Disease rides the dogs of war as polio, measles, typhoid capitalize on chaos

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A Pakistani health worker administers polio vaccine drops at Karachi International Airport on May 7, 2014 in Pakistan.

Umaima Ahmed opens her mouth at a polio vaccination booth outside the international airport in Karachi, Pakistan, as a health-care worker squeezes a few drops of clear liquid onto the three-year-old’s tongue.
“It’s good that the kids are vaccinated,” says Tariq Ahmed, the girl’s uncle, as another uncle wraps a garland of rose petals around her neck. “Let’s go, let’s go,” says a relative, as the family of nine enters the terminal to board a flight to Saudi Arabia for the Umrah, a religious pilgrimage.
Saudi Arabia is one of a handful of countries that require visitors from Pakistan to be vaccinated against polio. Now Pakistan is preparing to inoculate all travelers to meet new World Health Organization requirements aimed at curbing a global resurgence of the crippling virus.
The WHO this week declared polio a global health emergency, less than two years after the virus was driven to the brink of extinction. A ban on vaccinations by a Taliban leader in retaliation for U.S. drone strikes, and attacks on health-care workers after a fake vaccination campaign was used to hunt down Osama bin Laden, have hampered eradication efforts and enabled polio to spread inside Pakistan and to Egypt, Israel, Syria and Iraq.
“Things got bad when the bin Laden incident happened,” Mohammad Ibrahim, a Taliban negotiator, said in a telephone interview. “The militants are not against the polio drive. The campaign is not being carried out because there is a war-like situation.”
Polio vaccination
Pakistan’s army will start accompanying polio vaccinators next week, said Major Waheed Akhtar Bukhari, a spokesman for the military in Karachi. At least 168 people were vaccinated at a new counter in Islamabad’s main hospital this week after the WHO declaration.
Pakistan isn’t alone in its struggle against a disease that piggybacks on conflict. Somalia last year had 194 polio cases, mostly in areas controlled by Islamist militants, six years after being declared free of the disease. Syria, whose last case was in 1999, reported 35 last year as the health system crumbles and vaccination rates plunge amid its three-year civil war.
Nor is polio, the paralyzing infection primarily spread by fecal contact, the only disease to rear its head in countries suffering from war or disaster. Cases of typhoid; hepatitis A; and cutaneous leishmaniasis, a disfiguring skin infection, have been reported in Syria, and at least 930 cases of measles, after vaccination rates fell to 65 percent from 90 percent before the war, according to the WHO.
Conflict areas
Most of the measles cases are in the northeast governorates such as Deir Ezzour, the same area where polio was detected, where the conflict is fiercest and children are most inaccessible, according to the United Nations Children’s Fund.
“As long as we don’t have full and regular access to these children, transmittable diseases like polio and measles will not be contained and they are likely to spread not just within Syria but also to neighboring countries,” Juliette Touma, a Unicef spokeswoman, said in an e-mail.
Measles is also spreading in the Central African Republic, which has been gripped by violence since mainly-Muslim members of the disbanded Seleka militia seized power in March 2013. Medecins Sans Frontieres this week suspended all but emergency care in the country after three of its staff were killed in an attack on a hospital.
System breakdown
“There are a number of diseases that lend themselves well to areas where health systems break down,” said Alan Brooks, a special adviser for immunization at the GAVI Alliance, a Geneva-based buyer of vaccines for developing countries. On top of polio and measles, respiratory infections and diarrheal diseases, “will inevitably pop back up in these environments,” he said.
By 2012, an $11.8 billion eradication campaign backed by Rotary International and the Bill & Melinda Gates Foundation had polio cornered in just three countries: Pakistan, Afghanistan and Nigeria. Cases fell to a record low of 223 that year.
The virus resurged last year, with 416 cases reported in eight countries, according to the WHO. So far this year, 74 cases have been reported globally, compared with 26 in the same period last year. Of those, 59 were in Pakistan, including 36 in North Waziristan, a Taliban-dominated tribal region along the country’s border with Afghanistan.
Pakistan link
Cases in Afghanistan, Syria and Iraq have all been linked to Pakistan, and virus detected in sewage in Israel was a match for the strain circulating in Pakistan, according to the WHO.
The eradication campaign in North Waziristan has been stymied by a ban on polio vaccination issued in 2012 by Hafiz Gul Bahadur, the leader of a Pakistani Taliban faction in the area, in response to U.S. drone attacks.
Vaccination efforts have also been hampered by rumors the inoculations cause infertility and after the U.S. Central Intelligence Agency used a fake vaccination program to help hunt down bin Laden. As many as 60 polio vaccinators have been killed in Pakistan since December 2012, said Aziz Memon, chairman of Rotary International in the country, which has been active in polio eradication programs there.
“Vaccinators stand discouraged throughout Pakistan,” Memon said in an interview. “This was the time when we were almost done with polio. We were moving very fast, we were very close.”
Other Islamic leaders have expressed support for polio vaccination, including Sami ul Haq, the so-called Father of the Pakistani Taliban, who issued a fatwa, or religious decree, supporting vaccination against polio and other diseases in December. The same month, Ul Haq was photographed vaccinating children with Imran Khan, a former captain of Pakistan’s cricket team and the head of a political party that runs a province bordering Afghanistan.
Grace period
Pakistan’s government has asked for a two-week grace period to implement the WHO measures, Saira Afzal Tarar, Pakistan’s health minister, said at a May 7 briefing in Islamabad, adding the government doesn’t have enough supply of polio vaccine to give it to every international traveler.
“We have protested with WHO and showed our displeasure that it made recommendations, the travel advisory in haste,” she said. “God forbid if we fail to eradicate polio, these restrictions could be extended.”
Health officials at the Pakistan Institute of Medical Sciences hospital in Islamabad have ordered 5,000 extra doses of the vaccine in anticipation of increased demand at the new counter opened the day after the WHO’s declaration, said Javed Akram, the institute’s head.
Getting started
“We have started it voluntarily because we thought people would be worried after the announcement,” Akram said in a telephone interview. “It takes hardly few minutes to vaccinate a person and get the certificate.”
Pakistan already had vaccination booths at airports in six cities for travelers to India and Georgia, whose governments require Pakistanis to be vaccinated for polio before they travel, said Anwar ul Haque, a health officer at the international airport in Karachi, Pakistan’s biggest city. Haque said he’s now waiting for orders from the government to implement the WHO’s recommendations.
Saudi Arabia has for years vaccinated visitors from Pakistan upon their arrival, such as those making the annual Hajj pilgrimage to Mecca.
There are also some vaccination booths at checkpoints along the country’s border with Afghanistan, according to a government spokesman.
Lifting the ban on polio vaccinations in North Waziristan should be part of reopening stalled talks with the Taliban, Tarar said, adding that Pakistan shouldn’t bear all the blame for the failure to get rid of the virus.
“Lots of problems are because of the international community,” she said. “We aren’t solely responsible for all this.”
Still, Rotary’s Memon said he’s not giving up hope.
“We are still, and always remain, optimistic,” he said. “We should be able to eradicate polio from Pakistan. It’s just a matter of time.”

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