As the American media continues to inexplicably divert its attention from the conflicts and disease ravaging through several countries in Africa in favor of the ongoing violence in Syria and Iraq, a similar situation to that which characterizes Western Africa has re-emerged in the more remote regions of Afghanistan: an outbreak of an infectious and deadly disease.

In the 21st century, the world has reached a level of interdependence and connectivity that far outdistances any in human history. The capacity for human beings to travel to areas lacking basic medical care has increased exponentially in the last 100 years. With this flattened world structure comes a heightened risk of spreading disease at epidemic rates.

Throughout the summer months of 2014, health and aid workers in Afghanistan once again began sounding the alarm about a rising threat of polio infection in Eastern Afghanistan. Kunar and Khost Provinces, specifically, have experienced a rise in the rate of infection and a staggering escalation of violence targeting health workers who labor to eradicate the disease.

The rise in polio infections was noted in the summer of 2012 when cultural aversion, insurgent intimidation, and fundamentalist religious beliefs conflated in Shigal District, Kunar province to present a difficult work environment for prospective medical vaccination teams:

More than 10,000 children in Afghanistan’s Kunar province have missed out on polio vaccinations because both insurgents and local radio stations have campaigned against the programme, health officials say.

Three people have contracted polio this year, and 10,250 children have not received the vaccine in the Sarkano, Khas Kunar, Marawara, Shigal, Nari and Watapur districts, according to the head of the provincial public health department.

Two FM radio stations are warning residents not to vaccinate their children, while some refugees returning from Pakistan are spreading the same message, officials said.

Residents claim they are being warned that the inoculations are “haram”, or forbidden by Islam, and that the vaccine may cause disease.

Hazrat Gul, a 45-year-old resident of Shigal district, is among the parents who have not vaccinated their children.

“This is a border area and we have been threatened that if anyone receives this vaccine, they will not have a pleasant time,” he said. (Institute for War and Peace Reporting, August 29, 2012)

Previously, health officials had noted a decrease in the number of cases in eastern Afghanistan, particularly in Khost. However, recent migration of refugees fleeing the Pakistani military offensive in North Waziristan that the government launched in June has catalyzed a fear of the spreading of the disease:

Rahmat Khel, head of vaccination in the provincial health department, told IWPR that no new polio cases had been seen in Khost since 2012, but concerns were raised when people started arriving this summer.

The Pakistani Taleban have systematically targeted and killed vaccination workers, whom they regard as agents of the West.

According to Mashal Radio, 80 new cases of polio were recorded in North Waziristan in 2013 and 2014.

Afghan health officials have embarked on an emergency vaccination programme among the refugees who have arrived in Khost.

Hedayatullah Hamidi, director of public health in Khost, told IWPR that his staff had identified one confirmed case and nine possibles among the incoming refugee population, and had forwarded the test results to Kabul and Islamabad. (Institute for War and Peace Reporting, August 22)

In recent years, fundamentalist ideology and the violence that often accompanies it in the Tribal Areas of Pakistan has threatened to once again raise the rate of polio infection beyond sustainable levels. On September 10, gunmen shot and killed a member of tribal police charged with guarding a polio vaccination team in Damadola of Bajaur Agency in Northwestern Pakistan:

Officials said the attack took place on September 10 in Damadola area of Bajaur, a tribal area on the border with Afghanistan where polio is a serious problem.

Nobody has claimed responsibility for the assault, but the Pakistani Taliban have attacked polio workers in the past, claiming the vaccination program is a cover for espionage.

According to AFP news agency, about 58 people have been killed in militant attacks on polio vaccination teams in Pakistan since late 2012.

Pakistan is one of only three countries, along with Afghanistan and Nigeria, where polio is endemic. (RFE/RL, September 10)

On August 9, a public health official stated that new cases of polio had emerged in the remote and insurgent-saturated province of Kunar in eastern Afghanistan. Specifically citing a lack of security, aid workers have expressed frustration with their inability to vaccinate thousands of at-risk children in the province. Khan Wali Sarazai of Pajhwok Afghan News reported:

Last month, a polio case was registered in the militancy-plagued Shaltan valley of Shegal district, where an 18-month-old girl, Qaneta, was found suffering from the crippling disease.

Mohammad Ishaq, in charge of the polio vaccination branch at the Department of Public Health, identified the victims as 24-month-old Kamran and 15-month-old Jawad.

