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.

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Who is the EU's chief Brexit negotiator Michel Barnier?

The former French foreign minister has shown signs that he will play hardball in negotiations.

The European Commission’s chief Brexit negotiator today set an October 2018 deadline for the terms of Britain’s divorce from the European Union to be agreed. Michel Barnier gave his first press conference since being appointed to head up what will be tough talks between the EU and UK.

Speaking in Brussels, he warned that UK-EU relations had entered “uncharted waters”. He used the conference to effectively shorten the time period for negotiations under Article 50 of the Lisbon Treaty, the legal process to take Britain out of the EU. The article sets out a two year period for a country to leave the bloc.

But Barnier, 65, warned that the period of actual negotiations would be shorter than two years and there would be less than 18 months to agree Brexit.  If the terms were set in October 2018, there would be five months for the European Parliament, European Council and UK Parliament to approve the deal before a March 2019 Brexit.

But who is the urbane Frenchman who was handpicked by Commission President Jean-Claude Juncker to steer the talks?

A centre-right career politician, Barnier is a member of the pan-EU European People’s Party, like Juncker and German Chancellor Angela Merkel.

A committed European and architect of closer eurozone banking integration, Barnier rose to prominence after being elected aged just 27 to the French National Assembly.  He is notorious in Brussels for his repeated references to the 1992 Winter Olympics he organised in Albertville with triple Olympic ski champion Jean-Claude Killy.

He first joined the French cabinet in 1993 as minister of the environment. In 1995, Jacques Chirac made him Secretary of State for European Affairs, teeing up a long and close relationship with Brussels.

Barnier has twice served as France’s European Commissioner, under the administrations of Romano Prodi and José Manuel BarrosoMost recently he was serving as an unpaid special advisor on European Defence Policy to Juncker until the former prime minister of Luxembourg made him Brexit boss.“I wanted an experienced politician for this difficult job,” Juncker said at the time of Barnier, who has supported moves towards an EU army.

 

Barnier and the Brits

Barnier’s appointment was controversial. Under Barroso, he was Internal Market commissioner. Responsible for financial services legislation at the height of the crisis, he clashed with the City of London.

During this period he was memorably described as a man who, in a hall of mirrors, would stop and check his reflection in every one.

Although his battles with London’s bankers were often exaggerated, the choice of Barnier was described as an “act of war” by some British journalists and was greeted with undisguised glee by Brussels europhiles.

Barnier moved to calm those fears today. At the press conference, he said, “I was 20 years old, a very long time ago, when I voted for the first time and it was in the French referendum on the accession of the UK to the EU.

“That time I campaigned for a yes vote. And I still think today that I made right choice.”

But Barnier, seen by some as aloof and arrogant, also showed a mischievous side.  It was reported during Theresa May’s first visit to Brussels as prime minister that he was demanding that all the Brexit talks be conducted in French.

While Barnier does speak English, he is far more comfortable talking in his native French. But the story, since denied, was seen as a snub to the notoriously monolingual Brits.

The long lens photo of a British Brexit strategy note that warned the EU team was “very French” may also have been on his mind as he took the podium in Brussels today.

Barnier asked, “In French or in English?” to laughter from the press.

He switched between English and French in his opening remarks but only answered questions in French, using translation to ensure he understood the questions.

Since his appointment Barnier has posted a series of tweets which could be seen as poking fun at Brexit. On a tour of Croatia to discuss the negotiations, he posed outside Zagreb’s Museum of Broken Relationships asking, “Guess where we are today?”

 

 

He also tweeted a picture of himself drinking prosecco after Boris Johnson sparked ridicule by telling an Italian economics minister his country would have to offer the UK tariff-free trade to sell the drink in Britain.

But Barnier can also be tough. He forced through laws to regulate every financial sector, 40 pieces of legislation in four years, when he was internal market commissioner, in the face of sustained opposition from industry and some governments.

He warned today, "Being a member of the EU comes with rights and benefits. Third countries [the UK] can never have the same rights and benefits since they are not subject to same obligations.”

On the possibility of Britain curbing free movement of EU citizens and keeping access to the single market, he was unequivocal.

“The single market and four freedoms are indivisible. Cherry-picking is not an option,” he said.

He stressed that his priority in the Brexit negotiations would be the interests of the remaining 27 member states of the European Union, not Britain.

“Unity is the strength of the EU and President Juncker and I are determined to preserve the unity and interest of the EU-27 in the Brexit negotiations.”

In a thinly veiled swipe at the British, again greeted with laughter in the press room, he told reporters, “It is much better to show solidarity than stand alone. I repeat, it is much better to show solidarity than stand alone”.

Referring to the iconic British poster that urged Brits to "Keep Calm and Carry On” during World War Two, he today told reporters, “We are ready. Keep calm and negotiate.”

But Barnier’s calm in the face of the unprecedented challenge to the EU posed by Brexit masks a cold determination to defend the European project at any cost.

James Crisp is the news editor at EurActiv, an online EU news service.