The Shots Heard Around the World

From global-health success story to nightmare: How a worldwide effort to eradicate polio went from Jonas Salk to Islamist terrorist.

New shots are jeopardizing humanity's battle to eradicate polio, and they don't include syringes or vaccines. Rather, they're the gunshots of Islamist terrorists.*

The fight to eliminate polio is now imperiled, according to the World Health Organization (WHO), by "insecurity, targeted attacks on health workers and/or a ban by local authorities on polio immunization," and violence in the Middle East. In a March 2014 report, the organization warned that the virus, which existed in only three countries at the dawn of 2012, is now returning to places from which it had been eradicated, and "risk of further international spread remains high, particularly in central Africa (especially from Cameroon), the Middle East, and the Horn of Africa."

The collective forces of global health are watching their efforts backtrack, thanks to warfare and to the growing belief within Islamist circles that the polio-eradication effort is a secret CIA plot, designed to harm or contaminate Muslim children. Amid assassinations and bombings of vaccination sites, chiefly in Pakistan and Nigeria, the death toll for healthcare workers now exceeds the number of children dying of polio, and could soon surpass the tally of new virus-paralyzed youngsters worldwide.

What was once a triumphant example of humanity and solidarity has transformed into something deeply dangerous.

In 1988, Rotary Club International combined forces with UNICEF in an effort to eradicate polio from the planet by the year 2000. In just 12 years the global effort reduced the estimated number of polio cases from 400,000 in 1980 to just over 7,000 cases in 1999. As the clock ticked toward the millennium, the then-new Bill & Melinda Gates Foundation threw considerable financial weight behind the effort, which has now immunized 2.5 billion children and youth in 200 countries, corralling a force of more than 200 million volunteers, at a combined cost of $8.6 billion.

But 2000 came and went with polio still in circulation in several countries, chiefly Pakistan, Nigeria, Afghanistan, and India. In 2003 -- when just 784 polio cases were reported worldwide -- a handful of imams in Nigeria's northern Kano state, which is overwhelmingly Muslim-populated, concluded that the vaccine contained American-made sterilizing agents that would render their daughters incapable of bearing children. Some were also convinced that the HIV virus was deliberately added into the vaccine.

Among the imams were well-read scholars who drew their conclusions after perusing websites similar to those former South African President Thabo Mbeki used back in the day. Mbeki concluded that AIDS did not exist and that Western pharmaceutical companies invented false HIV claims in order to compel drug sales across Africa. A Harvard study found that the former president's AIDS denialism and refusal to allow treatment for his people cost more than 300,000 South African lives.

The polio-is-a-CIA-plot idea spawned in northern Nigeria spread to Afghanistan and Pakistan, where some Taliban members added vaccination to their list of complaints against American military forces. By 2006, the polio caseload had risen to more than 2,020 children.

In 2007, a chief surgeon and head of polio eradication in northern Pakistan, Abdul Ghani Khan, was assassinated in a Taliban bombing attack. His murder followed a fatwa issued by Mullah Fazlullah, the leader of the Taliban in Swat, declaring war on all who vaccinated children against polio. Since 2003, public health leaders and Muslim scholars have struggled in northern Nigeria, Pakistan, and Afghanistan to convince the public that their local imams and Islamist leaders are wrong, the vaccine is safe, and the alternative of widespread child paralysis is unconscionable.

In 2008, the polio effort took on a more tightly targeted approach under a new WHO-led Global Polio Eradication Initiative (GPEI), which struggled to maintain international momentum and funding, to design sophisticated vaccination methods, and to counter mistaken beliefs about immunization safety. At that time, only four countries -- Nigeria, India, Pakistan, and Afghanistan -- had endemic polio, meaning the wild virus was still circulating in contaminated water supplies and between infected children. Fifteen other countries in 2008 had isolated polio cases, typically imported from those big four remaining endemic nations, or resulting from the very rare vaccine-induced disease. The eradication effort focused on the wild polio virus. 


There are two main types of polio vaccines. One type, a descendant of that originally invented by Jonas Salk in the 1950s, is made from killed viruses and is injected. The other, more commonly used today, is an oral vaccine that contains live viruses that have been crippled so that they cannot cause illness. Invented in the late 1950s by Albert Sabin, the oral vaccine takes care of two failures of the Salk approach. First, it doesn't require needles, therefore poses no risk of needle-born contamination and sterilization problems. And second, unlike the Salk vaccine, which prevents viruses from causing disease in the individual, the Sabin product eliminates polio from the gastrointestinal tracts of children, thereby stopping fecal passage of the virus into sewage and water supplies. The problem, however, is that in rare cases some of the live viruses are not properly crippled, and may cause polio in the vaccinated child.

