The struggle for a Polio-free Pakistan

What is behind the the sudden upsurge of violence towards polio vaccinators in Pakistan?

On Sunday 16 June, gunmen on motorbikes shot dead two polio workers carrying out a vaccination drive in Peshawar, a crowded city in Pakistan’s north-west. One of the men who died was a schoolteacher, the other a paramedic. Both left behind grieving families. Their deaths bring the total tally of polio workers assassinated in Pakistan up to nearly 20 since last December.

“People are scared,” says Muslim Raza, who heads the polio team in the Karim Poora area of Karachi. “Before this happened, many local people would come for a day’s training before joining the vaccination drives [which normally run for between three and five days each month]. Now nobody is volunteering to work.”

The attempt to stamp out polio through oral immunising drops has been running in Pakistan since 1994. In recent years, huge strides have been made towards stamping out the disease, which used to affect tens of thousands of people every year. In 2011, there were 198 new recorded cases of the polio virus in Pakistan; in 2012, just 58.

Yet Pakistan is one of just three countries – including Nigeria and Afghanistan – where it remains endemic. While paralysis strikes just a small percentage of those carrying the virus, the effects are devastating. Unable to support themselves, many people disabled by polio beg at the side of the traffic-filled roads in Pakistan’s big cities.

The attacks started on 18 December 2012, when five female health workers were killed within 20 minutes of each other, four in the southern port city of Karachi and one in Peshawar, in a brutal co-ordinated attack. News of the assassinations, shocking even by Pakistan’s blood-soaked standards, spread across the world.

In the aftermath of those first attacks, the three-day vaccination drive, which would have immunised 5.2 million children in Karachi alone, was suspended. In the intervening months, the programme has resumed. The chalk markings which denote that the polio team has been to visit can be seen on gates, doors, and walls outside houses across the country, from the upmarket areas of Islamabad, to slums, and remote villages. But despite high security in the problematic areas – the north-western province of Khyber-Pakhtunkhwa (KPK), parts of Karachi, and the Federally Administered Tribal Area – the death toll has risen. Many, though not all, of the victims have been women.

As yet, no-one has claimed responsibility. The Tehreek-e-Taliban Pakistan has denied they are behind the attacks, although they have spoken out against vaccinations in the past and are certainly responsible for perpetrating misinformation. The attacks are clearly planned and co-ordinated, but there have been no arrests and no high profile investigation – merely a huge increase in the number of police escorts. The latest development is that the new provincial government in KPK is planning to give polio workers weapons licences to carry their own guns.

Meanwhile, teams of health workers – partly made up of civil servants drafted out to the polio campaign, and partly of local volunteers working for a fee of 200 rupees (£1.50) per day – are continuing to go out to immunise children. Who are these unsung heroes? And why has this senseless campaign of violence begun?

Khoram Shehzad, 29, is a polio vaccinator from Karachi’s Kimari Town area. Like many vaccinators, he comes from the local community. Experts say that employing local volunteers is a crucial component of the programme as it means that the community feels a sense of ownership over the vaccination drive. “More than anything, more than police protecting you, the best protection is from those vaccinators coming from the community itself,” says Dr Elyas Durry, head of the World Health Organisation (WHO)’s polio team in Pakistan.

Shehzad left a job as a computer engineer three years ago to join the polio campaign, and currently earns 250 rupees (£2) per day for each four day immunisation drive. “I didn’t start doing this for the money. I am doing this for the people of Pakistan. These are the children, the future of the country,” he tells me when we speak on the phone. “We are all afraid because of the targeted killings. Some people don’t want to work in the field any more, but it is important for our country and our people.”

The resistance to the vaccine is deep-rooted. Several rumours circulate. One – perpetrated and spread by extremist Islamic leaders – is that the vaccine is a CIA plot to sterilise Muslim children. Another is that it contains materials forbidden by Islam, such as alcohol and pig’s blood.

“Some uneducated people don’t take the drops,” says Shehzad. “They say the medicine in the vaccine is haram [forbidden by Islam]. We tell them the government wouldn’t start this if it was bad for your children.”

The misconceptions are worse among the Pashtun population, who come from the conservative north-west of Pakistan. The rumours and misinformation have been perpetrated through radio broadcasts and other propaganda channels of extremist organisations. Shehzad’s area in Karachi, where there is a high security risk, is 85 per cent Pashto-speaking.

“It is mainly illiterate and uneducated people that refuse the vaccine,” says Fahmeeda Malik, a polio worker from Rawalpindi. “We reason with them, saying, if the government wanted to give you family planning medicine, there are a lot of places they can do it for grown ups. Why children? If they think over it, they normally agree. But if they don’t, we are helpless.”

Across the country, polio workers I speak to say that refusals make up just a tiny minority of the whole. Yet that small percentage is enough to jeopardise the goal of totally eliminating polio. The problem is compounded by the fact that Pakistan’s population is highly mobile, so the disease can easily spread outside the pockets where it is cornered as people are displaced or relocate in search of work.

