Polio in Somalia: an intersection of political instability and global health

While many perceive polio as a largely eradicated disease of the past, a recent resurgence of new cases in politically unstable regions of the world has brought the disease back into the news.  Polio is devastating and highly infectious: it affects the nervous system and can cause irreversible paralysis and death, primarily in young children.  While there is still no cure for polio, five vaccines are able to prevent transmission of the polio virus.  Global immunization and other strategies have decreased cases by 99% in approximately two decades.  However, since most people infected with polio do not show symptoms, the World Health Organization (WHO) treats any confirmed case as a potential epidemic.  Although evidence has shown that polio eradication is possible through widespread immunization, the disease is still endemic in three countries (Afghanistan, Nigeria, and Pakistan) and tackling the last 1% of polio cases around the world has proved a challenging task.

vaccine photo
Child receives polio vaccine

All countries currently remain at risk for ‘imported’ cases of polio, particularly states bordering endemic areas or when political instability or other factors inhibits necessary immunizations.  So far in 2013, there have been 192 reported cases of polio worldwide.  Of those reported cases, 108 were in Somalia, a non-endemic war-torn country whose political instability and violence has made providing necessary medical services, like immunizations, dangerous and difficult.

Somalia has experienced civil war and violence for decades, and the health of its citizens has subsequently suffered.  According to the WHO’s most recent data, Somali citizens live 20 years less than the global average and less than 30% of Somalia’s population has consistent access to improved water and sanitation facilities.  In Somalia, there is on average only one physician for every 250,000 people, and health providers – both from the government and international organizations – are unable to access many under-immunized children.  The Global Polio Eradication Initiative (GPEI) reports that 70% of children in areas that are difficult to access are under-immunized in Somalia, compared to 20% of children in areas that are easy to access.  While Somalia was declared a non-endemic country in 2001, this 2013 outbreak demonstrates the continued need for surveillance and immunization programs in Somalia and other vulnerable countries.

Médecins Sans Frontières (MSF) – also commonly known as Doctors Without Borders – has operated in Somalia since 1991 but announced on August 14, 2013 that it was closing its operations in the country.  Dr. Unni Karunakara, MSF’s international president, explained that “we are ending our program in Somalia because the situation in the country has created an untenable imbalance between the risks and compromises our staff must make, and our ability to provide assistance to the Somali people.”  That assistance in 2012 included 624,000 medical consultations, nearly 60,000 vaccinations, and 7,300 delivered babies, along with a wide range of medical services offered by 1,500 staff.  MSF had historically worked in both government and rebel controlled areas and had suffered dozens of attacks on its staff, resulting in 16 deaths and two staff members being abducted and held hostage for 21 months.  While MSF did not itself immunize the Somali people against polio, the organization’s story illustrates the challenges aid organizations and health providers face in politically unstable environments around the world.

How can the international community succeed in accomplishing goals like polio eradication, which are technically possible but hindered by complex problems and real-world realities, when success depends on stability in inherently unstable environments?

In the absence of political instability and widespread violence, other factors that limit the effectiveness of immunizations – like poverty and lack of infrastructure – have been overcome in other technically challenging locations.  For example, India succeeded in stopping polio in January 2011, showing that immunization programs can be effective.  However, Somalia remains a cautionary tale, with potential global implications.  Polio immunization programs in Somalia are usually managed by the Somali government- which does not have access to populations living in rebel-controlled regions.  According to the WHO, in our increasingly inter-connected world, “failure to stop polio in the last remaining areas could result in as many as 200,000 new cases every year, within 10 years, all over the world.”  The Bill and Melinda Gates Foundation, one of the major international organizations working to eradicate polio in countries like Somalia through immunization, says that “all of our vaccine-related work depends on strong systems within countries.”  That dependence, then, poses a challenging question: how can the international community succeed in accomplishing goals like polio eradication, which are technically possible but hindered by complex problems and real-world realities, when success depends on stability in inherently unstable environments?

The story of polio’s global rise and fall is, in many ways, a positive one that demonstrates our ability, through international cooperation, medical advancements, and public-private partnerships, to protect global populations against health threats like polio.   The story, however, is not over.  Political instability, violence, lack of development, poverty, and other factors continue to be significant challenges faced by all actors in the international community as the fight to eradicate polio continues- especially in seemingly far-away countries, like Somalia.

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