The world nearly beat polio. But fake records, an imperfect vaccine and
missteps aided its comeback
[August 05, 2025]
By MARIA CHENG and RIAZAT BUTT
KARACHI, Pakistan (AP) — For the past decade, Sughra Ayaz has traveled
door to door in southeastern Pakistan, pleading with parents to allow
children to be vaccinated against polio as part of a global campaign to
wipe out the paralytic disease. She hears their demands and fears. Some
are practical – families need basics like food and water more than
vaccines. Others are simply unfounded – the oral doses are meant to
sterilize their kids.
Amid rampant misinformation and immense pressure for the campaign to
succeed, Ayaz said, some managers have instructed workers to falsely
mark children as immunized. And the vaccines, which must be kept cold,
aren’t always stored correctly, she added.
“In many places, our work is not done with honesty,” Ayaz said.
The World Health Organization and partners embarked on their polio
campaign in 1988 with the bold goal of eradication — a feat seen only
once for human diseases, with smallpox in 1980. They came close several
times, including in 2021, when just five cases of the natural virus were
reported in Pakistanand Afghanistan. But since then, cases rebounded,
hitting 99 last year, and officials have missed at least six
self-imposed eradication deadlines.
Afghanistan and Pakistan remain the only countries where transmission of
polio — which is highly infectious, affects mainly children under 5, and
can cause irreversible paralysis within hours -- has never been
interrupted. The worldwide campaign has focused most of its attention
and funding there for the past decade.
But in its quest to eliminate the disease, the Global Polio Eradication
Initiative has been derailed by mismanagement and what insiders describe
as blind allegiance to an outdated strategy and a problematic oral
vaccine, according to workers, polio experts and internal materials
obtained by The Associated Press.
Officials have falsified vaccination records, selected unqualified
people to dole out drops, failed to send out teams during mass
campaigns, and dismissed concerns about the oral vaccinesparking
outbreaks, according to documents shared with AP by staffers from GPEI –
one of the largest and most expensive public health campaigns in
history, with over $20 billion spent and nearly every country in the
world involved.
In Afghanistan and Pakistan – which share a border, harbor widespread
mistrust of vaccines, and have weakened healthcare systems and
infrastructure – local staffers like Ayaz have for years flagged
problems to senior managers. But those issues, along with concerns by
staffers and outside health officials, have long gone unaddressed,
insiders say.
Officials tout the successes – 3 billion children vaccinated, an
estimated 20 million people who would have been paralyzed spared – while
acknowledging challenges in Pakistan and Afghanistan. Remote villages
are hard to reach, some cultural and religious authorities instruct
against vaccination, and hundreds of polio workers and security staff
have been killed because of their alignment with a Western-led
initiative.
Dr. Jamal Ahmed, WHO’s polio director, defended progress in those two
countries, citing workers’ tailored response in resistant pockets.
“There’s so many children being protected today because of the work that
was done over the past 40 years,” he said. “Let’s not overdramatize the
challenges, because that leads to children getting paralyzed.”
Ahmed said he believes authorities will end the spread of polio in the
next 12 to 18 months. Its latest goal for eradication is 2029. The
campaign says about 45 million children in Pakistan and 11 million in
Afghanistan must be vaccinated this year. Children typically need four
doses of two drops each to be considered fully immunized.
Dr. Zulfiqar Bhutta, who has served on advisory groups for WHO, the
Gates Foundation and others, said campaign officials should listen to
the criticism of its tactics.
“Continuing blindly with the same strategies that we have relied on
since eradication began is unlikely to lead to a different result,” he
said.
Documents show yearslong problems on polio vaccination teams
Internal WHO reports reviewing vaccination drives in Afghanistan and
Pakistan over the past decade – given to AP by current and former
staffers – show that as early as 2017, local workers were alerting
significant problems to senior managers.
The documents flagged multiple cases of falsified vaccination records,
health workers being replaced by untrained relatives and workers
improperly administering vaccines.
On numerous occasions, WHO officials noted, “vaccinators did not know
about vaccine management,” citing failure to keep doses properly cold.
