April 2015/ Spring Econ 0702B Qayyum, Naina

Senior Economic Thesis

Droning Polio: The Impact of Covert Drone Strikes on Polio Immunization Rates in Pakistan

Student: Naina Qayyum ‘15

Academic Advisor: Professor Erick Gong

Middlebury College

Spring 2015

[Honor Code: I have neither given nor received any unauthorized aid on this assignment.]

Signed: Naina Qayyum

May 11, 2015

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Acknowledgement

I would like to thank my thesis advisor, Professor Erick Gong for his continuous guidance and encouragement in writing this thesis. I am also grateful to Thomas Hitz’15 for giving very useful feedback as a referee and to my Econ0702B class for their inputs and suggestions. I am forever

thankful to my family and my friends for their support and prayers. This thesis is dedicated to the children who are bravely fighting their battle against polio and are lost in the midst of war.

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Droning Polio: The Impact of Covert Drone Strikes on Polio Immunization Rates in Pakistan

Abstract

For many, poliovirus, a debilitating disease, is part of history. However today, in the year 2015, there are only three countries including Nigeria, Afghanistan, and Pakistan that are still fighting the polio battle. Pakistan tops the charts in the number of polio-infected children where the highest number of confirmed polio cases were 297 in 2014. Apart from systemic inefficiencies in polio eradication efforts in Pakistan, the War on Terror (WoT) in the form of Central Intelligence Agency (CIA) operated Covert Drone Strikes Program has greatly affected the polio vaccination campaigns. The connection between drone strikes and polio lies in the vexatious presence of the Taliban in the Federally Administered Tribal Areas (FATA) of Pakistan who retaliate against polio vaccination campaigns as a way to avenge the drone strikes that have killed over 2500 individuals to date. This study is the first empirical study done to measure the impact of drone strikes on polio vaccines. It employs longitudinal data using individual and time fixed effects to measure the impact that drone strike has on the likelihood of children getting polio immunization in Pakistan and Afghanistan. Empirical evidence shows that overall, on average, increase in the number of drone strikes lowers the likelihood of a child receiving polio by 0.442 percentage points in Pakistan and Afghanistan. However, on country level where Afghanistan has a negative causal relationship between drone strikes and polio immunization, Pakistan shows a statistically positive result. There are factors that may be contributing to such difference in the results for the effect of drone strikes on polio immunization, which the paper will discuss at the end.

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1. Introduction

Poliomyelitis (Polio) is a crippling fatal viral disease in humans that affects the central

nervous system and induces lifelong paralysis (CDC, 2015). Polio is highly contagious as it can

pass through fecal-oral route in unsanitary conditions. Children less than five years old are more

prone to contract poliovirus (WHO, 2014). Fulfilling the World Health Assembly’s commitment

to completely eradicate polio by the year 2000, the number of polio endemic countries was

reduced from 125 in 1988 to just 3 in 2014 (WHO, 2014). Today, poliovirus is rife in only three

countries; Pakistan, Afghanistan, and Nigeria (GPEI, 2015). The remains of poliovirus strains

pose a global threat of polio’s resurgence (a negative externality) and demands hastened efforts

for its eradication.

Pakistan represented 85% of the Wild Poliovirus Type 1 in 2014 with 303 confirmed

polio cases (GPEI, 2015). The polio strain in Pakistan was found in five other countries namely

Afghanistan, Syria, Iraq, Cameroon, and Equatorial Guinea since 2012. The pattern of poliovirus

spread indicates that it can become a global threat to polio eradication efforts, especially in

developing countries that have insufficient vaccination coverage and poor health infrastructure

(Ghilzai, 2014). In Pakistan, polio campaigns started in 1994 under the Polio Eradication

Initiative, 15 years after the Expanded Program for Immunization (EPI), and functioned as

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Supplementary Immunization Activities (SIA). Until 2009, 88 rounds of SIA were conducted

and Pakistan was able to bring down the number of polio cases from 1155 in 1997 to 28 in 2005,

which is a marked improvement in achieving a polio-free Pakistan (Nishtar, 2010). However, in

2008 polio cases began to increase again, as shown in figure 11, even though there were no cases

reported in the previous year in 2007. This sudden increase of polio cases reflects the failure of

the polio eradication campaign in Pakistan due to the lack of proper vaccine service delivery and

negligence in polio vaccine maintenance and coverage.

The increase in the polio cases is also a result of political instability in the region. The

polio vaccination campaigns have fallen prey to challenges stemming from weak health

infrastructure, poverty, and security threats to polio workers from anti-polio vaccination groups,

such as the Pakistani Taliban (Ghilzai, 2014). Added on that, the fake Hepatitis campaign ran by

the CIA to hunt down Osama bin Laden in May 2012 and subsequent military operation to

capture him, raised suspicion in the Pakistani public about any sort of vaccination campaign,

especially when administered by foreign agencies (Ghilzai, 2014). Even though the CIA

announced that it would not make use of vaccination campaigns for spying operations, the

Osama bin Laden incident remains fresh in many people’s mind (Firger, Jessica, CBS News).

According to a resident of FATA, whose son was crippled by polio, admitted his negligence of

not giving polio vaccine to his child and said,

“I know now I made a mistake. But you Americans have caused pain in my community.

Americans pay for the polio campaign, and that’s good. But you abused a humanitarian

1 See Appendix (Section A)6

mission [vaccination campaign] for a military purpose [capturing Osama bin Laden]”

(McNeil ,2013).

Apart from the aforementioned structural and policy glitches, polio eradication has also

suffered due to the US War on Terrorism (WoT) that greatly affected the political climate in

Pakistan and Afghanistan. The use of fake vaccination campaign by the CIA marked the

politicizing process of polio. As a result, terrorist groups such as the Taliban used banning polio

vaccination as a way to seek revenge from the US for targeting them and spying on them using

vaccinators and health workers. This thesis is an attempt to explore the connection between the

US WoT, in the form of drone strikes program in the Federally Administered Tribal Areas in

northwestern Pakistan, and polio immunization rates in Pakistan as well as in the neighboring

country, Afghanistan.

The following study is organized as follows: section one gives a background about the

polio situation in Pakistan and Afghanistan and an overview of the drone strike program and the

FATA region. Section two consists of literature review and my contribution to the literature.

Section 3 describes the data sets used in the study and section 4 explainss the empirical design.

Section 5 presents the results, whereas section 6 and section 7 consist of the discussion of the

results and conclusion, respectively.

SECTION ONE: Backgroun Information

1.1 Background of the Federally Administered Tribal Areas (FATA)

The study design uses child fixed effect model to study the impact of covert drone strikes

occurring in the Federally Administered Tribal Areas (FATA) on the polio immunization rates in

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Pakistan. As shown in the map in figure 32, FATA consists of seven districts and is located

halfway between Afghanistan and Pakistan. Being federally administered means that FATA is

considered to be a territory of Pakistan per Article 1 of the Constitution of Pakistan but the laws

made in the Pakistani parliament do not apply in the region (FATA.Gov, 2015). Hence, it is the

president of Pakistan who has executive authority in governing FATA. Due to the constant

change of government in Pakistan and changing priorities of each administration in power,

FATA never received a consistent source of funding or attention making it a politically and

economically marginalized region. The economy of FATA mainly consists of subsistence

agriculture and livestock and dissemination of unskilled labor force to other cities of Pakistan

and parts of the Middle East. According to the last census conducted in 1998, the population of

FATA was about 3.18 million (FATA.Gov, 2015).

