NEW YORK - This week's tragic reappearance of polio in Kabul, the capital of Afghanistan, after 13 years, poses serious questions about the future of health in the country following the scheduled withdrawal of United States military personnel at the end of 2014. Without their military escorts and protection, humanitarian and non-governmental aid organizations are expected to draw down foreign personnel as well.
Although the polio vaccine is safe, vaccination remains a sensitive topic in the region and aid workers face a mounting wave of cultural challenges. Some militants believe the common misconception that vaccinations are against Islamic law or are administered as part of a broader American plot to sterilize children or infect them with HIV. Taliban in Pakistan have been attacking polio workers and their security teams since it was revealed in 2011 the CIA used a fake Hepatitis B vaccine campaign in Abbottabad as part of an attempt to obtain blood samples from Osama bin Laden's children in order to confirm the al-Qaida chief's location.
Despite the Pakistani government's efforts to provide police protection, at least 31 polio vaccination workers have been killed in Pakistan since July 2012. (Police and security personnel working with them have also been shot at, wounded and killed.) These attacks, unfortunately, have had their desired effect. Along with systemic problems in supply chains and personnel management, the intimidation and violence have increasingly led mothers to opt out of all kinds of vaccines, and have stymied health efforts; outbreaks of vaccine-preventable diseases, such as measles, have increased. And as a result, polio remains unchecked in several provinces, particularly in the tribal regions bordering Afghanistan.
The 3-year-old Afghan girl named Sakina who was diagnosed with polio in Kabul comes from one of these tribal communities, the Kuchi nomadic tribe. Although her family currently resides in east Kabul, they regularly cross the border between the two countries. According to Kaneshka Baktash, a spokesman for Afghanistan's Ministry of Public Health, it is likely that Sakina contracted the virus while in Pakistan. The strain of polio she has is identical to the one circulating in Pakistan, further evidence that the case was imported. Sakina is paralyzed as a result of the disease; her family brought her to Pakistan where she is receiving treatment.
The family's nomadic lifestyle may have played a role in the young girl's illness. Baktash suggested the family may have been away from home when vaccination teams visited their neighborhood in Kabul. The Kuchis in Kabul, such as Sakina's family, live in a poorer district of the capital where there is no running water. The polio virus can live in the human gastrointestinal (GI) tract without causing disease, and is primarily spread via feces. This means that the disease can be passed through sewers, polluted drinking water, and unclean hands. Oral administration of polio vaccine is the only way to ensure immunization of the entire GI tract; it is therefore preferred to use drops, versus polio shots. Although shots do give a stronger immunity to the individual child, the oral vaccine protects the public. Even though Kabul has the best sewage and water systems in the country, when a sewage system is contaminated, the only option to prevent outbreaks is mass vaccinations, and mass vaccination campaigns require a strong, well-coordinated public health response.
When Israel found samples of live polio virus after routine sewage tests in May 2013, authorities quickly launched a comprehensive response. The strain, originally discovered in Rahat, also matched the strain currently circulating in Pakistan, demonstrating how easily the disease can spread across borders. Subsequent tests showed polio in the sewer systems in several parts of the country including Jerusalem as recently as September 2013. But starting in August 2013, the oral polio vaccine was administered to 980,000 Israeli children under 9 years old, or 79 percent of the children in that age group. Because of this seven-month coordinated public health effort, there were no human cases of the disease, and recent samples from the same sewage treatment plant have tested negative for polio.
The ongoing outbreak of polio in Syria, on the other hand, demonstrates how quickly polio, measles and other vaccine-preventable disease can make comebacks when routine vaccinations are disrupted. Despite not reporting a single case since 1999, Syria recorded 17 cases of polio in October 2013; this strain is also closely related to the one found in Pakistan. International organizations have been trying to reach and vaccinate these vulnerable populations in Syria, but their efforts have been continuously stymied. Just last month, the World Health Organization and UNICEF condemned fighting in the city of al-Raqaa for interrupting a polio immunization campaign. Conflict zones in the Middle East, South Asia, and Africa are rife with vaccination disruptions and outbreaks that are impeding global progress toward eradication.
The global health community is focused on polio because it is possible to eradicate the virus -- an achievement reached for only one human pathogen to date: smallpox. But the campaign to eliminate polio is revealing larger health system issues that exist worldwide. The infrastructure and funding behind the global polio effort far exceeds that supporting any other childhood contagious disease -- save, perhaps, HIV in Africa. Where polio efforts can fail, all of the less well-funded, weaker achievements in health are also in peril.
Time will tell if this case of polio in Kabul is a harbinger of grim times ahead. Achievements in health have been made in Afghanistan since the overthrow of the Taliban in 2001. The total number of polio cases dropped from 120 in 2000, to just 14 in 2013. Other health indicators have also been improving, in no small part because of huge U.S. investment in the country. USAID has spent approximately $15 billion in Afghanistan since 2002, and $113.9 million on improving health outcomes in 2011 alone.
The results speak for themselves: Between 2004 and 2010, the infant mortality rate fell from 115 deaths per 1,000 live births to 77 deaths per 1,000 live births, and the estimated life expectancy rose from 42 years to 62 years.
But these advances in health outcomes are fragile, and continued investment is needed to keep up these gains. The Global Polio Eradication Initiative estimates that $156.82 million in funding is needed between 2013 and 2015 to eradicate the disease from Afghanistan alone. Maintaining forward movement in the improvement of health must be a key part of all agreements related to the withdrawal of U.S. military and government personnel, United Nations agencies, and NGOs. Otherwise, there is the real possibility that Taliban plots to obstruct polio vaccinations could derail many hard-fought gains in global health and development.
The children of Afghanistan must not pay the price for political squabbles both between Kabul and Washington, D.C., and inside the country itself.
Garrett is a fellow for global health and Builder is a researcher at the Council on Foreign Relations in New York.