Death is rarely the result of a polio infection -- less than one out of 3,000 infected children will suffocate as their capacity to breathe is paralyzed. But crippling, permanent paralysis occurs in about one out of 200 cases. As the overall numbers of polio-stricken kids have fallen, so have the horrors of paralysis and death.

Polio eradication witnessed astounding successes in previously desperate places: northern India, Southeast Asia, Ethiopia, and West Africa. In recent months, both India and all of Southeast Asia have been declared polio-free, having gone without wild polio cases for more than three years.

In 2013, for the first time in years, there were more polio cases outside the endemic countries than inside Pakistan, Afghanistan, and Nigeria: 240 versus 160 cases. The surge outside of the endemic areas was due to warfare that interrupted child vaccination in Somalia and Syria -- and in both cases, genetic analysis revealed the new outbreaks were caused by strains of the virus identical to those circulating in Pakistan. It is not known precisely how the Pakistani virus reached Somalia and Syria. However, there is a possible link: The militaries that were present in both countries trained inside Pakistan.

As of March 26, a total of 47 polio cases have been reported in 2014 -- all but six of them in the endemic countries, mostly Pakistan.

Today, far more polio vaccinators are dying than the toll of children killed or permanently paralyzed by the virus. At least 59 vaccinators and their security team members have been murdered over the past 20 months, primarily in Pakistan. GPEI has identified Pakistan's Peshawar valley and abutting North Waziristan as the world's "main ‘engine' of poliovirus transmission." Not coincidentally, these are strongholds of Taliban-aligned Islamists and the locations of most violent assaults on vaccinators.

The attacks and murders have targeted unarmed, usually female polio volunteers and health workers, or more recently their police or private security protectors.

In January 2014, three female polio workers were gunned down outside Karachi, prompting a mass walk-out by immunization employees locally, and then nationally. Shortly after, six polio security team members were felled in a bombing outside Charsadda, Pakistan. On February 11, a police officer was killed amid a hail of gunshots aimed at polio volunteers in northwest Pakistan. On March 2, a mass funeral was held in Khyber District, mourning 11 vaccinators, a police officer, and a child killed in a coordinated set of two bomb assaults. Salma Ghani, a 32-year-old female health worker, was kidnapped from her Peshawar home on March 24 by five unidentified men; her bullet-riddled body was found dumped on a roadside the following day. On March 27, in Balochistan, assailants opened fire on vaccinators from a speeding motorcycle, killing a police officer. It was perhaps coordinated with another, nearly simultaneous motorcycle attack in Larkana, which killed a police officer and a vaccination volunteer. A female polio worker in Bannu was killed on March 31, when gunmen opened fire as she left her home to start work with an anti-polio team.


The distinct escalation in assaults and killings of polio vaccinators can be traced directly to the May 2011 U.S. Special Forces assault on the Abbottabad compound inhabited by Osama bin Laden, his family, and al Qaeda elite. Three months after the raid, in which bin Laden was killed, the Guardian revealed that the CIA used a Pakistani doctor, Shakil Afridi, to carry out a fake hepatitis B vaccine effort in hopes of gaining DNA samples from the children living in the mysterious compound by injecting them and retaining the syringes. Afridi, who is now imprisoned in Pakistan as a traitor, never managed to gain entry to the compound.

Shortly after the CIA ploy was disclosed, Orin Levine of the Gates Foundation and I warned in the Washington Post that any use of vaccination by intelligence operatives risked worsening conditions in the fight against polio. And David Ignatius wrote, "Afridi and his handlers should reckon with the moral consequences of what they did."

As predicted, in 2012 several Taliban leaders and mullahs issued decrees, linking polio vaccination to U.S. military use of drones and accusing vaccinators of being CIA spies. They called for a jihad against immunizers. Maulvi Ibrahim Chisti of the Muzaffargarh district declared the anti-polio campaign "un-Islamic" and parents started refusing vaccines. By the end of the summer of 2012, hundreds of thousands of children across Pakistan were going without immunizations, not only for polio, but all of the key childhood diseases.

Matters worsened in early 2013 after DVDs of the movie Zero Dark Thirty turned up in the Pakistani black market. The Kathryn Bigelow film mistakenly depicted an Afridi character as a polio vaccinator.

As the pools of unvaccinated children grew, so, too, did the courage of the men and women carrying out polio work. It is hard not to describe these unarmed, poorly-paid, or volunteer workers -- who, while dripping Sabin's fluid into the mouths of babies, are well aware that they are being watched, their names noted, their addresses logged -- as saints.