FATA used to be a peaceful area prior to 9/11 but after the US launched military

operations against terrorists in Afghanistan, a large number of these terrorist militants sought

refuge in the remote and mountainous areas of FATA (FATA.Gov). Since then FATA has

become the hub of drone strikes and the central ‘war zone’ in the US fight against terrorism.

There is believed to be a large number of militant hideouts in FATA and the youth of the area are

joining these terrorist forces, as there are not sufficient job or education opportunities available

to engage them. Thus, the local people of FATA are displaced and lack a secure living condition

as well as social services of health and education (Orakzai, 2009). FATA is a religiously

conservative region and lags behind social indicators compared to the rest of Pakistan. The

literacy rate is only 17% (compared to 45% in Pakistan), where females only make up to 3% of

the statistics. There is 1 bed per 2327 people on average in hospitals in FATA, which is

2 See Appendix (Section A)8

extremely low and inadequate compared to the ratio of 1 bed: 1450 people in Pakistan. Only

43% of the populations have access to safe drinking water and there is only 1 doctor available

per 8189 people (FATA.Gov). With such poor health and education infrastructure in place, it is

inevitable for terrorist groups to manipulate the local population and take over the administrative

system of the region. The hostility of the local people of FATA against foreign intervention and

the Pakistani government is perpetuated by the lack of attention and consideration given to the

innocent people of the area.

1.2 Background of Drone Strikes and Their Impact on Polio Immunization

The link between polio eradication campaigns in Pakistan as well as in Afghanistan and

the on going War on Terror (WoT), lead by the United States is significant. This is evident in the

Federally Administered Tribal Areas (FATA) that makes up 12% of Pakistan’s territory in the

North Western part of the country (Nishtar, 2010) and is the hotbed for the Taliban terrorist

group’s activity. The Tehrik-i-Taliban (TTP) influence in FATA through their extremist

teachings convinced 90% of local clergy to preach against the polio vaccine (Mahmood, 2014).

Out of the 235 cases reported in Pakistan, 199 were from FATA and these figures just emboss

the intensity of the polio situation in the region (Mahmood, 2014). According to a UN official,

“I [Polio campaign teams] can no longer go to most areas in NWFP [now called Khyber

Pakhtunkhwa (KPK) province] and FATA. It is regrettable that the area is passing

through circumstances where I cannot even monitor vaccination campaigns”

(Ahmad, The Lancet, 2007).

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Polio eradication efforts in Pakistan are mainly hampered by the Taliban in the Federally

Administered Tribal Areas (FATA) in the North Western part of Pakistan. The Taliban envisage

polio campaigns as an American venture and therefore oppose it by doing anti-polio vaccine

propaganda to retaliate against the CIA drone strikes that has killed 1770 terrorist and 258

civilians to date (New America, 2015). Leaflets are distributed by the Taliban amongst the

masses in FATA to misinform them against the US. Such as stated in one pamphlet,

“In the garb of these vaccinations campaigns, the US and its allies are running their

spying networks in FATA, which has brought death and destruction [to the Taliban] in

the form of drone strikes” (Boone, The Guardian, June 2012).

Figure 13 illustrates how polio cases in Pakistan trend with the number of drone strikes in

the same year and the year before. The polio cases count and the drone strikes roughly follow

each other and this correlation is stronger for drone strikes from previous years, indicating a lag

effect of drones on polio cases. The year 2014 marks the peak number of polio cases when the

number of drone strikes was less. This could be due to the killing of female polio workers and

misguidance of the public against the polio vaccine by the Taliban that added on to the drone

factor and halted immunization activities in FATA and adjacent areas (Beaubien (NPR), 2014).

In the light of the negative effect of drone strikes on the polio immunization campaigns in

Pakistan, this study will carry out an empirical analysis to calculate the magnitude of this impact.

The identification strategy is that the drone strikes created an anti-western sentiment in the

Pakistani population and, since polio vaccine is also considered western, it is opposed by many

and that leaves a lot of children vulnerable to contracting the crippling disease. FATA is the area

where a large number of terrorist hideouts are thought to be present and hence it is the hub of

3 See Appendix (Section A)10

drone strikes since 2004. Hence, the hypothesis set forth for the empirical analysis considers that

provinces in Pakistan and Afghanistan that share a border with FATA will see a significant

reduction in their polio immunization rates for children who are willing to get the polio vaccine,

compared to the provinces that do not directly share a border with FATA.

SECTION TWO: Literature Review and Contribution

There is limited economics literature available that empirically analyzes the impact of

political or social factors on the polio eradication efforts in Pakistan. A significant part of the

literature consists of news articles, qualitative survey analysis about polio campaigns in Pakistan,

and official reports from the World Health Organization (WHO) updating about the progress of

the polio eradication campaigns in Pakistan. The target killing and US drone strikes in the FATA

region in Pakistan have made it a conflict-ridden area. Since June 2004 until mid-September

2012, data shows that there have been 474-8814 civilian casualties due to drones in FATA, of

which 176 are children (The Bureau of Investigative Journalism - TBIJ). Data from TBIJ also

reports structural damages to buildings including schools and hospitals in the area that makes

access to health care harder for civilians. Hence, drone strikes affected areas can be compared to

civil conflict experience where the cost incurred by the unarmed and innocent civilians is similar

to the situation faced by populations in war-ridden and conflict areas.

There is a relatively larger pool of literature available that empirically analyzes the

overall impact of civil conflicts on children's health and immunization outcomes. Overall, these

studies find a negative impact of exposure to conflict on children’s health. Various studies that 4 The figure is reported in a range because often there is ambiguity in the reports of the actual numbers of casualties by the media. The US is not willing to accept that there can be so many civilian deaths due to drones and hence the actual figures are hidden. In fact, the US government claims that the number of innocent deaths are in single digit and this way the drone program is saved from accountability from the democratic system. (livingunderdrones report - http://www.livingunderdrones.org/report/)

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employ the difference-in-difference methodology discover that children who are more exposed

to violence have a lower age-to-height z score than those who are less exposed or not exposed to

violence (Akresh, Lucchetti, Thirumurthy, 2011; Minoiu and Shemyakina, 2012; Bundervoet,

Verwimp, Akresh, 2008).

Cetorelli (2013), through a difference-in-difference method, found that in Iraq between

2000-2011, children in more violent areas were 21.5 % points less likely to have complete

neonatal immunization coverage than children in the relatively safer Kurdish areas. Senessie et

al. (2007), in their study on Sierra Leone civil war, found that almost half of the children in their

sample living in the conflict area were not fully immunized. The authors also found the rural

areas to be far more affected by war in terms of lack of immunization than urban areas.

