters. It was also in 2015 that the Taleban banned vaccinations in areas still under their control in Nangrahar province. That ban included Achin, Dehbala and Rodat districts (see here). Both of these security-related factors were probably behind difficulties in vaccinating and the four positive polio cases, as this report) also found. Dr Sebghatullah, in charge of polio vaccination in Achin at the time, told AAN that he remembers that two of four children infected in 2015 were from Taleban families.
It is interesting, however, that there were no positive polio cases in Achin during most of the ISKP rule over the district, despite their strict ban on the government provided public health services. AAN research on service delivery in Achin found that the ISKP opposes both the running of health services, as well as the administration of any vaccination campaign in areas under its rule. The significant factor here may be something different, however, a doctor from Achin, Ezzat Shah Samim, told AAN that between 2016 and 2018, there had not been any positive polio cases in Achin because most of the people had fled areas under ISKP rule.
The history of positive polio cases in Achin shows the impact that lack of access for vaccinators, either because of bans or insecurity, can have on community health.
2. Nad-e Ali, Helmand province
The ethnographic make-up of Nad-e Ali district is somewhat different from Achinâs, although the communities in both districts are largely monoethnic, predominantly Pashtun. Achin is traditionally inhabited by members of the Shinwari tribe and as such is a homogenous community, albeit with significant sub-tribal conflict (see this AAN report). Nad-e Ali has a diffuse tribal structure as a result of large-scale government-led irrigation and settlement schemes that began in the 1950s. According to David Mansfield in his 2016 book A State Built on SandÂ (p 247), the mixing of new settlers with the original population resulted in a rural Ă©lite that is âfragmented, competitive and limited in its geographic sphere of influence.â
Nad-e-Ali communities are extremely dependent on opium cultivation. The district frequently featured as either the top or second place opium poppy-cultivating district during the mid and late 1990s. During the 2000s, opium poppy cultivation decreased, and the Helmand Food Zone project that began in 2008 aimed to replace illicit crop with licit ones. This led to the loss of income for many farming families and lowered health expenditure. By, 2018 Nad-e Ali was yet again the top opium cultivator in the county with 21,396 of a total countrywide estimated 263,000 hectares.
According to the data received from WHO, the district has had at least one positive polio case on an almost annual basis during the past 14 years, apart from a four-year break between 2014 and 2017. The number of cases was respectively: one in 2005; three in 2006; two in 2007 and 2008; four in 2009; three in 2010; up to a maximum of eight in 2011; and down again to two in 2012 and one in 2013, followed by four years without any recorded cases. A new case was registered in 2018. The increase in positive polio cases between 2009 and 2011 may have been indicative of lower incomes for most of the farming communities in the district.
There are other theories, too, as to why polio has persisted in Nad-e Ali. UNICEFâs communication specialist for polio eradication, Sayed Kamal Shah, told AAN that, of the 80 positive polio cases in Afghanistan in 2011, 11 in Helmand were transmitted by people who often go to Pakistan. According to this theory, cross-border transmission played a key role in spreading the virus. Helmandâs provincial WHO coordinator, Tahsil Khan, offered a more comprehensive explanation. He told AAN that the reasons for the 2011 polio cases were the bad quality of the vaccination campaign, the lack of cooperation from communities, fighting and the negligence of polio vaccinators and supervisors.
Cultural considerations also play a role, according to one of the interviewees from the province consulted as part of AANâs service delivery in insurgent-affected areas research:
Because of traditional restrictions, families do not want their women going out of their homes. The people are poor, and the male members of the families are busy in daily labouring or working their lands. Therefore, a number of children have been deprived of immunisation. It is why we have polio positive cases in Helmand province.
According to the national eradication programme, Nad-e Aliâs poor immunisation record is mainly due to persistent access problems caused by insecurity. Added to this, the illicit nature of most of Nad-e Aliâs agriculture also ensures farmers and their families stay away from government-provided health services.