Meanwhile, the Pakistani polio strain has surfaced in Syria's battlefields and, from there, has spread across the Middle East -- from refugee camps to Palestinian outposts to the sewers of Israel. In its recent report the WHO said:

The major risks to eradication are: the bans on immunization campaigns in the North Waziristan agency in Pakistan and parts of southern and central Somalia; the continued targeting of vaccinators in Khyber Pakhtunkhwa province and Karachi in Pakistan; ongoing military operations in Khyber Agency (within the Federally Administered Tribal Areas) of Pakistan; insecurity in Eastern Region, Afghanistan, and Borno state, Nigeria; active conflict in the Syrian Arab Republic; and gaps in programme performance in Kano state, Nigeria, and in the outbreak response performance in Cameroon. These risks are compounded by gaps in polio surveillance and the continued threat of new international spread of wild poliovirus.

The tone of alarm in the WHO's statement reflects the recent discovery of a six-month-old baby in Baghdad suffering from polio paralysis. It has been 14 years since polio has been seen in Iraq, and the Iraqi family had not traveled in known polio-hit areas. The child's strain matched the one circulating in Syria.

Though still unconfirmed, there is a possible polio case in a Syrian refugee baby residing in Lebanon, and this has increased concern throughout the Middle East. More than 400,000 refugees and internally displaced people have fled Iraq's Anbar Province, where conflict has rendered immunization especially dangerous. Fewer than 48 percent of the area's children were vaccinated over the last two years, according to UNICEF. Better than 90 percent coverage is essential to creating "herd immunity," bringing human-to-human spread of polio to a halt. The Iraqi government now talks about creating an immunization firewall across its northern border, blocking further spread of polio from Syria.

The vocabulary of warfare has been injected into the Middle East polio struggle. Because much of Syria is inaccessible to humanitarian workers, the exact extent of polio in the country is not known: 37 paralysis cases have been reported since the Syrian outbreak began sometime in October 2013.

Despite mass vaccination in 2013, environmental sampling in Israel, the West Bank, and Gaza continues to test positive for polio -- the sources are unknown. A large population of Palestinians has been trapped inside Syria throughout the war, only receiving vaccines in February 2014, and it's possible that refugees from this enclave have carried polio to nearby Palestinian territories.

The Global Polio Eradication Initiative has set new targets, new strategies, and new funding goals struggling to stay ahead of the virus -- and Islamist zealots. It has done so before, of course, managing to conquer challenges but often twarted by political reality. In the end, polio will be eradicated when counterterrorism no longer includes fakery, and Islamists cease believing in jihad against health workers. 

*Correction, April 19, 2014: This article originally misstated the source of the gunshots. They were fired by Islamist terrorists, not Islamic terrorists. (Return to reading.)

Photo: RIZWAN TABASSUM/AFP/Getty Images; Chart: Global Polio Eradication Initiative


If We Can Let Syria Burn, Have We Learned Anything at All from Rwanda?

The legacy of genocide and why humanitarian intervention still needs a president that's compelled to act.

When we think about Rwanda today, it is not the genocide that began 20 years ago that we are likely to recall, but the much more recent incidents of repression which President Paul Kagame is alleged to have perpetrated against opponents at home and abroad, and his exploitation of the chaos in next-door Congo. Kagame has undermined Rwanda's reputation, and its victim status.

We should not, however, allow Kagame's misdeeds to obscure the extraordinary achievement of the Rwandan people over the last two decades -- thanks in part to Kagame himself. At an event at Yale University commemorating the mass killing, I had a long conversation with Yvette Rugasaguhunga, a Rwandan diplomat who as a Tutsi teenager had survived the killings by hiding with a succession of Hutu families, almost all of whom were at the same time actively slaughtering her own people. Her father, her brother, and her grandparents were murdered.

Yvette described all this with great composure until the conversation turned to the accusations against Kagame, at which point she furiously interjected that in the months and years after the genocide she had been so full of hate that had anyone given her a weapon, she would have happily killed any Hutu she came across. She mastered her own vindictive rage, she said, only because Kagame demanded that Tutsis seek reconciliation, in part through the use of local gacaca courts which turned the whole country into a sort of truth and reconciliation commission.

Kagame has earned the right to continue drawing attention to his role in preventing reciprocal massacres, as he did in a recent interview in Foreign Affairs. The Rwandan atrocities were bigger and far more intensely personal than those in the Balkans; but Rwandans have moved past them much more effectively than Bosnians have. No doubt that has a good deal to do with the dominant position Tutsis now enjoy in Rwanda, and the enforced meekness of Hutus; but it would not have been possible without an ethos of reconciliation.