Measuring health outcomes is challenging, hence most empirical studies use height-to-age Z

score as an indicator of a child’s health. Minoiu et al. (2012), Bundervoet (2008), and Akresh

(2011) use the height-to-age z scores and found that war and conflicts in countries have negative

impacts on the children residing in those countries. It is important to consider the impact that

drone strikes had on maternal attitude towards having children and use of contraception. Valente

(2011) focuses on child health through the impact of war on maternal health. Using data for

Nepal, the author derives that in high intensity of conflict, there are higher chances of

miscarriages and exposure of children to violence in their first few years of life can adversely

impact their health.

According to the Pakistan Demographic Health Survey (DHS) 2012-2013, only 54% of

the children between the ages of 12 to 23 months were fully immunized, which means they had

received one dose of BCG vaccine and three doses of DPT and four doses of Polio vaccine.

There were 5% children in the DHS data set that had not received any vaccine coverage at all.

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There was variation in vaccine coverage in rural (48%) and urban (66%) areas and within

provinces where the lowest was in Baluchistan (16%) and highest was in the Capital Territory,

Islamabad (74%) (2012-13 DHS key findings p.9).

My research contributes to the scarce empirical literature available about polio and it is

the first of its kind, in my knowledge, that is evaluating the impact of the drone strikes on the

polio immunization rates in Pakistan and Afghanistan. I include Afghanistan in the analysis

because it shares border with FATA and also has polio rates that could be affected by the drone

strikes.

SECTION 3: Data

3.1 Pakistan

The individual child level data for Pakistan consists of cross sectional household surveys

obtained from the Demographic Health Surveys (DHS). From the available DHS surveys for

Pakistan, I used the 2012 - 2013 child level survey dataset. The DHS collect reliable information

about demographic and maternal and child health indicators in many countries around the world

(DHS report 2012-13). DHS consists of a nationally representative sample of ever-married men

and women, children and household characteristics. The 2012-2013 survey area excluded the

Federally Administered Tribal Areas (FATA) as well as the disputed Kashmir territory with

India as shown in figure 45. The exclusion of FATA will be a limitation to the study because

FATA is the nucleus of the CIA operated drone strikes and it is the area that reports the bulk of

Wild Poliovirus (WPV) cases in Pakistan. In 2012, 84% of the case (92 cases) was reported from

5 See Appendix (Section A)13

the FATA region and low security areas of Khyber Pakhtunkhwa province (CDC, 2015). Due to

the unavailability of polio immunization data from FATA, I am unable to find the direct impact

of drones on polio vaccination. However, I am able to measure the indirect impact that drones in

FATA can have on adjacent areas. In FATA drones can halt the supply of polio vaccines but in

the neighboring areas, polio vaccine supply is not affected by the drone strikes. The only factor

in the adjoining areas affected by drone will be the demand for polio vaccine. Hence, using the

indirect impact study design, I am still able to isolate the polio vaccine’s demand side effect due

to drone strikes.

For the purpose of the study, I employ the children and mothers data from the DHS

Pakistan. The children in the sample are between the ages of 0 to 5 years and are born between

the years 2008 and 2013. I created a longitudinal panel where the unit of observation is a single

child in a given month of a given year over a period of 5 years. The survey was conducted on a

random sample of clusters in different regions and further randomly sampled different

households in the clusters. According to the survey, a household is a group of related or

unrelated people who share the same living area and have similar cooking and eating

arrangements and agree on a single household head, who usually lives in the house (DHS report,

2013). For the child survey, questions were asked from mothers who were between the ages of

15 and 49 years. In the analysis, I controlled for time invariant factors through child and month

and year fixed effects. There was inconsistency in the reporting of the polio immunization and

other vaccines for children. For accuracy, I only considered those polio vaccination records that

were marked in the immunization card of the child and dropped those values that were reported

by the mother’s recall and had no specific month or year mentioned. As shown in the table

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below, there were a total of 11,763 children in the dataset whose mothers were interviewed in

Pakistan.

Has a vaccine card for at least one polio immunization

Punjab Sindh KPK* Baluchistan Gilgit Baltistan

Islamabad Total

No = 0 70.2% 81.9% 72.7% 92.3% 79.1% 61.9% 77.1%

Yes = 1 29.8% 18.1% 27.3% 7.7% 20.9% 38.1% 22.9%

Percentage of children who received at least 1 polio vaccine dose in each province in Pakistan.*KPK is Khyber Pakhtunkhwa, previously known as the North West Frontier Province.(Source: Demographic Health Survey of Pakistan. 2012-2013)

Children who had no record of polio vaccinations were dropped out of the dataset and there were

only 2,694 children left in the dataset. Out of the total there were only 2, 694 children who had at

least one of the four polio vaccination doses. On regional level, Islamabad had the highest

number of immunized children who had at least one polio dose (38%), followed by Punjab

(29.8%). Baluchistan province, which is a neighboring province to FATA, has concerning figure

of 92% for children who have not received even a single dose of polio vaccine.

3.2 Afghanistan

The Afghanistan data came from Multiple Indicator Cluster Survey (MICS) conducted

between 2010 and 2011 by the United Nation’s Child Fund (UNICEF) in collaboration with the

Government of Afghanistan. The MICS was initially started in 2010 to monitor and measure the

fulfillment of the Millennium Development Goals, especially related to women and children in

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Afghanistan. MISC uses three modules of questionnaire: for households, for women between the

ages of 15 and 49 years, and children under the age of 5 years (CSO, 2010).6

There was no Demographic Health Survey (DHS) for Afghanistan but MICS provided a

very similar alternative. MICS survey consisted of similar questions about female fertility,

household characteristics, as well as children’s health and education information that DHS asked

from its respondents. I combined the child, household, and women’s data to create a child-level

panel data set. I also recoded the relevant variables for the Afghanistan data set to match them

with the Pakistan data set in order to merge them together.

3.3 Drone Strikes

The data on drone strikes is from The Bureau of Investigative Journalism (TBIJ)- an

independent private non-profit news reporting agency that pairs up with university research units

to gather up-to-date data of the Central Intelligence Agency’s drone strikes mission in Pakistan.

The data is available from the year 2004, when drone strikes started in Pakistan during Bush

administrations, until May 2014. The drone strike data set has record of the time, day, month,

year and place of the strike as well as the human and material casualties resulting from it. The

TBIJ’s source of information regarding the drone strikes comes from several places such as

media reporting, legal cases filed by the victims of drone strikes, fieldwork done by researchers,

and leaked US intelligence records. Even if I claim that the drone data is not completely

accurate, it is the best I can get for the purpose of this analysis. Figure 2, 7 shows the number of

drone strikes that occurred during each month for every year from 2004 to 2013. From the graph,

I can observe some time variation in the drone strike occurrence. The variation in the drone 6 CSO stands of Central Statistics Organization, Islamic Republic of Afghanistan (http ://cso.gov.af/en/page/1723) 7 See Appendix (Section A)

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strike allows me to capture the changing polio immunization rates as a result of changing drone

strikes over time. The intensity of drone strikes increased after year 2008, when US president

Barack Obama took charge of office and intensified the drone strike policy. According to the

data, since 2004, 413 drone strikes have occurred, of which 362 were done during Obama’s time.

