On July 3, 2013, a female health worker was killed in northwest Pakistan while conducting polio vaccinations; she was the latest to die in an on-going anti-vaccination campaign by militants. About three weeks earlier, on June 16, militants killed two male volunteers who were administering polio vaccines in northeast Pakistan. That these two attacks follow the fatal shooting of female health workers engaged in a polio vaccination campaign on May 28 provides a stark reminder that polio vaccinators in Pakistan continue to face a serious threat of violence.
Polio, a virus with no cure that can cause paralysis and death, has been the target of a worldwide eradication effort and since the vaccination campaign began in 1988, there has been a 99% decline in reported cases. Afghanistan, Nigeria, and Pakistan are the only countries were the virus is still endemic and continued violence against Pakistan health workers poses a threat to the continued success of these eradication efforts.
The recent wave of violence against polio workers is likely linked to opposition from the Pakistani Taliban to the vaccination campaign. On June 16, 2012, Taliban leaders in both North and South Waziristan banned the vaccination campaign pending a cessation of American drone strikes in the region. Since then, there have been at least 27 incidents of violence against health workers involved in Pakistan's polio vaccination campaign, and against the security personnel tasked with protecting them. At least 22 people involved in these efforts have been killed and another 14 people have been injured.
Increased opposition to polio vaccinations may also be linked to the revelation that the CIA used a fake Hepatitis vaccination program during its attempt to locate Osama bin Laden. Media outlets as diverse as Business Week, The Guardian, and Scientific American published pieces criticizing the ruse for endangering polio vaccinators. One anti-polio worker commented on the effects of the fake vaccination program in 2012 saying, "It's been over ten months since the Al-Qaeda Chief Osama Bin Laden is dead [sic], but his ghost is still haunting our efforts not only to persuade the people in the country's northwestern parts, particularly in the tribal belt, to get their kids vaccinated, but also to move freely."
In July 2012, this surge of violence against polio health workers in Pakistan began with two shootings in Gadap Town, Karachi. On July 17, a UN doctor from Ghana and his driver were shot; three days later, another polio worker involved in the same campaign was also shot. In October 2012, a polio vaccinator was killed in the Killi Jeo area of Quetta during a three-day vaccination campaign. But the violence against polio workers reached new heights in December 2012. In the span of just two days, eight people were killed in six separate attacks.
The increasing violence against health workers, as demonstrated by the December attacks, forced a widespread change in the way polio vaccinations are conducted in Pakistan. The World Health Organization suspended its vaccination campaign due to its inability to ensure security for its workers. The Pakistani government provided security guards for vaccination teams and issued new guidelines urging vaccination campaigns to avoid publicizing their visits out of fear of encouraging attacks.
In February 2013, Pakistan's Capital Development Authority (CDA) announced the launch of a four-day sub-national polio vaccination campaign, prompting some to report that the campaign violated the new guidelines. In particular, an anonymous senior official with the Prime Minister's polio monitoring cell was quoted as saying: "The CDA's fanfare that accompanied the launching drive has put the lives of over 160 vaccinators at stake." These fundamental changes and the confusion they have created is also illustrated by the refusal of some health workers, including the two killed on June 16, to accept protection from security details, out of fear that it will actually make them targets.
While the intensity of the violence against polio health workers decreased after the December attacks, it did continue. In January 2013, there were three incidents that killed three people (though one involved a roadside bomb that might have only incidentally targeted polio vaccinators). One person was killed in Ghalia Der, Mardan in February; and in March, a polio center was bombed, injuring one health worker, and another polio vaccinator was abducted for ransom. There were another seven violent incidents targeting polio teams in April and three more in May.
The violence against polio workers takes many forms. Shootings are the most prominent method of attack, constituting all but six cases, and at least 12 of the 27 incidents involved shootings by multiple attackers. The remaining incidents consist of two cases of abduction and mistreatment (including torture), one bombing of a polio center, one roadside bomb explosion, one attack with an ax, and one case of stone throwing.
The cases involving multiple shooters suggest that there is an organized attempt to target polio vaccinators by militant groups with the capability to direct such attacks. In none of the cases, however, did a militant group claim responsibility for an attack. In fact, the Pakistani Taliban has regularly denied involvement in the attacks.
The violence has taken a tremendous toll on Pakistan's polio workers, but it is not simply an issue for Pakistan's health and development workers. Setbacks in Pakistan's eradication efforts threaten the ability of other countries to remain polio free, as seen when strains of polio linked to Pakistan caused a small outbreak in China in 2011 and were found in an Egyptian sewer in 2012. While the number of registered polio cases in Pakistan dropped in 2012, the surge in violence against health workers occurred at the very end of the year, making its effects unlikely to show up in the numbers. As of July 10, 2013, there have been 18 cases of polio so far this year, compared to 22 cases during the same period last year.
The wider global community would also do well to pay attention to the attacks on polio workers in Pakistan because violence against health workers is an issue affecting many other countries. In May, the International Committee of the Red Cross issued a report showing that, in 2012, there were 921 violent incidents affecting healthcare in 22 countries experiencing armed conflict and other emergencies. Nigeria in particular has seen attacks on health workers and polio vaccinators similar to those in Pakistan. At least nine polio workers were killed by gunmen in attacks there in early February 2013.
Historical experience suggests that health workers will often become targets in civil wars and insurgencies as they did in Nicaragua and Mozambique in the 1980s, Chechnya in the 1990s, and in Somalia in the 2000s. Giving greater attention to what does and doesn't work in Pakistan with regard to protecting polio workers will pay dividends in securing future global health efforts. In particular, examining Pakistan's efforts may provide international aid organizations with new information regarding the costs and benefits of eradication strategies that minimize publicity and increase the presence of armed security personnel in order to continue vaccinations during conflict.
David Sterman is a Master’s candidate at Georgetown University’s Center for Security Studies and an intern with the New America Foundation.