In June 2012, North Waziristan’s Taliban leader issued a fatwa banning polio vaccination campaigns. Other Pakistani Taliban leaders in Khyber Pakhtunkhwa and South Waziristan quickly followed suit. Pamphlets dispersed throughout these regions made it known that anyone involved in the vaccination campaign moving forward would be subject to great loss and harm.
That harm came swiftly.
In Karachi, a doctor working for the polio program was shot while traveling through a resistant part of the city. One by one, polio vaccinators—predominantly women working for just a few dollars a day—were being targeted and killed. Police officers assigned to protect them would soon meet the same fate. By 2015, an estimated 70 polio vaccine workers had been assassinated.
It wasn’t because the Taliban was against vaccination. In fact, militant groups in Pakistan and Afghanistan had been facilitating access and guaranteeing vaccine coverage in their territories for years. But in these particular conflict-affected areas, polio eradication was a powerful leverage point. The communities stifling polio campaigns backed by the United States and Western nations were the same communities being brought to their knees by U.S. drone strikes. In this political minefield, anti-Western narratives easily took root. The Taliban’s 2012 directive was firm: stop the drone strikes and we’ll allow vaccination.
The Taliban’s directive was firm: stop the drone strikes and we’ll allow vaccination.
The unexpected recipient of that message was the Global Polio Eradication Initiative, the only public health program that sends vaccinators door-to-door in remote, underserved communities throughout the world. They aim to reach every child under-five with polio drops, multiple times, until virus transmission is interrupted.
Equipped with vaccine coolers, vaccination teams set off in the earliest hours of the morning. They often walk for miles to reach communities left behind by health systems and basic infrastructure. Outside of every home they visit, they leave a small mark. Sometimes these markings look like fractions, denoting the number of children vaccinated out of the total number of children living there. Other times they are big X’s, signifying a household that refused the vaccine altogether. In areas that lack centralized and accurate data on their residents, these symbols scrawled across doorways, gates, and makeshift entryways ensure that every child is counted and, ideally, protected.
For nearly a decade, we worked as behavior change specialists for UNICEF’s polio eradication team, one of the core member-organizations of the Global Polio Eradication Initiative. We were just two out of hundreds of national and international civil servants, alongside tens of thousands of frontline workers striving toward the same, singular objective—eliminate polio from the Earth, so that no child has to suffer from a lifetime of preventable paralysis. In the 1980s and 90s, polio was paralyzing over 350,000 kids each year. Because of efforts like this one, by 2011 that number was down to several hundred cases a year.
The global strategy to build demand for the polio vaccine was to increase knowledge and awareness of the dangers of polio among parents with young children. Before each campaign, radio and TV spots would air, and thousands of health workers and community mobilizers would take to the streets, often with megaphones in hand, to announce campaign dates and to remind parents to make sure that their children were home when the vaccinators came knocking. By 2011, that approach had successfully eradicated wild poliovirus in all but three countries in the world: Nigeria, Afghanistan, and Pakistan.
One by one, polio vaccinators—predominantly women working for just a few dollars a day—were being targeted and killed . . . By 2015, an estimated 70 polio vaccine workers had been assassinated.
In northern Nigeria and other countries, there had been incidents of rock throwing, knife wielding, and even cases of vaccinators getting kidnapped by aggressive resistors to the vaccine. It was not uncommon for communities to furnish a list of demands in exchange for vaccinating their children. These would often include paved roads or reliable electricity: things that were vital, if difficult, to deliver. The program was no stranger to resistance, but the violence erupting in Pakistan was unlike anything the public health world had ever witnessed.
At first, we saw the bans in the same way we saw the rocks, blades, and lists brandished at vaccinators: reckless, instead of relatable. How could they use their children as a bargaining chip? How could they not want to protect their children?
We began to realize that we were asking the wrong questions.
Behind the polio bans were some of the poorest, most marginalized communities in the world. Like all parents, they wanted the best for their kids. For us, that meant vaccines. For them, it meant safe roads, school buildings, and health clinics. It meant clear and harmless skies. Doorways free of fractions that might turn their homes into targets. Taliban leaders may not have been fully representing community views, but everyone was trying to protect their children in the way that made the most sense for their context—a context we didn’t fully understand.
