KARACHI – For almost 40 years, efforts led by the World Health Organization and its partners have aimed to eradicate polio, a paralyzing disease that dates back to ancient times. Although polio cases have decreased by over 99%, the disease persists in certain regions of Afghanistan and Pakistan.

Attempts to eliminate the virus by WHO and the Global Polio Eradication Initiative have faced setbacks due to mismanagement and sticking rigidly to an outdated strategy, as well as issues with the oral vaccine, according to staff, polio experts, and internal documents reviewed by the Associated Press.

While officials highlight significant achievements – vaccinating 3 billion children and preventing paralysis in an estimated 20 million people – they also admit difficulties in Pakistan and Afghanistan. WHO polio chief Dr. Jamal Ahmed expressed confidence in the tailored responses of workers in hard-to-reach areas in these countries.

Here are some takeaways from AP’s report on what’s happened in one of the most expensive efforts in all of public health.

Documents show major problems on polio vaccination teams

Internal WHO documents, shared with AP by current and past employees, review the polio vaccination efforts in Afghanistan and Pakistan over the last ten years. As early as 2017, local personnel raised issues with top management, the documents showed. They highlighted numerous instances of fake vaccination records, unqualified relatives replacing health workers, and improper vaccine administration.

WHO officials frequently remarked that “vaccinators did not know about vaccine management,” pointing out failures to maintain the correct temperature for doses. They also noted careless or falsified reporting, with records showing “more used vaccine vials than supplied.”

An August 2017 report from Kandahar, Afghanistan, described vaccination teams working “in a hurried manner” without a proper monitoring plan. In Nawzad, Afghanistan, a team managed to cover only half of their target area, missing 250 households entirely, with village leaders reporting a lack of visits for at least two years.

Polio workers say problems have gone unaddressed

Health officials in Afghanistan and Pakistan told AP their efforts to vaccinate children are often stymied by cultural barriers, misinformation about the vaccines, and poverty.

Sughra Ayaz has traveled door to door in southeastern Pakistan for the past decade, pleading for children to be immunized. Some families demand basics such as food and water instead of vaccines. Others, without citing proof for their beliefs, repeat false rumors and say they think the oral vaccine doses are meant to sterilize their kids.

Ayaz said that given the immense pressure for the campaign to succeed, some managers have instructed workers to falsely mark children as immunized

“In many places, our work is not done with honesty,” she said.

Some scientists blame the oral vaccine

Polio eradication demands perfection — zero polio cases and immunizing more than 95% of children.

But some scientists and former WHO staffers say the campaign’s efforts are far from perfect, blaming in particular the oral vaccine. It’s safe and effective, but in very rare instances, the live virus in the oral vaccine can paralyze a child. In even rarer cases, the virus can mutate into a form capable of starting outbreaks among unimmunized people where vaccination rates are low.

Except for Afghanistan and Pakistan, most polio cases worldwide are linked to the vaccine; several hundred cases have been reported annually since 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 isn’t enough injectable vaccine — which uses no live virus and doesn’t come with the risks of the oral vaccine — to eliminate polio alone.

The injectable vaccine 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 campaign problems.

Last year, former WHO scientist Dr. T. Jacob John twice emailed WHO Director-General Tedros Adhanom Ghebreyesus calling for a “major course correction.” John wrote that “WHO is persisting with polio control and creating polio with one hand and attempting to control it by the other.”

Ahmed told AP 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.”

Critics say there’s no accountability

Dr. Tom Frieden, who sits on an independent board reviewing polio eradication, said he and colleagues have urged WHO and partners to adapt to obstacles in Afghanistan and Pakistan. Since 2011, the board has issued regular reports about program failures, but had little impact.

“There’s no management,” he said.

With an annual budget of about $1 billion, polio eradication is among the most expensive initiatives in public health. WHO officials have privately admitted that sustaining funding will be difficult without signs of progress.

Roland Sutter, who previously headed polio research at WHO, said donors had spent more than $1 billion in Pakistan trying to get rid of polio in the last five years — and made little progress.

“If this was a private company, we would demand results,” he said.

Ahmed pointed to the program’s many successes.

“Let’s not overdramatize the challenges, because that leads to children getting paralyzed,” he said.

Mistrust of the vaccine persists

Vaccine workers and health officials say 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.

The campaign 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.

In a mountainous region of southeastern Afghanistan where most people survive by growing wheat and raising cows and chickens, many are wary of the Western-led initiative.

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, fearing 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.

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Department of Science Education and the Robert Wood Johnson Foundation. The AP is solely responsible for all content.