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“While some people view 

engagement with violent 

anti-government groups, 

especially those that attack 

civilians, as reprehensible, 

vaccination campaigns have 

often succeeded because 

they operate on the belief that 

children, who are innocent 

victims of war, should not be 

further victimized by refusing 

to engage with groups that 

could help facilitate immunizations against polio and 

other childhood diseases.”

November 3, 2010 

Defying Expectations: Polio 

Vaccination Programs Amid 

Political and Armed Conflict

Summary

•	 Defying expectations, successful polio vaccination campaigns have taken place in well over 

two dozen armed conflicts, and continue today. Polio vaccination campaigns amid war have 

often succeeded in gaining the cooperation of anti-government forces such as Sendero 

Luminoso in Peru, multiple rebel groups in the Democratic Republic of Congo, and the Taliban 

in Afghanistan. Diplomatic means have also been employed to overcome severe political 

obstacles to such campaigns, even when the campaigns have become a flashpoint in places 

of political turmoil. 

•	 Such campaigns face many challenges because vaccinators need to reach all villages without 

threats to their own lives or the programs’ implementation. They require security for safe passage for immunizations and sometimes temporary cease-fires. 

•	 The many successes of vaccination campaigns can be attributed to the programs’ exclusive 

focus on the immunization needs of children; the use of interlocutors who are credible because they demonstrate neutrality; transparent discussions with opposition groups about the 

reasons for the campaigns; a role for opposition groups in facilitating the campaigns; limits on 

the number of days vaccinations take place; and the absence of any strategic or political goals 

for the effort beyond polio eradication. 

Introduction

The disruption and targeting of health programs are two of the most pervasive features of modern 

armed conflict. Yet in more than two dozen conflicts spanning over 20 years, polio vaccination 

campaigns have successfully immunized millions of people, mostly children, against the disease—

defying conventional wisdom. These campaigns have continued despite political chaos and 

violence and in some cases have gained the tacit or explicit cooperation of armed groups such as 

Sendero Luminoso in Peru and the Taliban in Afghanistan that launch attacks against civilians or 

civilian agencies. At the same time, even in nonconflict environments, polio vaccination campaigns 

can themselves become flashpoints during periods of political tension, and can require political 

means to resolve these setbacks. 

To better understand the factors that have led to the successes of polio vaccination campaigns 

and the implications for governments, donors and nongovernmental organizations (NGOs) that 

Leornard Rubenstein

E-mail: lrubenst@jhsph.edu

Phone: 443.287.8749

peaceBrieF64
© USIP 2010 • All rights reserved.

Defying Expectations: Polio Vaccination Programs Amid Political 

and Armed Conflict page 2 • PB 64 • November 3, 2010

seek to advance health in the midst of conflict or political turmoil, the U.S. Institute of Peace 

Health and Peacebuilding Working Group held a panel discussion on the subject on June 29, 2010. 

Speakers included Ellyn Ogden, Worldwide Polio Eradication coordinator for the U.S. Agency for 

International Development, Jose Bastos, health coordinator in Afghanistan for the International 

Committee of the Red Cross, and Judith Kaufmann of Johns Hopkins University’s School for 

Advanced International Studies. Leonard Rubenstein, coordinator of the USIP Working Group, 

moderated the discussion.

Polio Eradication Campaigns in War

Worldwide polio eradication, a potential triumph for global health, has become an achievable goal. 

Since the start of the global eradication initiative cases have declined by 99 percent. Nevertheless, 

the virus remains endemic in parts of four countries (Afghanistan, Pakistan, India and Nigeria), has 

reemerged in Angola, Chad and the Democratic Republic of Congo (DRC).1, 2 It is no coincidence 

that most of the countries where the polio virus survives are experiencing war or severe political 

conflict, both of which can disrupt vaccination programs and lead to new outbreaks. 

Vaccination campaigns always pose significant logistical and political challenges. These include 

the needs for safe transport of vaccines, establishing and managing vaccination sites, assuring 

the protection of vaccinators, and gaining the trust of the local population and its leaders for an 

initiative that may not be the community’s highest health priority. In extreme cases, the campaigns 

themselves can become pawns in political agendas. In Nigeria, which until recently had among the 

largest number of polio cases in the world, disparities in wealth and political power between the 

north and the more powerful south, combined with a failure to meet the north’s need to address 

malaria, measles and other health priorities, led to deep mistrust and ultimately a boycott of a 

polio vaccination campaign. The boycott began in communities in the north but was taken over by 

political and religious leaders for their own political ends. 

Such immunization challenges are exacerbated during war. Supply lines are easily disrupted, 

vaccinators become potential targets for attacks, and manipulation of vaccination programs to 

gain political advantage is tempting. Protection for vaccinators and, in some cases, temporary 

cease-fires must be negotiated among all combatant forces. These forces may include groups that 

do not respect the laws of war and may engage in terrorist acts. 