3.4 Summary Statistics

Table 18 shows the summary statistics for some variables of interest for both Pakistan and

Afghanistan. The table report mean values for the listed variables on child level. It can be

observed that there are differences in the indicators for both Pakistan and Afghanistan.

Considering variables such as age of respondent (mother), number of children who are less than

5 years in a household, and age of child, there is not much difference in the means. But I do see

that Pakistan is doing much better in indicators for the polio vaccination rates for the 4 polio

doses and there are more children in the Pakistan sample who received any of the polio doses

compared to children in the Afghanistan sample. Both countries are similar in terms of the

wealth index as they both lie in the third quintile of the wealth index, but Pakistan is at the higher

end of the quintile than Afghanistan. There are, on average, more rural areas in Afghanistan than

in Pakistan. The average mother’s education level is higher in Pakistan than in Afghanistan,

which can explain the higher polio immunization of children in Pakistan compared to

Afghanistan. The mean number of drone strikes experienced by children in both the countries is

almost the same; about 5 drones occurred in FATA during the child’s lifetime in my sample.

SECTION FOUR: Study Design and Empirical Models

8 See Appendix (Section B)17

4.1 Geographic Aspect of the Study Design

Figure 49 shows the complete map of Pakistan and all its provinces as well as the

neighboring countries. The Federally Administered Tribal Areas (FATA) are located in the north

west of Pakistan and the provinces surrounding it are Khyber Pakhtunkhwa and Baluchistan. In

the map FATA is shaded gray because it was excluded from the Pakistan DHS Survey due to its

instable condition. The exclusion of FATA from the survey data does not allow me to measure

the direct impact of drone strikes on polio immunization, but it does allow me to study the

indirect impacts in the neighboring areas that share a direct border and physical closeness. In the

drone data set, FATA is the only area where the drone strikes are occurring and causing

destruction.

The study design focuses on the differential impact of drone strikes when one resides in a

province near FATA, and thus being more affected by the physical as well as political

consequences of drone strikes. Hence, I will utilize the available Demographic Health Survey

data for the adjacent provinces to FATA in Pakistan (n = 2) and Multiple Cluster Survey in

Afghanistan (n = 5). For these 7 provinces that are immediately bordering FATA, they will get

an indicator value of 1 and the other provinces will get 0. With creation of a dummy,

NEAR_FATA, I expect to see spatial variation in the way drone strikes in FATA affect the

likelihood of children receiving polio immunization. For the purpose of stating a hypothesis, I

expect there to be a negative causal effect of drone strikes and polio immunizations for the 7

provinces surrounding FATA. Hence, there should be lesser likelihood of children getting the

polio vaccine in near FATA areas than those in the non-bordering areas. The null hypothesis will

indicate no effect of drone strikes on polio immunizations. One can expect there to be variation

9 See Appendix (Section A)18

within the provinces in terms of the health access and other characteristics that impact the

likelihood of a child receiving the vaccine or not. Since I am carrying out the fixed effects

analysis at individual child level, any time-invariant or regional variations will be accounted for

in the model.

Through the aforementioned study design, I hope to estimate the effect of being near

FATA; hence more exposed to the violence of drone strikes, versus being further away and less

exposed to the drone strikes on the polio immunization rates in Pakistan and Afghanistan. The

identificationl strategy here is that people near FATA will also be influenced by the Taliban

propaganda against polio vaccines due to the affluence of media such as radio, newspapers, and

television. The Taliban’s propaganda against polio vaccinations includes distribution of

pamphlets, running radio shows, publishing newspapers that misinform people about the polio

vaccine. Calling the polio vaccine unislamic, source of infertility, a western propaganda are

enough to influence the uneducated masses and make them reject the vaccine (Roul, 2014). In

recent times, these sources of misinformation have spread across FATA into neighboring

districts in KPK, such as Swat and Peshawar (Murakami, 2014). Therefore, parents staunchly

believing in the false information against polio vaccine may not get their children immunized

against polio putting them at a higher risk of getting disability for life.

As mentioned before, in FATA, both the demand and supply of the polio vaccine is

affected but in the adjoining areas to FATA, where there are relative better health facilities, I can

isolate only the demand for polio vaccine that has changed as a result of the drone strikes. The

change in demand for polio vaccines will be driven by those children who are seeking the polio

vaccine, meaning they are in the process of getting the vaccines and may have received at least

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one or, at most, three polio vaccine dose(s). Figure 610 shows the breakdown of children in the

sample and divides them into four groups. FATA and its neighboring areas are underdeveloped

and the dissemination of information regarding the occurrence of a drone strike or a false fact

about polio vaccine depends on the availability of communication devices as well as literacy rate

of individuals. The child level data for both Afghanistan and Pakistan controls for the

information source available at the household level including the availability of television, radio,

newspaper, and electricity to run these devices as well as the literacy rate of household head,

which determines if they are able to read the newspaper. The media can have a strong influence

on the minds of people and in the adjoining areas of FATA.

Just how manipulative media and information can be is evident from the pamphlet that

the Taliban in the FATA area drafted and disseminated to the local population as shown in figure

5.11 According to pamphlet, the Taliban of the North Waziristan area clearly ask the population

to refuse polio vaccinations unless drone strikes are stopped in FATA because drones strikes are

more threatening and harmful for the local population than poliovirus. This may not be a big

concern because the decision to take polio or not does not occur right after a person hears about a

drone strike. There are militant and local mosques that talk about drone strikes and influence

people’s decision regarding polio vaccine when the polio campaign activities’ time comes. The

ban on polio vaccination in the North and South Waziristan district and Khyber Agency in

FATA lead to about 300,000 children being deprived of polio vaccines. There are similar ethnic

groups living in the FATA and neighboring area so there is no concern for the difference in the

ethnicity of a child and their decision to get polio vaccine. However, in the non-neighboring

areas there are different ethnic groups who are relatively open to getting the polio vaccine. As an

10 See Appendix (Section A)11 See figure 5 in the appendix (Section A) to see the original pamphlet and its translation.

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extreme measure of opposition there have been murder cases of polio workers who are visiting

areas in FATA to administer polio vaccination to the local population. The incidence of polio

workers being killed has increased overtime. One can deduce the intensity of the worsening of

the polio worker security situation by the fact that from January to November 2014, there were

42 polio workers killed of which18 were in FATA and 13 were in the neighboring Khyber

Pakhtunkhwa province that shares same ethnicity groups as FATA.

4.2 Estimations

The Fixed Effects (FE) regression is as follows:

Y ijkmt=β0+β1 ( No . of DroneStrike)+δi+γ t+μm+εijkt (1)

According to equation (1) the dependent variable Y is the dummy variable for polio

immunizations that takes a value of 1 if a child received a polio dose in the given month and 0 if

otherwise. The equation also has fixed effects parameter where δ i accounts for child (i) fixed

effects that control for any time invariant characteristics of the child such as their gender,

ethnicity, family characteristics. γt Is the year fixed effect and μm is the month fixed effect that

controls for any time invariant factors during the time period that can affect polio immunization

such as political and economic changes. ε ijkt Is the error term?

