Conspiracy Theories Keep Polio Alive
by Daniel Pipes
In my 1996 book, The Hidden Hand: Middle East Fears of Conspiracy (New York: St. Martin's Press), I wrote about Arab and Iranian phobias concerning Westerners seeking to infect them with diseases:
Western colonialism stands accused of causing all "diseases rampant in the Arab lands." Specifically, the British imported cholera and malaria to Egypt after World War II. A British midwife who trained in the Kabylia province of Algeria got accused by his angry Algerian supervisor of working in league with the "white-coated saboteurs passing their hands from vagina to vagina, infecting my heroic people with syphilis!" An unnamed enemy—presumably American—infiltrated deadly diseases into Iraq via maggot-ridden cigarettes. Israel transmitted cancer to Palestinians by getting them to take dangerous factory jobs or subjecting them to phosphorous searches. It also smuggled irradiated fruit into Egypt to cause cancer.
AIDS, combining sex and disease, prompts recurring nightmares. Jerusalem hires young Jewish women infected with AIDS to spread the affliction in Egypt. One article in the Egyptian press focuses on an Israeli named Sarah who cavorted in luxurious apartments and infected the young and the prominent, while other versions count between 20 and 327 infected Israeli agents. The most imaginative account conjures up a "special formula" of the AIDS virus that infected sexual partners without in any way affecting the Israeli female carriers.
Comment: Ibrahim Datti Ahmed, 68, carries much responsibility if his conspiratorial ideas succeed in keeping polio alive not just in Nigeria but globally. (August 9, 2003)
Jan. 4, 2004 update: An important article in today's Baltimore Sun by John Murphy establishes how the Muslims of northern Nigeria are listening to Ibrahim Datti Ahmed and suspect that the polio vaccines being offered them gratis are in fact "contaminated with an anti-fertility agent that would sterilize their children or perhaps infect them with the AIDS virus, all part of an American plot to depopulate the developing world." Murphy tells this shocking anecdote from the village of Fanisau, Nigeria:
In January last year, Nigerian health workers knocked on [Halima] Umar's door, offering her newborn daughter a free dose of polio vaccine. Two drops of the oral polio vaccine taken at least three times as a child, the health workers told her, would protect her daughter, Zaliha, from the crippling virus for life. But Umar turned the vaccinators away. Most of her neighbors did the same, some hiding children under their beds.
They had heard a rumor circulating through the hot, dusty villages of northern Nigeria that the vaccine had been contaminated with an anti-fertility agent that would sterilize their children or perhaps infect them with the AIDS virus, all part of an American plot to depopulate the developing world. The villagers believed it. It didn't matter that the World Health Organization, the Nigerian government and dozens of doctors and scientists dismissed the allegations as baseless, assuring the public that the vaccine taken by 1 billion children worldwide is safe. "We just didn't like the vaccine," says Umar.
During the following three months, vaccinators returned to Umar's neighborhood two more times to immunize the children. On both occasions, the shy 22-year-old mother politely but firmly declined their offer. Then in June, 10-month-old Zaliha developed a fever and diarrhea. Zaliha, who had recently learned to crawl, suddenly could no longer sit up. A few days later, paralysis, polio's damning trademark, arrived, leaving her legs limp and lifeless. …
Standing in her doorway on a recent morning, holding her crippled daughter, she expresses no regret. Asked if she would accept the vaccine if she could wind the clock back to that day health workers first knocked on her door, she does not hesitate with her answer. "No," says Umar, shaking her head. "I would do the same."
On other occasions, villagers have "chased, threatened and assaulted vaccinators. Frustrated, some vaccination teams dumped thousands of doses of the vaccine rather than face angry villagers" and three northern Nigerian states canceled immunization campaigns last year.
Ali Guda Takai, a WHO doctor, explains the logic: "What is happening in the Middle East has aggravated the situation. If America is fighting people in the Middle East, the conclusion is that they are fighting Muslims." Indeed, the number of polio cases has increased sharply with the wars in Afghanistan and Iraq: 9 in 2001, 54 in 2002 and 74 in the first 11 months of 2003.
The source of the problem lies with the doctors, imams, political leaders and professors who endorse the conspiracy theory. They are led by Ibrahim Datti Ahmed, 68, whom the article quotes as saying of Americans, "They are the worst criminals on Earth to sterilize children for life. Even Hitler was not as evil as that."
Not only does this conspiracy theory harm Nigerian children like Zaliha, but it has worldwide consequences, obstructing a $2 billion-effort to eradicate polio. So long as it lives on in northern Nigeria, it lives on everywhere: "All it takes is for someone to hop on an airplane ... to start reinfecting another part of the world," notes the epidemiologist David Heymann. Chalk up one more tragedy to the baneful influence of conspiracy theories.
Feb. 26, 2004 update: Ibrahim Shekarau, governor of Kano, one of the three Nigerian states refusing the polio vaccine, justified this decision on the following brilliant grounds: "it is a lesser of two evils to sacrifice two, three, four, five, even ten children [to polio] than allow hundreds of thousands or possibly millions of girl-children likely to be rendered infertile."
March 1, 2004 update: "Laboratory tests have confirmed that Nigeria was the source of the virus that caused a case of polio in Ivory Coast. … Ivory Coast is the eighth previously polio-free country in Africa where the crippling disease has reappeared in recent months. Its last polio case was reported in July 2000. Nigeria is believed to have also exported the infections to the seven other previously polio-free African countries: Benin, Burkina Faso, Cameroon, the Central African Republic, Ghana, Togo and Chad. The World Health Organization says the exported cases and continued opposition to polio vaccination by religious and political leaders in the northern states of Nigeria are jeopardizing its efforts to eradicate polio by the end of this year." So reports today's New York Times on the further ravages of conspiracy theories.
March 22, 2004 update: Good news: "Some Nigerian States End Polio Vaccine Ban" reads the Associated Press headline. Nigeria's president himself put the polio vaccine into five babies' mouths, a sign that the six-month polio vaccine boycott had eroded in Nigeria's predominantly Muslim northern region, dubbed the global epicenter of polio. All the more dramatic was it that one of those five children is the son of the state governor of Zamfara, who until recently rejected the vaccine.
Kano now remains the only one of Nigeria's 36 states still rejecting the anti-polio campaign. It is the largest remaining reservoir of the polio virus in Nigeria, which in turn hosts nearly half of the world's polio cases.
