For decades, polio was one of the world’s most feared diseases, disabling and crippling millions. Its near eradication has been one of the great achievements of modern medical science.
But polio stubbornly holds on in three countries – Pakistan, Afghanistan and Nigeria – where communities, alongside local and international authorities, are making concerted efforts to stamp out the last pockets of the virus.
In Pakistan and Afghanistan, the big obstacle, experts say, is not lack of money to fight it, but mistrust of the western governments who bankroll the vaccines.
Now Donald Trump could be about to deepen that mistrust. If the president makes good on his bellicose threats to take a harder line on Pakistan, he will undoubtedly incite anti-US sentiments, which in the past have led to attacks on polio workers and prompted tribal leaders to ban vaccination campaigns.
It would not be the first time the US got in the way of the war on polio.
The fight against polio suffered its biggest blow in 2011 when the CIA concocted a fake hepatitis vaccination campaign as part of its efforts to find Osama bin Laden. The ruse, exposed in the Guardian, only confirmed Taliban claims that inoculation campaigns were smokescreens for espionage. The Taliban issued fatwas and murdered dozens of health workers. In 2014, Pakistan recorded more than 300 polio cases.
But even before the vaccination ploy, polio was gaining ground, coinciding with an intensified US drone campaign. As attacks spiked in 2008, so did polio cases. When drone strikes hit a high of 128 in 2010, the number of polio cases reached 198 the following year.
Drone strikes in Pakistan have now become rare and since 2014, the fight against polio has bounced back. In 2016, only 37 cases were recorded worldwide, 20 of them in Pakistan.
Meanwhile, in his recently announced South Asia strategy, Trump signalled a tougher line on Pakistan:
“We have been paying Pakistan billions and billions of dollars at the same time they are housing the very terrorists that we are fighting. But that will have to change, and that will change immediately,” he said.
Trump has shown a penchant for airpower. In Afghanistan, the US is dropping more bombs than at any point since 2012.
It is hard to predict how local communities will respond to health workers if bombings pick up, said Monica Martinez-Bravo, a researcher at CEMFI and co-author of a new paper on mistrust of vaccines in Pakistan.
But she has documented a clear correlation between support for Islamist groups, at times a result of air campaigns, and decline in immunisation rates.
“Everything the US does that reduces trust will damage the vaccination campaigns,” Martinez-Bravo said.
Bombings complicate access for immunisers, and insurgents have used polio to demand a halt to air strikes in return for allowing vaccinations.
This year, in Kunduz in northern Afghanistan, the Taliban banned inoculators for 15 months, relenting only when a 14-month girl contracted polio.
Polio primarily affects children under five, and is incurable. The virus causes paralysis, sometimes within hours of infection. It often hits the legs and spine, but can also kill victims by immobilising breathing muscles.
Since the Global Polio Eradication Initiative was launched in 1988, an estimated 16 million people have been saved from paralysis, and 1.5 million children from death.
Yet, without sustained efforts, polio could flourish and spread quickly. For every known case, about 200 people carry the disease without symptoms.
The virus loiters in the environment. Last week, standing above a river in Rawalpindi overflowing with sewage after the monsoon rains, Sarwat Boobak, area coordinator for WHO, said her team had detected wild polio, a sign that people were still shedding the virus, even in the capital Islamabad.
A long-time polio worker, Boobak fled her hometown of Karachi in 2012 after the CIA vaccination scheme was revealed.
“Our work suffered so much after that,” she said.
The backlash predominantly hit female health workers who make up the backbone of vaccination teams. Since then, at least 41 polio workers have been killed in Pakistan, as have several polio workers in Afghanistan. However, WHO in Afghanistan did not provide statistics, and said it was not clear whether the workers were killed because of their polio work.
Although an overwhelming majority of Pakistanis welcome vaccination workers, a few refusals can keep the disease alive.
“Polio vaccines are produced in western countries, and are made out of pig fat or contain alcohol, the two things that are forbidden in Islam,” said Akbar Wazir, a tribal elder from North Waziristan. Equally false are beliefs that vaccines transmit HIV or cause sterilisation.
Tahir, 43, from Karachi, who has four children under five, said he does not allow vaccinators into his house after reading local newspaper reports about vaccines killing children.
Such misconceptions grew stronger after the CIA ruse, said Martinez-Bravo.
“Once people found credible evidence for one claim, it lent credibility to the others,” she said.
This year, 250,000 Pakistani polio workers will target 38 million children who require a course of 10-15 vaccinations. A campaign of that magnitude requires goodwill from communities.
“Certain elements don’t want the Pakistani government to succeed, including in polio campaigns,” said Rana Muhammad Safdar, emergency coordinator for polio eradication in Pakistan.
He would not rule out that military operations could endanger vaccination campaigns.
“By now we have been able to prevent 500,000 paralysis cases in Pakistan alone,” he said. “We all must be extra careful.”
Additional reporting by Haroon Janjua