As Afghanistan’s fragile health system battles for survival, hard-earned gains of the past 20 years in the tenacious battle against polio are under threat. But on a hopeful note, the new Taliban regime has just launched its first national polio vaccine campaign – reversing years of opposition to the life-saving intervention. 

Afghanistan witnessed the lowest ever polio transmission in 2021 providing what WHO officials have described at a recent Executive Board meeting as an “unprecedented” opportunity to interrupt transmission of wild poliovirus and ultimately achieve eradication. 

Only four cases of wild poliovirus type 1 (WPV1) were reported in the country last year.  Previously,  dozens of such cases would typically emerge. Leading up to this, two nationwide campaigns undertaken last year before the Taliban takeover in August 2021.  The campaign reached eight million children, including 2.6 million who were vaccinated for the first time. This has raised hopes for an end game for the crippling virus.

Taliban launch first-ever polio campaign – as Afghan health minister visits Geneva

After years of opposition to vaccination, the Taliban government have pledged to maintain the momentum. The new Afghan government recently launched its first national polio immunization campaign for 2022, targeting 9.9 million children aged 0 – 59 months. However, the campaign is taking place against the continued spectre of hunger, humanitarian crisis and a “dire” health situation, according to WHO’s Director General Dr Tedros Adhanom Ghebreyesus.

Tedros met this week in Geneva with the Taliban’s acting Health Minister, Dr Qalandar Ebad, who arrived Sunday with a larger Taliban delegation, upon the invitation of the humanitarian group, Geneva Call, as part of an effort to unblock desperately needed humanitarian aid.

“Despite some improvements since then, the health situation in Afghanistan is still dire, and the acute humanitarian crisis is continuing to put lives at risk,” wrote Tedros in a tweet Wednesday, after Tuesday’s meeting.   Calling for continued dialogue with the Taliban, Tedros’ message also focused on the need to support Afghanistan’s COVID response and girl’s education. It was his  second meeting to date with the new Afghan health leader, following a visit by the WHO DG to Kabul in September 2021.

Yesterday, I met with Qalandar Ebad, the Taliban Health Leader, to discuss the health needs in #Afghanistan. My full statement below: pic.twitter.com/v8GXhv6aLh

— Tedros Adhanom Ghebreyesus (@DrTedros) February 9, 2022

Taliban campaign reverses years of vaccine hesistancy

Desperately seeking international recognition and support, the Taliban-run Ministry of Public Health clearly now sees the uptake of polio vaccinations as an international and domestic win-win.  It has taken the lead in promoting polio vaccinations and convincing people to get their children vaccinated,  reversing years of vaccine hesitancy that characterised hardliners in the group.

In a televised interview this week, Ebad, a medical doctor by training, mentioned that immunization was among his ministry’s top priorities.

“Together with the international community, we would try our best to eradicate polio that is nearly diminished from Afghanistan. As a physician, I assure people that this is a disease that needs to be defeated on science-based international strategy, be it polio, measles or Covid-19 we would follow a global strategy,” he said. 

Afghanist & Pakistan are only countries remaining with wild poliovirus

Afghanistan and Pakistan are the only countries in the world that have been unable to stop endemic transmission of wild poliovirus, according to the World Health Organization (WHO). 

Pakistan has long blamed its polio cases on Afghan migrants and refugees, so Afghanistan’s battle is also one with high stakes for neighbouring countries who are concerned that any renewed outbreaks could spill over borders. 

While Afghanistan and Pakistan are still grappling with the wild poliovirus, the world is gearing up to roll out a new generation of polio vaccines to fight vaccine-derived polio cases that have been a problem in 27 countries in the African, Eastern Mediterranean, Europe and Western Pacific regions.

Finishing the eradication of wild polio in Afghanistan and Pakistan as well as advancing new vaccines to stamp out vaccine-derived polio cases in Africa, the Middle East and parts of Latin America and Asia,  were twin themes at the recent WHO Executive Board discussions on polio eradication – a health stream that is one of the largest in WHO’s budget. 

The discussions, which continued for hours, featured countries in Africa, Asia and the Eastern Mediterranean describing the challenges they face in rolling out a new generation oral polio vaccines to help wipe out vaccine-derived polio cases from older, less effective vaccine technologies – while remaining watchful of any risks from wild polio outbreaks. 

Ground Zero in the polio battle  

Last year, Africa was declared free of polio as a result of a determined 30-year effort. 

But in the fight against wild polio, Afghanistan remains ground zero in the battle. And the new immunization drive is taking place against the spectre of health worker protests that are stalling health service more generally. 

Evidently exhausted from relentless hours of duties, doctors and other frontline health workers have been on the street in a number of provinces protesting against the non-payment of salaries for months as the Taliban government struggles to manage budget flows amid the tough international sanctions imposed on it by the west.  

One protesting doctor based in the northern region of the country, Habibaullah Ahmadi, told the Health Policy Watch that he had not received his salary for 10 months now and was battling to survive. 

“We have decided to only continue work with few more days, but if we are still not paid our salaries, we will close the door of the hospitals because we all have families and we have a lot of problems, and we ask the international community to intervene and pay our due rights,” said Ahmadi.

