Breathing Space: Vaccination Ceasefires in Armed Conflict

"...evidence from past vaccination ceasefires shows that communication matters..."

In February 2021, the United Nations (UN) Security Council adopted Resolution 2565, which demanded that "all parties to armed conflicts engage immediately in a durable, extensive, and sustained humanitarian pause to facilitate, inter alia, the equitable, safe and unhindered delivery and distribution of COVID-19 vaccinations in areas of armed conflict". From the Political Settlements Research Programme (PSRP), this report examines past experiences of using ceasefires to facilitate vaccination campaigns in diverse contexts around the world and considers how these experiences might deepen understanding of the conflict-peace-COVID-19 nexus.

As the report outlines, the use of ceasefires to facilitate vaccination campaigns and other public health initiatives emerged in the mid-1980s. In 1984, the Colombian president arranged for a vaccination drive to take place in rebel-held areas amidst a ceasefire agreement. The following year, negotiations took place in El Salvador to organise a series of pauses in fighting so that nationwide polio vaccination campaigns could be carried out. From 1985 to 1991, these so-called "days of tranquillity" were held on three Sundays every year. As a result, child immunisation coverage rose from just 3% to around 80% by the end of the 6-year campaign. Partly aligned with the push for polio eradication that occurred in the 1980s and 1990s, days of tranquillity came to be a recognised part of the toolkit of interventions of actors seeking to address public health issues in conflict-affected contexts.

In addition to a literature review, the analysis in this report relies on the VaxxPax Vaccination Ceasefires Dataset, which is an original dataset of 74 vaccination ceasefires, covering instances of such events reported in the media and by non-governmental organisations (NGOs) across the world from 1985 to 2018. The data consist of cases where a cessation of hostilities was agreed during a conflict for the purpose of, in part or in full, conducting a vaccination campaign or similarly addressing a public health need. Part 2 of the report uses the VaxxPax dataset to provide an overview of the characteristics of vaccination ceasefires, highlighting, for example, the tendency for vaccination ceasefires to be focused on children.

Part 3 examines evidence regarding the relationship between vaccination ceasefires and conflict dynamics and comments on the contributions vaccination ceasefires have made to public health outcomes in different contexts. Overall, the analysis finds that there is limited evidence to support the argument that health-related ceasefires make significant contributions to peace in the long term, although there are some examples of more extended periods of peace emerging from initial vaccination ceasefires (e.g., in Sudan and Afghanistan). Beyond a lack of peacebuilding efficacy, some literature suggests that these health interventions could, if poorly done, in fact worsen conflict situations. Arya (2007), for example, argues that "by working through existing power structures in order to gain access to people in need, international assistance agencies can prolong oppression by authoritarian regimes. By adopting policies of solidarity with groups fighting for their legitimate rights, international donors can contribute to the will of the people to engage in violent conflict over prolonged periods of time". A further question relates to the degree in which such activities actually build trust and foster communication between warring parties, with a clear absence of systematic data on this issue.

Recognising the role vaccination ceasefires can play in delivering health services to populations in conflict zones, Parts 4 and 5 of the report present an overview of issues relevant for conducting vaccination ceasefires. Throughout, the authors point to potential implications of these issues for vaccination ceasefires in the context of COVID-19. Part 4 starts by examining the role of negotiators and intermediaries before moving to discuss issues of trust. For instance, the United States (US) Central Intelligence Agency (CIA)'s use of a fake Hepatitis B vaccination campaign in Pakistan as part of efforts to locate Osama bin Laden in 2011 led to widespread distrust of immunisation processes; in some areas, the death and destruction from drones came to be seen as connected to vaccination campaigns. Findings suggest that discovery of the CIA's ruse and subsequent anti-vaccination propaganda significantly reduced vaccination rates in parts of Pakistan. Not only can the erosion of trust lead to the revoking of access and affect the efficacy of campaigns, but it can also increase security risks for healthcare workers, particularly those who are members of communities under rebel governance regimes.

Also in the context of the Global Polio Eradication Initiative (GPEI), the provision of multiple, similar health services concomitantly, such as vitamin A supplements with polio vaccinations, has been a useful tool for building community trust, with such tactics forming part of the GPEI's revised global strategy following the disruption to polio eradication work caused by COVID-19. Careful consideration of which services to provide alongside vaccinations is required, however, to avoid negative associations impacting upon trust in vaccinations. For example, in Pakistan, polio workers' use of leftover jackets connected with a family planning campaign may have been detrimental to its success, particularly given the presence of rumours that the vaccine drops were part of a Western conspiracy to sterilise Muslims.

Next, the authors comment on considerations related to communication practices around vaccination ceasefires. They note that the first step in achieving days of tranquillity in Lebanon in 1987 was strictly an information phase, during which the United Nations Children's Fund (UNICEF) went first (approximately six months before the start of the campaign) to the official government and then to the de facto authorities and foreign forces to inform them of their intentions. The meetings were communicated to the media, creating a public record that could be used, along with later declarations to the national and international media about the planned ceasefire, to pressure groups into a cessation of hostilities in the absence of any formal agreements. To cite another example: "In El Salvador, thorough briefings were given to guerrilla representatives on polio eradication, the immunisation campaign, and the importance of collaboration, with communication between and within parties to the health campaign and ceasefire being key to success."

