Analysis of attacks on polio workers in Pakistan
Authors: Shiva Shah, Zachary Horsington
Notable contributors: Ishan Ray, Benjamin Lapping, Ria Nerlikar, Nicholas Crowther
First published: July 2021 Last updated: September 2021
Key judgements
The recent announcement of vaccination efforts and the increase in the number and lethality of attacks across 3-year intervals is indicative of an increasing likelihood of violence.
Attacks are concentrated in remote urban and rural settlements in the KPK region, they are primarily driven by the proliferation of anti-vaccine disinformation, discontent with government services and institutions
The Taliban’s takeover in Afghanistan poses a general threat to the safety and security of individuals and teams operating in the KPK region.
Context:
The use of false vaccination drives to enable the assassination of Osama Bin-Laden in 2011 had led to a nationwide surge in violent attacks against healthcare professionals involved in combatting the ongoing polio epidemic in Pakistan. While initially conducted by Islamist militant groups, the threat of attack against vaccine teams has been dispersed across a variety of actors and has persisted till date. Fatalities have begun to rise to pre-COVID 19 levels as of July 2021.
Threats to the internal security and stability of Pakistan are produced by complex interactions between its multi-ethnic social fabric and dysfunctional political and economic institutions, defined by institutional corruption, Islamic extremism and socioeconomic inequalities. This is reflective in both the historical and current factors responsible for the risk of violence faced by vaccine teams.
Breakdown of historical trends:
Phase 1 (2011-2014)
The assassination of Osama Bin-Laden enabled by intelligence provided by false vaccination drives leads to a spike in the targeting of polio vaccination teams driven by a desire for retribution and suspicions about future targeting
Phase 2 (2014-2016)
The declaration of a polio epidemic sees a small surge of polio workers into high-risk areas leading to more attacks
Campaigns’ intersection with the US drone program leads to higher levels of public discontent in the northern provinces
Phase 3 (2016-2018)
Consistent increases in total fatalities, the highest total of fatalities to incidences compared to prior phases
Multiple declarations of epidemics across the period
Decreased US-Pakistan diplomatic and security cooperation due to tensions with China and foreign policy under Trump
Analysis of key judgements:
1. The continued correlation of the increase in the number and lethality of attacks with announcements of vaccination efforts is indicative of an increasing likelihood of future violence.
Breakdown of current trends (2018-Present)
As government priorities begin to shift away from the management of the COVID 19 crisis towards more routine issues, national leadership will be incentivized to resume efforts to tackle humanitarian and developmental issues that are of international interest as a means of improving the state's external image and reputation. On the 14th of June 2021, Pakistan resumed anti-polio vaccination efforts. The resumption was subsequently followed by a sharp rise in the number of fatal attacks. This development is consistent with the historical correlation of increases in attacks with the announcement and initiation of state-sponsored, large-scale vaccination campaigns.
As of July 2021, Prime Minister Khan has publicly reaffirmed the administration’s intent to continue efforts towards the eradication of polio in partnership with the Global Polio Eradication Initiative (GPEI) and the Gates Foundation via a number of statements.
As government priorities begin to shift away from the management of the COVID 19 crisis towards more routine issues, national leadership will be incentivized to resume efforts to tackle humanitarian and developmental issues that are of international interest as a means of improving the state's external image and reputation. On the 14th of June 2021, Pakistan resumed anti-polio vaccination efforts. The resumption was subsequently followed by a sharp rise in the number of fatal attacks. This development is consistent with the historical correlation of increases in attacks with the announcement and initiation of state-sponsored, large-scale vaccination campaigns.
As of July 2021, Prime Minister Khan has publicly reaffirmed the administration’s intent to continue efforts towards the eradication of polio in partnership with the Global Polio Eradication Initiative (GPEI) and the Gates Foundation via a number of statements.
At present, violence is returning to pre COVID-19 levels. Attacks against vaccine teams are primarily comprised of random acts of physical violence or armed assault orchestrated by groups or individuals from the general public. They are also perpetrated by members of regional militant groups who have reemerged as a small, yet critical proportion of the violence. Unlike their civilian counterparts, militants are primarily known to attack police and security forces guarding vaccine teams.