There is no reverse causality issue in the empirical model between the number of drone

strikes and polio immunization of a child. Drone strikes can impact whether a child may or may

not receive any polio immunization, but a child’s polio vaccination does not impact or cause the

occurrence of drone strikes in any way. Omitted variable bias will be accounted for in the model

since it is using child and time year fixed effects. Hence, completely time invariant factors such

as gender of child, ethnicity, health status at birth of the child and the mother, as well as slowly

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changing time variant factors such as household income, sanitation condition, parents’ education,

access to news, migration of the family will all be controlled for in the fixed effects model.

However, the omitted variables of concern will be those that must vary with time and must be

correlated with drone strikes and therefore bias the immunization chances of a child. One factor

could be the intensity of Taliban’s activities that can cause terror. So over time, if the Taliban are

recruiting more people in their forces and carrying out more threatening acts of terror in the

world, then there are chances that they may be targeted more by intensified drone strikes

program. The intensity of the drone strikes, as shown in figure 1, can lead to a stronger ban on

polio vaccination campaigns and hence can affect the child’s opportunity to receive a polio

vaccine dose. However, such a factor is not a major concern for the model because the data

accounts for such changing trends in drone strikes that are a reflection of policy change from the

Obama administration to speed up the process of killing and capturing terrorist that can be

potential threat to the security of the United States.

The data set includes children who have already been immunized against polio, meaning

that they received all the four doses of polio until the day the mother was interviewed. Since, the

mother was providing the information about the child, it was important to restrict the sample to

only those children whose immunization status was confirmed. Hence, all the children in the

analysis are those who showed a vaccination card with the dates of their polio immunization

records. This helps to remove any biases that may have resulted from data obtained through

memory recall of the mother.

After incorporating the geographic aspect of the study design, the fixed effects regression

equation became as following:

Y ijkmt=β0+β1 ( No . of DroneStrike)+β2 (Seeking )+δ i+γ t+μm+εijkt (2)

22

Y ijkmt=β0+β1 ( No . of DroneStrike)+β2 (Seeking )+β3 (Drone∗See king )+δi+γt+μm+εijkt

(3)

In equations (2) and (3), I include the variable ‘Seeking’ that accounts for the children who are in

process of completing their polio immunization course. Instead of including a dummy variable

for a child’s location of being near or far from FATA, I applied a condition while running the

regressions, thus the equation was run first for the condition that the child is near FATA and then

for the condition that he/she is far away from FATA. I also include the interaction term of

Drone x Seeking to measure the partial impact of an increase of one drone strike on the

likelihood of a seeking child getting their polio vaccine dose. The overall impact of drone strikes

occurring in a month is a sum of β1+ β3 .

This interaction term, Drone x Seeking is important to be included in the model because it

captures the effect of varying drone strikes over time on the outcome for the vaccine seeking

group of children. As explained in figure 6, there are children who have received one or more

doses of polio vaccination but they have not yet completed the four-dose polio vaccination

course. The ‘seeking’ is the group of children who can give us the most accurate outcome of the

impact of drone strike on their polio vaccination. They are in the process of getting the vaccine

and if they do not proceed with their vaccination routine, given that the model controls for other

factors impacting their decision to take the vaccine, then I can safely say that it is the impact of a

drone strike occurring during that month in FATA that let them to not continue their full

vaccination course. The other children who are in the non-seeking group are either those who

never had a polio dose due to its unavailability and who may not have access to any health

facility from where they can get the vaccine or those children who have completed all the four

23

doses of their polio vaccine and will not be impacted by drone strikes. These children need not

be included in the seeking sample and the estimation, since they have already completed their

vaccination course and even if there were a drone strike, it would not impact their likelihood of

taking a polio vaccine.

SECTION FIVE: Results

5.1 Results of Empirical Estimations

This section presents the results of the empirical model described previously. Table 2A12

shows the combined result for the impact of drone strikes on polio immunizations in Pakistan

and Afghanistan. Column (1) of Table 2A shows a statistically insignificant negative effect

(0.028 percentage points) of an increase in drone strike in a month on child’s likelihood of

receiving polio immunization. Upon addition of the ‘Seeking Polio Immunization’ variable, the

effect becomes negative and statistically significant at 5 percent level. Thus, an increase of 1

drone strike in a month will, on average, lead to a decrease in the chances of a child getting polio

immunization by 0.39 percentage points, which is a not a very large effect. The coefficient for

the ‘Seeking Polio Immunization’ is very large and it remains to be for the rest of the columns in

table 2A. With increase in the number of drone strikes, the results show that the likelihood of

seeking children receiving polio immunizations increases significantly with a large value. For

example in column (3) where I included the “No. Of Drones x Seeking” interaction term, the

likelihood of a child receiving polio vaccine that month increased by 32.3 percentage points. For

near FATA areas, the coefficient is greater (33.7 percentage points) than for far from FATA

areas (31.7 percentage points). The interaction term of “No. of Drones x Seeking” gives the

partial impact of having an additional drone strike on the polio immunization status of a child.

12 See Appendix (Section B)24

Table 2A also shows that overall the effect of drone strikes, considering that the child is seeking

vaccine, is negative and shows a statistically significant 0.53 percentage points decline. The

comparison of the interaction term of near FATA and far from FATA regions show that the

impact of drones on the vaccine seeking children is higher for far from FATA areas (0.56

percentage points decrease) than in near FATA areas (0.35 percentage points decrease). The

linear combination coefficients provide the total effect of drone strikes on child immunization

status by adding the coefficients for “No. of Drone Strikes in a Month” and “No. of Drones x

Seeking”. According to the linear combination coefficients, the overall effect of drone strikes

occurring in FATA is 0.42 percentage points decline on average in the likelihood of a child

receiving a polio immunization dose in the same month as the drone strike. This effect is smaller

for near FATA areas (0.32 percentage points) than for far from FATA area (0.44 percentage

points).

To get a better sense of the outcomes shown in table 2A, I tried to break it down at

country level and carried out similar empirical estimations and conditions for Pakistan and

Afghanistan.

Table 2B represents the results for Pakistan and these result are surprising considering the

hypothesis stated for this paper. According to the Pakistan result, if I consider the linear

combination coefficients, I observe that the effect of drone strikes on child’s likelihood of

receiving polio immunization is negative and statistically significant with a value of 0.19

percentage points. But when considering the linear combination for near FATA area, the value

(0.35 percentage points) becomes positive and statistically significant at the 1 percent level.

However, for the far from FATA areas, the value stays positive and becomes statistically

insignificant. Looking at the interaction term, “Drone x Seeking”, all the coefficients are positive

25

and statistically significant making the claim that considering only ‘seeking’ children, an

increase of 1 drone strike in a month in FATA will cause the likelihood of a child in near FATA

area to increase by 0.36 percentage points on average and in far from FATA areas to increase by

0.15 percentage points. Contrary to my hypothesis, Pakistan not only shows a positive outcome

for polio vaccinations due to drone strikes, but also indicates that the positive effect is much

more in near FATA areas than in non-neighboring areas to FATA.

