Editor’s note: Since this story was first written in late 2022, the Taliban has banned women from working for national and international NGOs. Global Citizen confirmed that the health workers quoted in this article were able to continue their work thanks to an update from UNICEF on Jan. 21.
With the Taliban's takeover of Afghanistan in August 2021, health experts are concerned about the potential for polio outbreaks due to possible restrictions to immunization programs in the months and years ahead.
These concerns, although not the only obstacles facing polio eradication in the country, are not without cause.
While the Taliban has allowed more vaccine access in recent years, the group has historically opposed many vaccination campaigns and denied access to rural areas. Health workers in the region have also been targets of attacks for which the fundamentalist group has not claimed responsibility.
Following news of the US Central Intelligence Agency (CIA) carrying out a fake vaccination campaign while searching for Osama bin Laden in Pakistan in 2011, the Taliban launched an anti-vaccine campaign on both sides of the Pakistan-Afghanistan border. The CIA's mission would ultimately have grave consequences on global health initiatives in the years following.
In 2018, the Taliban’s ban on door-to-door polio vaccinations prevented more than 3 million children from accessing the vaccine, which was further exacerbated by multiple factors, including the COVID-19 pandemic. In 2021, the United Nations successfully negotiated with the Taliban to reintroduce door-to-door vaccinations. However, recently, some of these gains have been lost — door-to-door vaccinations have now been banned in some parts of the country. The UN continues to negotiate with the Taliban for access.
Afghanistan remains one of only two countries worldwide, alongside neighboring Pakistan, where polio is endemic.
Poliomyelitis (polio) is a highly infectious viral disease. While most polio cases are asymptomatic, the virus can cause paralysis or death. Although there is no cure, the disease is preventable through safe and effective vaccines.
Polio cases have declined by 99% since 1988, which marked the launch of the Global Polio Eradication Initiative (GPEI), but the disease's prevalence in the two countries is preventing total eradication and international NGOs say the Taliban is further encouraging that.
Female patients wait with their children to see a health worker at Rahman Maina District Hospital in Kabul, Afghanistan in November 2022.
For UN agencies, the Taliban's rule has ushered in additional restrictions in an already-challenging environment, according to Shamsher Khan, UNICEF's chief of polio in Afghanistan.
Polio campaign organizers at UNICEF have typically negotiated with Taliban leaders to access Taliban-controlled areas for polio campaigns. Now, with the Taliban control of the entire country, Khan told Global Citizen he is worried that their access will be further restricted and polio progress will backslide.
According to Khan, the Taliban has given UNICEF and the World Health Organization (WHO) access to conduct door-to-door vaccination efforts in 70% of the country. The remaining 30% is conducted at mosques, health clinics, or other gathering areas — which generally reach fewer people than door-to-door canvassing. The country's southern and northeastern regions are two areas of particular concern, as vaccinators have been denied access to door-to-door canvassing.
"We have had several meetings at all levels — national, provincial, and even district level — trying to convince them [the Taliban] to allow us to do the house-to-house campaign, but there is some sort of resistance," Khan told Global Citizen.
When door-to-door campaigns are not permitted, vaccinators can only immunize 50% to 60% of children, according to Khan, which is staggeringly off-base from their target of 100%.
Additionally, Khan said that while accessing remote areas and towns in Afghanistan has always been a challenge, the Taliban is now imposing limitations on health workers in cities such as Lashkargāh, which is "very worrisome for the progress [of polio eradication] because there's a lot of movement in and out from the districts to these places."
For each national polio campaign, UNICEF aims to vaccinate 10 million children under 5. Due to the Taliban-enforced restrictions, they have only been able to reach 8.5 to 9 million children in every campaign, Khan said. Still, in 2022, the UN agency conducted six nationwide and three sub-national campaigns — the highest number of campaigns conducted in Afghanistan in any particular year.
In 2022, Afghanistan had two wild poliovirus cases in the eastern and southeast regions, respectively. The country had four wild poliovirus cases in 2021 and 52 cases in 2020. Cases of circulating vaccine-derived poliovirus (cVDPV2) are also present and the country had 43 such cases in 2021.
A child's hand gets marked after receiving the polio vaccine at Rahman Maina District Hospital in Kabul, Afghanistan in November 2022.
"There's a really good trajectory — it's on a downward trend," Khan said.
Several causes for concern remain, including an outbreak of 20 poliovirus cases across the border in Pakistan, adjacent to Afghanistan's southeast region. With cross-border travel, UNICEF is concerned about polio infections entering Afghanistan and is vaccinating every adult and child who crosses this border, according to Khan.
During door-to-door vaccination campaigns, community health workers canvass neighborhoods in both cities and villages to inform parents about the importance of the polio vaccine, survey the number of children in the household, and vaccinate them.