April 24, 2004 update: Bad news: "Holdout Threatens Global Polio Eradication Effort." The details:
June 30, 2004 update: Good news: The mostly Muslim Nigerian state of Kano, which banned polio vaccinations last year, will resume them in the next few days, the World Health Organization has announced. Ibrahim Shekarau, Kano's governor, has accepted that the oral polio vaccine is safe and effective. This is key, as Kano State "is now the only polio-endemic area where immunization is not taking place," according to the WHO.
Nigerian authorities have reported 259 polio cases so far in 2004, compared with 56 in the same period in 2003. Globally, the total number of polio cases has reached 339 in 2004, almost double the number for the same period in 2003.
July 2, 2004 update: Bad news: "Major Polio Outbreak Reported in Nigeria." Officials in the heavily Muslim northern Nigeria state of Kano disclosed today that dozens of suspected polio cases have appeared among children in recent weeks. Each of 15 districts in the city of Rogo has seen an average of two cases, all of which showed the symptoms associated with polio, with some children already paralyzed. In all, Nigeria this year has reported 259 polio cases, or over 60 percent of the 339 cases reported worldwide). Noteworthy too is that fact that all six countries classified as polio-endemic by the WHO—Afghanistan, Egypt, India, Niger, Nigeria and Pakistan—have substantial Muslim populations. This raises the question, whether conspiracy theories similar to those found in Nigeria are found in the other countries too.
July 21, 2004 update: More bad news: "Muslim radicals still oppose polio vaccine." Kano State may have accepted the polio vaccine but Nafiu Baba Ahmed, secretary general of the influential Supreme Council for Sharia in Nigeria, continues to reject the vaccine and warns that "A lot of people will no longer take part in the polio vaccination exercise because of the fear that they have regarding the immunisation and in particular the scientific proof that it can cause infertility in children."
Aug. 24, 2004 update: What the medical authorities feared is now coming to pass, namely its spread to countries near to Nigeria, including Sudan, Guinea, and Mali, according to the World Health Organization and other agencies. Bruce Aylward, coordinator of the WHO's anti-polio initiative, said this means that the major polio epidemic "we've been fearing has now spread beyond the firewall we put in place ... as we tried to contain the virus as close as possible to the epicenter in Nigeria." In all, the disease which was limited to only two at the beginning of 2003, has now appeared in about a dozen countries and the WHO's hope to eradicate polio by Jan. 1, 2005 is defunct – thanks to the conspiracy theories swirling among northern Nigeria's Muslim population.
Aug. 27, 2004 update: A parallel problem is now developing in India, where conspiracy theories rampant among Muslims in eastern Bihar state are again leading to reluctance to take polio immunizations. In this case again, the purpose of the immunization is thought to be to cut down on population; in the slums of Gaya, about 60 miles from the state capital, Patna, "many poor and ignorant women regard the anti-polio drops as a deceptive strategy to control the birth rate. In the long run they feel it will reduce the fertility of future generations," notes Mahjabeen Anjum, a health worker. "The misgivings against the polio drops are more pronounced among poor Muslims," she continues. For example, Sanjeeda Khatoon, a vegetable vendor, explained why she disallowed polio drops for any of her nine children. "The government is more concerned with population control than the health of the people."
Sept. 6, 2004 update: Health workers have taken to the field in Kano State, Nigeria, and have immunized 57 percent of its 3.8 million children. This relatively high number results from a massive public-information effort by the government to urge polio immunizations.
Oct. 11, 2004 update: The worst of the polio resistance seems to be over. The Times of India reports from Lucknow that Maulana Khalid Rashid, a member of All India Muslim Personal Law Board, personally administered two drops of polio vaccine to a child at Aishbagh Eidgah yesterday. "Not only the children of my madarsa [madrassah], I would like to convey the message to children all over India that this [vaccine] do not have any 'side effect,'" he said, referring to impotency. The newspaper notes that this was perhaps the first time UNICEF had ever knocked on the doors of a madrassah in its efforts to eradicate the virus.
Jan. 12, 2005 update: The World Health Organization reports today that the number of new polio cases rose dramatically in 2004 to 1,185, compared with 784 in 2003, due to the boycott in Nigeria led to a resurgence of the disease in parts of Africa. Most of the new cases were in Africa - Benin, Botswana, Burkina Faso, Central African Republic, Chad, Cameroon, Ghana, Guinea, Mali, Togo – but some appeared in Saudi Arabia. This has stymied efforts to eradicate the disease by Dec. 31, 2005.
Feb. 20, 2005 update: The Polio Conspiracy Theory seems to be dying out. "Squeezing drops of vaccine into the mouths of wailing babies," reports the Associated Press,
March 27, 2005 update: Spoke too soon. Statistics for 2005 from the Nigerian Red Cross and the U.N. World Health Organization indicate that Nigeria has recorded 20,859 measles cases, of which 20,606 occurred in the mainly Muslim north and only 253 in the mainly Christian south. All of the 589 victims who died all lived in the north. Further, anti-vaccine conspiracy theories spread by imams could also affect measles, the outbreak of which is also surging in northern Nigeria.
April 22, 2005 update: A. H. Jaffor Ullah notes in Muslim World Today that this sad story of polio resurgence comes fifty years after the introduction of the polio vaccine on April 12, 1955, by a team of scientists led Jonas Salk.
May 2, 2005 update: The polio infection has traveled from Nigeria to Indonesia, probably via Mecca, Donald G. McNeil Jr., reports in the New York Times. Indonesia's last case of polio had been in 1995; now it is the 16th country to be re-infected by the virus from northern Nigeria. Because the virus is closely related to a strain found in Saudi Arabia in December, the most likely explanation is that it was brought back from there by an Indonesian worker or by a pilgrim who went on hajj in January. Polio, McNeil notes, "is now found almost exclusively in Muslim countries or regions."
May 7, 2005 update: Things are getting interesting: The World Health Organization, whose campaign to eradicate polio has cost nearly US$4 billion since 1985,
The WHO is talking bluntly, in the way United Nations organizations rarely do:
Multiple calls over two days by a New York Times reporter to the Saudi and Kuwaiti embassies in Washington went unreturned.
And who did give to the polio-eradication campaign? Rotary International, over $600 million, the U.S. government over $500 million (plus the use of staff and laboratories), British and Japanese governments over $250 million each, the European Union, World Bank, and the governments of Canada, Germany, the Netherlands more than $100 million each. Other major donors include several European countries, Russia, Australia, the Bill & Melinda Gates Foundation, and the United Nations Foundation.