Afghanistan results, on the other hand, show a different, rather an opposite, picture from

Pakistan. According to table 2C , which is just showing results for Afghanistan, per the linear

combinations, there is a statistically significant negative impact of a value of 0.48 percentage

points on average of drone strikes on polio immunization status of Afghan children. I observe

that this effect is negative and statistically significant and much larger for areas near FATA (1.01

percentage points) than areas far from FATA (0.42 percentage points). This comparative effect

is also reflective in the interaction variable for ‘No. of Drones x Seeking” where the effect of an

increase in one drone strike leads to a decrease in the likelihood of receiving polio immunization

for a child by 1.09 percentage points in near FATA Afghan provinces and 0.72 percentage points

in Afghan areas far from FATA.

Taking a step back and looking at all the results for the empirical analysis, there can be

seen variability in how the data is predicting the effect of drone strikes on polio immunization

status of children in Afghanistan, Pakistan and overall. Taking FATA as the nucleus point where

drone strikes are occurring, I found that the indirect impact of drone strikes on near FATA and

far from FATA areas is statistically significant and negative for those children who are seeking

the polio vaccine. Even if my hypothesis of predicting a negative impact of drone strikes on

polio immunization stays true, the geographical predictability is reversed. Areas far away from

26

FATA are more likely to experience a larger negative impact of 0.44 percentage points decline

than in near FATA areas where the decrease is 0.31 percentage points. Once reason for the low

number of near FATA can be due to the decrease in the number of observations available for the

near FATA areas compared to the far from FATA areas. Probably, a bigger sample size for near

FATA could have made the effect larger and help better understand the phenomenon driving

these results. Overall, the R2 values for all the result tables are below 50%, meaning that less than

50% variation in the means of the variables is explained by the data. This is not a major concern

because in studies consisting of human responses and behavior, the R2 value is usually low.

Nevertheless, the results from the data and estimations give an interesting insight into the drone

strike’s impact on polio immunizations that I will discuss more in the next section.

5.2 Robustness Checks

In order to explore potential source of drivers that may be giving the results in section

5.1, I ran some robustness checks. For both Pakistan and Afghanistan separately, I ran robustness

checks by running the empirical estimations by conditioning on ethnicity of a child, whether the

child lives in a rural area and the mother not having any education.

Ethnicity

The ethnicity factor is very important to consider especially in the case of Pakistan where

the Pashto speaking ethnic group (known as the Pashtuns) is notorious for polio vaccine refusals

in FATA, and other provinces where they are residing. Pashtun is a major tribe in Afghanistan

with some population residing in Pakistan. According to a newspaper article in The New York

Times, “ [In Pakistan] virtually all those with polio are from the Pashtun tribe, in which

resistance to vaccination is highest. It is Afghanistan’s largest ethnic group and the wellspring of

27

the Taliban, but a minority in Pakistan. Pakistani Army sweeps and American drone strikes have

driven many Pashtuns from their mountain valleys into crowded cities.”

One of the a main cities that has become a pocket of poliovirus is Karachi, which is an

industrial city with a population of about 23 million people. A large number of Pashtun’s fleeing

from the war torn FATA moved to Karachi and they are the ones with highest number of polio

cases and the most intense refusal cases. They are still showing their opposition to drone strikes

that forced them into displacement by opposing the polio vaccine that is, unlike FATA, readily

and freely available in Karachi (Mansoor, 2014).

Considering the link of Pashtun background people with polio, I ran the regressions for

both Pakistan and Afghanistan. In case of Pakistan, a Pashtun child near FATA who is seeking

polio vaccine is still more likely to receive a polio drop when a drone strike occurs and the

coefficient for Pashtun children far from FATA is positive but statistically insignificant. This

could be because there are only 66 children in the data set who are Pashto speaking and live far

from FATA. The linear combination coefficient is also positive and significant for a Pashtun

child living near FATA (0.34 percentage points increase on average). In Afghanistan, the effect

is negative and statistically significant. For Pashtun children living near FATA , they are on

average 1.09 percentage points less likely to take the polio vaccine if there is an increase in drone

strike. If an Afghan Pashtun child is living far away from FATA, they are also likely to be

negatively affects by an increase in the drone strike and will see a 0.76 percentage point decrease

in their demand for polio vaccine. Similarly, the linear combination coefficient shows an overall

1.09 percentage points decline in getting polio immunization as a result of drone strikes in near

FATA areas of Afghanistan.

28

Rural Area Residence

The connection of polio and rural areas is that there is often not very good sanitation and

health facilities available in rural areas. Children often defecate in the open and such system of

human waste management can aid in the spread of poliovirus, which is transferred via the fecal

oral route. Isolating the village factor, in Pakistan, there are higher chances for children in rural

areas to be seeking polio vaccine than in urban areas. The linear combination coefficient is 0.413

percentage points increase on average in getting polio immunization if the child is in a rural area

in Pakistan. However, in Afghanistan, the village factor shows negative effect of drone strikes on

polio immunizations. Children in the rural areas are 0.9 percentage points less likely to seek

polio vaccine in the occurrence of a drone strike than children in the cities who are 0.68

percentage points less likely on average to seek the vaccination.

Mother’s Education

As much as mother’s health can influence the health outcomes of a newborn, her

education level can also effect, directly or indirectly, her child’s health (Brown, Washington

Post, 2010). Having knowledge about diseases and their prevention can convince a mother to get

her child vaccinated against the disease such as polio. In the Pakistan sample we find that the

coefficient for the interaction variable, Drone x Seeking, as well as the linear combinations have

positive but statistically insignificant values indicating that there is no concrete evidence whether

the mother being uneducated has an impact on the child receiving polio immunization. However,

for far from FATA areas we find that uneducated mother’s are more likely to get their children

immunization against polio even when there is a drone strike. Similarly, linear combination for

this specification also tells us that on average uneducated Pakistani mothers are 0.27 percentage

points more likely in far from FATA regions to get their children vaccinated. In Afghanistan,

29

uneducated mothers are 1.08 parentage points less likely to get their children get a polio

vaccination in the occurrence of a drone strike compared to uneducated mothers in far from

FATA areas who are 0.74 percentage points less likely to get the polio vaccine for their child.

In both cases for Afghanistan, the negative effect of drone strike on polio immunization is high

for mothers who are uneducated and living near FATA.

SECTION SIX: Discussion

It is surprising to see that there is a much negative affect of drone strikes occurring in

Pakistan, on children in Afghanistan than on children in Pakistan. Drone strikes in the Federally

Administered Tribal Areas are often linked with the increase in polio cases in Pakistan and, to

some degree, in Afghanistan. The findings of the study showed statistically significant impact of

drone strikes in FATA for both Pakistan and Afghanistan. The causal relationship between drone

strikes and polio immunization was positive for Pakistan (0.22 percentage points increase in

column (3)) and negative for Afghanistan (0.75 percentage points decrease in column (3)), while

negative for both countries combined (0.53 percentage points increase in column (3)).

