A number of years ago, I was in New Delhi, at the end of an exhausting 18 hours in which I had torn around the city to watch a National Immunization Day. On those days – like a national holiday, with flags and banners and kids let out from school – tens of millions of children line up to stick out their tongues and receive the sugary drops that contain the vaccine that should protect them against polio.

The Indian government, along with the Centers for Disease Control, the World Health Organization and the volunteer ground troops of Rotary International, has been organizing these days now for most of two decades, always coming closer to the goal of eradicating polio, never quite getting there. On this day, which occurred close to the end of weeks I had spent embedded with a WHO "STOP Polio" team, 135 million children were expected to queue in cities and suburbs and rich neighborhoods and slums. I spent the day with the team I had been observing, racing in a battered turquoise Tata from neighborhood to neighborhood, trying to understand where the campaign's message was working and where its earnest persuasions had failed. (You can read my account of the day here.)

There was one neighborhood, about 15 miles outside the center of New Delhi, where things were not going well. It was a Muslim area, and the local masjids supported the campaign – all the imams had preached in favor of it – but the appeals had not penetrated. Only a few children, about 25 in a slum that held thousands, had wandered up to receive the drops and the swipe of gentian violet across a fingernail that would signal to canvassers that a child had been immunized.

A young mother selling fish in a muddy side street shrugged and dismissed the importance of her four children receiving the vaccine. In the next few days, she said, the government would send "mop up" vaccinators into the alleys to find the children who had missed the big campaign. Maybe they would find her children; maybe she would get paying work that day, and then she would be away from home, and the children too. The government's priorities were not hers.

Late that night, over whiskey-sodas served without ice because of the water quality, a longtime local health worker explained what he thought was going on. Hypothetically, protecting against polio requires four rounds of drops. But in tropical temperatures, with inadequate sanitation and endemic diarrheal diseases, it can take many more rounds of immunization to ensure a child is immune. That unplanned-for reality had combined with the longstanding distrust between Hindus and Muslims to produce a situation that no one had foreseen.

"We come back to their neighborhoods, month after month, telling them that these drops will protect their children from being paralyzed," he said. "We come 10, 11, 12 times and the kids become paralyzed anyway. They start to think we're doing this for some other reason, and they suspect us, and they don't want to bring the kids out any more."

And that is why the CIA's decision to use a fake vaccination program in the hunt for Osama Bin Laden, if that story is true, is such an appallingly, idiotically bad idea.

As reported by the Guardian and subsequently by the New York Times, intelligence operatives funded a sham vaccination program in hopes of obtaining a sample of DNA to prove that bin Laden, then rumored to be in the area, was actually living in the compound where he was subsequently found and killed. From the Guardian:

DNA from any of the Bin Laden children in the compound could be compared with a sample from his sister, who died in Boston in 2010, to provide evidence that the family was present. So agents approached [Shakil] Afridi, the health official in charge of Khyber, part of the tribal area that runs along the Afghan border. The doctor went to Abbottabad in March, saying he had procured funds to give free vaccinations for hepatitis B. Bypassing the management of the Abbottabad health services, he paid generous sums to low-ranking local government health workers, who took part in the operation without knowing about the connection to Bin Laden. Health visitors in the area were among the few people who had gained access to the Bin Laden compound in the past, administering polio drops to some of the children... In March health workers administered the vaccine in a poor neighbourhood on the edge of Abbottabad called Nawa Sher. The hepatitis B vaccine is usually given in three doses, the second a month after the first. But in April, instead of administering the second dose in Nawa Sher, the doctor returned to Abbottabad and moved the nurses on to Bilal Town, the suburb where Bin Laden lived.

There is no evidence the "vaccinations" produced DNA that helped identify bin Laden. The physician named in the article has been arrested by the Pakistani security forces. The CIA has understandably refused any comment. But the allegation that a vaccine program was not what it seemed – that it was not only suspect, but justifiably suspect – has been very widely reported.

This is awful. It plays, so precisely that it might have been scripted, into the most paranoid conspiracy theories about vaccines: that they are pointless, poisonous, covert shields for nefarious government agendas meant to do children harm.

That is not speculation. The polio campaign has already seen this happen, based on just those kind of suspicions – not in a single poor slum in New Delhi, but across much of sub-Saharan Africa.

In the fall of 2003, a group of imams in the northern Nigerian state of Kano – the area that happened to have the highest rate of ongoing polio transmission – began preaching against polio vaccination, contending that what purported to be a protective act was actually a covert campaign by Western powers to sterilize and kill Muslim children. The president of Nigeria's Supreme Council for Sharia Law said to the BBC: "There were strong reasons to believe that the polio immunisation vaccine was contaminated with anti-fertility drugs, contaminated with certain virus that cause HIV/AIDS, contaminated with Simian virus that are likely to cause cancers."

