Max Becherer/Polaris

Polio vaccinators risk their lives to save lives in Pakistan

All but eradicated a few years ago, polio is now resurgent. The global fight against the disease depends on vaccination campaigns in Karachi, Pakistan – but violence and mismanagement have put those efforts at risk

Topics:
International
Pakistan
Health

KARACHI, Pakistan — Tahira Yasmeen wraps a shawl around her face as the driver inches our car through mud and over rocks, maneuvering the bouncing white Corolla down a lane in Machar Colony, one of the most dangerous areas in Gadap Town’s Union Council 4 (UC-4). The impoverished accretion of settlements on the edge of Karachi is home to some 300,000 people, mostly Afghan refugees and, since 2008, tribal Pashtuns fleeing war in South Waziristan and other tribal areas. It is here, say United Nations health officials, that the global fight against the resurgent polio virus will be decided. So far, that fight is being lost.

Men peer into the car as they walk to attend Friday prayers in a ramshackle cinder-block mosque that sits on the ridge of a small hill. Below, sludge floats along a stream that routinely floods the area with raw sewage. Young children, ubiquitous, some blond and light-eyed, play barefoot outside small homes, many no more than wood planks topped with thatched palm fronds. Over the past three years, the Pakistani Taliban have extended their control in a part of this megacity long neglected by local and provincial governments, through intimidation and efficient, often brutal justice. 



Pakistani security officials escort health workers as they administer vaccines to children in Karachi on Feb. 23.
Shahzaib Akber/EPA

Pakistan, along with Afghanistan and Nigeria, is one of three countries where polio is now endemic. Last October, the WHO confirmed an outbreak in Syria, the first since 1999. The type 1 polio virus found in UC-4, the largest reservoir in Karachi, is the same strain that’s spreading in Syria.

The WHO now says cases in Pakistan have spiked from 58 in 2012 to 93 last year. And for every confirmed case, 200 other children are likely infected. Karachi, which along with northwest Khyber-Pakhtunkhwa (KP) province and the Federally Administered Tribal Areas (FATA) is one of three parts of the country where polio is endemic, is key to the global efforts to eradicate the disease. Because of the city’s status as a trade hub, WHO officials have called the possibility of polio's spread here “a nightmare situation.” “Karachi is the only megacity in the world that is a polio reservoir, so if you shut that down, you stop the possibility of the polio virus spreading globally. Otherwise, the chance of it spreading to other countries is great,” says Jan Markus Hellstrom, a UNICEF official in Karachi. 

(This year) is make-or-break. If we don’t start seeing success soon, then it could be too late.

Jan Markus Hellstrom

UNICEF

Yasmeen, a UNICEF employee, has worked to eradicate polio in UC-4 for nearly five years, leading teams of young Pashtun women from Gadap. They work as “mobilizers” to persuade residents and influential local figures to vaccinate their children and support the campaign. “I have good contacts in Gadap — every child and influential person in every street knows me,” Yasmeen says as we drive past a small government-run dispensary where residents once brought their children for polio vaccinations. It now sits empty; posters exhorting Pakistanis to vaccinate their children hang ripped and peeling from its exterior walls.

After it was revealed in 2011 that the CIA had used a Pakistani doctor, Shakil Afridi, to run a fake hepatitis vaccination program as a ruse to collect DNA from Osama bin Laden’s suspected hideout, polio workers began to face violent resistance as militants thought they might be working to gather intelligence. "It is against Islam and our traditions. These foreign nongovernmental organizations can easily use polio as cover for spying,” a spokesman with the Tehrik-e-Taliban Pakistan (TTP), an assortment of militant groups based in the tribal areas, recently told The Wall Street Journal. 



The TTP, which began filling the vacuum of governance in parts of Karachi where many Pashtun migrants have settled, played off the fears long spread by right-wing clerics that the vaccine is part of a Western plot to sterilize Muslims. But the TTP’s opposition was less ideological than tactical. A militant commander, Hafiz Gul Bahadur, said in 2012 that polio vaccinators would be allowed into North Waziristan and other areas controlled by the TTP if the CIA stopped its drone strikes.

A child is vaccinated in Karachi. Pakistan is one of three countries where polio is endemic.
A child is vaccinated in Karachi. Pakistan is one of three countries where polio is endemic.
Max Becherer/Polaris

One night in June 2012, the TTP sent messengers to all of Yasmeen’s mobilizers’ houses, and insisted their families send one male to a deserted patch of land near Gadap at midnight. There the militants warned the men that the women in their families must stop working for the U.N. because the international agencies were using them as spies, and the aid agencies worked with Western governments to kill Pakistani children in drone attacks. Terrified, the mobilizers tried to explain their predicament to Yasmeen, and together they decided to engage the militants in discussions. After being shown fatwas from hard-line clerics in support of the vaccines, the TTP eventually relented. “They said, ‘OK, you can do this work, but we are telling you we don’t want to see in our area U.N. vehicles, U.N. people, foreigners,’” Yasmeen says, keeping her hand in her purse where she stores a 9mm pistol. “Also, no female from the Wazir, Burki or Mehsud tribes (Pashtun tribes from which the TTP draws most of its members) are allowed to work in the polio program.” Yasmeen says she relayed the threats to UNICEF and WHO officials. “I said, ‘Please don’t send any foreigners there (to UC-4),’ yet they kept coming.”