In an exclusive talk with Pajhwok Afghan News, Ishaq said that Kamran’s father had refused to have his children vaccinated against polio. And despite a campaign in Asmar, children have relapsed into the disease. (Pajhwok Afghan News, August 9)

For their part, the local Taliban insurgent network warned that the Afghan government should concern itself with other matters and disengage from efforts to eradicate the deadly disease from Kunar:

On the other hand, the insurgents said they had never impeded a vaccination campaign. “If the government can conduct it, the anti-polio drive should be left to the Taliban,” the group’s spokesman said.

But Zabihullah Mujahid accused the authorities of sending intelligence operatives in the guise of health volunteers to Taliban-dominated areas. He said the fighters would naturally obstruct such individuals. (Pajhwok Afghan News, August 9)

As is often the case with aid and development work in the restive and mountainous areas of Eastern Afghanistan, medical personnel dedicated to the eradication of highly contagious and deadly diseases such as polio run afoul of local insurgent groups while administering medical assistance. A confluence of culturally-derived xenophobia and a mixture of fundamentalist-inspired anti-western rhetoric fuels an intense distrust of aid workers and medical personnel who work tirelessly to prevent spread of disease. In Asadabad, the capital of Kunar Province, an aid worker was killed by militants in the province on September 23.

This antipathy towards medical teams could inspire an intense and dramatic rise in the rates of polio infection in both the Pakistani tribal areas and Eastern Afghanistan. While aid workers have continued to brave security environments in which Afghan forces lack the will or the support necessary to ensure control, medical teams have encountered cultural aversion to vaccination not unlike that which plagues many areas of the Pakistani tribal areas:

People’s attitudes toward the vaccine are another challenge.

In a dusty hillside neighborhood of Bagh Qazi, Freshta Faizi, a volunteer, trudged from house to house on Monday, asking residents if their children had been given their drops.

“Sometimes they just say no and shut the door,” said Faizi. “They say it won’t make any difference. I’ve had people tell me the vaccine is just American urine.”

In August, Human Rights Watch reported that in parts of the southern province of Helmand, the Taliban had stopped health officials from sending out mobile vaccination teams.

That was an alarming development, because – unlike some militant factions in Pakistan, which have targeted and killed anti-polio campaigners – the Afghan Taliban have pledged support for vaccination. (Krista Mahr and Mirwais Harooni, Reuters, August 21)

The threat of disease epidemics such as polio links the futures of Pakistan and Afghanistan. Medical professionals who note that the genetic origins of the polio strain plaguing both countries are in Pakistan often comment about the difficultly in surmounting dogmatic opposition to vaccination. The battle to stem the rising tide of the disease in Eastern Afghanistan is approaching levels that could overwhelm both governments in Kabul and Islamabad if not effectively contained in the coming months. Again linking the :

Complicating matters, this summer over 150,000 refugees from North Waziristan, a tribal region of Pakistan where leaders banned the polio vaccine in 2012, poured over the border into Afghanistan, seeking refuge from a military offensive against insurgents.

The influx from an area that has generated most of Pakistan’s polio cases this year immediately raised alarm.

Most of Afghanistan’s new cases of polio this year are genetically linked to Pakistan, according to HealthNet TPO. But the government says that, so far, only one case has been identified as having coming from a North Waziristan refugee.

The flood of refugees yielded an unexpected opportunity, however: over 400,000 vaccine doses were given out in Pakistan along the routes residents used to flee their homes, according to the Global Polio Eradication Initiative.

That’s good news for the global fight to exterminate polio and particularly for Afghanistan, where thousands of residents move across the Pakistan border every day.

“If there is control in Pakistan, there will be control in Afghanistan,” said Siddiqi. “If there is no control in Pakistan, the problems in Afghanistan will continue.” (Krista Mahr and Mirwais Harooni, Reuters, August 21)

What is past is truly prologue. If gone untreated, small outbreaks of disease risk spreading to cities with even the most advanced vaccination efforts and medical expertise. As the world has witnessed with the outbreak of ebola in Western Africa, the risk of global epidemic runs highest when cultural aversion to medical treatment and the risk of an erosion of security impede the efforts of medical experts to head off disease before it spreads to communities with dense populations and a transient traveler environment. Dogmas and fear are the enemies of public health.