Not all forms of communication about vaccination-related ceasefires are supportive, the authors stress. In particular, the propagation of misinformation and anti-vaccination sentiments may be detrimental to both the public health activity and the cessation of hostilities. In northern Nigeria, for instance, a polio immunisation campaign was brought to a halt in 2003 as religious and political leaders linked vaccination programmes to a Western plot to sterilise Muslims. In Pakistan, a 2012 Taliban ban on vaccination was followed by targeted attacks on vaccinators, which led to an increase in the use of armed escorts for vaccinators that further increased suspicion among some groups. However, prominent Islamic scholars in Pakistan have also issued fatwas (formal Islamic rulings) endorsing vaccination campaigns, highlighting the complex interactions that can occur between non-health issues and the conduct of vaccination ceasefires.

"Bound up with these dynamics is the increasing use of social media, which has become an important factor in the spread of information and misinformation in Pakistan and elsewhere. Ittefaq et al. (2021) describe an extreme case in Pakistan where misinformation spread through social media about children getting sick after receiving a polio vaccine sparked the burning down of a small hospital, the temporary suspension of the polio vaccination campaign, and a jump in vaccine refusal cases in one affected city from 256 in March 2019 to 88,000 in April 2020. The lack of trust in state systems and the use of anti-state, as well as anti-West, rhetoric may mean that the spread and impact of misinformation about vaccines is particularly pronounced in conflict zones."

Clear and consistent communication is emphasised as vital facet of the implementation of vaccination ceasefires in Part 5. This portion of the report explores how the particularities of who delivers vaccination campaigns, how security provisions are organised, and where such campaigns take place can be significant for the functioning of vaccination ceasefires. For instance, the 2021 GPEI strategy emphasises the need for "co-ownership and co-implementation" of programmes with communities, especially in areas with high levels of vaccine mistrust and hesitancy. It also calls for increased female representation at all levels of the polio vaccination programme, which suggests further emphasis on employing local female healthcare workers to deliver polio vaccinations.

Part 6 of the report summarises core findings and highlights potential implications for vaccination ceasefires in response to the COVID-19 pandemic. Three key issues that the authors argue ought to be thought through in order to improve the impact of vaccination ceasefires to combat COVID-19 include:

1. Trust and the lessons of the past: In some contexts, a history of providing medical care can earn health actors trust with states and armed groups, which can then facilitate the organisation of vaccination ceasefires. There is also the matter of trust in the vaccines. While health actors negotiating vaccination ceasefires for polio, for example, can point to the long history of the polio vaccine and its safe use across the world, they have faced an uphill struggle to make the same case for more recently developed COVID-19 vaccines. In addition, previous vaccination ceasefires have generally taken place to facilitate immunisation against childhood diseases such as polio. Compared to these ceasefires, different language, concepts, and negotiating approaches may be required to arrange vaccination ceasefires for COVID-19, given that the disease affects adults (the cohort that tends to constitute the majority of armed group members) more severely than children.
2. Communicating COVID-19 clearly: While radio campaigns about vaccination ceasefires in a variety of contexts, including Afghanistan and El Salvador, are often framed in terms of encouraging participation in vaccination initiatives, it is feasible that such forms of communication may play a role in improving armed actor adherence to cessation of hostilities agreements due to greater public expectations and pressure. However, in conflict-affected contexts, where trust in authorities is often already fragile, the propagation of misinformation and anti-vaccination sentiments - particularly on social media - may be particularly detrimental. The widespread availability of information and misinformation on COVID-19, and the potential for that information to change as the virus evolves, may make it even more difficult for negotiators and health actors to maintain consistent messaging. When combating misinformation, experience has shown that care needs to be taken to not suppress the legitimate concerns populations might have about public health campaigns. Failing to engage with the concerns and grievances of conflict-affected communities can further damage trust and endanger future cooperation.
3. Making connections: The logistics around vaccination campaigns need be thought of in terms of their impacts on conflict dynamics and vice versa. COVID-19 vaccines can require multiple doses, but that level of consistent deployment of ceasefires is not possible in all conflict contexts. Furthermore, how vaccination ceasefires fit within the wider sequencing of peace processes - let alone in the context of multiple competing health priorities and scarce resources - may have implications for how those negotiations evolve. For these reasons, a narrow, intense focus on raising COVID-19 immunisation rates through vaccination ceasefires might, in fact, be detrimental. One immediate consequence of such an approach could be a heavier security burden on humanitarian actors and health workers, whose safety may be jeopardised by more frequent interventions in areas of ongoing conflict. Such risks need to be carefully weighed against the potential benefits of any ceasefires.

"A final point to note is that vaccination ceasefires are not the only option for vaccine delivery in conflict-affected contexts. Evidence from Nigeria, for instance, points to the possibility of vaccinating using alternative strategies, such as military escorts or military personnel trained to vaccinate, although each approach has its own drawbacks. In some contexts, for example, there is the potential for military involvement, or even the perception of military involvement, in health campaigns to increase the threats posed to health actors."