There has also been an increase in such incidents on either side of the northern border with Afghanistan. Notably, gunmen killed a polio vaccine police escort, (12 Jan 2021), a roadside bomb targeted another polio vaccine police escort (18 Feb 2021), and two police officers protecting a polio vaccination team were shot (9 June 2021). This coincides with the resurgence of Taliban activity prior to US and allied withdrawal and the august 15th takeover
2. Attacks are concentrated in remote urban and rural settlements in the KPK region, they are primarily driven by the proliferation of anti-vaccine disinformation, discontent with government services and institutions.
Disinformation campaigns:
In 2019 the Pakistan Telecommunications Authority (PTA) ordered the removal of a total of 174 links associated with the spread of dinsformation regarding the effects and motivations behind the polio vaccine and vaccination efforts. 130 sources were from Facebook, 14 from Twitter and 30 from YouTube (tribune). This only represents a small proportion of the articles and sources of anti-vaccine disinformation circulating in the region today.
Central elements of anti-vaccine disinformation campaigns include anti-Islamic or haram ingredients or properties, sterilizing, fatal or other harmful side effects deliberately intended by foreign actors. Articles of disinformation also take advantage of existing conspiracy theories and fundamentalist rhetoric to frame effects as an existential threat to both the shared values and lives of its target audience, generating a sense of paranoia and panic.
Articles are distributed through both physical and digital means, with sites offering printable pamphlets and infographics as well, widening their reach to rural communities with limited access to internet and telecommunications services. Facebook and Twitter pages act as hubs for the transmission of articles to less active or previously unpolarized users.
Further investigation into sources and audience has revealed the following:
While a large number of major hubs may have been eliminated, the viral nature of popular articles and media has sustained their circulation. With anti-vaccine related content continuing to circulate via smaller, local influencers on private and peer-to-peer platforms such as Telegram and WhatsApp
Some major hubs that continue to remain or have merged post the 2019 purge have received significantly less engagement relative to their counterparts.
While the spread of the disinformation is national, articles collected and identified by GSI can be attributed to individuals located or associated with the KPK region.
Servers hosting such sites appear to be masking their identities through the use of Virtual Private Servers (VPSs) attributed to organisations known to host the content of similar Islamic fundamentalist organizations.
Spatial overview of recent incidents
Geographic concentration of attacks:
Analysis of incidents aggregated by conflict observatories and local news sources point to the majority of attacks having taken place in the KPK region. Attacks also tend to take place outside the limits of urban population centers and are primarily concentrated in surrounding semi-urban and rural settlements. This is mainly due to the designation of these areas as polio hotspots. Such settlements are also affected by a number of issues with immediate-term effects on the overall quality of life and socio-economic development of the community. While these factors may not necessitate the flight to violence alone, the combination of grievances against state institutions with distrust generated via disinformation may contribute to the likelihood of attacks.
Such issues include:
Limited access to essential services and utilities such as hospitals, electricity and clean water.
Ageing, damaged or unmaintained roads, electricity and telecommunications grids and other critical infrastructure.
Deteriorating economic conditions due to the diminishing returns of local agriculture and industries.
The absence of state efforts to sufficiently address such issues has given way to a sense of discontent and resentment towards the agenda of the national and regional government. As a result, affected populations tend to perceive the spread of polio as relatively insignificant in contrast to higher priority issues. Members of such communities have been known to resist or demonstrate hostility towards vaccination efforts as a form of leverage or protest.
More recently, residents of the Batwar locality of Salarzai tehsil in Bajaur tribal district, KPK held a boycott of vaccination drives in protest of the weak mobile signal coverage in the area. It was called off on the 9th of June 2021 as health officials informed the community that the administration was not responsible for the matter.
Widespread discontent caused by socioeconomic grievances may also be linked to attacks via the increased support for militant groups. The failure of state and regional institutions to address communal grievances facilitates higher levels of radicalization. Sympathetic individuals may be led to adopt militants’ views on vaccination, leading to an increased rate of incidents.
Polio eradication efforts are also primarily perceived as a product of western political influence. Areas within the KPK region were disproportionately affected by US drone strikes conducted as part of various counterterrorism operations since2014. Consequently, members of the public are further incentivized to align with the narratives and agendas of militant groups due to the grievances caused by previous western interventions.