Comment: (1) It is noteworthy that the World Health Organization, a U.N. body, should focus on the Muslim countries to pay for a mostly Muslim incidence of polio outbreaks. (2) The trivial participation of the wealthy Muslim countries in the polio campaign fits into a larger pattern (remember the non-aid to the tsunami victims in late 2004) best understood by reading David Pryce-Jones' Closed Circle : An Interpretation of the Arabs.
May 11, 2005 update: The World Health Organization announced that Yemen has more than 63 cases of polio since April 21, 2005, a larger outbreak than found in any other country. Nigeria follows with 54 this year. Indonesia has 6. The Yemeni situation has received special attention: "It's a much bigger outbreak than we originally thought, and it's spread throughout the country," noted the doctor in charge of WHO's polio-eradication campaign, David L. Heymann. Testing shows that the Yemeni strain originated in northern Nigeria, traveled east through Chad and Sudan, and jumped the Red Sea early in 2005.
Yemen and Indonesia are the most recent of 16 previously polio-free countries that have reported new cases since the vaccine boycott began in Nigeria in 2003. Polio in Yemen and Indonesia can be contained through immunization, but the WHO worries especially about Somalia, where anarchy would impede a vaccination campaign. "We have already seen polio reintroduced in Ethiopia," noted Oliver Rosenbauer, spokesman for the WHO's polio eradication program. "If it spreads to Somalia, it will be a problem because it is logistically very, very challenging there."
May 17, 2005 update: The WHO has confirmed 83 cases of polio in Yemen, a country until a month ago thought permanently free of the disease. This amounts, it says, to "a major epidemic."
May 24, 2005 update: I summarized the information in this weblog in more polished form in a column today, "A Conspiracy Theory Spreads Polio."
May 29, 2005 update: Fergus Walsh in the Observer finds that the polio immunization program is "back on track" in Nigeria. In part, this is because the reigning conspiracy theory has taken a new turn, one for the better. Sheikh Aminudeen Abubaker, chief imam of the Daawah mosque in Kano, still believes the polio vaccine contains an anti-fertility agent but he supports immunization because he sees the agent as temporary, like a contraceptive pill. When females stop taking it, they can conceive. Also, to win more support for immunization, the vaccine now used in Kano is manufactured in Muslim-majority Indonesia.
June 1, 2005 update: It's slightly off-topic, but a report by Laura M. Kelley and Nicholas Eberstadt, Behind the Veil of a Public Health Crisis: HIV/AIDS in the Muslim World (National Bureau of Asian Research), points to parallel problems resulting from the Muslim unwillingness to deal with HIV/AIDS:
July 5, 2005 update: The Associated Press reports from Indonesia that 111 children in that country have come down with polio, including one on the island of Sumatra, which until just last week was polio-free. The other cases have since April 2005 appeared in the provinces of Banten, West Java, and Jakarta. Health experts believe the disease was imported from Nigeria and the WHO expects the number of polio cases in Indonesia to continue to climb.
Media coverage of this appalling development is handled seriously and honestly by the print media; for example, this AP report mentions that the problem originated in Nigeria, "where polio vaccinations were suspended for several months in 2003 after radical Islamic preachers warned parents not to vaccinate their children because they believed it was part of a U.S. plot against Muslims." But the National Public Radio coverage of this story at 9 p.m. EDT this evening attributed the problem to "unfounded reports of contaminated vaccines," shamelessly hiding its cause.
Aug. 9, 2005 update: Indonesia has registered 205 cases of polio in five provinces and 14 districts, including two victims in the capital city, Jakarta. At least 700,000 out of 6.5 million eligible children were not immunized in a recent campaign, some of them because their many parents believed the vaccine was dangerous. Rumors in Indonesia are similar to those that spread earlier in Nigeria.
Aug. 20, 2005 update: A hero to the rescue – and it is none other than the Kingdom of Saudi Arabia, which is requiring, effectively immediately, that visitors under 15 years of age from nineteen countries be vaccinated against polio on arrival in the kingdom, whether or not they were previously vaccinated. Those countries are Afghanistan, Angola, Burkina Faso, Cameroon, the Central African Republic, Chad, Egypt, Eritrea, Ethiopia, Guinea, India, Indonesia, Ivory Coast, Mali, Niger, Nigeria, Pakistan, Sudan and Yemen.
Interestingly, the Saudis have engaged in similar health campaigns before, such as the one against meningitis in the 1960s, when they required proof of a meningitis vaccination before granting a hajj visa. Also of note is that two cases of polio were found during the hajj of early 2005; Saudi Arabia being polio-free since 1995, these clearly came from abroad.
This vaccination requirement stems the potential for contagion as millions of Muslims convene for the hajj – and also at other times of the year, when much smaller but still sizeable numbers go on the 'umra. Beyond the practical dimension, this step firmly places the considerably authority of the Saudi state behind polio vaccination, something likely to be important in places like Nigeria and Indonesia.
Aug. 30, 2005 update: With 225 cases of polio in the country since March 2005, coming after ten years without any, the authorities in Indonesia are swinging into action with a US$24 million polio vaccination drive intended to include 24 million young people. In addition to more than 750,000 health workers at 245,000 posts at health clinics, bus depots, rail stations, and airports, political leaders and celebrities are trying to counter rumors that vaccinations are dangerous and violate Islamic law. For example, Kristiani Yudhoyono, wife of the president, administered the drops to several children in a Jakarta suburb. "People should not be afraid," she said. "We are doing this for the sake of the children, for the sake of the next generation."
June 15, 2006 update: Educe Ababa, a Nigerian health official, announced that Nigeria recorded 467 polio infections in the first months of 2006, compared with 224 new cases for the whole of 2005, more than doubling the prior rate of infection. Nearly 90 percent of the new infections were reported in Nigeria's predominantly Muslim north.
Aug. 15, 2006 update: Polio cases in Afghanistan have increased substantially in recent months, but less due to conspiracy theories than anarchy in the south, obstructing vaccinations. At least 25 cases of polio have been identified so far this year, compared with 9 in all of 2005.
Oct. 18, 2006 update: Kenya has just reported its first case of polio in 22 years, a three-year-old girl in the Dadaab Somali refugee camp in the country's north-east. Dadaab houses about 157,000 refugees. Polio re-emerged in Somalia in 2005 after an absence of three years. About 200 cases have been reported since then.
