On a barren stretch of road near Iraq’s northern border with Syria, relief workers handed out bottled water and plates of chicken with rice. Hundreds of Yazidi men, women, and children were fleeing into the Kurdish region of Iraq every hour from the Sinjar Mountains. As part of the tiny minority of non-Muslims in the region, the Yazidis had come under attack from the armed group calling itself the Islamic State. They had crossed first into Syria and then back into Kurdish Iraq. Most of the displaced didn’t even have a change of clothes.
A total of 1.2 million Iraqis have been forced to move by recent fighting; tens of thousands of displaced Iraqis are now crowded into tent camps. Though air strikes by the U.S. have given the Yazidis room to breathe for the time being, a breakdown of health care services resulting from war, turmoil, and official ineptitude has caused an outbreak of a dangerous virus that may prove longer-lasting. For the first time in 14 years in Iraq, polio is back.
The World Health Organization has confirmed 38 cases in Iraq and Syria since late last year. It declared, following a teleconference of the International Health Regulations Emergency Committee in April, that the outbreak was a “public health emergency of international concern.” That was only the second such declaration in WHO’s history.
The current Middle East outbreak is of a strain of virus known to have originated in Pakistan. It paralyzed 27 children in Syria last year, then spread to Iraq. Pakistan is one of the only countries never to have eradicated the crippling and often fatal disease; religious extremists from northwestern Pakistan came to Syria to fight against the regime of President Bashar al-Assad. (The U.S. spy conducting surveillance on what proved to be the home of Osama bin Laden was posing as a doctor operating a vaccine clinic; this has raised suspicions of vaccine efforts in the country, hampering eradication.) Though not nearly as severe as the thousands of deaths from Ebola in the outbreak striking West Africa, the causes are similar, said Dr. Omer Mekki, a Sudanese doctor and WHO consultant in the Iraqi city of Erbil.
Displaced Iraqis “are exhausted from overcrowding,” said Mekki. "They can’t sleep. The overcrowding is a very bad hygienic situation" that can facilitate polio’s spread.
This spring, WHO and UNICEF, working with local public health agencies and NGOs, launched a massive vaccination campaign in Iraq, Syria, and Egypt, where the virus was detected in sewage in 2013. They hoped to reach 20 million children younger than five over five days. Vaccines were shipped to areas near the northern city of Mosul, according to Dr. Sarhang Jambaz, director of the Preventative Health Department in Erbil. This summer, just when authorities thought they had turned the tide, Islamic State fighters launched a deadly offensive and overran Mosul and surrounding towns, throwing the campaign into turmoil.
“The change was unbelievable,” said Jambaz. “All of a sudden complete districts fell to IS. We didn’t know the fate of vaccine in captured areas.”
Doctors and nurses had to reorganize and obtain new supplies. “These people worked day and night,” he said.
Soon after, officials received the news that the Islamic State, a movement claiming to represent Sunni Muslims, hadn’t halted the polio vaccinations, or general health services being provided by the Shia-dominated Iraqi government. Provision of health and other services has been key to gaining popular support for insurgent groups and Islamist political parties including Hamas in Palestine and Hezbollah in Lebanon, and the Islamic State may have been following this script.
Mekki hoped the Islamic State would continue to allow the program to proceed, whatever its motive. “Maybe in the future they will change their mind,” he said. “But now they want to prove that the population is supporting them. It is to some extent political.”
The polio crisis had been brewing for years. Syria’s public health system broke down in many parts of the country when the uprising against Assad’s despotic rule began in 2011. Two years later, the polio infection had taken root, according to Mekki. “It affected the youngest children because the older children are already vaccinated,” he explained.
Another contributing factor, he said, was that health officials in both Syria and Iraq had become complacent about polio vaccinations. “People managed the campaigns as business as usual,” he said, with few efforts to reach remote areas or the inner cities.
Then two cases of polio surfaced this year in the slums of Baghdad. Neither child had been vaccinated. Mekki explained that the virus can live in the gut of vaccinated children and not infect them. When unvaccinated children come into contact with infected feces, they can contract the disease.
“Once it finds a child who isn’t immunized, he gets the disease,” said Mekki. “This is how the virus, in a clever way, will identify to us pockets of high-risk areas.”
So starting in April, WHO and UNICEF, working with local public health officials, launched vaccination campaigns in big-city slums, refugee and displaced person camps, and anywhere else there might be children who had missed their vaccinations.
Before the U.S. invasion in 2003 and the anti-Assad uprising in 2011, both Iraq and Syria had relatively high-functioning governments that provided basic health care services and educated parents on the importance of vaccinations, including against polio. Some Iraqis continue to benefit: Parents at the Nazdar Bamerny Clinic in central Erbil one day late last month were taking the initiative—no public outreach program necessary.
Locals and displaced Iraqis sat patiently on plastic chairs holding crying babies. Toddlers scampered around the room. Nurses cracked open plastic vials and dropped the polio vaccine into the mouths of squirming infants.
One man had fled a town near Mosul. (He declined to give his name fearing possible Islamic State retaliation if he returns home.) He brought his and his brother’s children to the clinic. “We knew the kids needed vaccinations,” he said, “and we heard they are free, so we came.”
“This means that they are motivated,” Mekki said. “They are insisting to vaccinate their children.”
The man said he lives in a four-bedroom rented house with 15 members of an extended family. Regular electricity blackouts and lack of air conditioning make life difficult.
The man got vaccinations for all the children he had brought to the clinic. So did dozens of others that August day. Overall, the campaign reached 3.75 million of the 4 million children under five living in Iraq, UNICEF announced earlier this month. WHO officials said no new polio cases have been confirmed in the country since April.
The overall success of the campaign, however, depends on whether the fighting and massive displacements end.