The rumors caught like wildfire, and they were spread further by political operatives who saw an opportunity to disrupt a recent post-election power-sharing agreement between the Muslim north and the Christian south. Three majority Muslim states – Kano, Kaduna and Zamfara – suspended polio vaccination entirely. Vaccination acceptance in the rest of the country fell off so sharply that the national government was forced to act. It ordered tests of the vaccine by Nigeria's health ministry and empaneled a special commission to visit the Indonesian labs where the vaccine administered in Nigeria was made. The WHO convened emergency meetings.

And polio began to spread. At the end of 2003, when the boycott began, there had been only 784 known polio cases in the entire world. By the end of 2004, there had been 793 new cases just in Nigeria. Polio leaking across Nigeria's borders reinfected Benin, Botswana, Burkina Faso, Cameroon, Chad, the Central African Republic, Cote d'Ivoire, Ethiopia, Ghana, Guinea, Mali, Sudan and Togo. Nigerian strains appeared in Yemen, site of the largest port on the Red Sea, and in Saudi Arabia, imperiling the millions of pilgrims coming to the country on hajj. (Here's a 2004 round-up of the consequences from the South African publication Science in Africa, and one that I wrote in 2005.)

The last holdouts in Kano did not fully accept polio vaccination until the end of 2004. By then, so many children had gone unprotected that when Nigeria experienced the random bad luck of a vaccine-virus reversion to wild type in 2006, it ripped through the country in weeks – and further fueled lingering suspicions that had never really gone away.

The accusations that polio vaccination was a Potemkin cover for anti-Islamic activities almost ruined the international eradication of polio when they were false. Now, on the basis of the CIA's alleged appalling ruse in Pakistan, they may be made again. And they will be much more believable, because this time they might be be true.

Notable reactions, among many: Longtime global-health reporter Tom Paulson says this will "undermine global health" and expands on the possible consequences; Seth Mnookin, author of The Panic Virus, calls it a "horrible move with potentially dangerous consequences"; infectious-disease physician Kent Sepkowitz says it's a "paranoid's dreamy nightmare"; and blogger Brett Keller bluntly calls it "despicable." Update: The Guardian's Sarah Boseley adds: "a black day for medical ethics and a one-off crazy scheme." And James Fallows at The Atlantic warns this has "tremendously damaging implications that must be addressed."

I agree with them all.

Update: And here we go. The Associated Press reported this afternoon:

Pakistani health officials held meetings about the alleged CIA scheme on Tuesday and expressed concern that it could have a negative impact on immunization programs in other areas of the northwest, especially in Pakistan's semiautonomous tribal region along the Afghan border, said a Pakistani official involved in polio eradication efforts... One of the Pakistani Taliban's top commanders, Maulvi Faqir Mohammed, recently called on people in the northwest to avoid vaccines offered by the international community, claiming they were made with "extracts from bones and fat of an animal prohibited by God — the pig." "Don't fall prey to these infidel NGOs and this U.S.-allied government and its army," said Mohammed over the illegal radio station he transmits from his sanctuary in eastern Afghanistan. Pakistani officials and their international partners have pushed back against these claims, but the CIA's reported activities in the country may have made their job that much harder. "The medical mission has to be immune from manipulation for political and military purposes and health care workers generally must not be compelled to conduct activities contrary to medical ethics," said [Michael O'Brien, a spokesman for the International Committee of the Red Cross in Pakistan].

*Update 2: *Wednesday evening, US sources acknowledged that the vaccine campaign did happen. They insisted that real hepatitis vaccine was used. They did not address that, since only one of three doses was delivered, the vaccination was effectively useless. From the Washington Post:

U.S. officials on Wednesday defended a tactic used by the CIA to attempt to verify the whereabouts of Osama bin Laden — the covert creation of a vaccine program in Abbottabad, the town in Pakistan where he was later killed in a U.S. raid... A senior U.S. official said the campaign involved actual hepatitis vaccine and should not be construed as a “fake public health effort.” “People need to put this into some perspective,” said the official, speaking on the condition of anonymity because of the sensitivity of the issue. “The vaccination campaign was part of the hunt for the world’s top terrorist, and nothing else. If the United States hadn’t shown this kind of creativity, people would be scratching their heads asking why it hadn’t used all tools at its disposal to find bin Laden.” ...The senior U.S. official declined to say whether DNA from bin Laden’s relatives was collected as part of the vaccine program.

*Update 3: *Thursday, Doctors without Borders (know in most of the world as MSF for Medecins sans Frontieres), which has teams in a number of Pakistani and border provinces, released a statementsaying the fake campaign interferes with health care and endangers health workers:

“The mere suggestion that the provision of medical care was carried out under false pretenses damages public perception of the true purpose of medical action,” said Dr. Unni Karunakara, MSF’s international president. “With all populations in crisis, it is challenging enough for health agencies and humanitarian aid workers to gain access to, and the trust of, communities—especially populations already skeptical of the motives of any outside assistance... The risk is that vulnerable communities—anywhere—needing access to essential health services will understandably question the true motivation of medical workers and humanitarian aid. The potential consequence is that even basic health care, including vaccination, does not reach those who need it most.”

See Also:

Flickr/Gak/CC