Nov. 4, 2006 update: As the Government of India presses forward with an "Intensive Pulse Polio Immunisation" program in a week, 4-page pamphlets in Arabic and copies of the September 2006 issue of an Urdu-language monthly, Taameer-e-Hayaat, published from Lucknow, are appearing in Muslim sectors of Vadodara (or Godhra) to warn against taking the anti-polio vaccination. They state that the vaccine is imported from Israel and contains chemicals that render impotence or sterility. The Taameer-e-Hayaat article by Shahbaz Hindi reads: "While the Ulemas of Nigeria have issued a fatwa against polio drops, president of Nigeria's Supreme Council of Sharia Laws Ibrahim Datti, himself a well-known physician, has accused the United States of mixing certain elements into the polio vaccines that causes infertility." To counter this article, Chief District Health Officer Dr Prakash Vaghela circulated materials pointing out that the Saudi authorities do not permit children on the hajj unless they have received their polio vaccines.
Nov. 12, 2006 update: Some rare good news from the polio front, this time in India. Having imams explain that polio inoculations are not a plot by the kafirs to render children infertile seems to be working in Uttar Pradesh, India's most populous state. Biswajeet Banerjee of the Associated Press tells the story of Farzaan Siddaqui, who in August 2006 assaulted health workers when they argued with him to allow them to immunize his 3-year-old son and 1-year-old daughter. This time, Wajhat Valdi, his imam, told of what happened earlier, entered Siddqqui's house alone and a mere 15 minutes later, a smiling Siddaqui, agreed to the procedure, which in turn opened up his neighborhood for the inoculations. "I am so happy that they have listened to me," Valdi said. "It was the will of Allah that I should come here."
On a larger scale, the Uttar Pradesh top health official, A. K. Mishra, noted that nearly three-quarters of the state's new polio cases are in Muslim families. The state has seen 438 new polio cases in 2006, of which 25 appeared over the past week.
Feb. 17, 2007 update: A remote-controlled roadside bomb in Salarzai, a village about 50 kilometers northeast of Khar, the main town in Bajur Agency, instantly killed Dr Abdul Ghani Khan, chief surgeon at the main government hospital in Bajur, and injured three others in his car, one critically. He was returning from a jirga (tribal council) where he had been trying to convince tribesmen to immunize their children against polio.
Feb. 23, 2007 update: From Pakistan, Declan Walsh finds a situation comparable to Kano, Nigeria in 2003.
The government made strenuous efforts against the conspiracy theories about an "infidel vaccine," with health workers carrying copies of a fatwa, endorsing the vaccinations signed by leaders of Pakistan's most powerful religious parties. This seemed to work, in that some 9 million children have been or will be shortly vaccinated. Only 24,000 children have been denied the vaccine, but health officials indicate that is enough to provide the virus with the needed toehold. Walsh provides the political context for the conspiracy theories:
It gets even worse.
July 28, 2007 update: Sudanese Islamists have jumped into the act. Here's an interview (video available) with the leader of the country's Muslim Brethren, Sadeq Abdallah bin Al-Majed, who declaims on this topic after declaring the Darfur problem the result of an American conspiracy:
Oct. 11, 2007 update: Just what was needed in Nigeria - an outbreak of polio caused by a mutating polio vaccine, 16 cases recorded by April 2007, perhaps 70 by now. In other words, the vaccine itself is creating new cases of polio to occur. Though unusual, this problem has occurred in various places around the world. One can only imagine the impact of this news on the Islamists so suspicious of the vaccine in the first place.
On the positive side, the New York Times article reporting this news also, in passing, notes that the polio cases spread to many new countries from the initial 2003 outbreak in Nigeria have mostly been "snuffed out."
Mar. 29, 2008 update: And now measles. The northern Nigerian state of Katsina reports a measles epidemic that has killed nearly 165 children and infected 3,000 in the past three months, though the death toll could be much higher due to unreported cases. Katsina's director of disease control, Halliru Idris, says that "over 95 percent of all the children that have measles are those whose parents have not allowed them to receive immunization."
June 8, 2008 update: The Daily Times of Pakistan reports on "5 polio cases reported, more feared": "Five polio cases have been reported in Karachi recently and have been traced to out-of-town carriers. More cases are suspected to have developed."
July 17, 2008 update: Polio surfaced in Ali Gram, a village in the Swat Valley of Pakistan when an eight-month-old girl tested positive with type 1 polio, the most dangerous and contagious strain. This is the first confirmed case of the disease in Swat since 2003. A pro-Taliban religious leader, Maulana Fazlullah, condemned polio vaccinations as a Western conspiracy to render Muslims infertile, prompting Islamists to campaign against the innoculation, going so far as to beat up medical teams.
Sep. 16, 2008 update: The Taliban claimed responisiblity for a suicide bombing in southeastern Afghanistan, killing two Afghan doctors employed by the World Health Organization, leading the WHO to cancel polio jabs for 1.2 million Afghan children.
Mar. 22, 2009 update: The whole polio problem started in Nigeria, and so maybe now will the solution come from there, reports Katy Pownall of the Associated Press.
June 4, 2009 update: In a much ballyhooed speech to Muslims in Cairo, Barack Obama announced: "Today I'm announcing a new global effort with the Organization of the Islamic Conference to eradicate polio," implicitly recognizing that the survival of polio is a problem connected to Islam.
Sep. 8, 2009 update: The Taliban prohibition against polio vaccinations in the Swat Valley of Pakistan held for a year but has been pushed aside.
Jan. 25, 2010 update: A Pakistani woman's magazine in Urdu, Mahnama Banat-e-'Aisha, contains a lengthy article "Polio: Disease or Dangerous Jewish Conspiracy?" by Mohammad Kamran Talib. For the imaginative details, see MEMRI's summary and excerpts.
May 20, 2010 update: The persistence of polio among Muslims imperils the ambitious goal of elminating the disease entirely, as "donor fatigue" threatens to end the US$750 million a year required to keep the effort going. Maria Cheng reports for the Associated Press:
June 2, 2010 update: Indiana University Press has announced The Politics of Polio in Northern Nigeria by Elisha P. Renne, an anthropologist at the University of Michigan. Here's the ad copy:
More bluntly, as one of the book's blurbers puts it, Renne tries to "persuade you that Muslims' fears were justified."
Comment: Typical of the academy: Choose the opposite of common sense.
