WASHINGTON—On April 14, during the second phase of a nationwide anti-polio campaign, gunmen in Pakistan opened fire on a police vehicle escorting polio vaccinators in Hangu, a district in Khyber Pakhtunkhwa (KPK) province along the Afghan border. One officer was killed and four were wounded.
The attack captures a paradox at the heart of Pakistan’s final mile fight against polio. Pakistan is one of just two countries—the other is Afghanistan—where polio is still endemic. Fortunately, the country is closer than it has ever been to ending a disease that once paralyzed thousands of Pakistani children every year. Yet frontline health workers are operating inside one of the world’s most violent security environments, complicating efforts to reach the finish line. Recent years have brought a surge in cross-border militancy, including the resurgence of Tehrik-i-Taliban Pakistan (TTP), an al-Qaeda-allied group that in an earlier era was responsible for thousands of attacks across Pakistan. These included multiple assaults on polio workers and their security details that killed nearly sixty people from 2012 to 2014.
How Pakistan navigates this paradox this year will shape the outcome of a thirty-year global eradication effort. If the eradication campaign falters, wild poliovirus cases could rise in Pakistan and Afghanistan, squandering years of progress and risking transmission beyond the region.
Precarious progress
The Global Polio Eradication Initiative reports just six confirmed new poliovirus cases worldwide so far this year, all in Pakistan and Afghanistan. Pakistan’s trajectory reflects fragile progress: There were seventy-four cases in 2024, a more than tenfold jump from just six in 2023. Intensified campaigns brought the figure back down to roughly thirty in 2025, before its new lows this year. Three new cases have been confirmed in Pakistan so far in 2026—including two in KPK, not far from last month’s attack in Hangu.
However, these low absolute numbers can be misleading. World Health Organization (WHO) genetic sequencing has linked virus samples collected in Karachi, a megacity in southern Pakistan, to reservoirs in Jalalabad in eastern Afghanistan—evidence that Pakistan and Afghanistan function as a single epidemiological bloc. Wild poliovirus has also recently been detected in wastewater in Germany. This is a reminder that until the disease is completely eradicated everywhere, it threatens children anywhere. The WHO Polio Emergency Committee has explicitly described the first half of 2026 as a “critical opportunity” to interrupt transmission. That window is open now, but may not stay open for long if terrorist organizations continue to threaten and target vaccinators.
Anatomy of a threat
Pakistan was ranked first on the Global Terrorism Index 2026, with 1,139 terrorism deaths in 2025, its highest annual figure since 2013 and its sixth consecutive yearly increase. The Islamabad-based Pak Institute for Peace Studies recorded 699 militant attacks in 2025. Attacks by TTP, which benefits from a sanctuary in Taliban-led Afghanistan, rose by 24 percent.
Mapping Pakistan’s polio landscape against its biggest hotspots for terrorist violence yields an unsettling fact: The geography is nearly identical. The majority of attacks are concentrated in KPK and Balochistan provinces. Those same two provinces continue to host persistent reservoirs of wild poliovirus, accounting for the bulk of Pakistan’s recent caseload, including both KPK cases confirmed so far in 2026.
Vaccinators have become the biggest casualty of this geographic overlap. According to Pakistani officials, more than two hundred polio workers and police escorts have been killed since the 1990s. Government data tracked since 2012 record ninety-six deaths and 170 injuries from attacks on polio campaigns, including sixty-one police officers and twenty-seven health workers, with TTP and affiliated Islamist militant factions responsible for the overwhelming majority. In November 2024, a single attack on a police van escorting a polio team killed nine people, five of them children.
TTP has banned door-to-door vaccination in areas under its influence and treated polio teams as justified targets. That posture has multiple origins. In 2011, the CIA ran a fake Hepatitis B vaccination drive in the KPK city of Abbottabad to gather DNA in the hunt for Osama bin Laden. Suspicion of vaccination campaigns has run deep ever since. But there have also been long-standing conspiracy theories, propagated by clerics and militant groups alike, that claim polio vaccines are a Western plot to sterilize Muslim children or are otherwise religiously impermissible.
Balochistan presents a parallel and distinct challenge. The province absorbed 254 militant attacks in 2025, the second-highest provincial total after KPK, and it sits on the cross-border transmission corridor that makes Pakistan and Afghanistan a single epidemiological bloc. Researchers have identified the Chaman border crossing as an emerging wild poliovirus type 1 hotspot linking Quetta in southwestern Pakistan to Kandahar in southeastern Afghanistan, with the same genetic cluster appearing on both sides. The principal armed actors in Balochistan are the Balochistan Liberation Army and Balochistan Liberation Front. They have a history of conducting hijackings, highway blockades, and operations like the March 2025 Jaffar Express siege, a strikingly sophisticated attack that commandeered an entire passenger train.