3. The Taliban’s takeover of Afghanistan poses a general threat to the safety and security of individuals and teams operating in the KPK region.
Growing Influence and Expanding Capabilities of Militant Groups:
Covert Afghan Taliban networks housed with coal miners in the mountains of Baluchistan province have been soliciting large flows of cash contributions from locals, consolidating influence over the citizenry and eroding government authority in the region. Militant groups operating in Pakistan have thus consolidated their influence over rural populations, cementing themselves in Pakistan in such a way that the government is forced to negotiate with them. Pakistan's Interior Minister has already pleaded to the Afghan Taliban and the TTP to restrain themselves, conceding that Pakistan will not invite US forces into the region.
Prior to the takeover, Afghanistan's former president revealed that more than 10,000 Taliban fighters had sought refuge in Pakistan between June and July this year (week). He highlighted Pakistan’s passivity in allowing Taliban fighters and their family's medical treatment and safe passage into Pakistan following clashes with Afghan government forces on the border (week). In Pakistan, the Pashtun Tahafuz Movement (PTM) protests against the government, accusing Pakistani military forces of clandestine support for various Taliban factions while oppressing civilians in its counterinsurgency operations.
Pakistan’s authorities lack a unified stance, which has led to reactive and opportunistic policy. Passive support and acknowledgement of militant groups operating in Pakistan plays into exacerbating regional disorder and acts to bolster militant legitimacy. This will affect the viability of vaccine operations in Northern Pakistan as rural provinces will become increasingly inaccessible to both state forces and outsiders.
The Taliban have also stashed a growing arsenal of small arms and heavy armour in Pakistan and has taken control along the Afghan-Pakistan border. The TTP is also known to be well-armed. As the situation in Afghanistan continues to deteriorate, further looting and expansion may see these illegal weapons caches grow further.
Weaknesses in Pakistan’s counterterrorism and law enforcement capabilities:
Pakistan’s complex federal law enforcement structure operates with crosscutting functions, that exercise blurred lines of authority
Counterterrorism units exist in each provincial police department in the form of the criminal investigation departments. There are also counterterrorism units within the FIA, the ISI, the Pakistan Rangers, the FC, and the IB. While the ISI, FC, and IB have the authority to arrest terrorists, they cannot prosecute them. Conversely, provincial criminal investigation departments and the FIA can prosecute terrorists, but cannot arrest them. Overlapping jurisdictions leads to gaps and duplication in counterterrorism efforts weakening the scope for efficient coordination and execution of efforts.
Law enforcement agencies operate in silos
Competition task redundancies among institutions has led to information hoarding. In 2009, when Mushtaq Mahar disclosed that knowledge of a thumb drive recovered in a terrorist encounter, containing plans of high-profile attacks, including the attacks on army headquarters in Rawalpindi and oil terminals in Karachi was not disclosed to the Sindh Police by Punjab authorities. Soon after, terrorists mounted an attack on oil terminals in Karachi. Moreover, when information is shared, it does not reach the relevant office or the designated leadership.
When Master Riaz, the mastermind of a bomb blast in a seminary in Punjab, informed investigators that the local criminal investigation department offices in Karachi would be targeted in future, the investigation failed to share this information, leading to the subsequent targeting of Criminal Investigation Department offices in 2010.
Instances of corruption and mismanagement continue to undermine counterterrorism efforts
Ehsanullah Ehsan, who was responsible for major attacks such as the killing of 132 schoolchildren in the Army Public School attack in Peshawar in December 2014, recently mysteriously escaped custody due to a serious security lapse on the part of Pakistan’s security agencies. While direct collusion has not been proven, it is understood that he was being pampered by the authorities even while in his custody, as he was allowed to give TV interviews. Such a security lapse, moreover, puts a question mark on Pakistan’s ability to challenge militant groups altogether.
Outlook:
In consideration of the risk factors above, there is a high likelihood that vaccine teams may be confronted by armed hostilities or other physical security threats in the region. In light of this assessment, it is recommended that organizations operating in the region should avoid participation in vaccination drives at this time if possible. Alternatively, they should take necessary precautions to ensure the safety of vaccine teams, such as regular risk assessments and coordination with local police and security forces.