On July 17 of that year, a team of vaccinators was attacked in UC-4 by militants who snatched their vaccine cooler, smashing the vials of pink liquid into the dirt. “They were saying, ‘We are giving you half an hour to leave our area, otherwise you will see the result,’” Yasmeen says. Later that evening, two polio workers from the WHO were shot. The campaign continued, and two days later a local WHO polio worker was shot and killed. 

Since then, 54 polio workers and vaccination security personnel have been killed in Karachi, northwest KP province and FATA. In UC-4 and Karachi’s other high-risk neighborhoods, most of the campaigns since 2012 have been interrupted by violence or lack of security, and the teams’ efforts have been rendered frustratingly ineffective.

Pakistan security officials attend the funeral ceremony of police officials killed in twin bomb explosions near the Afghan border with Pakistan. The men from the tribal Khasardar Force were guarding polio vaccinators when they were killed, officials said.
Pakistani security officials attend the funeral of men from the tribal Khasardar Force who were killed in twin explosions near the border with Afghanistan while they were guarding polio vaccinators, officials said.
Bilawal Arbab/EPA

The Pakistani government, with money and assistance from the WHO and UNICEF, has launched a high-profile vaccination campaign endorsed by prominent religious figures and celebrities. It’s part of an urgent push that began last year to reduce the virus’s spread, which could cause Pakistanis to face travel restrictions that could in turn lead to major economic damage in a country kept afloat by remittances from workers abroad. More control has been given to district commissioners to adapt the campaign to the particular local conditions, and provincial governments have promised police protection for every team.

This Sunday, in 24 of Karachi’s highest-risk areas, such as Gadap, government health officials will try a new tactic — a routine immunization drive for an assortment of diseases, with no mention of polio, that will include drops for the disease. Markus Hellstrom of UNICEF says that “2014 is make-or-break. If we don’t start seeing success soon, then it could be too late.” But the new campaign is already being undermined, not just by the Taliban but by other factors.

On a chilly afternoon in early January, Dr. Munir Pitafi paces the dirt courtyard of the government clinic in UC-4 that is home base for 174 vaccination teams setting out on the first campaign of the year. It is the first attempt since the TTP attacked workers in UC-4 in December.

Dozens of the women who go door to door to administer the polio drops to children sit on the clinic’s front steps and on the blue coolers that contain doses of the vaccine, waiting for security escorts that are hours late. They are paid roughly US$2.50 per day, a pittance even in this overwhelmingly poor country. Despite the provincial government’s promise to send an armed policeman out with every vaccination team, only 50 or so officers eventually show up, instead of the 200 who were promised. “We are stranded and left alone here,” Pitafi says with an exasperated laugh. “Because we have no security, we are not working. Every time, we are not getting enough security.”

We are stranded and left alone. Because we have no security, we are not working.

Dr. Munir Pitafi

But while it is easy for health officials to blame Karachi’s police force, cops in the city are on the front lines of the fight against an amalgam of violent groups, including not only the Taliban and sectarian terrorists but also gangsters and political thugs. Criminal gangs view polio vaccinations in much the same way as the Taliban does: cover for intelligence gathering. With terrified judges and prosecutors unable to secure convictions in many cases, the police are left without protection from the state, and they die in greater numbers — more than 190 last year alone — than in any other city in the world outside of a war zone. 



Pakistan’s administrative bureaucracy also plays a role in the polio campaign’s struggles. While the provincial government has given more control to Karachi’s six district-level administrators to run the campaigns according to the specific needs of their areas, not all the commissioners have prioritized the vaccination campaigns. Qazi Jan Mohammed, the dapper, chain-smoking commissioner of district Malir, has made tackling polio a priority in the swath of Karachi under his control. He has employed creative tactics, like giving street children a few rupees each for taking the vaccination, that have rendered his domain polio-free. But other commissioners are not as motivated, and some even exaggerate the number of people who’ve received vaccinations in their areas.

At the street level, mismanagement is also a long-standing problem. Vaccinators complained of not being paid on time and facing trouble accessing the direct-deposit accounts created for them. Many quit; Yasmeen says she has had entire teams of workers desert after being trained.

But while it is easy for health officials to blame Karachi’s police force, cops in the city are on the front lines of the fight against an amalgam of violent groups, including not only the Taliban and sectarian terrorists, but also gangsters and political thugs. Criminal gangs view polio vaccinations in much the same way as the Taliban does: cover for intelligence gathering. With terrified judges and prosecutors unable to secure convictions in many cases, the police are left without protection from the state, and they die in greater numbers — more than 190 last year alone — than in any other city in the world outside of a war zone. 


