Dr Heidi J Larson
Former Associate Fellow, Centre on Global Health Security

With Tia Powell, MD, Director, Montefiore Einstein Center for Bioethics; Professor, Clinical Epidemiology, Clinical Psychiatry, Albert Einstein College of Medicine, New York, NY  

Earlier this month, India took a step towards achieving polio-free status by completing two years of not reporting a single polio case, a huge result for progress of the global polio eradication initiative. However, in neighbouring Pakistan the worst tragedy in the history of the polio eradication programme occurred, when nine polio workers were murdered because of their line of work. This was followed by the killing of seven community education and health workers which some suspect was also linked to their polio vaccination work. This was not the first time polio vaccinators have been targeted for their work. 

Hampering the global polio fight

Vaccination efforts are an extremely effective way to improve global public health by dramatically reducing the incidence of infectious diseases. Nonetheless, vaccination has often been the target of false information, superstition, and fear.

In the developing world, one particularly damaging perception has been that vaccination efforts disguise covert security operations. The use of an immunization ruse in the assassination of Osama bin Laden gave credence to this belief. It also featured, among other various anxieties about the motives of the 'West', in the 2003-04 boycott of the polio eradication initiative in five northern Nigeria states which led to the disease spreading to a further 20 countries across Africa. A decade later, Nigeria is still struggling with persisting polio vaccination refusals for a variety of reasons, and remains one of three polio endemic countries.

Health workers in developing nations already take risks. Their work is crucial to improving health in their countries of work, but not always well understood by their peers and viewed with suspicion by local insurgents. Vaccine campaigns are associated with global institutions and contemporary science, and often viewed with mistrust by insurgents. Evidence of a real covert intelligence operation disguised as a public health programme further contributes to distrust and conspiracy theories. Participation in these campaigns can be a way for local women to work in their communities, but they are also similarly subjected to the threat posed by those who would curtail the rights of women.   

In UNICEF’s 2012 Situation Analysis of children and women in Pakistan report, the context was clear. It states that, 'Immunization coverage has actually fallen in all the provinces except Punjab, with the sharpest decline seen in Balochistan...There is also a problem with data availability and reliability in three administrative units affected by conflict: Balochistan, KP and FATA. Continuing conflict and a deteriorating security environment have had disastrous effects on child health, education and protection and on environmental factors in these areas.'

Going forward 

Successful public health efforts are not only valuable in their own right. They also can support efforts to improve global security. Yet public health efforts cannot succeed by placing health workers at risk, nor can the risks be addressed by surrounding health workers with armed guards. Redoubled efforts to design public health interventions that align with local culture may help. But no amount of cultural sensitivity in programme design will overcome the damage done when covert operations subvert crucial public health goals.

The targeted murders of polio health workers in Pakistan should be a wake-up call to the global health community. Global security, stability, and the promotion of health need to move forward together, with mutual respect, or not at all.