“Days of Tranquility”

Starting in the 1980s, Dr. Ciro De Quadros and others from the Pan American Health Organization 

led vaccination campaigns during armed conflicts in El Salvador, Peru and elsewhere. One of the 

most notable initiatives was the “days of tranquility” in El Salvador, where the parties agreed to 

cease-fires for the purpose of vaccination campaigns, and rebel groups cooperated in the polio 

vaccination campaign. Over the course of five to six years, more than 250,000 people were vaccinated annually. Since then, defying expectations, successful polio vaccination campaigns have 

taken place in well over two dozen armed conflicts, and continue today. 

In the DRC, for example, polio eradication campaigns began in 1997 throughout the country, 

but the violence in the eastern provinces hampered progress. By 2000, 36 factions and eight countries were involved in the DRC’s war and the international community searched for an interlocutor 

to attempt to achieve “days of tranquility.” With the support of the DRC government in Kinshasa 

and U.S. Ambassador William Swing, USAID used back-door channels to develop relationships with 

rebel leaders in the east and conveyed that eradication would be welcomed by parents, carried no 

monetary cost and would be supported by the international health community. Ultimately, groups 
© USIP 2010 • All rights reserved.

Defying Expectations: Polio Vaccination Programs Amid Political 

and Armed Conflict page 3 • PB 64 • November 3, 2010

agreed to permit the vaccination initiative. Over the course of several vaccination days, more 

than 4.2 million children were vaccinated. Within 18 months, indigenous polio virus had been 

eliminated from the DRC, though periodic campaigns are still undertaken in response to a recent 

importation of the virus in 2008.

In Afghanistan, prior to the start of U.S. military operations in 2001, the Taliban had cooperated 

in polio eradication campaigns. After the U.S.-led invasion in 2001, vaccination campaigns continued but as the Taliban presence strengthened over time, the initiative was hampered by insecurity. 

In response, the United Nations, upon request of the Afghanistan Ministry of Public Health, 

approached the International Committee of the Red Cross (ICRC), which was known by the Taliban 

for its neutral stance and making its health programs accessible to Taliban fighters, to take the 

lead as interlocutor with the Taliban. The ICRC enlisted the Taliban leader, Mullah Omar, to lend his 

support. As a result, he signed a letter, carried by every vaccinator, urging local Taliban commanders to cooperate in polio vaccination campaigns and reassuring parents that the campaign was a 

humanitarian activity. This letter significantly helped facilitate the movement of vaccinators and 

increase access to children living in Taliban strongholds. Other military forces also agreed to allow 

safe passage. The campaign was administered by the Ministry of Public Health and supported by 

the World Health Organization (WHO) and UNICEF, and now reaches some of the most volatile 

areas of the country, though coverage remains far from complete. As of December 2009, more 

than 150,000 children, representing 12 percent of those living in southern parts of Afghanistan, 

could not be reached due to widespread security concerns.

Lessons Learned: Engagement and Neutrality 

Several elements appear particularly important in successful polio vaccine campaigns during 

armed conflict. The first is convincing all military forces and local leaders, including rebel commanders and warlords who may control access to vaccinations or security for vaccinators, to 

allow the program to go forward. In successful talks, the emissaries provide each group with data 

about the global polio situation, the status of polio in the country and its neighboring countries, 

the impact of polio paralysis on children, and the nature of the immunization campaign. They 

also generally convey that because the vaccine is free and operational costs are supported by 

international organizations, the program would bring modest resources to their area. In Peru, such 

discussions were accompanied by a media campaign that helped convince Sendero Luminoso 

that communities would benefit from a vaccination program. Building support for the vaccination 

campaign must extend down to the community level, which in some cases could include rival 

leaders. For example, in Afghanistan, because Mullah Omar’s letter is insufficient to gain cooperation from factions that do not follow the Taliban hierarchy, the ICRC approaches these groups 

directly, or local vaccinators try to reach agreement with them regarding dates for immunization. 

The second element of best practices includes the participation of rebel groups, warlords and 

other anti-government groups in the vaccination process. In Somalia, Peru and Afghanistan such 

groups transported vaccines and provided security. In the DRC, rebel groups assured safe passage for NGO-operated planes and for vaccinators, assured protection for office space, supplies, 

equipment, vehicles and fuel, and even became involved in the surveillance system. Government 

military forces can also contribute to safe passage and refrain from attacks where campaigns are 

underway.A third element is ensuring transparency and neutrality throughout the vaccination 

process. In Somalia, Peru and Afghanistan, seeking support for a vaccination campaign from 

groups that may engage in terrorist acts has raised moral as well as political concerns. While some 

people view engagement with violent anti-government groups, especially those that attack 

civilians, as reprehensible, vaccination campaigns have often succeeded because they operate 
© USIP 2010 • All rights reserved.