TTP and its allies, not Baloch insurgents, are the primary attackers of polio teams. But the insecurity generated by Baloch militants also disrupts vaccination logistics and threatens the security forces that vaccinators rely on in the field.
The limits of government responses
Islamabad’s response to surging terrorism has been to heavily rely on its military forces. In June 2024, the government announced Operation Azm-e-Istehkam, a counterinsurgency campaign. Nearly two years later, the operation has not only failed to bring back security, but it has also produced anger within the very communities served by polio workers. In KPK, the Pashtun Tahafuz Movement, a grassroots campaign that advocates for the rights of ethnic Pashtuns, and tribal jirgas rejected Azm-e-Istehkam from the moment it was announced. They justified their opposition by citing the mass displacements from earlier counterterrorism campaigns.
This alienation of local communities has direct public health consequences. An independent monitoring board of the Global Polio Eradication Initiative reported that more than 420,000 children went unvaccinated during Pakistan’s 2024 campaigns, with over two hundred community-level refusals of polio vaccination in KPK.
Refusals in Pakistan’s high-risk districts are driven by many overlapping factors, including conspiracy theories about sterilization, religious objections, militant intimidation, and, as peer-reviewed research has documented, “community hostility and anger” tied to grievances against the state and a fragile relationship between residents and government health programs. Polio teams are typically government workers. So when residents associate the state with displacement and aerial strikes, polio teams, often perceived as extensions of that same state, carry that association when they knock on the door.
The Pakistani polio program has nonetheless built real operational capacity. It runs the largest single-disease surveillance network in the world, with 127 environmental sampling sites across eighty-seven districts, and has synchronized its national campaigns with those in Afghanistan since 2025. The April 2026 synchronized round reached 44.8 million children in Pakistan and 12.8 million in Afghanistan over the course of a week.
But the harder question is whether that commitment can survive its inevitable collision with a severely flawed counterterrorism strategy. That strategy is carried out in regions where the military’s writ is heavily contested, and the strategy is directed at an adversary sheltered across a border that the state cannot effectively secure despite multiple attempts to do so over the years. These efforts have included a larger security force presence and border fencing.
Necessary correctives
Vaccinators’ security needs multiple forms of investment. The convoy model, in which provincial police absorb most of the casualties, is necessary in active operating environments and will remain so. This is why donor-supported training, equipment, and survivor benefits for police families are essential. But convoys alone have not produced trust. Recruiting security personnel from the same areas where vaccination teams operate, rather than rotating in officers from elsewhere in the province, would embed protection in the community rather than impose it.
Still, security investments won’t on their own resolve a problem that is fundamentally about trust. The grievances voiced by tribal jirgas and the Pashtun Tahafuz Movement are not abstract. Memories of displacement from earlier counterterrorism campaigns, the demolition of homes, and the prolonged absence of basic services have produced a population that views state-led campaigns of any kind with suspicion. The Pakistan Polio Eradication Program itself now formally tracks what it terms “demand-based boycotts,” and the US Centers for Disease Control has documented community refusals during vaccination campaigns “for reasons mostly unrelated to polio, such as requests for electricity services.” Reporting from KPK and Karachi describes families telling vaccinators they will only allow their children to be vaccinated once they get clean water, soap, or routine health care, asking why the state can mobilize for polio but not for the services they actually need.
Pakistani government and public health officials should include tribal jirgas and ulema councils, whose endorsements of vaccination campaigns have historically reduced refusal rates, in campaign planning earlier and more systematically. Additionally, these officials should recruit more Lady Health Workers, female government employees who carry out the bulk of door-to-door vaccinations, from the same communities they serve. They are the foundation of Pakistan’s eradication efforts. Expanding recruitment in districts where their presence is thin is an essential corrective. More broadly, campaigns should also combine vaccinations with delivery of basic goods such as soap, clean water, and oral rehydration salts—a model the WHO and Pakistan’s Emergency Operations Center have piloted to reduce refusal rates in high-resistance districts.
The Afghan Taliban has allowed synchronized cross-border polio vaccination campaigns to continue through 2025 and 2026, even as broader bilateral relations with Pakistan have deteriorated. Protecting those vaccination corridors and maintaining synchronized campaigns are narrow diplomatic objectives. Certainly, they are no substitute for shining counterterrorism successes that eliminate threats to polio workers. But they are wholly achievable, and therefore very much worth pursuing.