At the same time, the Taleban, who have controlled most of the district since 2016, do not generally oppose polio vaccinations. On the contrary, according to the respondents in AANâs research, they recommended their own people for hire by the health department. Despite this, the Taleban have imposed occasional bans on immunisation, the most recent one, between May and December 2018, covered four provinces â Helmand, Kandahar, Ghazni and Uruzgan. According to Taleban spokesman Zabihullah Mujahed, the decision to ban vaccinators was made by the movementâs health commission and approved by the Emirateâs leadership and was motivated solely by security. He repeated the Talebanâs allegation that immunisation staff doubled as âspiesâ:
The enemy was misusing the polio vaccination process in Helmand, Kandahar, Ghazni, Uruzgan and all other areas where the fighting was intense. The enemy was misusing vaccinators for collecting intelligence data. [âŠ] We have witnessed some night raids and bombings in some areas where the enemy had collected intelligence information via the polio vaccination process. In such raids, commanders of the Islamic Emirate were targeted and their houses identified.
Yet, Mujahed also underlined the general need for vaccination:
At the same time, there is a serious need for people to vaccinate their children. Therefore, the [Taleban] Health Commission worked on another solution. They decided that, as every village has a mosque and a malek, so the children should be vaccinated either in the house of the malek or in the mosque of the village. This way, the vaccinators will go to the mosque or the malekâs house where people will bring their children to vaccinate them. The commission also told the people that when vaccinators come to a village, a public announcement should be made via the mosque loudspeakers. [âŠ] When it was decided, mujahiden [sic] go from village to village and inform the villagers about the new procedure for vaccinating children.
However, he said the âintelligence collectingâ had not been witnessed in other parts of the country in 2018, so in other provinces, health staff were allowed to go door-to-door to vaccinate children. (9)
Public health officials and other stakeholders AAN spoke to in Nad-e Ali said the Taleban plan was inadequate. They said that most people, especially women, cannot bring their children to the mosque. Because of the difficulty of getting to a central location, all parties agreed to open polio vaccination centres in each village on 25 February 2019, when the last polio campaign resumed in Nad-e Ali.
Nad-e Ali district is an example of how polio-related politics in Afghanistan work and the array of actors involved. It is also interesting that the Taleban sometimes take a regional approach in their health-related decision-making and that bans are not left only to the will of the local commander, as was the case in Dasht-e Archi in Kunduz province in 2017 (more on which below). It also shows that polio policies have consequences. The form of polio vaccination favoured and supported by the Taleban was implemented too late for one three-year-old from Nad-e-Ali, who became the latest positive case from the district and who will remain permanently paralysed.Â
3. Dasht-e Archi, Kunduz province
Dasht-e Archi, a district in the northeastern corner of Kunduz province, is almost entirely controlled by the Taleban (see this AAN report). They have established shadow sub-national governance structures, while most Afghan government officials are absent and work remotely from the provincial capital. Although the Taleban do not provide any services themselves, they have co-opted many governmental and non-governmental organisation (NGO) services in the district and these continue to run.
According to the WHO database, Dasht-e Archi had one positive polio case in February 2017. This happened after a local Taleban Committee for the Prevention of Vice and Promotion of Virtue introduced a district ban on Kunduzâs door-to-door campaign between March 2016 and February 2017. There were two reasons for this ban, according to AAN sources in the district. First, the local Taleban representatives had argued that the polio vaccination was âharmfulâ for children and the vaccine âuseless.â The second reason was security-related â the Taleban said the vaccinators took photos of their location and shared it with the government. According to WHO estimates, because of this ban, 176,000 children were unable to access the vaccination programme in 2016 and 2017. As seen in the 2016 UNAMA Civilian Casualties report, during the November 2016 vaccination campaign â50 per cent of children missed vaccination due to active fighting while the remaining half missed it due to a ban on the house to house polio vaccinations imposed by Anti-Government Elements.â
The ban was lifted after the intervention of local elders who put pressure on the Taleban, locally, to allow vaccinators to carry on with their campaign. The solution at the local level ie, between community elders, provincial government officials and Taleban shadow provincial government officials, shows how powerful and successful communities can be, if united on an issue of concern. It was essentially local elders who stood firm for vaccinations to be carried out, in opposition to the Taleban committeeâs decision.