Local authorities acknowledged the issue of non-payment of salaries, but blame the freeze on Afghan state reserves worth around $9 billion in the US for it. 

Recently,  doctors returned to work when the regional health head, Zaman Azami, assured the protesting health workers that their problems would be resolved ‘soon’.

The northern region of Afghanistan was the site of some of the deadliest clashes between the Taliban and the former government forces backed by  NATO, which resulted in disruption to the immunization drives last year and the emergence of most y of the new wild polio cases.

Although fighting has mainly ceased with the rise to power of the Taliban, the economic hardship that has followed has had an impact on the vaccination drives.

Meanwhile, the hardline Islamic State’s Khorasan (IS-K) chapter that recently claimed multiple deadly attacks in Afghanistan, continues to oppose the vaccination.

In the eastern provinces of Afghanistan marred by IS-K terrorism, at least four members of the polio vaccination team were gunned down and three others wounded last June. Back in March, three more members of polio vaccination team, all female, were shot dead by unknown assailants in the same area. 

Vaccine scepticism and attacks on vaccination teams

Researcher and author, Ziaur Rehman, who has worked on polio campaigns for years, told Health Policy Watch that although the Taliban’s public stance on vaccinations has evidently changed, the mindset they nurtured against vaccinations during the past 20 years of insurgency will take years to address.

“If you remember it was broadly reported that the American CIA had used a Pakistani doctor, Shakil Afridi, to set up a fake polio vaccination campaign as a cover for the search for Al Qaeda chief Osama bin Laden in Pakistan. Ever since then, health authorities in Afghanistan and Pakistan have been struggling to win public confidence on the immunization,” Rehman said. 

A bunch of the Taliban splinter groups, particularly in the border regions between Afghanistan and Pakistan, continue to issue death threats to all those involved in the immunization campaigns despite the rise to power of the group in Kabul.

Echoing these concerns, senior Afghan paediatrician and former deputy director health, Dr Kabeer Ahmad told Health Policy Watch that scepticism towards polio and other vaccines still remain high, particularly in the rural communities. 

“If you go to the remote villages there are many people who still have serious doubts about the vaccine. It is in these communities, which also frequently travel between Afghanistan and Pakistan, that you see the virus transmitting.”

It is worth noticing that the WHO had said in a statement that Afridi was never part of any polio vaccination program in Pakistan – genuine or fake – and that baseless reports linking him to anti-polio efforts had damaged the ongoing vaccination campaign.

Remarkable progress

At the WHO Executive Board last month, WHO officials praised the “remarkable progress” in the fight against the virus in Afghanistan, and it was labelled as the “best opportunity” to end polio for the entire world. 

“To reach the final goal (of polio eradication). We need more of what we saw in 2021, the government leadership at all levels, and embedded access to children, informed and engaged communities and the highest quality of operations. And we need all of this to be sustained until transmission (of the virus) is interrupted, and the number of paralyzed children is at zero and kept,” said  Dr Ahmed Salim Saif Al Mandhari, WHO Regional Director for the Eastern Mediterranean Region, which includes Afghanistan and Pakistan.

The WHO has an estimated budget of $4.2 billion set aside for the five-year Global Polio Eradication Initiative 2019-2023 in partnership with UNICEF. The second component, starting in 2022, is the one-time cost of $121 million to have oral polio vaccine stockpiles (OPV) in place for use post-certification. Together, it brings the overall cost to achieve and sustain polio eradication to $5.1 billion

It was also underlined at the meeting that the world must not overlook the challenges that remain on this front such as the outbreaks of vaccine-derived polio viruses. 

Taliban seek international financial support

“I urge the member states to make domestic funding available to respond when needed, so that National Public Health capacities respond to outbreaks, as well as the COVID 19 pandemic, and are robust and can be integrated into broader public health services across steadily,” said Dr Al Mandhari, who also visited Kabul and met the Taliban leadership along with Tedros in September.

At the EB, many members state expressed commitment and support for the WHO’s immunization drive. It was stated that the financial support from the Global Polio Eradication Initiative will continue until the end of 2023 for the 10 countries at higher risk for polio, including Afghanistan while the 37 low-risk polio countries are being funded through the WHO based budget. 

After the assurance of funds by the international community, Ebad said that the immunization programs would cover the entire country rather than the 30-40% previous target.

The novel oral polio vaccine for type two, which received WHO’s first-ever emergency use listing in November 2020, has been introduced and delivered at scale in 12 countries using almost 200 million doses aimed at eradicating vaccine-derived polio transmission. 

The supply chain has since been strengthened with 640 million doses planned for delivery during 2022, according to the WHO. Still, at the Executive Board meeting of the WHO last month, the global health body’s chief, Tedros Adhanom Ghebreyesus warned against lowering guard against the crippling virus. 

“When there is success, we tend to lower our guard. So what I say is we need to be more aggressive, and we shouldn’t lower our guard. That’s what I say but eradicating polio is within reach,” said Tedros.

Image Credits: UNICEF Pakistan, Ministry of Public Health, Afghanistan.