The Challenges of Vaccination in Taliban-Controlled Regions

In June 2012, the situation for polio vaccination campaigns in North Waziristan took a dangerous turn when the Taliban leader declared a fatwa, effectively banning all vaccination efforts. As this word spread, other Pakistani Taliban factions in regions like Khyber Pakhtunkhwa and South Waziristan swiftly followed suit, issuing warnings that anyone attempting to conduct vaccinations would face severe consequences.

Tragically, the threats soon transformed into violence. In Karachi, a dedicated doctor working for the polio program was shot while traversing an area known for its hostility towards vaccination efforts. Assassinations became alarmingly common, with an estimated 70 polio vaccinators—many of whom were women earning meager wages—murdered by 2015. Even law enforcement personnel tasked with their protection fell victim to the brutality.

But this hostility towards vaccination was not rooted in an outright rejection of healthcare. Militant groups had previously aided in providing access to vaccines across both Pakistan and Afghanistan. Here, the fight against polio had become embroiled in political machinations, as the communities resisting the vaccination efforts were simultaneously suffering from U.S. drone strikes. The Taliban’s ultimatum was clear: cease the drone assaults, and they would permit vaccinations to resume.

The Global Polio Eradication Initiative (GPEI), the global campaign aimed at eliminating polio, found itself unexpectedly caught in this crossfire. The campaign had previously aimed to meticulously reach every child under five with multiple polio drops, employing door-to-door vaccination methods that are crucial in remote and underserved communities. Teams often began their day at dawn, walking miles to reach families lacking access to healthcare. Outside each home, they marked their visit with symbols to denote vaccinated children, ensuring no child was overlooked in the shadow of extensive health care gaps.

Over the years, as behavior change specialists for UNICEF’s polio eradication team, my partner and I observed the complex and growing resistance to these vaccination campaigns. Though efforts had significantly reduced polio cases globally—from 350,000 annual cases in the 1980s to just a few hundred by 2011—the eradication campaigns faced intense challenges in Pakistan. The use of vaccination campaigns by the CIA to locate Osama bin Laden further tarnished the reputation of public health initiatives, linking vital health services to espionage.

Despite traditional tactics to raise awareness, such as community mobilizations and media broadcasts, we began to realize that these methods were insufficient. The socio-political landscape in these communities was vastly different from the contexts health programs usually operated in. The lack of trust and the inflammatory context called for a rethinking of our strategies.

In our pursuit of guidance, we began collaborating with experts from various disciplines—political scientists, social marketers, and security specialists—to enrich our understanding of community dynamics, particularly those under the Taliban's influence. Convening discussions in a neutral space allowed us to explore the complex reality for families living under constant threat.

It became clear that if the polio eradication campaign was to regain legitimacy, a new approach was essential. Shifting vaccination campaigns into the hands of local leaders and representatives from within the communities became a priority. Communicating the call to vaccinate through trusted Muslim and Pashtun voices rather than external entities could foster necessary buy-in from local populations. We envisioned vaccine coolers adorned with messages in Urdu or Pashto rather than English to resonate with local families.

Changing the trajectory of a global health initiative nurtured over 25 years would not happen overnight. However, the discussions sparked optimism and a desire for a collaborative, community-centered model of public health that takes into account local culture and socio-political realities.

Today, through our organization, Common Thread, we strive to implement these principles by asking the tough but necessary questions: How do we incorporate local beliefs and social structures into our health strategies? How can we respect and understand the communities we serve to create holistic health solutions?

These reflections have illuminated a path forward, emphasizing that sustainable public health efforts must honor local priorities while striving for better community health outcomes. By fostering understanding and collaboration, we hope to ultimately pave the way for a healthier future for all, regardless of the political landscape they navigate.