Jonathan Kennedy

This article investigates whether the United States' counterinsurgency operations have inhibited polio eradication efforts in northwestern Pakistan, the world's last major reservoir of polio. Anecdotal evidence suggests that militants disrupt polio vaccination programs because of suspicions that campaigns are a cover for gathering intelligence on Central Intelligence Agency (CIA) drone targets. This paper analyzes national-level quantitative data to test this argument. Between 2004 and 2012, the number of polio cases in Pakistan closely mirrored the number of drone strikes. But from 2013 onward, polio cases increased while drone strikes fell. This can be explained by the CIA's use of a fake immunization campaign in a failed attempt to obtain the DNA of Osama bin Laden's relatives prior to his assassination in 2011. This seemingly vindicated militants' suspicions that vaccination programs were a cover for espionage. Militants consequently intensified their disruption of immunization campaigns, resulting in an increase in polio cases in Pakistan, as well as in Afghanistan, Syria, and Iraq. For politicians and military planners, drones are attractive because they are said to harm fewer civilians than conventional methods of warfare. However, this paper demonstrates that drone strikes had negative effects on the well-being of civilians in Pakistan and further afield because they undermined global efforts to eradicate polio.

States and the World Health Organization (WHO), an international organization that is mandated to respect the sovereignty of its member states, are still the leading actors in global health. This paper explores how this discrepancy inhibits the ability of global health partnerships to implement programmes in conflict-affected areas that are under the de facto control of rebel organizations. We concentrate on a single crucial case, the polio outbreak in Syria in 2013, analysing a variety of qualitative data—twenty semi-structured interviews with key actors, official documents, and media re-ports—in order to investigate the events that preceded and followed this event. The WHO's mandate to respect the Syrian government's sovereignty inhibited its ability to prevent, identify and contain the outbreak because the Assad regime refused it permission to operate in rebel-controlled areas. The polio outbreak was identified and contained by organizations operating outside the United Nations (UN) system that disregarded the Syrian government's sovereignty claims and cooperated with the militants. Thus, we identify a serious problem with so-called global health partnerships in which nation states and international organizations remain key actors. Such initiatives function well in situations where there is a capable state that is concerned with the welfare of its citizens and has exclusivity of jurisdiction over its territory. But they can encounter difficulties in areas where rebels challenge the state's sovereignty. Although the response to the Syrian polio outbreak was ultimately effective, it was reactive, ad hoc, slow and relied on personnel who had little experience. Global health partnerships would be more effective in conflict-affected areas if they put in place proactive and institutionalized plans to implement their programmes in regions outside government control. • The WHO's mandate to respect the Syrian government's sovereignty inhibited its ability to prevent, identify and contain the polio outbreak in Syria in 2013. • The polio outbreak was identified and contained by organizations that disregarded the Syrian government's sovereignty claims and cooperated with the militants. Although these organizations were ultimately effective, they were reactive, ad hoc, slow and relied on with limited experience personnel. • Global health partnerships would benefit from putting in place proactive and institutionalized plans to implement their programmes in conflict-affect areas that are outside government control.

Background: There is widespread agreement that civil war obstructs efforts to eradicate polio. It is suggested that Islamist insurgents have a particularly negative effect on vaccination programmes, but this claim is controversial.

Methods: We analyse cross-national data for the period 2003-14 using negative binomial regressions to investigate the relationship between Islamist and non-Islamist insurgency and the global distribution of polio. The dependent variable is the annual number of polio cases in a country according to the WHO. Insurgency is operationalized as armed conflict between the state and an insurgent organization resulting in ≥25 battle deaths per year according to the Uppsala Conflict Data Programme. Insurgencies are divided into Islamist and non-Islamist insurgencies. We control for other possible explanatory variables.

Results: Islamist insurgency did not have a significant positive relationship with polio throughout the whole period. But in the past few years – since the assassination of Osama bin Laden in 2011– Islamist insurgency has had a strong effect on where polio cases occur. The evidence for a relationship between non-Islamist insurgency and polio is less compelling and where there is a relationship it is either spurious or driven by ecological fallacy.

Conclusions: Only particular forms of internal armed conflict – those prosecuted by Islamist insurgents – explain the current global distribution of polio. The variation over time in the relationship between Islamist insurgency and polio suggests that Islamist insurgent’s hostility to polio vaccinations programmes is not the result of their theology, as the core tenets of Islam have not changed over the period of the study. Rather, our analysis indicates that it is a plausibly a reaction to the counterinsurgency strategies used against Islamist insurgents. The assassination of Osama bin Laden and the use of drone strikes seemingly vindicated Islamist insurgents’ suspicions that immunization drives are a cover for espionage activities.

Keywords: Polio eradication, Vaccination programmes, Civil War, Insurgency, Islamism, Taliban, Boko Haram, Al-Qaeda, Osama bin Laden, Political determinants of health.

This paper analyses a unique district-level dataset to demonstrate that mineral abundance increased the probably of Maoist insurgency in India over the past three decades. Nevertheless, we show that this finding must be qualified in two respects. First, mineral abundance has a much stronger effect on the probability of insurgency after the liberalization of the mining sector in the mid-1990s, which precipitated the rapid expansion of mining and related activities. Second, mineral abundance has a much stronger effect on the probability of insurgency in the central Indian tribal belt, where communities have strong symbolic and material links with nature. Our analysis contributes to the broader debate on resource conflicts, which is largely informed by cross-national statistical analyses. It suggests that abundant natural resources do not mechanically increase the probability of insurgency. Rather, economic policy and social structure play a crucial but overlooked role in mediating this relationship.

Para derrotar el virus tendremos que superar las caricaturas de los OPINIÓN El islamismo militante y el escepticismo sobre la vacunas La posición que los insurgentes islamistas adoptan sobre las campañas de vacunación contra la polio tiene más que ver con la dinámica del conflicto en que están inmersos