They also found sloppy or falsified reporting, with workers noting “more
used vaccine vials than were actually supplied.”
According to an August 2017 report from Kandahar, Afghanistan, local
government authorities and others interfered in choosing vaccinators,
“resulting in the selection of underage and illiterate volunteers.”
Vaccination teams worked “in a hurried manner,” reports said, with “no
plan for monitoring or supervision.” A team in Nawzad, Afghanistan,
covered just half of the intended area in 2017, with 250 households
missed entirely. Village elders said no one visited for at least two
years.
Vaccine workers and health officials in Afghanistan and Pakistan
confirmed the issues in the documents and told AP it’s hard for campaign
leadership to grasp the difficulties in the field. Door-to-door efforts
are stymied by cultural barriers, unfounded stories about vaccines, and
the region’s poverty and transience.
“Most of the time when we go to vaccinate and knock on the door, the
head of the house or the man is not at home,” said one worker, speaking
on condition of anonymity because they weren’t authorized to talk to the
press. “Many people find it offensive that a stranger knocks on the door
and talks to a woman.”
Some workers find families have moved. Occasionally, they say, the
encounter abuse.
“We have shared these problems with our senior officials,” the worker
told AP. “They know about it.”
In an email response to AP’s questions about officials’ knowledge of the
issues, WHO polio director Ahmed noted “operational challenges” in
Afghanistan and Pakistan and said the program has “robust monitoring and
evaluation processes.”
Worker Ayaz described “fake finger marking” — placing the ink used to
show a child is vaccinated on their pinky even when no vaccine has been
given.
“There is so much pressure,” Ayaz said.
Critics point to continued use of the oral polio vaccine
Before the first polio vaccine was developed in 1955, the disease —
spread mostly from person to person, through contaminated water and via
fecal particles — was among the world’s most feared, paralyzing hundreds
of thousands of children annually. People avoided crowded places during
epidemics, and hospital wards filled with children encased in iron lungs
after the virus immobilized their breathing muscles.
Polio is mainly spread when people are exposed to water infected with
the virus. In countries with poor sanitation, children often become
infected when they come into contact with contaminated waste.
WHO says that as long as a single child remains infected, kids
everywhere are at risk.
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Afghan children wait in line to get a polio vaccine in Jalalabad,
Afghanistan, May 26, 2025. (AP Photo/Shafiullah Kakar)
 Eradication demands near-perfection
– zero polio cases and immunizing more than 95% of children.
But public health leaders and former WHO staffers say campaign
efforts are far from perfect, and many question the oral vaccine.
The oral vaccine – proven to be safe and effective — has been given
to more than 3 billion children. But there are some extremely rare
side effects: Scientists estimate that for every 2.7 million first
doses given, one child will be paralyzed by the live polio virus in
the vaccine.
In even rarer instances, the live virus can mutate
into a form capable of starting new outbreaks among unimmunized
people where vaccination rates are low.
Worldwide, several hundred vaccine-derived cases have been reported
annually since at least 2021, with at least 98 this year.
Most public health experts agree the oral vaccine should be pulled
as soon as possible. But they acknowledge there simply isn’t enough
injectable vaccine — which uses no live virus and doesn’t come with
the risks of the oral vaccine — to wipe out polio alone. The
injectable vaccine also is more expensive and requires more training
to administer.
More than two dozen current and former senior polio officials told
AP the agencies involved haven’t been willing to even consider
revising their strategy to account for some of the campaign’s
problems.
Dr. Tom Frieden, a former director of the U.S. Centers for Disease
Control and Prevention who sits on an independent board reviewing
polio eradication, said it would be impossible to eliminate polio
without the oral vaccine. But he’s urged authorities to find ways to
adapt, such as adopting new methods to identify polio cases more
quickly. Since 2011, he and colleagues have issued regular reports
about overall program failures.
“There’s no management,” he said, citing a lack of accountability.