July 21, 2011 update: In a failed effort to collect DNA from Osama bin Laden's family, the CIA sponsored an anti-hepatitis vaccination program that is now having repercussions on the anti-polio effort in Pakistan. Public-health organization officials worry it could harm efforts to vaccinate Muslim children. "In a nation swirling with rumors of CIA plots, critics say, this real-life one could cement public suspicions, play to radical clerics' anti-vaccine propaganda and endanger health workers."
Jan. 17, 2012 update: Cases of polio have tripled in Afghanistan and Pakistan over the past year. Rod Nordland reports for the New York Times that the former saw 25 cases in 2010 and 76 in 2011, while in Pakistan the incidence went from 80 in 2010 to 192 in 2011. Polio is now endemic only to those two countries and to northern Nigeria. Interestingly, the Taliban have endorsed the polio vaccine, unlike many other Islamists.
July 16, 2012 update: Pakistani authorities postponed a three-day anti-polio campaign, targeting 34 million children under five, in the country's northwest region of Waziristan when the Taliban leader Hafiz Gul Bahadur banned inoculations, on the grounds that it is a cover for espionage. At least 240,000 children will not receive the polio drops. In 2011, Pakistan recorded 198 cases of polio, the highest number in a decade.
Oct. 17, 2012 update: (1) As an anti-polio team administered vaccine to small children on the outskirts of the Pakistani city of Quetta, gunmen on a motorcycle opened fire, killing one. This follows Taliban threats against the polio campaign. This follows the shooting death of a doctor administering polio vaccines in Karachi in July 2012.
(2) Jason Beaubien reports that northern Nigeria
Dec. 4, 2012 update: Jason Beaubien reports for National Public Radio about a recent outbreak of vaccine-derived polio in Pakistan – ten cases between in a two-month period - which has the World Health Organization wondering about the effectiveness of its work there. (Vaccine-derived polio occurs when the weakened strain of polio in an oral vaccine infects unvaccinated people.)
Dec. 6, 2012 update: As Hanisa, 22, was on her way to her first day of work as a vaccination assistant in the village of Kalota, north of Kabul, Afghanistan, three men on two motorcycles shot her at least six times. She died from the wounds.
Dec. 18, 2012 update: Pakistani gunmen killed a male volunteer for the anti-polio campaign in Karachi on Dec. 17 and five Pakistani women (four of them in Karachi) on the 18th. The government responded by suspending vaccination efforts in parts of the country.
Dec. 20, 2012 update: Mushtaq Yusufzai and Waj S. Khan of NBC News counts nine dead in Pakistan in recent days and notes all were killed by assassins on motorcycles. It also notes that polio "disproportionately affects members of the Pashtun population in Pakistan, who largely live in the country's northwest and border region. They account for roughly 15 percent of the population, but 75 percent of all polio cases."
Dec. 25, 2012 update: The New York Times ran an analysis today, "Getting Polio Campaigns Back on Track," by a staff writer, Donald G. McNeil Jr., which makes the astonishing argument that the West is much to blame for Muslim resistance to polio vaccinations:
Funny, I don't recall the Birch Society murdering any one to stop the fluoride program.
Now, there's a leap in logic.
McNeil goes on to explain the logic of thinking that the vaccine contains either pork, the virus that causes AIDS, or an element that sterilizes Muslim girls.
Comment: When there is no right and wrong, this split-the-difference approach is inevitable. Thank you, New York Times.
Dec. 31, 2012 update: In addition to the conspiracy theories which prevent polio from being eradicated, Pakistan suffers from an even more debilitating rumor: That iodized salt causes infertility and therefore must avoided, leading to such maladies as spontaneous abortion, stillbirth, goiters, mental retardation, and birth defects, which in turn lead to lethargy, lower IQ scores, and reduced productivity. Nearly half of Pakistan's population of 200 million suffers from some form of iodine deficiency disorder. Richard Leiby reports for the Washington Post on the origins of this bizarre problem:
Religious leaders promote the notion of iodine as part of a Western plot.
Jan. 24, 2013 update: And now the polio virus has been found in the sewers of Cairo, Egypt, apparently of Pakistani provenance, according to the World Health Organization. Egypt had been clean of polio since 2004. Pakistani authorities will post teams at international airports vaccinating all passengers leaving the country up to four years old.
Feb. 8, 2013 update: Gunmen presumably from the Boko Haram gang of Islamists, killed nine or twelve women (depending on which source one credits) as they immunized children against polio in Kano, Nigeria. By way of background, Nigeria reported 121 cases of polio in 2012, more than any other country.
Apr. 10, 2013 update: As a team of female polio workers in northwestern Pakistan (Mardan district in Khyber Pakhtunkhwa province) were administering polio drops to children, unknown gunmen killed one policeman and wounded another.
Apr. 24, 2013 update: Writing in the British medical journal, The Lancet, Qanta A Ahmed, Sania Nishtar, and Ziad A Memish offer a creative and counterintuitive argument in "Poliomyelitis in Pakistan: time for the Muslim world to step in" that the Saudi government, with its modern medical sector, its immense resources, and its control of the hajj can pressure countries like Pakistan to get with the polio vaccination program.
Apr. 25, 2013 update: The Guardian Nigeria published a scorching piece today about the rejection of polio vaccinations (and modern medicine more generally) by Itunu Ajayi, "Tackling vaccines' rejection in Northern Nigeria." An excerpt:
Apr. 30, 2013 update: In an attempt to win support for polio vaccinations, Bill Gates (whose foundation is active in the polio eradication campaign) traveled to Doha, Qatar where he met with Muslim religious leaders attending the 10th annual Doha International Conference for Interfaith Dialogue (DICID) and connected to the International Union of Muslim Scholars in a successful effort to win their cooperation to in convincing local religious leaders, especially in Nigeria, Pakistan, and Afghanistan, to permit children to be vaccinated.
May 17, 2013 update: Nigeria's International Islamic Fiqh Academy, a subsidiary of the Organization of Islamic Cooperation, has given its support to the anti-polio campaign, calling on parents to "ensure that their sons and daughters get vaccinated against polio" while condemning acts of violence against vaccinators.
May 27, 2013 update: The World Health Organization has announced that two Somali children have recently been found to have polio, one in southern Somalia and one in a Kenyan camp with Somali refugees. This may not sound like much but a New York Times account by Donald G. McNeil Jr. explains its significance:
And an update on the disease: "Polio is very close to eradication. Last year the world had only 223 known cases of paralysis. Until recently they were found only in Nigeria, Afghanistan and Pakistan. Virus has also been found this year in the sewers of Cairo, but no paralyzed children have been found in Egypt."
