Conflict and polio: winning the polio wars.

The global polio eradication initiative is at a critical crossroads. Some 25 years ago, the World Health Organization (WHO), supported by Rotary International, launched a global goal of eradicating polio from the world by 2000.1 Although the eradication target may not have been achieved, there has been remarkable progress. From more than 350 000 cases of poliomyelitis globally spread over 125 countries with endemic disease in 1990, a mere 223 cases were reported in 2012, with the disease largely restricted to a few regions of Nigeria, Pakistan, and Afghanistan. These hotspots of polio, with a total population exceeding 380 million, include geographic diversity, conflict, and population displacement. Although all 3 countries have made tremendous strides in controlling endemic disease affecting thousands of children annually, they face many residual pockets of polio and widespread virus circulation. Based on concerns about lack of progress in polio eradication and local challenges in these countries, an emergency plan for polio eradication was launched in 2011 by the governments of each of these countries2 and has now been supplemented by the Global Polio Eradication and Endgame Strategic Plan3 targeting eradication by 2018. Essential objectives of the new polio strategy are to detect and interrupt all poliovirus transmission, to strengthen immunization systems and withdraw oral polio vaccine, to reduce the risk of vaccine-derived poliovirus infections, contain poliovirus and certify interruption of transmission, and integration of the huge polio program infrastructure and capacity into routine immunization and monitoring services. Key elements of this new approach, distinguishing it from past efforts, are the focus on ending all polio disease (wild and vaccinerelated), an emphasis on improving immunization systems in key areas in each country, and the introduction of new, affordable injectable polio vaccine options for managing long-term poliovirus risks and potentially accelerating wild poliovirus eradication. In addition, given recent episodes of violence against polio workers, there is the focus on reducing undue risks and provision of security to program workers. Although the 3 remaining countries are much smaller in size and population than India, the major polio eradication success of the last decade, these remaining pockets of poliomyelitis may also be the most difficult to eradicate and could be a source of reinfection in other populations. Indeed, that is already the case with the emergence of wild poliomyelitis cases in Somalia and parts of northern Kenya. From an early report of a single case in May 2013,4 there are now more than 80 reported cases of wild poliovirus type 1 infections in the region. With the recent detection of wild polioviruses in sewage in Cairo, Israel, and Paris, the threat of global reemergence and spread of polio will remain as long as any country has pockets of endemic disease. A common thread across all the 3 remaining endemic countries and the most recent outbreak zone in the horn of Africa are underlying conflict, insurgency, and humanitarian emergencies. There are clear contextual differences though; the Afghanistan/ Pakistan border area and migrant colonies of Karachi are a mixture of inaccessible and disaffected populations, whereas northern Nigeria has huge areas under the control of local insurgents—Boko Haram, who have their particular anti-education and anti–polio immunization philosophy. In the horn of Africa, conflict, famine, and population displacement are among the root causes of failure of immunization systems and population coverage. An additional deplorable dimension in this challenging environment is the emergence of overt violence against polio workers (health workers and support staff) in northern Nigeria and Pakistan.5 These sporadic and deadly attacks reflect deliberate targeting of polio workers by terrorists as opposed to push back by the populace. The causes for this disaffection and morphing of the program into a “polio war” are multiple and complex. First, the eradication program has gone on for too long as a stand-alone program with repeated populationbased vaccination rounds. To illustrate, Pakistan alone has held more than 100 national and subnational polio immunization campaigns over the last decade. Although there is visible progress with the vast majority of the country now being polio free, the fact that many areas are still not clear of polio reflects distinct geographic challenges, insecurity, and a certain degree of “polio fatigue. ” The latter is not only an issue within the program but is also notable among sections of the population who no longer understand the priority given to polio amid yawning gaps in general primary care services. The polio program was allowed to continue for years with issues of poor governance and dubious quality. In overcoming these barriers, one has to address multiple contextual issues related to the program as well as public perceptions. A factor in this conundrum is the suspicion that public health workers and polio program staff face in the wake of the Central Intelligence Agency–sponsored fake vaccine campaign to trace Osama Bin Laden.6 Not surprisingly, there has also been an upsurge in the overt politicization of the program by deliberate spread of disinformation against the oral polio vaccine and limitations imposed on movement of polio campaign workers as a bargaining chip by local Taliban warlords. However, much of the population has continued to support polio vaccination, and there has been no major effect on recruitVIEWPOINT