Claire Hajaj
Tuesday Reitano
Publication Date
October 16, 2016

"[T]he [polio] eradication drive might benefit from a shift from a high-profile [immunisation] campaign approach to a more holistic strategy integrated with the local hierarchy of needs in charged ideological settings. In this way it may be possible to mitigate the overemphasis on polio over other priorities that have too often made polio a point of contention and resistance, rather than an issue of shared concern."

This article examines how the conflict between Salafist groups and global interests has affected broad patterns of polio transmission since 2001 - and how these epidemiological patterns to some extent mirror the expansion and cross-fertilisation of extremist ideologies. (Salafism is an ultra-conservative reform movement within Sunni Islam). As noted here, although polio is nearly completely eradicated on a global scale (this is what the title references: "the Golden Millimeter"), in recent years, new cases have been found in Iraq, Syria, Somalia, and Afghanistan in locations that had long been declared polio free. "It appears that instead of vanishing, polio has been transformed into a lever of ideological conflict, now specifically confined to countries experiencing internal struggles linked to Islamic extremist armed groups and other strains of fundamentalist Islam." The article explores the implications of this new paradigm for the success of polio eradication and similar development efforts in fragile states, arguing that "the eradication drive might benefit from a shift from a high-profile campaign approach to a more holistic strategy integrated with the local hierarchy of needs in charged ideological settings. Traditional strategies centered on national ownership," which emphasise state actors and institutions, can lead to counterproductive fallout, and so - as is the central claim of authors Claire Hajaj and Tuesday Reitano - international agencies need to place greater emphasis on inclusive ownership to engage a fuller spectrum of state and non-state actors in fragile states and transitional environments.

The article briefly traces the history of the Global Polio Eradication Initiative (GPEI), noting that, by 2003, at the onset of war in Iraq, indigenous polio was confined to 2 distinct types of areas: conflict zones (Somalia and Afghanistan), where access for vaccinator teams was difficult and dangerous, and the economically poorest regions with the worst development indicators, such as the northern governorates of Nigeria, its impoverished neighbour Niger, and impoverished areas of Pakistan and India. Fortunately, scaled-up outreach efforts to build public trust and increase participation in vaccination campaigns began to have a marked impact on vaccination uptake. Yet, the 2013 outbreak of polio in Somalia and the 2014 cases in Iraq and Syria highlighted 3 trends in human security that redefined the challenges of cooperation between international and local agendas: (i) politically motivated resistance to Western and secular objectives backed by a core cadre of experienced fighters moving internationally with pan-Islamic or jihadist motives - any increase in movement linking polio reservoirs with conflict zones or otherwise insecure, enclaved communities presents a clear risk for polio containment. (ii) the many profound ideological differences between Salafist values and those espoused by Western development models have been aggravated by a perception that the West and its allies are both insincere and untrustworthy - the well-documented Nigeria polio vaccine boycott (discussed in detail here) demonstrates how local mistrust, fuelled by ideological opposition to Western engagement in other Islamic settings, can create complex entanglements with local political power plays to trap global initiatives. "The Nigerian experience proved that leveraging global, 'moderate' Islamic support is no longer always the key to securing the trust of poorer and more conservative local factions with their own specific interests to protect." (iii) a new "legitimisation" of aid-worker targeting - vaccinators have been killed in Pakistan and Nigeria, including in Boko Haram operational territory.

Hajaj and Reitano stress that, while ideologies have certainly played a major role in this trend, they are not solely responsible. "Insistence on repeated polio vaccination over other diseases of public concern has created fatigue, resentment, suspicion and resistance even without the complications of active conflict. The high-profile 'flagship' approach to polio eradication by the international community has also made the initiative an equally high-profile target for local rejection and protest....A senior official in the Somali Ministry of Health recently expressed the common view that the emphasis placed on the polio vaccine above all of these other priorities appears self-serving on the part of the UN [United Nations] and NGOs [non-governmental organisations]..." The article explores the ways in which polio has become mixed up in a polarising political agenda in Syria, where the delivery of humanitarian assistance has become increasingly an issue of confrontation.

In this context, the authors ask: "How can local health workers be persuaded to risk their lives for little perceived local benefit in comparison to other needs? And can a high-profile global initiative be reconciled to intransigent local forces playing out a political drama beyond its control, with built-in incentives to hold it hostage?....Can the polio eradication prove, as it once did, that common ground can be found in the unlikeliest of circumstances? The answer is a cautious yes with caveats." They suggest that:

  • The polio eradication drive could consider shifting from a flagship programme to a more holistic approach that integrates polio advocacy into more convincing programmes for public health and social justice. "Never before has it been so important to demonstrate proportional concern to meet the urgent basic needs of vulnerable populations, and to deliver visible results....[T]his is the first step towards a more open and sincere relationship."
  • Rather than empowering state-actors and institutions, "consider a more open and inclusive sharing of program ownership to include non-state actors willing to enter into dialogue. Such an approach would require engagement with appropriate brokers as an extensive and detailed mapping of local political, economic and ideological interests at a micro-community level....The difference between polio's trajectory in Afghanistan and Pakistan demonstrates clearly how sensitive development cooperation can be to local power balances."
  • "The UN and international community "need to establish a long-term presence within vulnerable Islamic communities, to build trust based on mutual understanding rather than 'parachuting' in for crises or to further specific global program agendas."

In conclusion: "The powerful human drive to unite around the innocent often requires customized and nuanced engagement to ignite in these complex ideological settings. Polio has shown before how this can be achieved. But once ignited, it must be supported and rewarded with something more lasting and meaningful from governments than just vaccine drops."


Global Health Governance, Volume X, No. 2 (Fall 2016), pp. 64-79. Image credit: UNICEF/NYHQ2013-0919/Razan Rashidi