May 28, 2013 update: For an overview of the Bill & Melinda Gates Foundation efforts to eradicate polio – and the problems it faces in a handful of Muslim-majority countries – see Michael Toole, "Polio eradication efforts need money and political commitment."
June 1, 2013 update: I reflect today on the senselessness of a Nigerian doctor's single-handed success at stopping eradication efforts at "Islamism's Decade of Spreading Polio."
June 4, 2013 update: The polio virus was detected on April 9, 2013, in sewage water of the southern Israeli Bedouin town of Rahat, population 53,000. No reports of paralytic polio infections have appeared, nor are any likely. It appears to be the same strain as was found earlier in 2013 in Cairo sewage, which in turn resembles the strain found in Pakistan and Afghanistan.
June 6, 2013 update: Islamabad's International Islamic University is holding a two-day international conference for Islamic scholars from Saudi Arabia, Egypt, Yemen and other countries to propose ways to overcome opposition to polio vaccinations in Pakistan.
A sample opinion, from Mohammad Wesam Abbas Khidr, secretary general of the Egyptian organization issuing fatwas: "Depriving a child of polio drops is equal to committing a sin. Protecting your child from disease is a religious obligation." In a more threatening tone, his Saudi counterpart, Abdulqahir Mohammad Qamar of the International Islamic Fiqh Academy in Jeddah said that "If Pakistan fails to stop transmission of polio virus, there are chances the Saudi government may impose travel restrictions on Pakistanis."
June 17, 2013 update: Unknown assailants shot and killed a schoolteacher and a government health worker giving polio drops to children in the northwestern Pakistani district of Swabi.
June 18, 2013 update: The polio virus in the sewage of one Bedouin town of Israel has now spread to sewage in Be'er Sheva, Kiryat Gat, Ashdod, Tel Aviv, and three other locations. Plus, it turns out, according to medical experts, that about 10 percent of the Negev residents have not been inoculated against polio.
June 19, 2013 update: When polio appears, well, the reaction in Israel is different from Nigeria and Pakistan: scare gets parents rushing to immunize their kids
Even the Muslims respond differently in Israel: "Kaeed Abu-Alkayan, a parent from the Bedouin village of Hura, near where the strains were discovered, said he and other parents were so worried they could not sleep at night. He said that running sewage in the street and a nearby dump were fertile breeding spots for any number of diseases."
July 11, 2013 update: Israel's Health Ministry reports that traces of the polio virus are continuing to appear in sewage in the southern and central parts of the country, prompting the ordering of nearly a million doses of the "live attenuated" oral vaccine and the continuous examination of stool samples.
July 20, 2013 update: Polio struck in Somalia in 2006-07, then disappeared, only to re-emerge again in May 2013. Now, Jason Beaubien reports for National Public Radio,
July 21, 2013 update: A New York Times account of polio in Pakistan by Donald G. McNeil Jr. basically blames the suspicion about vaccinations on the CIA's fake anti-hepatitis campaign connected to bringing down Osama bin Laden – ignoring the fact that the suspicion long preceded news of this gambit in mid-2012.
Plus, it ascribes the country's leadership wanting the disease eradicated to its rivalry with India which has successfully eliminated polio.
There are some signs of success:
It finds the epicenter of the disease to be
Aug. 1, 2013 update: The World Health Organization, worried about of a medium- to high-likelihood of Israel's polio virus spreading to other countries, has issued a travel advisory warning visitors to be vaccinated before reaching Israel. To which, Health Ministry Deputy Director Dr. Boaz Lev replied that "The World Health Organization is over-reacting to the situation. Their hysterics are disproportionate to the situation on the ground."
Aug. 4, 2013 update: More on the polio virus found in Israel:
Aug. 9, 2013 update: The discovery of viral strands of polio in the sewage facilities from Lod and Ramle means that, starting in a few days, all Israeli children born since 2004 (i.e., ten and under) will be vaccinated for polio. Twenty eight virus carriers have been identified, 26 of them children under ten. The presence of the polio virus is one of the most serious public health problems Israel has faced in decades.
August 22, 2013 update: In a survey of efforts to eradicate polio, the New York Times finds it "is facing serious setbacks on two continents," and more precisely in Somalia and Pakistan.
Aug. 30, 2013 update: The U.S. Centers for Disease Control and Prevention has added a polio alert to its page on Israel under its advice to "most travelers":
Sep. 2, 2013 update: To be on the safe side, even though there is not a single incident of polio outbreak in Israel, the authorities have decided to vaccinate a million children.
Sep. 4, 2013 update: The Saudi authorities convened a group of Islamic scholars mainly from Pakistan for a two-day meeting at the Islamic Development Bank headquarters in Jidda to win and announce their support for polio eradication programs.
Oct. 7, 2013 update: A remote-controlled bomb exploded near a government health center in Peshawar, in northwestern Pakistan near Afghanistan, during the distribution of anti-polio kits, killing 2 (including a policeman) and wounding at least 12.
Oct. 12, 2013 update: The polio virus has appeared in Sudan's South Kordofan and Blue Nile provinces where the SPLM-North rebel group backed by South Sudan is fighting Sudanese government forces. According to the United Nations, more than 165,000 children in the two Sudanese states are at risk "due to a lack of immunization in the border area in more than two years." The Security Council has called on the warring sides "to urgently overcome differences" and allow a two-week polio vaccination campaign can to begin as scheduled on Nov. 5.
Oct. 25, 2013 update: In a plaintive article one day after World Polio Day, "War on polio extremely hard," Sidrah Roghay reviews the situation in Pakistan. Excerpts:
Oct. 29, 2013 update: Initial reports of the discovery of a polio outbreak among 22 children in Deir al-Zour Province in northeastern Syria have now been confirmed in 10 of the 22 children according to the World Health Organization, with results of tests on the other 12 children expected soon. Most of the cases are in children under 2 years of age.
Before the Syrian civil war broke out in 2011, 95 percent of the country's population was immunized; now, half a million Syrian children have not been inoculated against polio. In response, the U.N. is starting a campaign to immunize 2.4 million children in Syria against polio and other diseases, as well as in the neighboring countries: Lebanon, Jordan, Iraq and Turkey, Egypt, and Israel.
The New York Times reports: "Public health officials have speculated that a possible source may have been jihadi fighters traveling to Syria from Pakistan."