Defying Expectations: Polio Vaccination Programs Amid Political 

and Armed Conflict page 4 • PB 64 • November 3, 2010

on the belief that children, who are innocent victims of war, should not be further victimized by 

refusing to engage with groups that could help facilitate immunizations against polio and other 

childhood diseases. The benefits for children outweigh other moral and political considerations 

in planning vaccination campaigns, and the neutral stance is critical to assure opposition forces 

that they will not be disadvantaged or manipulated for political, intelligence or military gain. As a 

result, these groups, though approached individually, hear the same presentation, and are offered 

the same level of assistance and otherwise treated equally. In the DRC, for example, USAID avoided 

engagement in any discussions with rebel leaders on political or tactical subjects. Because aid 

workers limited their discussions only to polio eradication and health, maintained low visibility, 

and provided a consistent message, rebel leaders gained confidence that the emissary was there 

in good faith and for the stated purpose, without an ulterior agenda. 

By the same token, entities not perceived as neutral in the conflict are encouraged to either stay 

away or maintain a low profile. In Afghanistan, neither police nor domestic or international military 

forces play any role in program support except to allow safe passage for vaccinators. Similarly, the 

ICRC has suggested that Afghanistan’s Ministry of Public Health and the Afghan president not take 

credit for the success of the vaccination campaign to avoid jeopardizing the continued cooperation of the Taliban and splinter groups although it is widely known that the eradication program is 

a national effort. 

Finally, because vaccinations are time limited, requirements for cooperation are not open ended 

and can be renewed at each stage. 

One potential consequence of pursuing these elements of a successful polio vaccination 

program is that rebel groups may realize a political benefit by gaining support from the populations receiving vaccinations, promoting relationships with international organizations, or in effect, 

advancing their own reputation. Nevertheless, experience suggests that these consequences 

do not always occur. Another possible consequence is that governments seeking to show their 

citizens their capacity to provide key services have to forgo the opportunity to tout their role in the 

vaccination initiative. 

Polio Campaigns and Peacetime Politics 

Sometimes vaccination campaigns encounter obstacles amid peacetime politics. In August 2003, 

in response to claims by community leaders that the polio vaccine was laced with anti-fertility 

drugs to sterilize Muslim girls, governors of most northern Nigerian states banned federally 

sponsored polio immunization campaigns. In January 2004, the governor of the northern Kano 

state continued the boycott, which contributed to outbreaks in many other countries in Africa. 

While acceptance of the vaccine had declined even before the boycott, both religious and political 

figures in the north used the issue for their own political reasons.

The resolution of the boycott was aided by the use of political and diplomatic tools to show 

political and thought leaders both the health and political advantages to be gained by supporting a vaccination program. Well-coordinated diplomatic initiatives by WHO, the U.N., the United 

States and the Organization of Islamic States were successfully brought to bear on the boycott 

proponents, while providing face-saving means for the governor of Kano state, who was the last 

official holdout, to permit vaccinations. U.N. Secretary-General Kofi Annan, his senior Africa adviser 

Ambassador Ibrahim Gambari, U.S. Secretary of State Colin Powell, U.S. Secretary of Health and 

Human Services Tommy Thompson, and WHO Director General J.W. Lee, and his Special Envoy 

for Polio David Heymann, joined the Global Polio Eradication Initiative to convince the governor 

that his personal reputation and that of his state were being harmed, and to find other actors, 
© USIP 2010 • All rights reserved.

USIP provides the analysis, training and 

tools that prevent and end conflicts, 

promotes stability and professionalizes 

the field of peacebuilding.

For media inquiries, contact the office 

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Defying Expectations: Polio Vaccination Programs Amid Political 

and Armed Conflict page 5 • PB 64 • November 3, 2010

About This Brief

This Peace Brief, based on a panel 

discussion convened by the U.S. 

Institute of Peace Health and 

Peacebuilding Working Group 

on June 29, 2010, was written by 

Leonard Rubenstein, coordinator 

of the USIP Working Group and a 

Senior Scientist at the Center for 

Public Health and Human Rights 

at the Johns Hopkins Bloomberg 

School of Public Health. 

particularly the Organization of the Islamic Conference, the African Union, and religious scholars 

from elsewhere in the world, to help counter the misinformation being used to justify the boycott.

Conclusion

Polio vaccination campaigns have a record of success in areas of armed or serious political conflict 

far greater than could be expected given the conditions under which they are implemented. A 

number of factors likely contribute to success during war: the programs focus exclusively on 

the immunization of children; interlocutors with opposition groups gain trust by consistently 

demonstrating their transparency and neutrality; opposition groups have the opportunity to play 

a supporting role in the campaign; governments do not attempt to use the campaign for other 

political or strategic goals beyond polio eradication; and the campaigns take place in limited time 

periods. These factors were also at play in Nigeria, where an understanding of the political situation led to the employment of political and diplomatic tools, including trusted intermediaries, to 

achieve a successful health outcome.

Endnotes

1. World Health Organization. Polio Global Eradication Initiative. Annual Report 2009. Available 

at http://www.polioeradication.org/content/publications/AnnualReport2009_ENG.pdf. 

2. World Health Organization. Polio in Angola and the Democratic Republic of Congo. September 8, 2010. Available at http://www.who.int/csr/don/2010_09_08/en/index.html.