Last year, former WHO scientist Dr. T. Jacob John twice emailed WHO
Director-General Tedros Adhanom Ghebreyesus calling for a “major
course correction.” John shared the emails with AP and said he’s
received no response.
“WHO is persisting with polio control and creating polio with one
hand and attempting to control it by the other,” John wrote.
In his response to AP, WHO polio director Ahmed said the oral
vaccine is a “core pillar” of eradication strategy and that “almost
every country that is polio-free today used (it) to achieve that
milestone.”
“We need to step back and really care for the people,” he said. “The
only way we can do that in large parts of the world is with oral
polio vaccine.”
Ahmed also pointed to the success WHO and partners had eliminating
polio from India, once considered a nearly impossible task. In the
four years before polio was wiped out there, health workers
delivered about 1 billion doses of the oral vaccine to more than 170
million children.
Today, nearly all of the world’s polio cases -- mostly in Africa and
the Middle East -- are mutated viruses from the oral vaccine, except
for Afghanistan and Pakistan.
Scott Barrett, a Columbia University professor, called for an
inquiry into how things went so wrong – particularly with a failed
effort in 2016, when authorities removed a strain from the oral
vaccine. They miscalculated, leading to outbreaks in more than 40
countries that paralyzed more than 3,000 children, according to an
expert report commissioned by WHO. Last year, a mutated virus traced
to that effort paralyzed a baby in Gaza.
“Unless you have a public inquiry where all the evidence comes out
and WHO makes serious changes, it will be very hard to trust them,”
he said.
Mistrust of the polio eradication effort persists
With an annual budget of about $1 billion, the polio initiative is
among the most expensive in all of public health. This year, the
U.S. withdrew from WHO, and President Donald Trump has cut foreign
aid. WHO officials have privately admitted that sustaining funding
would be difficult without success.
Some say the money would be better spent on other health needs.
“We have spent more than $1 billion (in external polio funding) in
the last five years in Pakistan alone, and it didn’t buy us any
progress,” said Roland Sutter, who formerly led polio research at
WHO. “If this was a private company, we would demand results.”
Villagers, too, have protested the cost, staging hundreds of
boycotts of immunization campaigns since 2023. Instead of polio
vaccines, they ask for medicine, food and electricity.
In Karachi, locals told AP they didn’t understand the government’s
fixation on polio and complained of other issues — dirty water,
heroin addiction. Workers are accompanied by armed guards; Pakistani
authorities say more than 200 workers and police assigned to protect
them have been killed since the 1990s, mostly by militants.
The campaign also is up against a wave of misinformation, including
that the vaccine is made from pig urine or will make children reach
puberty early. Some blame an anti-vaccine sentiment growing in the
U.S. and other countries that have largely funded eradication
efforts and say it’s reaching even remote areas of Afghanistan and
Pakistan.
In suburban southwest Pakistan, Saleem Khan, 58, said two
grandchildren under 5 were vaccinated over his family’s objections.
“It results in disability,” said Khan, without citing evidence for
his belief. “They are vaccinated because officials reported our
refusal to authorities and the police.”
Svea Closser, professor of international health at Johns Hopkins
University, said Pakistan and Afghanistan were less resistant to
immunization decades ago. Now, people are angry about the focus on
polio and lack of help for diseases like measles or tuberculosis,
she said, spurring conspiracy theories.
“Polio eradication has created a monster,” Closser said. It doesn’t
help, she added, that in this region, public trust in vaccine
campaigns was undermined when the CIA organized a fake hepatitis
drive in 2011 in an attempt to get DNA and confirm the presence of
Osama bin Laden or his family.
Workers see that continued mistrust every day.
In a mountainous region of southeastern Afghanistan where most
people survive by growing wheat and raising cows and chickens, a
mother of five said she'd prefer that her children be vaccinated
against polio, but her husband and other male relatives have
instructed their families to reject it. They believe the false
rumors that it will compromise their children’s fertility.
“If I allow it,” the woman said, declining to be named over fears of
family retribution, “I will be beaten and thrown out.”
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Cheng reported from London.
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