Nov. 6, 2013 updates: The polio outbreak in Syria has scared the World Health Organization into planning to vaccinate more than 20 million young children in the a Middle East period of six to eight months, a campaign that may divert vaccines intended for use elsewhere.
Nov. 7, 2013 update: The recent re-emergence of the polio strain in Israeli sewage points to the potential to spread to non-Muslim-majority countries. Two German specialists, Martin Eichner of the University of Tubingen and Stefan Brockmann of Reutlingen Regional Public Health Office, worry about polio spreading to Europe, especially should substantial numbers of Syrian refugees reach the continent. Conceivably too, tourists going to Israel could bring it back. Dr Benjamin Neuman, a virologist at the University of Reading, explains:
Eichner adds: "The WHO wants to get rid of polio completely and had got pretty close until recent outbreaks. The fact that most of those infected do not display symptoms but can still spread the disease makes it a very hard virus to get rid of as it is like fighting an invisible enemy."
Nov. 12, 2013 update: Civil war in the Sudan between the government and rebels in the South Kordofan and Blue Nile provinces blocked a polio vaccination campaign this past week directed toward 165,000 children, the United Nations reports.
Nov. 13, 2013 update: The polio outbreak in Syria has spurred governments and international organizations urgently to vaccinate 22 million children in Egypt, Gaza, the West Bank, Jordan, Lebanon, Turkey Syria, and Iraq,. The $30 million campaign will inoculate even children already vaccinated against polio.
Nov. 30, 2013 update: USA Today carries an article today, "Islamic law and suspicion fuel polio resurgence" by Imran Ali Teepu, that does not live up to its title, for it says very little about Islam.
Dec. 11, 2013 update: A parallel development on a minute scale exists among Hasidic Jews and measles: One third of all cases of measles in the United States, or 58 out of 175, were among Hasids in the Brooklyn. Given that there were 3 to 4 million cases of measles worldwide leading to 158,000 deaths, however, this is not a major problem.
Dec. 29, 2013 update: (1) One person, Zahid Gul, was killed and two injured yesterday when two armed men on a motorcycle opened fire on an anti-polio vaccination team at Matani Hospital, in the outskirts of Peshawar, Pakistan, near the tribal areas.
Also, a tally for 2013 finds that 82 persons were newly infected with the polio disease in Pakistan, compared to 58 in 2012. The same news report records two further December attacks on anti-polio workers in Pakistan: "On December 13, gunmen had attacked two separate polio teams in northwestern Pakistan, killing one polio worker and two guards. On December 21, unidentified militants gunned down a polio worker in the Jamrud Tehsil area of Khyber Agency."
(2) Syrian refugees in Turkey have brought 17 recently reported cases of polio to the country after an absence of 14 years and completely eradicated for 11 years.
Jan. 9, 2014 update: A rare piece of good news from Syria: according to the World Health Organization, the polio vaccination effort of children there appears to have stopped the spread of the disease just halfway the process, with no new cases for many weeks.
Jan. 11, 2014 update: The year 2013 saw 83 new polio cases reported in Pakistan, more anywhere else in the world, including Afghanistan and Nigeria, the other two countries where the disease is endemic. There had been just 51 reported cases in 2012, reports Pamela Constable for the Washington Post. Efforts to combat the virus, however, are hampered by attacks by Islamists; just the past three months have seen at least a dozen government vaccinators or their police escorts killed or wounded in the country's northwest. None of the perpetrators have been arrested.
In response, the government is enlisting influential figures, including Muslim scholars, in a campaign to endorse polio vaccines. For example,
Constable points out one new reason why the government is promoting vaccinations as it is:
The clinic technician, Jamal Shah, at a hospital in Akora Khattak, recalls (in Constable's paraphrase) "that when the government began immunizing children against polio in the 1980s, many people believed the vaccines were a Western plot to sterilize Muslims. With public education, he said, resistance gradually declined" until the case of Shakil Afridi, the Pakistani surgeon used by the CIA to get information on Osama bin Laden under the pretence of conducting a hepatitis immunization survey. Shah explains:
Still, the Afridi impact lingers: a few days ago, Taliban spokesman Ehsanullah Ehsan announced that the anti-polio campaign is "used to spy on our holy fighters."
Izrar Madani, an aide to Sami ul-Haq, says the anti-polio pamphlets and propaganda originally came from Nigeria, then reached Pakistan via India, confirming my research which found the source being a doctor in northern Nigeria in md-2003.
Jan. 22, 2014 update: Deutsche Welle's Shamil Shams reports on violence in Pakistan hampering the anti-polio campaign.
Feb. 10, 2014 update: MEMRI has published a lengthy study of the problem in Pakistan under the title "Rising Attacks on Polio Workers In Pakistan - Media Report: Rumors that the Vaccine 'Is a CIA Plot to Sterilize Muslim Children'; Article: 'Jews, Who Dream of Ruling The World, Have Invented... Vaccines, Drugs, and Injections... to Weaken Muslims'" and also made available an audio recording under the title "Pakistani Jihadi Audio Message Against Polio Vaccination: 'If A Polio Team Visits Your Area You Need To Shoot Them'."
Feb. 16, 2014 updates: (1) Pakistani Islamists raised the ante in Peshawar today by setting off a remote-controlled bomb at a polio vaccination center, killing one police officer and injuring another.
(2) An Associated Press analysis explains how the pool of polio genes in Pakistan threatens other countries as well:
Afghanistan and India, to Pakistan's west and east, are particularly vulnerable:
The prospets of ending this danger are dim indeed.
Dr. Imtiaz Ali Shah, the provincial government's polio campaign coordinator, notes the impossibility to eradicate the polio virus from Peshawar, because tribal peoples from the heavily infected regions arrive daily in the city, bringing with them the virus: tribal regions, he notes, "are producing so many cases."
Feb. 20, 2014 update: In a 5,000-word article in the New York Review of Books bearing the title, "Syria's Polio Epidemic: The Suppressed Truth," Annie Sparrow blames Bashar al-Assad for what she calls a "man-made outbreak" and argues that the Assad regime's willful spreading of polio has gone unremarked.
A critical-care pediatrician and assistant professor of global health at Mount Sinai in New York, she starts by noting that, of Syria's 93 or more cases, the average age is just under two and all live in territory not controlled by the government. Also, it all the instances are of wildtype 1, "the most vicious form of the disease." She estimates that "for each crippled child, up to one thousand more are silently infected. Polio is so contagious that a single case is considered a public health emergency. Ninety cases could mean some 90,000 people infected, each a carrier invisibly spreading the disease to others for weeks on end."