According to my hypothesis, I expected to find a stronger negative impact on the

probability of a child getting polio vaccination as a results of increasing number of drone strikes.

I observe that there is a statistically significant negative (0.75 percentage points) relationship

between drone strikes and polio vaccination only in the case of Afghanistan. In the case of

Pakistan, the increase of polio immunization for a child due to increase in drone strike is 0.22

percentage points on average. The average decrease in polio immunization for a child in

Afghanistan (75 % points) is larger than the average increase in polio immunizations in Pakistan

30

(0.25 % points). Overall, the impact of drone strikes on polio immunization is statistically

significant and negative with a value of 0.53 percentage points increase on average (column (3)).

There could be several factors contributing to the results that were found as a result of

this study. One explanation for this is that there are more provinces on the Afghanistan side of

FATA (n = 5) than on the Pakistan side (n = 2)13. The number of provinces can impact the

sample size and include more regional variation in Afghanistan than in Pakistan. Also, the

overall incidence of polio in Afghanistan is not as high as it is in Pakistan, which can explain the

small decrease of polio immunization (0.15 % points) in a child living near FATA. According to

a UNICEF study, in 2013 there were only 9 cases of polio in Afghanistan and that were also in

the provinces bordering FATA (UNICEF, 2013). These children might be the ones who are

already refusing polio vaccinations even if they have received one vaccine before or they may

most likely be displaced children from FATA who sought refuge in Afghanistan (GPEI).

According to a study, genetic tests confirmed that during 2010-2012 66.6% (12 cases) of wild

poliovirus was transmitted from Pakistan to Afghanistan (Shaukat et al., 2014).

It is interesting to note the result for children who are seeking polio vaccinations. I

observe that there is significantly negatively effect overall but on the country level, I find that the

effect is due to Afghanistan, which also gives a significant outcomes and Pakistan gives a less

statistically significant but a positive coefficient. The impact on children seeking polio is quite

large for Afghanistan and this is interesting because it means that a large percentage of children

are not getting polio vaccine because of the drone strikes, even though they would have

otherwise. Due to insufficient or non-existent data, it is hard to know exactly how many children

in Afghanistan are deprived of polio vaccines and how many are at the risk of contracting polio.

13 See Figure 3 in Appendix, Section A.31

There is fear that the Taliban in Afghanistan, which has been supportive of the polio campaigns

previously, may change their minds about the polio vaccine after seeing the multiple times polio

vaccination ban was imposed by the Pakistani Taliban in FATA (Harrison, The Guardian, 2013).

In recent times the recruitment of foreign fighters, who are often of extreme view, into the

Taliban has also caused pressure for banning polio campaigns in province like Nuristan in the

Eastern part of Afghanistan. The results for Afghanistan reflect this trend, albeit with a small

coefficient value, where the overall impact of drone strikes lead to a decrease in polio

immunization rates. Taliban and terrorist elements from FATA, fleeing drone attacks, may head

to the eastern provinces of Afghanistan that are neighboring FATA where the Taliban has a

strong control (Roggio, 2014).

One reason for an increase in the likelihood of children receiving polio immunization in

Pakistan’s near FATA as a result of increase in drone strikes can be due to the migration of

internally displaced person from FATA coming into the near FATA provinces such as KPK and

Baluchistan. FATA was declared a polio reservoir due to the high incidences of polio cases

arising from the area and presence of two different types of poliovirus found in children

(Shaukat et al., 2014). Polio from FATA was also found in Peshawar, a major city in Khyber

Pakhtunkhwa province (KPK) that hosts a significant number of refugees from Afghanistan as

well as internally displaced persons from FATA (Dawn News, Jan. 2014). One can expect there

to be a paranoia amongst the parents of KPK and Baluchistan, who for most parts are aware of

polio through mass media campaigns, about their child being exposed to poliovirus brought in by

the infected FATA children. Since we saw the polio seeking coefficients are quite large in

Pakistan indicating a demand for polio vaccine, it is likely that parents are trying to get their

children vaccinated against polio. The polio teams, unlike in FATA, have access to the KPK

32

province and thus are able to supply polio vaccine. The polio campaigns do try to target Afghan

immigrant families and IDPs from FATA, who to some extent are receptive of the polio vaccine.

These are often parents who, from fear of Taliban, may not have gotten their children vaccinated.

Upon arriving to a safer location, such as in KPK where Taliban influence is very minimal, these

same parents get their children vaccinated against polio. A poll found that when polio teams

were able to reach houses in FATA, of the parents interviewed in FATA, 95% confirmed the

visit of a polio vaccinator and that their child received polio dose (Aizenman, Npr, 2014). Thus,

majority of the parents are willing to give polio drops to their child and they will seek vaccine

wherever they will find it.

Like any other study employing secondary sources, for my study, limitations source from

few factors. In terms of the sample, the survey was taken from different sources of both Pakistan

and Afghanistan and they covered different time periods of survey, 2012-2013 and 2010-2011,

respectively. The data for both Pakistan and Afghanistan came from secondary resources and

there are naturally chances of missing data due to incomplete survey or communication barriers.

Since, in the case of both survey’s mothers of the less than five years old were interviewed, it

was hard to know whether the women were open to answering everything and provide full

information. Parts of areas of Pakistan and Afghanistan, where the mothers were interviewed are

conservative places and women are often not participating in public activities as they are not

given permission from their husbands or male elders. Thus, there may be a factor of fear in

sharing much about the household data with foreign survey teams. Differential reporting of the

actual situation can lead to immeasurable biases. In our case, the data was large enough to

dismiss a significantly huge bias resulting from incomplete or untrue information about the child,

mother, and the household. Not every mother will be giving incomplete or wrong information.

33

The sample size for the study can be increased to ensure a more robust analysis. The

Bureau of Investigative Journalism has only data for drones until 2014, but if the drone data

continued, it would have been interesting to see the impact of drones in the future. Moreover, the

absence of survey data for FATA itself became a challenge and I believe that the estimates in our

tables do not fully show the impact of drone strikes on polio immunization. Rather they show an

indirect effect by isolating the demand for polio vaccines. It is possible that the estimates will be

of greater values and may be more robust in predicting the hypothesized causal relationship

between drones and polio vaccines. As robustness, the analysis can be further broken down and

done separately do for the individual four provinces of Pakistan.

SECTION SEVEN: Conclusion

This study aimed to empirically analyze the effect of US drone strikes on polio

immunization rates in Pakistan. Results showed that overall, when considering both Afghanistan

and Pakistan, drone strikes on average can have a negative impact on polio immunization,

decreasing it by 0.53 percentage points. On country level, Afghanistan also shows a negative

causal relationship where drone strikes decreased polio immunization receiving by 0.72

percentage points. Pakistan, on the other hand, showed opposite scenario by showing a positive

causality between drone strikes and polio immunizations whereby a drone strike leads to a small

positive increase of 0.15 percentage points on average.

