Attacks by Islamist militants threaten to undermine a vast polio vaccination effort in Pakistan. In the first of a three-part series looking at the global fight to eradicate the infectious disease, Taimur Khan reports from Karachi, where healthcare workers endanger their lives to protect children.
KARACHI // Madiha Shah and her cousin Fehmida, both UN-employed polio vaccination workers, were walking home when two men on a motorcycle sprayed them with bullets, killing both women.
Two other polio workers in Karachi were killed the same night by suspected Pakistani Taliban militants, all within 30 minutes.
“Her death has given me more courage to fight this war against polio,” said Gulnaz Shirazi, 32, Shah’s aunt who now supervises a vaccination team in Karachi’s Landhi Town neighbourhood where the women, aged 18 and 46, were murdered in December 2012.
Since September, more than a dozen polio vaccinators or their security personnel have been killed in the Federally Administered Tribal Areas (Fata) in north-western Pakistan and Karachi in the south.
As a result, about 300,000 children have not been immunised in a country that had 91 new cases confirmed last year – more than in the world’s other two polio endemic nations, Nigeria and Afghanistan.
The attacks by militants in pockets of Karachi and in the north-west tribal areas threaten to undermine a revamped polio eradication campaign involving tens of thousands of workers that is being rolled out this year by health officials, Unicef and the World Health Organization.
Yet despite the threats, those in the front line of that battle remain unbowed.
“Why should I be afraid?” asks Ms Shirazi, whose nephew was killed and whose brother survived a shooting last year. Both were working on the polio eradication campaign.
“My day [of death] is fixed, and God has given me this opportunity to play a role in saving our country’s children,” she said, sitting in a government clinic in Landhi, a mostly ethnic Pashtun neighbourhood that has come under the increasing control of Taliban militants from the country’s tribal areas.
Along with polio workers, the militants have killed dozens of members of the local secular political party as they tighten their grip.
While Pakistan’s umbrella Taliban group, the Tehrik-e-Taliban Pakistan (TTP), has not claimed responsibility for the killing of polio workers, its leaders have banned the vaccine drive in areas under their control.
They call the vaccinations a western plot to make Muslims infertile and to spy on the group. In their propaganda, the religious extremists have effectively tied polio to US drone strikes, unpopular among many Pashtuns, as well as the CIA operation to use a fake hepatitis team to take a DNA sample from Osama bin Laden.
Karachi is linked to Fata, which had five new polio cases last week, through growing migration as militant violence and army operations displace hundreds of thousands of people from their homes. And this city is likely where the global battle against polio, which costs around US$1 billion (Dh3.67bn) annually, will be decided.
“The nightmare situation is if polio spreads in Karachi,” said Dr Naqi Bukhari, a WHO official leading the vaccination efforts in the city. “If it spreads here it will spread across the world … it is the only megacity and global shipping port that is polio endemic.”
Last year, the WHO confirmed the existence of polio virus for the first time in decades in Egypt, Syria, Israel and China, and found that they were the same strain, which originated in Karachi.
It is likely that Pakistani militants who travelled to Syria to fight President Bashar Al Assad’s forces carried the virus to the Middle East, Dr Bukhari said.
There is no cure for polio, which causes irreversible paralysis and can kill young children whose breathing muscles are affected. The global campaign to stamp out the virus completely has nearly succeeded, with just 223 cases reported in 2012, a drop from 350,000 cases in 1988, according to the WHO.
But if polio continues to spread in Pakistan, and especially Karachi, where five new cases have been confirmed this month, the global rates will begin to rise again.
“Pakistan is the key geographic location in the fight,” Dr Bukhari said.
With a renewed sense of urgency, last year the Pakistani government revamped its strategy to increase the scope and effectiveness of vaccinations. In Karachi, the police were ordered to provide security to all polio teams.
But even with 200 policemen, a campaign in the Gadap Town area, where there is a large TTP presence, came under attack by militants last month, though no workers were killed and the police managed to capture the TTP militant who led the attack, Amir Hamza.
Despite the renewed efforts, the continuing lack of security is hampering the vaccination drives, said an official who works with a group of local women from Gadap called social mobilisers, whose job it is to persuade families to vaccinate.
The official, who asked to remain anonymous, lives under threat from the TTP, and saw Unicef colleagues killed in Gadap in July 2012. “The refusals are increasing now because people are scared, and the quality of the campaign has decreased because of the security issue,” she said.
The police help because they can intimidate people into taking the vaccination drops, but they also hurry workers along and sometimes do not allow them to enter houses they feel might be dangerous, she said.
A team of female vaccination workers last week went door-to-door in Neelum Colony, a slum of tight alleyways, dirt paths and makeshift homes. The security risk is much lower in Neelum Colony than places like Gadap, but the required police escort failed to show up, and so the women went about their work unprotected.
Though the police are receiving training to assist in vaccinations from Unicef and the Pakistan government, Nausheed Kesar, a local health official, said that high turnover of staff is her biggest problem.
“Just today 11 workers didn’t show up, and I also had a group of nursing students who dropped out because their parents were too concerned about their safety,” Ms Kesar said. “If workers who we’ve trained don’t show up, it prolongs the campaign and decreases quality.”
The vaccinators are also only paid the equivalent of $2.50 per day, and many times there are months-long delays in delivering the salaries. Pakistani officials said they plan to double the daily rate, but so far the pay raise has not occurred.
Across Pakistan vaccination rates have reached 90 per cent, with more than 33 million children vaccinated each year.
But resistance from deeply religious segments of Karachi’s fast-growing Pashtun population has proved difficult to breach. In the highest-risk areas, both in terms of security and the prevalence of polio, many people are recent arrivals from Fata.
In the tribal areas, they lived under draconian colonial-era laws and were subject to collective punishment by the Pakistani government, while receiving almost no services. Their communities have also suffered the most from the US drone war and Pakistan army counterinsurgency operations, which fuels suspicion of the state.
“The government is not interested in doing any work for us, there is no education, we are given nothing at government health facilities,” said Qari Saboor, a Pashtun cleric in Hijrat Colony. “The children get sick from water, which runs on the same line here as sewerage. But they come again and again for polio … why just this focus on polio?”
Because of the security threats across Karachi, the campaigns that are meant to last three days, can drag out for much longer and the refusal rates increase as a sense of annoyance sets in, said the vaccination official in Gadap Town.
“One polio drive is easy. Six times a year is very difficult, even though it is necessary for covering all the children,” said Dr Bukhari. “But polio is not people’s top concern. Security, education and sanitation are.”
On the outskirts of Karachi, a polio team, with the help of paramilitary Rangers, board every passenger bus coming into the city from other provinces, vaccinating nearly 1,000 children a day.
On one bus, coming from the Swat valley, a social mobiliser moved down the rows of seats behind the vaccinators. A woman in niqab with two children refused to allow the workers to give the drops. As the passengers watched, she said, “No, this is not good for Muslims, I will not let you give it.”
The mobiliser gently tried to persuade the mother, saying that all pilgrims on Haj are given the drops by Saudi Arabian authorities, but she held firm. “You do your work, but I refuse, this is my belief.”