United Nations agencies deployed to Syria in early 2012 to respond to this government-created humanitarian crisis are in a Catch-22: they all must stay in Damascus because their mandate
Thus has Assad's war "generated the perfect conditions for polio: the severe malnutrition we see now in many opposition-held areas, on top of appalling living conditions." Nonetheless, the Syrian authorities refuse to take responsibility for controlling it. "For months the Syrian Ministry of Health denied that polio had even broken out." Once it did accept that polio had spread, it still failed to detect the polio outbreak, losing the chance to limit the virus to just one region.
Sparrow finds that Syria's children "are now at greater risk than children in the three countries where polio is still endemic (Afghanistan, Pakistan, and Nigeria) because they lack the natural immunity that comes from exposure and because the spread of polio by respiratory means is aggravated by the crowded conditions under which millions now live."
To avert a polio epidemic, "a surveillance system is required that can trace affected children and contacts more rapidly than the virus spreads, but the government's sloppy surveillance and months of denial mean that it is now impossible to contain it."
She finds the United Nations colluding with the Assad regime:
All of which provides incentive to leave Syria, bringing polio and other diseases to new countries:
Mar. 2, 2014 update: Twelve security personnel of the Khyber Khasadar Force and one passer-by child were killed and 11 others injured when two roadside bombs went off in Jamrud tehsil of Khyber Agency, Pakistan; ironically, the bombs were intended for a polio vaccination team but none of the anti-polio personnel were even injured. The paramilitary troops had ben guarding the anti-polio workers.
Apr. 1, 2014 update: The remarkable Qanta Ahmed, associate professor of medicine at the State University of New York, offers a personal account of efforts to combat polio in Pakistan in "Polio's endgame The debilitating and often deadly virus has almost been eradicated – now the Muslim world must finish the job." She also discerns a method behind the conspiracy theorists' madness:
Realizing the elimination of polio is a global goal, the Taliban see the eradication programme as a bargaining chip to exchange for the cessation of US-operated drone operations targeting militant leaders.
In the darkness, she espies "an opportunity for the Muslim world leadership – not just in government but in the worlds of business, philanthropy and even sport. Today, while the Muslim world struggles with deepening sectarian tensions, the opportunity to fight polio brings with it a chance of unity."
Apr. 6, 2014 update: UNICEF has announced the start of its first mass vaccination campaigns for polio in Iraq since the disease was recently found there. It will also begin efforts in Syria and Egypt, aiming to reach in all more than 20 million children over the five days.
May 9, 2014 update: The World Health Organization has, for the first time ever, declared the spread of polio an international public health emergency. It calls the current polio outbreaks an "extraordinary event" that requires a coordinated international response. It notes that the governments in three countries (Pakistan, Syria and Cameroon) have allowed the virus to spread beyond their borders and wants nationals of those countries to have a polio vaccination certificate in hand to travel abroad.
June 23, 2014 update: Wild poliovirus type 1 (WPV1) has appeared in the airport sewage of World Cup host city of Campinas, Brazil, base camp for the Portuguese and Nigerian teams. Genetically sequenced, it closely matches a strain recently detected in Equatorial Guinea, a near neighbor of Nigeria. Could a member of the Nigerian team have brought the virus with him?
Aug. 11, 2014 update: Will ISIS permit polio vaccinations in the territories it controls? UNICEF and the World Health Organization, which are planning a campaign in Iraq to reach four million Iraqi children under the age of 5, do not have contact with ISIS and are wondering what the answer might be. They are especially curious, as both organizations are part of the United Nations, which designated ISIS a terrorist group. This problem adds to others in the region facing vaccinators recently; the New York Times explains:
Aug. 12, 2014 update: Annie Sparrow, author of a major study on polio in Syria in February 2014, now has a second installment in "Syria: The Other Threat." In it, she concentrates on the culpability of international organizations who maintain too-high standards for a war zone like Syria and end up substantially undercounting the number of cases of polio.
She notes that "nearly all the cases of polio have occurred in areas of northern Syria under rebel control, where the government is seemingly doing everything in its power to prevent vaccination." As a doctor from Aleppo bitterly told Sparrow, "The government's polio control strategy for children is to kill them before they can get polio."
She sees polio in Syria possibly
Sparrow ridicules the statement by the director of WHO's polio effort, Bruce Aylward, for describing the polio eradication program as "in an extremely good position, aside from this spread in the low season, and aside from the situation in Pakistan."
Again, she blames the Syrian government for this breakout:
Comment: Sparrow's point boils down to this: In addition to conspiracy theories causing polio not to be eradicated, the hideous Assad regime is doing its best to spread this and other diseases in rebel-held areas of Syria. In other words, there are two major reasons for polio's revival, not just one.
Oct. 23, 2013 update: Laurie Garrett, Council on Foreign Relations Senior Fellow for Global Health, has posted a map of vaccine-preventable outbreaks that finds "a hostile climate for vaccinators thwarts the eradication of preventable illnesses such as polio." In particular, "the resurgence of polio in Pakistan is strongly correlated with the increase of attacks on vaccinators and health-care workers there."
Dec. 10, 2014 update: Two gunmen on a motorbike shot six bullets and killed a polio vaccinator, Muhammad Sarfraz, 40, in Faisalabad, Punjab Province, Pakistan on Dec. 9, on the day two of a three-day national vaccination campaign. Sarfraz, a school teacher, had volunteered for the campaign. This was the second time he had been attacked this year.
Feb. 14, 2015 update: Two developments in Pakistan: (1) Gunmen attacked a vehicle in the Khyber tribal region close to Afghanistan, that carried a polio vaccination team in, killing the driver and wounding a health care worker. (2) Two polio workers and two security guards were reported missing in Baluchistan.
Feb. 27, 2015 update: Pakistani officialdom in the northwestern province of Khyber-Pakhtunkhwa is finally getting serious about polio vaccinations, preparing to put recalcitrant parents in jail, if need be. (Out of 13 new cases in all of Pakistan in 2015, 11 of them have been in Khyber-Pakhtunkhwa or the tribal regions.) Deputy police commissioner for Peshawar, Riaz Khan Mahsud, explains: "We had 13,000 to 16,000 refusal cases. There is total determination on our part. We shall convince parents of the good of vaccinating their children, but if they refuse, we shall detain them. There is no leniency."
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