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 Images/Ian Forsyth
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The big battle in Corbyn's Labour party will be over organisation, not ideas

Forgotten and near-moribund institutions of the parliamentary Labour party will become vital once again, explain Declan McHugh and Will Sherlock. 

“Decidedly downbeat” was Chris Mullin’s assessment of the first Parliamentary Labour Party meeting following the 2001 landslide General Election victory. Blair was “received well, but without elation … the managing director was treated to some blunt warnings that this time around the boys and girls on the shop floor expect to be treated with more consideration.”

Assuming he wins the leadership, Jeremy Corbyn’s first PLP meeting will be anything but downbeat. The ‘shop floor’ will be more akin to a Lions’ Den. Labour’s new figurehead will face a PLP overwhelmingly opposed to him. Many will question the legitimacy of his election and some will reject his authority. From day one, he will face a significant number of Labour MPs not merely against him but actively out to get him. There has probably never been a situation where a leader of the Labour Party has been so far removed from the parliamentary party which he supposedly commands.

The closest historical parallel with Corbyn is arguably George Lansbury, another ardent socialist who took charge of the party after serious electoral defeat. But the comparison doesn’t really stand up to scrutiny. Lansbury may have been on the left but he had been a leading figure at the top of the party for many years. Corbyn has never been anything but part of the Labour fringe – rarely even attending PLP meetings.

Nevertheless an immediate move to oust him is unlikely. Whatever their concerns about the circumstances of his election, the scale of the contest will make MPs nervous about executing a coup. And crucially there is no obvious alternative leader waiting in the wings.

The internal battle against Corbyn will instead be more drawn out and fought through the internal structures of the party. The number of Labour MPs showing a sudden and hitherto undiscovered interest and expertise in the PLP Standing Orders is an indication of what is to come. When Labour is in government, journalists pay little notice to obscure internal committees. Now they are going to be the centre of attention. The PLP may be energised on an organisational front in a way that it never was during the Blair, Brown and even Miliband years. Conflict is likely to be focused in the following arenas:

  • Shadow Cabinet

Corbyn is now understood to populate his shadow cabinet by appointment, but opponents in the PLP are seeking a return to the system of elections. That will not be straightforward. Although the 2011 decision to end elections was primarily achieved by means of a PLP vote to change Standing Orders, it was subsequently agreed by the NEC and passed into party rules by Conference. It will be harder to undo that constitutional knot than it was to tie it. The PLP can vote to change Standing Orders again but the NEC and Conference will need to reflect that in further amendments to party rules if the decision is to have constitutional authority. That sets the scene for a messy clash between the PLP and the NEC if Corbyn chooses to defy the parliamentary party.

 

Even if elections are restored, it is not clear how Corbyn’s opponents in the PLP will respond. MPs seeking the return of shadow cabinet elections hope to run a slate of candidates who will work to emasculate the new leader. But others have already resolved to boycott the front bench, regardless of how it is selected. Corbyn’s opponents face a dilemma. On the one hand abandoning the shadow cabinet may be viewed as walking off the pitch at a time when others are prepared to get stuck in and organised. On the other, it will be impossible to take a shadow cabinet post without signing up to some level of collective responsibility. That means undergoing the daily grind of defending the party line in front of the 24 hour media spotlight, with all statements scrutinised and recorded by Conservative researchers for future use.  How many Labour MPs would be willing to support a Corbynite line on foreign affairs, defence and economic policy? The new Labour leader will soon find out.

 

  • PLP meetings

The Monday evening meetings of the PLP are a weekly arena in which the frontbench and the party leadership are held to account by the wider parliamentary party. In the Kinnock, Smith and Blair days, although occasionally raucous, there was a degree of deference to the Leader. That has waned of late but will likely be non-existent under Corbyn. No one can remember the last time the PLP voted on a matter of policy, but Standing Orders permit it to so – expect opponents of the leadership to use this device.

 

  • PLP Chair

John Cryer, the current PLP Chair, will have his work cut out trying to manage what are likely to be stormy meetings. Moreover, the annual election of the Chair is an important barometer of the parliamentary party’s mood and the easiest means of organising a proxy vote on confidence in the leader. Importantly, the Chair of the PLP approves what motions can be tabled at the weekly PLP meeting. 

 

  • Parliamentary Committee

The parliamentary committee are effectively shop stewards for the backbenchers and the election of representatives is similarly a reflection of political sentiment in the PLP. New elections won’t happen until next May but the PLP could decide to initiate earlier elections. Labour MPs will ask whether the current committee, which includes one Corbyn nominator, is representative of the majority view. If not, a slate opposed to the leader could be organised. The Parliamentary Committee has executive powers that it rarely uses but this may change and will be significant. 

 

  • Departmental Groups

The PLP’s internal policy committees have been in decline since the early years of Tony Blair and have rarely made waves but have potentially important powers, including the right of Committee Chairs to speak from the Despatch Box. MPs may use these bodies to challenge frontbench policy positions in a way that no leader has experienced, promoting alternative agendas at odds with the leadership line on foreign affairs, defence and the economy. The Chairs have not yet been elected and this could be a key focus in the autumn.

 

  • Whips Office

The idea of Jeremy Corbyn directing the PLP to follow three-line whips is, to many, a source of amusement. A man who regularly topped the charts of rebel MPs will struggle to maintain the traditional system of party discipline – and indeed he has already indicated that he has no intention of “corralling” MPs in the traditional way. Most likely the whips will play a distinctly different role in the future, acting more as shop stewards for backbench MPs who want their concerns made clear to the Leader’s Office. And the likely deputy keader Tom Watson, who hails from the right wing union tradition but is close to some of the left, will play a major part in trying to balance the needs of the new leadership with the real anger of backbench Labour MPs.

Corbyn’s lack of authority and support within the wider parliamentary party puts a major question mark over his long term prospects as Labour leader. He would certainly lose any direct trial of strength against the PLP.

But the Corbynite group will seek to avoid confrontation inside Westminster. They believe their strength lies in the party outside Parliament and in the new influx of members and supporters. Their agenda will be to capitalise – though they might not use the term – on the leadership triumph by instituting rule changes that will revive the left within the party machine. Not just inside the NEC, the Conference and the party HQ but in the regional and constituency party organisation.

Most particularly, they are likely to seek to convert supporters into members, with a role in the selection of parliamentary candidates. By such means they will seek to apply external pressure on MPs from their own constituency parties. Labour members may be understandably wary about moving to decapitate a new leader so soon after his election. But they face a race against time to prevent him and his supporters from reshaping the party machine in ways that will undermine them from below.

 Will Sherlock and Declan McHugh are former Labour special advisers who now work at Lexington Communication.