Complicating matters further was the recent news that the CIA used a door-to-door vaccine campaign in 2011 to confirm Osama bin Laden’s whereabouts. Their fraudulent campaign was for hepatitis B, but it didn’t matter. The process was stained. The national polio eradication effort, known by every Pakistani as the dose brought to your door, was now inextricably linked to U.S. surveillance.
The violence in Pakistan was our first encounter with the notion that the Global Polio Eradication Initiative’s singular approach to disease eradication could fail or, worse, do harm. The model that relied on a consistent supply of vaccines conveniently delivered to households was not fit for purpose in these conflict-affected, deeply polarized communities. This epidemiological approach didn’t sufficiently consider the cultural, social, and political webs that these children and their parents were tangled within.
Like all parents, they wanted the best for their kids. For us, that meant vaccines. For them, it meant . . . clear and harmless skies.
Until this point, our role had been to design strategies to motivate parents to vaccinate their children, not militant leaders taking the reins of underserved, war-torn communities. We felt monumentally ill-equipped to design behavioral strategies that could motivate the Taliban, or the communities they represented, to welcome vaccination given all that it represented. Suddenly, the long-established model felt too small. Yet we felt we had to do something. Every month under the Taliban’s decree left 200,000 children under the age of five unvaccinated.
We decided to break the model wide open. We got in touch with people who could offer a view from the outside of the program. We phoned political scientists and writers, behavioral researchers and pollsters, social marketers, security experts, filmmakers, musicians, and artists. We sought the people who understood the heartbeat of Pakistan, the patterns of the Taliban, and the ways of Pashtun tribes. We gathered those fluent in the dynamics of conflict, politics, and negotiation.
We brought these individuals together with our Pakistani colleagues in a Dutch conference room off the North Sea. We wanted everyone to use the neutral ground to share their distinct perspectives. With the help of these fresh eyes, we could see the harm of sending unfamiliar vaccinators into the homes of families who had become much too familiar with danger and its countless shapes. We could recognize the irony of a free health service delivered by foreign and domestic governments who filled their skies with smoke and left their streets abandoned. By the end of the week, people who had never thought about polio eradication were working alongside those who had dedicated their lives to it, cocreating solutions to a crisis that had long been mistaken as purely biomedical.
If we wanted a chance at restoring the vaccination campaign and eliminating polio, the program would need to change its face. There needed to be a public handoff to local Pakistani, Islamic, and Pashtun leaders. Vaccine coolers reading END POLIO NOW in English would need to be revised, recolored, and delivered in Urdu or, ideally, Pashto. The call to vaccinate needed to come more publicly from Muslim and Pashtun organizations and individuals that people could trust. The program would need to engage with communities to ensure that vaccination, and health care in general, was respectfully delivered and presented to meet their needs, not ours.
To understand the fabric of communities is just as important as biomedical science to design equitable and effective public health policies.
These ideas didn’t change the program overnight. It would take much more than a conference room full of hopefuls to change a 25-year-old global eradication effort. But these discussions planted seeds of possibility among us and others in the program. It was clear that public health could and should be collaborative, interdisciplinary, creative, and designed for those at the center of it. We left our jobs and founded Common Thread to focus full-time on building a new approach to public health guided by these principles.
In our work today, we try to ask the questions we didn’t know to ask back in 2012. How can we incorporate local culture, social norms, and politics into every public health strategy? How can the lived experiences of those we aim to serve change the way we design health services? How do we create solutions that respond to the needs, desires, and behavior of people living under pressures we can never fully comprehend? How do we cater to the beliefs of the resistant and those with radically opposite views?
We now know that to disparage those who oppose public health measures only deepens the divide. We now know, too, that to understand the fabric of communities is just as important as biomedical science to design equitable and effective public health policies. But most of all, we know that these lessons, and these questions, are only the beginning—and that by seeking to understand communities and honor their priorities as our own, we can find a path to better health for everyone.
This article first appeared in Behavioral Scientist’s award-winning print edition, Brain Meets World.
