Tiny Shamsa is a victim of the war against Islamist militants in northwest Pakistan, but it wasn't bullets or bombs that paralyzed her right leg. The 18-month-old contracted polio after fighting blocked vaccination teams from reaching her village.
In a country with no shortage of alarming statistics, here is another: Pakistan was the only country in 2010 to record an increase in cases of the crippling disease — 138, up from 89 in the previous year, according to World Health Organization figures. That made it the nation with the highest incidence of polio in the world.
Most cases were in the northwest close to the Afghan border, where battles between the U.S.-supported Pakistani army and Taliban fighters make many areas too dangerous to visit. The army bans travel to parts of the region, citing the security situation, and territory under militant control is highly dangerous for outsiders, even Pakistani aid workers.
Last year, one Pakistan Taliban commander declared the vaccine un-Islamic, echoing a few conservative clerics in other Muslim countries. But others have not publicly stated any objections. In Afghanistan, the Taliban cooperate with health workers administering the vaccine, in part because doing so adds to the movement's legitimacy.
Polio was eradicated generations ago from the Western world, but remains endemic in Pakistan, neighboring Afghanistan and India, as well as Nigeria. Sometimes fatal and highly contagious, it can be prevented with a few drops of bitter vaccine on a child's tongue.
Eradication needs a comprehensive vaccination campaign. Missing even a single child can mean the disease reappearing. In 2010, India recorded 41 cases, Afghanistan 24 and Nigeria 18, according to WHO. A WHO-backed campaign, which began in 1988, aims to eradicate polio from Pakistan by the end of 2011. But some doctors say privately that the target will not be met.
"It is upsetting to know that our only child could not get vaccine because of the troubles," said Shamsa's mother, Majeeda Ali, at a hospital in the main northwestern city of Peshawar recently where she took her daughter for treatment recently. "Yes, I am angry."
Workers from the United Nation's children's agency, which is helping administer the vaccine, say they have not been able to access Shamsa's village in the Khyber region for almost two years because of intensified Pakistan military efforts to rid the region of al-Qaida and Taliban militants. Shamsa caught polio last year.
WHO director general Margaret Chan raised the effect of the conflict on the worsening polio rate in October last year during a meeting with Pakistani President Asif Ali Zardari. She complained that health workers could only reach two in every three children in the northwest tribal border region due to the security situation, WHO said. Zardari pledged the government's support to eradicate polio.
"The number one reason (for the increase in cases) is that the majority of the cases are originating from those areas which are not accessible due to the war going on, or are cordoned off by the army which is not allowing any civilians or any WHO or UNICEF personnel to go there," said Aziz Memon, national chairman of the Polio Plus Pakistan Committee.
Army spokesman Maj. Gen. Athar Abbas said he was unaware of many areas where health organizations are not able to deliver necessary vaccinations. The army helps facilitate access in certain areas where the security threat is high, he said.
Vaccination in war zones is possible, but difficult and often politically sensitive.
UNICEF helped broker a truce between Sri Lanka and separatist rebels in Tamil Tiger-held territory during the 1990s that enabled families to travel safely to polio vaccinations centers on so-called "Days of Tranquility" when warring sides agreed to lay their weapons down. Polio has not been reported in Sri Lanka for well over a decade.
In Afghanistan, the Taliban fighting U.S. and Afghan forces allow vaccine teams to move around.
"All of the time, we are cooperating with the health workers," said Taliban spokesman Zabiullah Mujahid. "In the past and now, there is no problem because it is useful for the Afghan children."
Memon said organizing such a cease-fire was a far more complex proposition in Pakistan, where Pakistani fighter jets, helicopter gunships and CIA drone-fired missiles regularly pound targets. It would also rely on the support of the Pakistani state, which may well be reluctant to agree to something that could legitimize the militants.
"The Tamil Tigers were one group," Memon said. "Here, there are the Pakistani Taliban, Afghani Taliban, there are this man's group and that man's group — it's a totally messy affair."
Janbaz Afridi, director of the Pakistani government's polio program in the northwest, said vaccination teams were determined to reach all children in the northwest. New strategies include enlisting villagers to persuade militants to support vaccination, he said.
Other Muslim countries have also encountered some resistance from conservative clerics, which have spread false rumors that the vaccine was part of a sterilization campaign or derived from pig products. A few clerics have even argued that vaccination in general is un-Islamic because it tampers with the will of God.
"We will definitely reach each and every child even in those areas which are in conflict and where there are military operations," Afridi said. "There were some inaccessibly problems due to militancy, but these have been removed for the future."
Haris Ahmed, an expert on public health administration, said access to the tribal belt and gaining the trust of its inhabitants would be essential to eradicating polio in 2011. "If these two areas are addressed and you see 100 percent coverage and you see the trust coming back to the people, then anything is possible," Ahmed said.
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