This first time done empirical analysis to link the drone strikes with polio immunizations

sets a framework of child fixed effects and finds that the drones have caused an impact on the

polio eradication efforts, especially in Afghanistan. The first policy implication suggested from

this paper is to have a better mechanism of data collection, especially in FATA, in order to allow

34

an empirical analysis that can directly find the impact of drone strikes. If there is a very strong

causal relationship between drones and polio cases, then it may make policy maker rethink their

strategies as not to hamper public health initiatives that go in with the intention of betterment of

the innocent population, such as children.

The fight for polio eradication continues to date in Pakistan where the number of polio

cases unpredictably fluctuate and stay at higher numbers. The polio case in Pakistan gives an

idea that when public health campaigns are tied to the political turmoil in a place, it can

negatively impact that particular health outcome. Perhaps, better tracking of data and also

developing creative ways of getting polio vaccinations may convince parents to provide

immunization to their child and not be influenced by pamphlets disseminated to them as a

propaganda. Most importantly, it is important for political leaders to come to consensus and not

put a whole population, and the world, at stake of contracting a disease that is considered history

in almost rest of the world. Thus, it is important for the government of Pakistan to provide more

attention to people in FATA and make them realize their association with Pakistan and not the

Taliban. Maybe better negotiations between the different stakeholders such as the CIA and

organizations involved in the polio eradiation drive can help shape better administrative policies

and not lead to a situation that puts a public health issues at stake, almost permanently.

***End***

35

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Section A: Figures Appendix

The graph above illustrates a collinear relationship between the trends of confirmed polio cases in Pakistan and drone strikes occurring mainly in the FATA and on few occasions, in the neighboring areas during a given year from 2004 to 2014. The grey line traces lagged trend of drone strikes to compare the impact of previous year’s drone strikes on present year’s number of polio cases. It can be observed that there is a positive trend and relationship between drones strikes, both current and lagged, and the number of polio cases confirmed in a year. The trend stays true until the year 2012, where the number of polio cases decline sharply as the graph takes a deeper dip. Similarly, we observe that there is a discontinuation of the trend when there is a bigger gap between drone strikes and polio cases during years 2013 and end of 2014. There is in fact a sudden spike in the number of polio cases during the year 2014, when polio cases were more than 300. Once explanation for this could come from the trend in drone strike that was present 3 years before 2014 that may have caused resistance to finally take a strong form in the year 2014. There was also a Pakistan Army military operation during the time that caused resentment against the war on terrorism to aggravate and it also created an influx of refugee from the Waziristan area in FATA to flee to other safe cities in Pakistan. It was after this refugee population from FATA was examined for health that the high prevalence of polio cases came out. There was a surge in the spread of the contagious poliovirus as the infected children of FATA region spread across the country and lived in poor sanitation areas, while infecting other vulnerable poor population in areas where polio was completely eradicated. Another explanation for increasing trend in the polio cases after 2012 is the reiteration of ban on polio campaigns by the Taliban after the capture and murder of Osama bin Laden by running a fake vaccination campaign.(Data Sources: Acute Flaccid Paralysis data form polioinfo.org and Svea Closser. Drone data from Bureau of Investigative

Journalismwebsite.)

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Fi g u r e 2 . The set of graphs show the variation of drone strikes occurring on monthly based during different years (2004 to 2013). It can be observed that there is a within year variation in the number of drone strikes occurring. This justifies that drone strike is a time variant variable that can be controlled for in the regression model by using a Drone Strike variable.(Source: Bureau of Investigative Journalism- Drone Data for Pakistan Publically Available, 2014)

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FATA(7 Districts)

Drone Strike Dummy = 1

Fig ure 3 : Shows the map of the Federally Administered Tribal Areas (FATA) location on the border between Pakistan and Afghanistan. FATA is an unstable region with military operations conducted by the US and the Pakistan Army against Taliban and other terrorist organizations. FATA consists of7 districts where South and North Waziristan are the two districts that get the majority of the CIA drone strikes.

April 2015 Econ702B - Appendix Qayyum, Naina

Figure 4: Map of Pakistan showing the position of FATA in the northwestern part of the country on the border sharing with Afghanistan. The areas shaded with grey lines were not included in the DHS 2012 – 2013 survey.

Source: Pakistan Demographic and Health Surveys (PDHS) 2012-2013 report. (h t t p : // d h s pr o g r a m . c o m / p u b s / p d f / F R 2 9 0 / F R 2 9 0 . p d f )

April 2015 Econ702B - Appendix Qayyum, Naina

Figure 5: Pamphlet distributed by the Taliban in North Waziristan in FATA, 2012

Translation of the pamphlet: “Polio Vaccination will be banned in Pakistan until the drone attacks are stopped. We do not need the well wishing of such well wishers (America) who, on one hand give polio drops even though polio infects only 1 in a 100,000, and on the other hand this well wisher (America) with the help of its slave (Pakistan) is intensely doing drone strikes on us. Due to these drone strikes, a large number of our women, children and elderly have been martyred. And due to the constant drone strikes, almost every person in Waziristan has become a mental patient or is becoming one, which is a worse situation than polio. Hence, there is also the possibility of using polio vaccination campaigns as an undercover to spy on the militants. One example of this is the Shakil Afridi case. Therefore, from now on there will be a complete ban on polio drops and those who will oppose this will not have the right to complain against the consequences.”

Source: h tt p : / / a z f a rr i zv i . c o m/ h ome /t a l i b a n - b a n - p o li o -v a cc i n a t i on -c am p a i gn /

Box A Box B Box C Box D Children with no Children who may Children who Children with access to polio have access to started their polio record of vaccine either the polio vaccine vaccine course complete poliobecause of no but have not and may have immunization i.e.health facility in started the received up to 3 received all 4 the vicinity or no vaccine course. doses of polio. doses.visiting polio

April 2015 Econ702B - Appendix Qayyum, Naina

Figure 6: The study is trying to find the impact of drone strikes on the likelihood of a child under 5 years old getting a polio vaccine. Here, it is important to say a bit more about the sample of the children that is relevant to measure the aforementioned relationship between drones and polio immunization. There is variation amongst children in terms of who has received polio vaccination. Figure [boxes] illustrates the sample selection criteria for the empirical analysis. Box A, B, and D are not very useful in conducting the analysis and this is in particular because the children have either not received any polio vaccine because of non- availability of the vaccine (Box A) or not chosen to start the vaccine yet even though it maybe available (Box B) and may have already completed their polio vaccine dosage (Box D). Children in Box C are relevant to the sample because they are the cohort in the sample who are in the process of getting their polio vaccine doses and can demonstrate the impact of drone strikes, if any, on the likelihood of getting their vaccine either in the same month as the drone strike or in consequent months. I do not drop any of the children in Box A, B or D to include them in other aspects of analysis.

April 2015 Econ702B - Appendix Qayyum, Naina

Section B: Tables

T a b l e 1 : S u mm ar y S t a ti s ti c s

April 2015 Econ 0702B Qayyum, Naina

TABLE 2A

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TABLE 2B

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TABLE 2C

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R obus t nes s C heck s

TABLE 3A

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TABLE 3B