"We have social mobilizers who are provided with megaphones and they go into the community and make announcements that the vaccination team is in this particular area," Khan explained.
Female mobilizers, of which the country has over 500, are selected based on their background in midwifery and nursing, and play a crucial role as cultural norms prevent mothers from allowing male health workers into their homes.
In rural and remote areas in Afghanistan, UNICEF operates mobile health and nutrition teams of doctors, nurses, midwives, and psycho-social counselors. There are 170 teams that climb mountains and cross rivers to provide life-saving vaccinations to children, along with other health support, including birthing and breastfeeding guidance.
Zahra, whose name has been changed to protect her identity, was 16 when she decided to volunteer at a local medical clinic in Kabul, supporting their polio eradication program. Now, the 21-year-old is employed as the supervisor of a cluster of health workers in Kabul who go door-to-door vaccinating children as part of polio campaigns.
Zahra, who also works as the principal of a private school, is passionate about ensuring children are healthy so they can make the most out of life. One of the children in Zahra's neighborhood has polio, which has motivated Zahra to continue working on polio campaigns.
"To see a 10-year-old like this [partially paralyzed] for the rest of his days … It's something that shook me," she said.
The child contracted polio while living in Paktia Province in eastern Afghanistan on the border with Pakistan. Zahra said the boy’s family members consulted with doctors in Afghanistan and Pakistan, hoping the paralysis in the child's feet could be treated, but were told nothing could be done.
"It's something very close to my heart and something that I think is a big risk for children," Zahra said. "It could be a neighbor today [who contracts polio] and it could be someone in my family tomorrow."
(L) Vaccinator Zehra prepares to give the polio vaccine to children at Rahman Maina District Hospital in Kabul, Afghanistan in November 2022. (R) Zehra walks though the Rahman Maina District Hospital.
While health workers like Zahra remain committed, they face numerous barriers, including risks to their own safety. In February 2022, eight members of polio vaccination teams were killed in the country in multiple incidents.
In 2021, nine polio workers were killed by unknown militants during polio vaccination campaigns. These incidents have been condemned by the UN and disrupted vaccination campaigns, putting thousands of children at risk.
Amina, whose name has been changed to protect her identity, has been working with the polio eradication program in Kabul since 2016. She said it is challenging to convince parents to allow health workers to vaccinate their children. Several times, she and fellow health workers have been threatened with beatings and pistols as they go door to door.
"There have been so many times that we have come across families who have … negative beliefs and myths about the vaccine," she told Global Citizen.
One common myth is that the polio vaccine contains ingredients from pigs, which would make it forbidden in Islam as adherents follow a Halal diet. Others believe the vaccine will make their children develop mental illnesses or become impotent. During these instances, Amina tries to educate families, but she says she has limited success.
Zahra attributes these misconceptions to a lack of education, where conflict and socio-political factors in the country have led to a fragile education system and an adult literacy rate of an estimated 38%.
She attended two semesters of midwifery, which provided a solid foundation on the importance of immunizations. However, Zahra said others who aren't as educated tend to be skeptical of vaccination campaigns, primarily as it is largely international agencies that fund them.
Zahra told Global Citizen a typical response she hears while speaking with skeptical parents:
"If [polio vaccinations are] good, why isn't this done in the US itself, who is sending these vaccines? And since when has the US loved Afghan children so much that they would send us cures and protection? If they care so much about us, why are they not sending food, clothes, providing opportunities for jobs — why vaccination?"
While tackling polio is complex, it is crucial to strengthen polio surveillance systems and ensure high vaccination coverage. These strategies ensure parents understand the importance of vaccinating children and help us gather accurate data to trace polio cases and respond accordingly.
The Global Polio Eradication Initiative (GPEI) brings together governments, UNICEF, WHO, Rotary International, the US Centers for Disease Control and Prevention (CDC), the Bill and Melinda Gates Foundation, and Gavi, the Vaccine Alliance to tackle polio eradication.
By supporting GPEI's latest investment case seeking $4.8 billion to implement its 2022-2026 strategy, countries can help provide the necessary resources to give children everywhere a chance at a healthy life.
Vaccinator Zehra gives a child the polio vaccine at Rahman Maina District Hospital in Kabul, Afghanistan in November 2022.
The end of polio is in sight, but the virus is trying its best to stage a revival. The Comeback We Never Wanted is a content series that looks at how and why polio outbreaks have increased in recent years, diving into issues connected to access to health care, touching on the impact of COVID-19, the difficulty of navigating conflict zones and terrorist groups, and more.
Disclosure: This series was made possible with funding from the Bill and Melinda Gates Foundation.