This is an essential part of the legacy of the genocide in Rwanda. What about the international legacy? Asked whether Rwanda could happen again, one of the panelists at the Yale event, Edward C. Luck, the former special advisor on atrocities to U.N. Secretary-General Ban Ki-moon, pointed out that the shame over the failure there, and the rise of norms like the "responsibility to protect," has made both the U.N. and states react much more quickly to incipient atrocities than they did 20 years ago. In the Central African Republic, to take one current example, a combination of French and African Union forces have so far prevented the mutual massacres of Muslims and Christians from dissolving into wholesale slaughter. That is a success, if a very tenuous one.

The world really is better at preventive action, if still not very good. Today, the U.N. peacekeeping department would probably not bury a desperate telegram warning of an imminent pogrom, as it did in the case of Rwanda. But the fact remains that "another Rwanda," if that expression refers not just to genocides but to coordinated programs of mass murder, is happening right now in Syria, and there is no reason to hope it will stop any time soon.

Rwanda is not the most useful analogy to help us think about the world's failure to respond to the atrocities in Syria. The Rwandan genocide might have been prevented by decisive action beforehand, but the killings happened so fast that, once they began, the world's hesitation doomed the Tutsi people. On the other hand, the mayhem in Bosnia, as in Syria, was carried out by a national army and paramilitaries as a matter of state policy, which made it harder to prevent. And both went on for years, and thus offered outsiders innumerable opportunities to intervene.

President Bill Clinton desperately did not want to intervene in Bosnia. He feared the political costs of a failed intervention in the aftermath of the "Black Hawk Down" fiasco in Somalia in 1993. And he had convinced himself that Balkan blood feuds were immemorial and incurable, and thus that any deeper American engagement was likely to fail. Clinton worked to bring about a negotiated solution, hoping all the while that Europe would act. Unwilling to make a credible threat of force, the administration "applied a combination of half-measures and bluster that didn't work," as former Secretary of State Madeleine Albright writes in her memoirs.

President Barack Obama has also said repeatedly that the situation is Syria is hopelessly intractable. In a recent interview, Obama insisted that it's "a false notion that somehow we were in a position to, through a few selective strikes, prevent the kind of hardship that we've seen in Syria." Of course, no one has suggested that "a few selective strikes" would have toppled the Syrian regime. Rather, in 2012, several of his most senior advisors, including Secretary of State Hillary Clinton and CIA Director David Petraeus, proposed a much more serious effort to arm Syria's moderate rebels. Obama declined to act, just as Bill Clinton did until the killings in Srebrenica finally forced his hand. Obama, too, has hoped for a negotiated solution which has never had a ghost of a chance of succeeding without the threat of force.

We can't know for sure what's going on inside the president's head. What we do know is that he delayed acting as long as he could after his own Srebrenica moment -- the chemical attacks which killed 1,200 Syrians and thus crossed his "red line" -- and then seized on a Russian offer to remove the regime's chemical weapons rather than launch airstrikes. Obama is convinced that a deeper American engagement will fail, and he knows that such a failure would have grave political costs. Put otherwise, his acute awareness of the costs has predisposed him to listen to advisors who say that intervention of any kind won't work. The number of the dead in Syria now exceeds 150,000, with the regime in Damascus rolling barrel bombs out of helicopters into civilian areas. Obama has chosen not to destroy those helicopters with airstrikes, or to equip rebels with the capacity to shoot them down.

And yet this is the president who has established an Atrocities Prevention Board and who has surrounded himself with leading advocates of the responsibility to protect, including Susan Rice and Samantha Power. Obama did, of course, agree, if reluctantly, to join the NATO coalition assembled to prevent the expected mass killings in Libya were Muammar al-Qaddafi to have taken Benghazi in 2011. Yet Syria has proved too hard, as Bosnia did for Clinton until Srebrenica.

What, then, is the legacy of Rwanda? First, that reconciliation is possible even after the most horrific violence. Second, that the world has now developed mechanisms, and diplomatic reflexes, that may be deployed to prevent violence from exploding into mass killing. Regional organizations like the African Union are now prepared in some cases to send troops to quell such violence. But when the killing can be curbed only by the kind of force the West can bring to bear, the world will look to the United States, which means, to the president. And a sad legacy of Rwanda that we witness now in Washington is a president that looks at his options much more skeptically than advocates of action, including those in the White House -- both because he is fully aware of the kinks and weak spots of every plan, and because he fears the costs of failure. He will act only when the probability of success is very high.

The price of failure will remain prohibitively high so long as voters feel little urgency about stopping atrocities abroad. If, on the other hand, broad publics, and not just newspaper columnists and political opponents, clamor for some kind of intervention, the president's political calculus will change. But no leader can wait for public opinion on so agonizing an issue to change by itself. We need a president brave enough to explain to Americans why it is profoundly in their own interest, as well as humanity's, to act in such dire settings.