The New York Times, January 17, 2012

After Years of Decline, Polio Cases in Afghanistan Triple in a Year

Then last year, the number tripled to 76, the Afghan Ministry of Public Health said

By Rod Nordland

It has often been called the polio cease-fire.

In a country where insurgents have for years attacked and killed people working for the government or the international community, a small army of vaccination teams connected to both has, year after year, fanned out through some of Afghanistan’s most dangerous areas, quietly and mostly safely.

Appointed by the government, paid for by international agencies and given free passage by the Taliban in one of the last three countries in the world where polio is endemic, the Global Polio Eradication Initiative’s 65,000 volunteers and workers had seemed to have nearly wiped out the disease — until recently.

After years of steady decline, only 25 polio cases were reported in the country in 2010, prompting one international health care official to declare that “the Afghans are heroes.” Then last year, the number tripled to 76, the Afghan Ministry of Public Health said. While the total remains small, polio is highly contagious, and health experts say that each detected case is an indicator of hundreds of “silent” ones, mainly children with mild infections who become carriers.

Health workers are alarmed at the reversal of what has been a local and worldwide trend — particularly since some of the cases erupted far outside the disease’s traditional areas in Afghanistan.

“This is a national tragedy to end up with a major polio outbreak, especially with all the effort they have put into it,” said Dr. Bruce Aylward, the polio coordinator for the World Health Organization. “It increases the risk to neighboring countries and is both a local and national, and international, concern.”

President Hamid Karzai, in a statement, in effect blamed the Taliban. “Those who stand in the way of vaccination are the true enemies of our children’s future,” he said, calling on “the armed opposition to allow the vaccination teams to help save children against the lifetime paralysis.”

Fawad Rahmani, 11, wears his brand new pair of braces fitted from the ICRC Orthopedic clinic on September 25, 2009 in Kabul, Afghanistan. Fawad has had polio since he was two years old. Health care is one of many problems facing Afghanistan, eight years after the war began to oust the Taliban regime, even as the country receives billions of dollars in international aid. (Photo: Paula Bronstein / Getty Images AsiaPac)

Health care officials said they had experienced no change in the militants’ tolerance for the vaccination efforts, and the Taliban reacted indignantly. “It is not for Karzai to ask us to attack or not to attack someone,” said the Taliban’s southern Afghanistan spokesman, Qari Yousaf Ahmadi.

Mr. Ahmadi said there had been no change in Taliban policy toward polio vaccination teams. “We have never attacked medical teams, as long as they coordinate with us when they enter areas under our control,” he said.

After decades of worldwide immunization efforts, polio is now considered endemic only to Afghanistan and neighboring Pakistan, where cases also increased drastically last year, and in northern Nigeria. India, long a center of the disease, last week celebrated its first full year with no new cases, the World Health Organization reported.

“It has been a huge achievement,” Vidhya Ganesh, Unicef’s deputy representative in Afghanistan, said of the worldwide effort. Unicef and the World Health Organization oversee the $32 million eradication campaign in Afghanistan. “If polio were to be eradicated, it would be only the second disease ever,” she said. The last case of smallpox, the first human disease believed to be successfully eradicated, was diagnosed in 1977.

Ahmad Azadi, a spokesman for the World Health Organization here, said, “At only 25 cases, you could almost smell the victory.”

Peter Crowley, Unicef’s country representative in Afghanistan, said security was a factor in the rising number of cases, “but it is not the only factor.”

In Afghanistan, polio has traditionally been concentrated in the Pashtun belt across southern Afghanistan — some of the most dangerous areas of conflict in the country. Last year, however, cases also emerged in northern, central and eastern parts of Afghanistan, apparently spread by travelers or refugees from endemic areas in Pakistan.

One of Pakistan’s major polio areas is the Pashtun tribal region contiguous with Afghanistan’s. Just as a porous, rugged border has allowed the infiltration of insurgents, it has also provided pathways for the spread of polio.

New polio cases in Pakistan rose to 192 in 2011 from 80 in 2010, said Muhammed Taufiq Mashal, the director general of preventive medicine in the Afghan Ministry of Public Health. He blames much of the polio increase on infiltration from Pakistan, which World Health Organization scientists say is confirmed by gene sequencing of the virus in victims.

While some extremist Muslim leaders in Pakistan and Nigeria have denounced vaccination programs as a Western conspiracy, that has not been the case with the Taliban. Many polio vaccination teams carry a letter bearing the signature of the Taliban leader, Mullah Muhammad Omar, approving of their work.

Those who saw Mr. Karzai’s statement as politicizing the issue were sharply critical.

“I was very shocked when I read the president’s statement,” said an international health official, who spoke on the condition of anonymity because of his agency’s rules about criticizing a host country’s government. “Politicizing this issue is alarming. Health is not a political thing.”

A Western official speaking anonymously said, “The reason polio vaccination teams have been able to operate is because they’re allowed to operate.”

Naqibullah Faieq, who leads the health committee in the Afghan Parliament, said, “This health issue is nonpolitical, nonmilitary.” He added, “We want both the government and the Taliban to not use the issue of vaccination in their speeches.”

The World Health Organization is expected this week to declare increases in polio cases a “global public health emergency,” Dr. Aylward said. He said that the eradication program in Afghanistan remained effective, and that authorities on all sides seemed determined to make it work.

Still, he said, “anytime you see a three-fold increase in an epidemic-prone disease, you’ve got to be concerned about it.”

Donald G. McNeil Jr. contributed reporting from New York, and Sharifullah Sahak from Kabul.

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