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: ASA
Show Hide image

Harmful gender stereotypes in ads have real impact – so we're challenging them

The ASA must make sure future generations don't recoil at our commercials.

July’s been quite the month for gender in the news. From Jodie Whittaker’s casting in Doctor Who, to trains “so simple even women can drive them”, to how much the Beeb pays its female talent, gender issues have dominated. 

You might think it was an appropriate time for the Advertising Standards Authority (ASA) to launch our own contribution to the debate, Depictions, Perceptions and Harm: a report on gender stereotypes in advertising, the result of more than a year’s careful scrutiny of the evidence base.

Our report makes the case that, while most ads (and the businesses behind them) are getting it right when it comes to avoiding damaging gender stereotypes, the evidence suggests that some could do with reigning it in a little. Specifically, it argues that some ads can contribute to real world harms in the way they portray gender roles and characteristics.

We’re not talking here about ads that show a woman doing the cleaning or a man the DIY. It would be most odd if advertisers couldn’t depict a woman doing the family shop or a man mowing the lawn. Ads cannot be divorced from reality.

What we’re talking about is ads that go significantly further by, for example, suggesting through their content and context that it’s a mum’s sole duty to tidy up after her family, who’ve just trashed the house. Or that an activity or career is inappropriate for a girl because it’s the preserve of men. Or that boys are not “proper” boys if they’re not strong and stoical. Or that men are hopeless at simple parental or household tasks because they’re, well...men.

Advertising is only a small contributor to gender stereotyping, but a contributor it is. And there’s ever greater recognition of the harms that can result from gender stereotyping. Put simply, gender stereotypes can lead us to have a narrower sense of ourselves – how we can behave, who we can be, the opportunities we can take, the decisions we can make. And they can lead other people to have a narrower sense of us too. 

That can affect individuals, whatever their gender. It can affect the economy: we have a shortage of engineers in this country, in part, says the UK’s National Academy of Engineering, because many women don’t see it as a career for them. And it can affect our society as a whole.

Many businesses get this already. A few weeks ago, UN Women and Unilever announced the global launch of Unstereotype Alliance, with some of the world’s biggest companies, including Proctor & Gamble, Mars, Diageo, Facebook and Google signing up. Advertising agencies like JWT and UM have very recently published their own research, further shining the spotlight on gender stereotyping in advertising. 

At the ASA, we see our UK work as a complement to an increasingly global response to the issue. And we’re doing it with broad support from the UK advertising industry: the Committees of Advertising Practice (CAP) – the industry bodies which author the UK Advertising Codes that we administer – have been very closely involved in our work and will now flesh out the standards we need to help advertisers stay on the right side of the line.

Needless to say, our report has attracted a fair amount of comment. And commentators have made some interesting and important arguments. Take my “ads cannot be divorced from reality” point above. Clearly we – the UK advertising regulator - must take into account the way things are, but what should we do if, for example, an ad is reflecting a part of society as it is now, but that part is not fair and equal? 

The ad might simply be mirroring the way things are, but at a time when many people in our society, including through public policy and equality laws, are trying to mould it into something different. If we reign in the more extreme examples, are we being social engineers? Or are we simply taking a small step in redressing the imbalance in a society where the drip, drip, drip of gender stereotyping over many years has, itself, been social engineering. And social engineering which, ironically, has left us with too few engineers.

Read more: Why new rules on gender stereotyping in ads benefit men, too

The report gave news outlets a chance to run plenty of well-known ads from yesteryear. Fairy Liquid, Shake 'n' Vac and some real “even a woman can open it”-type horrors from decades ago. For some, that was an opportunity to make the point that ads really were sexist back then, but everything’s fine on the gender stereotyping front today. That argument shows a real lack of imagination. 

History has not stopped. If we’re looking back at ads of 50 years ago and marvelling at how we thought they were OK back then, despite knowing they were products of their time, won’t our children and grandchildren be doing exactly the same thing in 50 years’ time? What “norms” now will seem antiquated and unpleasant in the future? We think the evidence points to some portrayals of gender roles and characteristics being precisely such norms, excused by some today on the basis that that’s just the way it is.

Our report signals that change is coming. CAP will now work on the standards so we can pin down the rules and official guidance. We don’t want to catch advertisers out, so we and CAP will work hard to provide as much advice and training as we can, so they can get their ads right in the first place. And from next year, we at the ASA will make sure those standards are followed, taking care that our regulation is balanced and wholly respectful of the public’s desire to continue to see creative ads that are relevant, entertaining and informative. 

You won’t see a sea-change in the ads that appear, but we hope to smooth some of the rougher edges. This is a small but important step in making sure modern society is better represented in ads.

Guy Parker is CEO of the ASA