The three case studies show that local security and political context plays an important role in any successful immunisation campaign. In Achin district in Nangrahar, a complicated and often brutal conflict between three warring parties has been the main obstacle for the delivery of health services, and, in particular, the timely immunisation of children. In Nad-e Ali and Dasht-e Archi, which are also sites of armed conflict (although only between two parties) and political tensions, a combination of fighting and bans have been the main obstacles. Bans may be imposed locally (and may be resolved at a local level) or regionally, covering several provinces.
It may be that in the countryâs south (Uruzgan, Helmand, Kandahar and Ghazni), bans are mainly imposed by Taleban central command, based on a strategic approach to safeguarding territorial gains and not allowing any suspected intrusion of the governmentâs security apparatus. The 2018 ban in four provinces for a particular method of immunisation indicates that the Taleban there may be ready to propose and accommodate different solutions to the problem of getting children immunised during the conflict, ie immunisation in mosques or maleksâÂ homes, rather than the more intrusive, as they see it, door-to-door campaigns. That the Taleban should want to try to accommodate polio vaccinations should not come as a surprise, as the historical records on polio immunisation in Afghanistan show that the first national supplementary campaigns were carried out during their rule in the late 1990s, when the south was firmly under Taleban control. As the door-to-door campaign has become a cause of tensions since 2001, this approach probably requires some rethinking. While such campaigns would ideally guarantee that the majority of children are immunised, they may ultimately fail if both insurgents and communities perceive them as intrusive and harmful.
Fundamental for carrying out a successful door-to-door campaign would seem to be focused interaction between government and Taleban stakeholders on the timing and planning of the campaigns to build up trust and ensure better information. The examples of the past indicate that solutions were generally found, but post-facto, rather than in a pre-emptive fashion. Even if the Taleban are not part of the discussion on the timing of national immunisation days, health providers could consider including them at the planning phase and seek their consent and get guarantees of support for the campaigns.
The eradication of the poliovirus in Afghanistan will remain a top health priority in years to come. A reduction in violence, or indeed an end to the conflict, would be the single most useful factor for ensuring success in immunising Afghan children. However, regardless of how well or badly the current talks on a political settlement go, there are still changes that could be made to how immunisation is carried out to make better coverage more likely.
The AAN series on service delivery in insurgent-affected areas found that in most districts, health services at the local level are sub-standard. Health facilities lack the basics, from a scarcity of female health workers to a scarcity of electricity for the refrigerators used to store vaccines. In some districts, health facilities have been destroyed by fighting or temporarily occupied by parties to the conflict. Especially in remote villages, health facilities may not be available at all.
Afghan women, who are the primary target group for the timely vaccination of their children, face an additional obstacle: they lack the power to make health-related decisions due to âtraditionalâ cultural norms which mean men are responsible for the decisions affecting the health of their women and children. If more women had access to skilled health personnel during child delivery then compulsory vaccination at birth could easily be achieved. However, given that education of girls is often poor in these districts as well â often because of conflict and the same conservative norms â there are not the educated young local women coming through who could become midwives, nurses or doctors. Meanwhile, women from outside the districts do not want to work there.
The reasons for the persistence of polio in Afghanistan are many, but basically boil down to several difficult-to-tackle issues â conflict, poverty and lack of womenâs rights â and the geographical fact that Pakistan and Afghanistan continue to provide a reservoir of the poliovirus for the other.