“Often we ask people, who told you this is against the preaching of Islam? Mostly they say it is the leaders of mosques, so we go to them and convince them,” says Dr Khaled Randhawa, district health officer of Rawalpindi. In May this year, a group of international religious scholars met in Islamabad and issued an edict saying that the polio vaccine did not contravene Islam. “Depriving a child of polio drops is equal to committing a sin. Protecting your child from disease is a religious obligation,” said one of the scholars. This was a positive move, although it is too soon to say how much impact it will have.

“I have been working with these misconceptions about the vaccine for my whole life – in Somalia, in Nigeria, elsewhere,” says Durry. “But I don’t understand – nobody does – how it became such a violent reaction here in Pakistan. I don’t know why it has escalated.”

Many point to the CIA’s assassination of Osama Bin Laden. In the run up to the operation, the CIA ran a false hepatitis B vaccination drive so it could gather the DNA of local residents. It was a spectacularly irresponsible policy that leant credence to the conspiracy theories that were already widely circulated. The film Zero Dark Thirty depicted the fake drive as a polio campaign.

Yet is this alone responsible for the sudden upsurge of violence? Many experts believe it goes deeper. “It’s another way of trying to control the population through fear,” says Mustafa Qadri, Pakistan researcher at Amnesty International. “The aim is to terrorise, to make people scared, to make their conditions worse, and in that way to influence the society. Polio is not socially sensitive in the way that, for example, reproductive rights are: it is a very basic health requirement. When you’re attacking people’s access to these basic rights, you’re attacking their ability to live a normal life. And I think that is the overall objective: to control and to suppress the society.”

In the areas of the country where the risk is highest, polio field workers and team coordinators feel under siege.

“There is a big threat to these volunteers,” says Javed Marwat, the deputy commissioner of Peshawar, the provincial capital of KPK. “The situation is not good for anyone in the city. Every day there are bomb blasts, but the daily explosions get ignored. When a polio worker is killed, this news spreads to other countries, in the international media. The terrorists continue to kill polio workers because it has so much impact. More people die in blasts, but nobody cares about that.” Indeed, against the violent context of today’s Pakistan, the daily news of small scale terror attacks no longer makes an impact; the constant news of death is simply the background music to life. Increasingly, it is violence against unexpected or soft targets – the schoolgirl activist Malala Yousafzai, or health workers delivering life-saving vaccines – that makes national and international headlines.

At the District Health Office in Rawalpindi, I attended an evening meeting of polio workers. Here vaccination teams gathered in the evening to feed back on the day’s work. Most of them were women, clad in bright headscarves and face coverings, and drawn from the same conservative communities they are serving. They confidently talked through the day’s results, speaking over their male supervisor with details of refusals and the ways they had tackled them. “The woman in the house would not come out in front of a man, so I told my male colleague to leave,” says Saba, one of the vaccinators. Another, Aisha, added: “Since the last drive, we spoke to local notables about the refusals, and they have told people they should take the vaccine.” Of the 1,700 vaccinations they had carried out between them over the course of the day, there had been just one refusal.

It has been suggested that there is a gendered aspect to the violence. Not all polio workers are women, and some of those gunned down in recent months have been men. However, while the targeting of polio workers has suddenly escalated, there is a recent history of militant violence being directed against “lady health workers”, a body of more than 100,000 women who deliver door-to-door healthcare. The lady health worker programme was initiated by Benazir Bhutto in 1994, and for many women and girls in remote areas, they provide the only direct access to healthcare. A 2012 study published in the British Medical Journal looked at how the Taliban threatened and attacked female health workers in Swat during their brief period of control of the area. It found that not only did community health suffer significantly, but that lady health workers were socially ostracised after public vilification by the Taliban. It also found that many others stopped working or left the area due to their threat to their lives. Against this context, the recent attacks on polio workers could be yet another demonstration of the deep discomfort among the conservative elements of Pakistani society about women in public space, and women taking ownership of their bodies.

“By attacking these workers, the perpetrators of these attacks are cutting down people’s rights to services, particularly women and girls,” says Qadri. “When you target these people, you are effectively trying to destroy those parts of society that allow people to live with dignity.” In addition to this, he explains, the fact that the attacks have been sustained, despite extra security, compounds the desired effect of spreading terror. “Health workers are being targeted even when they have police escorts. They just feel very scared: even when the state is trying its best to protect people, they’re not safe. The impact for the community is profound.“

For the polio workers in the hotspots of Karachi and Peshawar, life goes on, for now. “My heart is full of terror when I hear that more workers, more workers, more workers are being targeted,” says Sadia Zaidi, a vaccinator from Peshawar whose name has been changed for security reasons. “Sometimes we don’t like to stay in one place for too long to convince refusers to take the vaccine, because we are at such risk. But we carry on. Some of my colleagues don’t even take the money because they just want to work for the people. My family is afraid for my safety, but I am doing this so my children can live in a polio-free Pakistan.”

 

A Pakistani health worker administers polio vaccine drops to a young child at a polio vaccination center in Karachi. Photograph: Getty Images

Samira Shackle is a freelance journalist, who tweets @samirashackle. She was formerly a staff writer for the New Statesman.

