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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Winning Scottish independence will be even harder than before - but it may be the only choice

Independence campaigners will have to find answers on borders, currency and more. 

The Brexit mutiny has taken not just the UK economy and its relationship with Europe into uncharted waters. it has also imperilled the union between Scotland and England. From Sir John Major to the First Minister, both Unionists and Nationalists had warned of it. The outcome, though, has made this certain. The Leave vote in England and Wales contrasted with an overwhelming Remain vote north of the border.

That every region in Scotland voted to stay In was quite remarkable. Historically, fishing and industrial communities have blamed the European Union for their woes. That antagonism was probably reflected in lower turnout - an abstention rather than a rejection. 

The talk now is of a second referendum on independence. This is understandable given the current mood. Opinion polls in the Sunday Times and Sunday Post showed a Yes vote now at 52 per cent and 59 per cent respectively. Moreover, anecdotal evidence suggests even arch No vote campaigners, from JK Rowling to the Daily Record, are considering the option.

The First Minister was therefore correct to say that a second referendum is now “back on the table”. Her core supporters expects no less. However, as with the economy and Europe, the constitutional relationship between Scotland and England is now in uncharted seas. Potential support for independence may be higher, but the challenges are arguably bigger than before. The difficulties are practical, political and geographic.

Of course the Little Englanders likely to take the helm may choose a velvet divorce. However, given their desire for the return of the Glories of Britannia that’s improbable. They’re as likely to wish to see Caledonia depart, as cede Gibraltar to Spain, even though that territory voted even more overwhelmingly In.

Ticking the legal boxes

Practically, there’s the obstacle of obtaining a legal and binding referendum. The past vote was based on the Edinburgh Agreement and legislation in Westminster and Holyrood. The First Minister has indicated the democratic arguments of the rights of the Scots. However, that’s unlikely to hold much sway. A right-wing centralist Spanish government has been willing to face down demands for autonomy in Catalonia. Would the newly-emboldened Great Britain be any different?

There are no doubt ways in which democratic public support can be sought. The Scottish Government may win backing in Holyrood from the Greens. However, consent for such action would need to be obtained from the Presiding Officer and the Lord Advocate, both of whom have a key role in legislation. These office holders have changed since the first referendum, where they were both more sympathetic and the legal basis clearer. 

Getting the EU on side

The political hurdles are, also, greater this time than before. Previously the arguments were over how and when Scotland could join the EU, although all accepted ultimately she could remain or become a member. This time the demand is that Scotland should remain and the rest of the UK can depart. But will that be possible? The political earthquake that erupted south of the Border has set tectonic plates shifting, not just in the British isles but across the European continent. The fear that a Brexit would empower dark forces in the EU may come to pass. Will the EU that the UK is about to leave be there for an independent Scotland to join? We cannot know, whatever European Commission President Jean-Claude Juncker may be saying at the moment. The First Minister is right to start engaging with Europe directly. But events such as elections in France and the Netherlands are outwith her control. 

Moreover, currency was the Achilles heel in the last referendum, and hasn’t yet been addressed. George Osborne was adamant in his rejection of a currency union. The options this time round, whether a separate Scottish currency or joining the euro, have yet to be properly explored. A worsened financial situation in the 27 remaining EU members hampers the latter and the former remains politically problematic. 

The problem of borders

Geography is also an obstacle  that will be even harder to address now than before. Scotland can change its constitution, but it cannot alter its location on a shared island. In 2014, the independence argument was simply about changing the political union. Other unions, whether monarchy or social, would remain untouched. The island would remain seamless, without border posts. An independent Scotland, whether in or out of the EU, would almost certainly have to face these issues. That is a significant change from before, and the effect on public opinion unknown.

The risk that's worth it

Ultimately, the bar for a Yes vote may be higher, but the Scots may still be prepared to jump it. As with Ireland in 1920, facing any risk may be better than remaining in the British realm. Boris Johnson as Prime Minister would certainly encourage that. 

David Cameron's lack of sensitivity after the independence referendum fuelled the Scottish National Party surge. But perhaps this time, the new Government will be magnanimous towards Scotland and move to federalism. The Nordic Union offers an example to be explored. Left-wing commentators have called for a progressive alliance to remove the Tories and offer a multi-option referendum on Scotland’s constitution. But that is dependent on SNP and Labour being prepared to work together, and win the debate in England and Wales.

So, Indy Ref The Sequel is on the table. It won’t be the same as the first, and it will be more challenging. But, if there is no plausible alternative, Scots may consider it the only option.

Kenny MacAskill served as a Scottish National MSP between 2007 and 2016, and as Cabinet Secretary for Justice between 2007 and 2014.