Maybe it is time in Afghanistan to rethink the delivery of health services in general and consequently to mend the health of the nation, which is still characterised by one of the highest rates of maternal mortality at birth and childrenâs mortality in the first five years. Empowering women and educating both men and women on health-related issues through all available channels, such as through radio, television and mosques, could also be used in a bottom-up approach to achieve a society that is more gender equal and thus more equitable
* Rohullah Sorush and Said Reza Kazemi reported on service delivery in Achin district in Nangrahar province, Obaid Ali reported on Dasht-e Archi in Kunduz province, Ali Mohammad Sabawoon who will be publishing on Nad-e Ali in Helmand province, and Fazal Muzhary helped with additional research.
Edited by Christian Bleuer and Thomas Ruttig
(1) Enteroviruses belong to a group of ribonucleic acid (RNA) viruses which typically occur in the gastrointestinal tract and sometimes spread to other parts of the body, including the central nervous. They also include Hepatitis A (see here).
(2) This is not a low percentage. By way of comparison, in high-income countries, the average health expenditure is just above 12 per cent of GDP.
(3) Life expectancy in Afghanistan remains low, for women it is 63.2 years and for men a little higher, at 63.6 years. Interestingly, while in most countries, female life expectancy is higher, in Afghanistan, it is men who tend to live a little longer.
(4) According to The Guardian report from 2017, the real number of maternal deaths at birth could be much higher. The newspaper quoted an unpublished report which said that the Afghan government found an average level of maternal deaths between 800 and 1,200 for every 100,000 live births.
(5) For the 2015 Afghanistan Demographic and Health Survey, 24,395 households were interviewed, including individual interviews with 29,461 married women age 15-49.
(6) The routine immunisation schedule in Afghanistan includes: Bacillus Calmette-GuĂ©rin (BCG) against tuberculosis; a pentavalent or five individual vaccines given in one go, intended to protect against Haemophilus influenza type B (bacteria causing meningitis, pneumonia and otitis), whooping cough (or pertussis), tetanus, hepatitis B and diphtheria; oral poliovirus vaccine (OPV); and the first dose of the measles vaccine.
The interviews for the study published in the BMC Public Health journal were conducted in 34 Afghan provinces with 6,125 caregivers of children aged 12â23 months at the time of the survey who were identified as eligible.
(7) In 2003, the government of Afghanistan introduced the Basic Package of Health Services (BPHS) programme. BPHS was established to improve access to healthcare services in rural areas, which account for more than 70 per cent of Afghanistanâs population. BPHS comprises several key elements, including maternal and newborn care, child health and immunisation, and communicable disease control. These services are provided through different tiers of the primary health sector, ranging from small health posts catering to approximately 100â150 families to district hospitals, which serve populations of tens of thousands of people. Health services administered through BPHS are provided on a graduated scale, with the higher tiers of health facilities providing a more comprehensive package of services compared with smaller health facilities. The tiers of BPHS facilities include: health sub-centres (HSCs) that represent the smallest and lowest levels of service delivery, with higher levels of services offered by basic health centres (BHCs) and comprehensive health centres (CHCs). District hospitals (DHs) represent the highest level of service delivery. All tiers provide immunisation services.
(8) In an attempt to confirm their suspicions that al-Qaeda’s leader was living in a compound in Pakistan, the US launched an immunisation scheme in 2011 with the objective of obtaining DNA from a resident in the property that would confirm any family link (see here and here). This event fuelled conspiracy theories about vaccines in Pakistan and Afghanistan (see here), and communities sometimes refuse vaccinations on the grounds that the government is collecting biodata.
(9) On 11 April 2019 the Taleban said that it has temporarily stopped the International Committee of the Red Cross (ICRC) and the World Health Organisation (WHO) from carrying out relief work in the areas it controls in Afghanistan and it has revoked security guarantees for their staff. The Taleban said in a statement that they have found WHO staff involved in âsome suspicious activitiesâ during vaccination campaigns and that the ICRC failed to practically implement pledges given to the Taleban. (see more here).