Photo: Getty
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The UK press’s timid reaction to Brexit is in marked contrast to the satire unleashed on Trump

For the BBC, it seems, to question leaving the EU is to be unpatriotic.

Faced with arguably their biggest political-cum-constitutional ­crisis in half a century, the press on either side of the pond has reacted very differently. Confronting a president who, unlike many predecessors, does not merely covertly dislike the press but rages against its supposed mendacity as a purveyor of “fake news”, the fourth estate in the US has had a pretty successful first 150-odd days of the Trump era. The Washington Post has recovered its Watergate mojo – the bloodhound tenacity that brought down Richard Nixon. The Post’s investigations into links between the Kremlin and Donald Trump’s associates and appointees have yielded the scalp of the former security adviser Michael Flynn and led to Attorney General Jeff Sessions recusing himself from all inquiries into Trump-Russia contacts. Few imagine the story will end there.

Meanwhile, the New York Times has cast off its image as “the grey lady” and come out in sharper colours. Commenting on the James Comey memo in an editorial, the Times raised the possibility that Trump was trying to “obstruct justice”, and called on Washington lawmakers to “uphold the constitution”. Trump’s denunciations of the Times as “failing” have acted as commercial “rocket fuel” for the paper, according to its CEO, Mark Thompson: it gained an “astonishing” 308,000 net digital news subscriptions in the first quarter of 2017.

US-based broadcast organisations such as CNN and ABC, once considered slick or bland, have reacted to Trump’s bullying in forthright style. Political satire is thriving, led by Saturday Night Live, with its devastating impersonations of the president by Alec Baldwin and of his press secretary Sean Spicer by the brilliant Melissa McCarthy.

British press reaction to Brexit – an epic constitutional, political and economic mess-up that probably includes a mind-bogglingly destructive self-ejection from a single market and customs union that took decades to construct, a move pushed through by a far-right faction of the Tory party – has been much more muted. The situation is complicated by the cheerleading for Brexit by most of the British tabloids and the Daily Telegraph. There are stirrings of resistance, but even after an election in which Theresa May spectacularly failed to secure a mandate for her hard Brexit, there is a sense, though the criticism of her has been intense, of the media pussy-footing around a government in disarray – not properly interrogating those who still seem to promise that, in relation to Europe, we can have our cake and eat it.

This is especially the case with the BBC, a state broadcaster that proudly proclaims its independence from the government of the day, protected by the famous “arm’s-length” principle. In the case of Brexit, the BBC invoked its concept of “balance” to give equal airtime and weight to Leavers and Remainers. Fair enough, you might say, but according to the economist Simon Wren-Lewis, it ignored a “near-unanimous view among economists that Brexit would hurt the UK economy in the longer term”.

A similar view of “balance” in the past led the BBC to equate views of ­non-scientific climate contrarians, often linked to the fossil-fuel lobby, with those of leading climate scientists. Many BBC Remainer insiders still feel incensed by what they regard as BBC betrayal over Brexit. Although the referendum of 23 June 2016 said nothing about leaving the single market or the customs union, the Today presenter Justin Webb, in a recent interview with Stuart Rose, put it like this: “Staying in the single market, staying in the customs union – [Leave voters would say] you might as well not be leaving. That fundamental position is a matter of democracy.” For the BBC, it seems, to question Brexit is somehow to be unpatriotic.

You might think that an independent, pro-democratic press would question the attempted use of the arcane and archaic “royal prerogative” to enable the ­bypassing of parliament when it came to triggering Article 50, signalling the UK’s departure from the EU. But when the campaigner Gina Miller’s challenge to the government was upheld by the high court, the three ruling judges were attacked on the front page of the Daily Mail as “enemies of the people”. Thomas Jefferson wrote that he would rather have “newspapers without a government” than “a government without newspapers”. It’s a fair guess he wasn’t thinking of newspapers that would brand the judiciary as “enemies of the people”.

It does seem significant that the United States has a written constitution, encapsulating the separation and balance of powers, and explicitly designed by the Founding Fathers to protect the young republic against tyranny. When James Madison drafted the First Amendment he was clear that freedom of the press should be guaranteed to a much higher degree in the republic than it had been in the colonising power, where for centuries, after all, British monarchs and prime ministers have had no qualms about censoring an unruly media.

By contrast, the United Kingdom remains a hybrid of monarchy and democracy, with no explicit protection of press freedom other than the one provided by the common law. The national impulse to bend the knee before the sovereign, to obey and not question authority, remains strangely powerful in Britain, the land of Henry VIII as well as of George Orwell. That the United Kingdom has slipped 11 places in the World Press Freedom Index in the past four years, down to 40th, has rightly occasioned outrage. Yet, even more awkwardly, the United States is three places lower still, at 43rd. Freedom of the press may not be doing quite as well as we imagine in either country.

Harry Eyres is the author of Horace and Me: Life Lessons from an Ancient Poet (2013)

This article first appeared in the 20 July 2017 issue of the New Statesman, The new world disorder