But while it is easy for health officials to blame Karachi’s police force, cops in the city are on the front lines of the fight against an amalgam of violent groups, including not only the Taliban and sectarian terrorists, but also gangsters and political thugs. Criminal gangs view polio vaccinations in much the same way as the Taliban does: cover for intelligence gathering. With terrified judges and prosecutors unable to secure convictions in many cases, the police are left without protection from the state, and they die in greater numbers — more than 190 last year alone — than in any other city in the world outside of a war zone. 



The ultimate success of the polio eradication efforts in Karachi may well depend on the social mobilizers, in UC-4 and other parts of the country, who try to persuade families who’ve refused vaccinations. Sana, 20, is one of the five mobilizers in UC-4. She declined to give her real name out of concerns for her safety. Sana is from the Mehsud tribe and works more or less undercover, defying the TTP ban on tribal women working for the polio cause. She began as a vaccinator, but quit after a neighbor she says was a Taliban supporter took video of her with her vaccination kit on his mobile phone and threatened to send it to the local militant leader. Once, not long after, she was followed by a young man as she left for her college. At first she thought he was trying to flirt with her. “But he was just watching,” she says. “My brother told me he belongs to the TTP.”

Now, when Sana leaves home for her social mobilizing work in an adjacent zone of UC-4, she brings multiple changes of clothes and makeup, even though she wears a niqab and alters her routes daily. “My family tells me I must leave this job immediately, but I want (other Pashtuns) to be aware that this is very important for the children. I told my family that maybe because of me, many people will give their children the drops and many children will be safe from this disease.” 



Among Pakistani health officials, it seems to be an accepted fact that Pashtuns are ignorant, uneducated and a big reason why the polio campaign is struggling. But this analysis obscures the many reasons for their long-standing distrust of the government, says a journalist who lives in Gadap and is originally from South Waziristan. Today in Karachi, for example, Pashtuns are often unfairly targeted by the police. “Most Mehsud hate the TTP,” the journalist says, “but if the police humiliate me I have no choice but to join them to seek revenge.”



One afternoon I accompany Shoaib Khan, a young medical student from the Swat Valley, during his rounds as a mobilizer in Hijrat Colony, a Pashtun slum in central Karachi. He declined to give his real name, saying he was fearful of militants. We set out from a local health center with a burly police officer who says a prayer as we leave, and who carries his pistol unholstered, hidden in his jacket pocket. Our first stop is a cloth shop on the congested commercial lane. A man sits among reams of white and blue cotton reading a newspaper. Shoaib says the man’s father, who owns the store, beat his son for allowing his children to be vaccinated. The mobilizer asks the man where his father is, and the cloth merchant smiles nervously and says his father is away.

Whenever someone tells me this vaccine is poison, I say no. I know what it is like to be paralyzed, and I want my children to be healthy, not suffer.

A man in Union Council 4

A group of men with polio sit in their bicycle carts in the streets of Karachi on Aug. 10, 2011.
Men with polio in their carts in the streets of Karachi in 2011.
Kate Geraghty/The Sydney Morning Herald/Fairfax Media/Getty Images

A Mehsud man in a light blue salwar kameez who had been standing in an adjoining back room, listening to our conversation, walks over to us. Shoaib greets him; the man, according to Shoaib, also refuses to vaccinate his children. “Why do they send this Pathan (Pashtun) again and again?” the man, growing angry, asks no one in particular. “I am sorry, I just wanted to ask you to please share with us why you have this problem with the polio vaccine,” Shoaib replies, hoping a sympathetic tone and smile might create an opening. Instead, the man grabs the newspaper — the right-wing Daily Ummat — from the shopkeeper and opens the front page, holding it close to Shoaib’s face. “Please don’t talk to me about this polio, otherwise there will be a problem.” A front-page story features a “scientist” who claims his tests found that the polio vaccine contains monkey’s blood, and is therefore haram, or forbidden. The Daily Ummat, an Islamist paper founded during the anti-Soviet war in Afghanistan, is hugely influential in Pashtun communities, and has taken an anti-vaccine stance.

The man throws the newspaper on the ground at Shoaib’s feet. “I am begging you, don’t come again or I will not leave you in peace. You are an enemy of the Pashtun. This vaccine is an American plot causing AIDS, causing dengue … you are giving poison to the people!”

The policeman stands back, watching. His gun is now by his side.

Shoaib apologizes and we leave. “I am facing daily threats like this. They know who I am; they know my family, where I live,” he says.

We walk down a residential lane deeper into the colony, passing low cinder-block homes, their entrances covered with hanging cloth. Shoaib approaches one of the doorways and asks if anyone is home. The cop pulls out his gun again, but Shoaib pushes down the cop’s hand. “If they see that, we’ll get killed,” he says, agitated. No one comes to the door, but two men and a child walk up to us and introduce themselves. They are neighbors. “We have vaccinated, but these people never will. They think it’s against Islam. I tried to convince them myself, but they just wanted to fight with me,” the man says, his withered left leg twisted unnaturally inward.

“I was infected with polio when I was 2 years old,” he says. “Whenever someone tells me this vaccine is poison, I say no. I know what it is like to be paralyzed, and I want my children to be healthy, not suffer.”