Print version ISSN 0042-9686
Bull World Health Organ vol.78 n.3 Genebra Mar. 2000
Polio, war and peace
Research Fellow, Centre for Foreign Policy Studies, Dalhousie University, Halifax, Canada. Current address: 14 chemin Colladon, 1209 Geneva, Switzerland
The central obstacle to polio eradication is not technical. After 11 years of concerted effort, it would appear that the necessary competence on the technical side of polio eradication has been achieved. This is illustrated amply in the successful eradication of polio from large parts of the planet. Rather, a key challenge to polio eradication is war or, more accurately, militarized violence as demonstrated in the continued prevalence of polio in a number of war-torn countries. In Africa these include Angola, Democratic Republic of Congo, Liberia, Sierra Leone, Somalia, and south Sudan. In Asia they include Afghanistan and Tajikistan.
The reason for militarized violence being such an obstacle to polio eradication is related to the changing nature of this form of violence, which now leaves limited space for health or humanitarian interventions. From Afghanistan to Bosnia to Rwanda, contemporary conflicts are increasingly dirty that is, the principal weapon of war is terror. Not only do war-makers systematically target civilians including children but they employ broad strategies of social, political and territorial control by the manipulation of fear. This includes scorched earth tactics designed to starve civilian populations and destroy infrastructure, as well as hacking off limbs, sexual torture, mass rape, ethnic and social cleansing, and genocide. According to a recent Swedish study, the civilian casualty rate in todays conflicts is estimated to be 84%, compared with 15% in the First World War and 65% in the Second World War (1).
Countries which have endured such conflicts have seen vast amounts of resources, both economic and human, diverted to support military actions. War-torn countries often find themselves in a state of complete economic and social collapse. Victory, if ever finally declared, has a very hollow ring indeed. In such conflicts there are no victors, only victims.
The central question raised by the articles in this issue by R. Tangermann et al. (2) and F. Valente et al. (3) is: how can development work continue in the midst of such violence? Amazingly, in the case of polio eradication we have seen that it is possible to have a positive developmental impact, even under conditions of war. Childrens health can become a superordinate goal on which interests can converge across battle lines to induce the cooperation necessary for immunization campaigns. Cambodia, El Salvador, Lebanon, and the Philippines provide important instances of this, from which lessons can be either learned or (as is too often the case) spurned.
In this context, the challenge is to monitor the impact of the conflict environment on immunization initiatives. However, it is equally important to consider the impact such initiatives may have on the conflict environment, because this may be the critical factor in explaining how interventions of this kind are possible in the midst of such brutalizing wars. This has important implications not just for the eradication of polio, but for the achievement of broader health objectives and ultimately the attainment of some semblance of sustainable peace.
There can be little doubt that the health impact of the polio eradication initiative has been profound in both war and non-war zones. The access that has been achieved under difficult circumstances has exceeded all expectations. For example, the National Immunization Days in the Democratic Republic of the Congo from 13 to 15 August 1999 reached an estimated 80% of the approximately 10 million children in that country. Despite fighting in the north-eastern city of Kisangani, 91% of the children there were immunized. Similarly, in Sri Lanka, in September and October 1999, Days of Tranquillity were established to permit the immunization of all children in the country for the fifth time since the conflict spiralled into violence in 1984 (2). Thus, for four days, government forces and anti-government forces laid down their arms to allow the campaign to take place. According to some experts, Sri Lanka may now be free of polio (4).
While the health impact of these immunization days is certainly appreciated, their peace-building impact is less widely recognized. However, there is a growing understanding among development workers on the ground that immunization days may be having a positive impact on efforts to end conflicts. For example, in the Batticaloa District of Sri Lanka, the process of organizing days of tranquillity in the war zone cultivated important informal channels of communication and cooperation across political and ethnic divides. These channels appear to have been central to the negotiations which finally brought electricity back to the region. In Somalia, the demand from the local population that their children be immunized led local leaders to de-mine roads to permit access for vaccination teams. Decrees were issued that no weapons were to be displayed on the days of the immunization campaigns. Such events have contributed both directly and indirectly to peace-building.
Years ago, the economist Albert Hirschman introduced the concept of the hiding hand (5). He used the phrase to refer to a collection of obstacles, problems, and headaches that appear during the life of a project, which if we had known about them when we started might have dissuaded us from starting in the first place. War, in the context of the campaign to eradicate polio, is a very large and no longer hiding hand that has to be tackled if we hope to meet the goal of eradicating polio from the face of the planet. The operative verb here is eradicate not minimize, not control, not contain. Such a grand, naïve and now attainable idea is what may enable us to see ourselves as a global community as opposed to simply a collection of self-interested and atomistic states. At the end of the bloodiest century of the millennium, this would be no small feat.
1. SIPRI yearbook 1999: armaments, disarmament and international security. Oxford, Oxford University Press, 1999.
2. Tangermann R et al. Eradication of poliomyelitis in countries affected by conflict. Bulletin of the World Health Organization, 2000, 78: 330338.
3. Valente F et al. Massive outbreak of poliomyelitis caused by type-3 wild poliovirus in Angola in 1999. Bulletin of the World Health Organization, 2000, 78: 339346.
4. Hull HF, Fighting Stops for Polio Immunization, updated, 14 December 1999. http://www.who.int/inf/polio.html
5. Hirschman O. Development projects observed, Washington, DC, Brookings Institution, 1967.