Female Vaccination Workers, Essential in Pakistan, Become Prey

By DECLAN WALSH and DONALD G. McNEIL Jr. The front-line heroes of Pakistan’s war on polio are its volunteers: young women who tread fearlessly from door to door, in slums and highland villages, administering precious drops of vaccine to children in places where their immunization campaign is often viewed with suspicion. Now, those workers have become quarry. After militants stalked and killed eight of them over the course of a three-day, nationwide vaccination drive, the United Nations suspended its anti-polio work in Pakistan on Wednesday, and one of Pakistan’s most crucial public health campaigns has been plunged into crisis. A ninth victim died on Thursday, a day after being shot in the northwestern city of Peshawar, The Associated Press reported. The World Health Organization and Unicef ordered their staff members off the streets, while government officials reported that some polio volunteers — especially women — were afraid to show up for work. At the ground level, it is those female health workers who are essential, allowed privileged entrance into private homes to meet and help children in situations denied to men because of conservative rural culture. “They are on the front line; they are the backbone,” said Imtiaz Ali Shah, a polio coordinator in Peshawar. The killings started in the port city of Karachi on Monday, the first day of a vaccination drive aimed at the worst affected areas, with the shooting of a male health worker. On Tuesday four female polio workers were killed, all gunned down by men on motorcycles in what appeared to be closely coordinated attacks. The hit jobs then moved to Peshawar, the capital of Khyber-Pakhtunkhwa Province, which, along with the adjoining tribal belt, constitutes Pakistan’s main reservoir of new polio infections. The first victim there was one of two sisters who had volunteered as polio vaccinators. Men on motorcycles shadowed them as they walked from house to house. Once the sisters entered a quiet street, the gunmen opened fire. One of the sisters, Farzana, died instantly; the other was uninjured. On Wednesday, a man working on the polio campaign was shot dead as he made a chalk mark on the door of a house in a suburb of Peshawar. Later, a female health supervisor in Charsadda, 15 miles to the north, was shot dead in a car she shared with her cousin. Yet again, Pakistani militants are making a point of attacking women who stand for something larger. In October, it was Malala Yousafzai, a schoolgirl advocate for education who was gunned down by a Pakistani Taliban attacker in the Swat Valley. She was grievously wounded, and the militants vowed they would try again until they had killed her. The result was a tidal wave of public anger that clearly unsettled the Pakistani Taliban. In singling out the core workers in one of Pakistan’s most crucial public health initiatives, militants seem to have resolved to harden their stance against immunization drives, and declared anew that they consider women to be legitimate targets. Until this week, vaccinators had never been targeted with such violence in such numbers. Government officials in Peshawar said that they believe a Taliban faction in Mohmand, a tribal area near Peshawar, was behind at least some of the shootings. Still, the Pakistani Taliban have been uncharacteristically silent about the attacks, with no official claims of responsibility. In staying quiet, the militants may be trying to blunt any public backlash like the huge demonstrations over the attack on Ms. Yousafzai. Female polio workers here are easy targets. They wear no uniforms but are readily recognizable, with clipboards and refrigerated vaccine boxes, walking door to door. They work in pairs — including at least one woman — and are paid just over $2.50 a day. Most days one team can vaccinate 150 to 200 children. Faced with suspicious or recalcitrant parents, their only weapon is reassurance: a gentle pat on the hand, a shared cup of tea, an offer to seek religious assurances from a pro-vaccine cleric. “The whole program is dependent on them,” said Mr. Shah, in Peshawar. “If they do good work, and talk well to the parents, then they will vaccinate the children.” That has happened with increasing frequency in Pakistan over the past year. A concerted immunization drive, involving up to 225,000 vaccination workers, drove the number of newly infected polio victims down to 52. Several high-profile groups shouldered the program forward — at the global level, donors like the Bill and Melinda Gates Foundation, the United Nations and Rotary International; and at the national level, President Asif Ali Zardari and his daughter Aseefa, who have made polio eradication a “personal mission.” On a global scale, setbacks are not unusual in polio vaccination campaigns, which, by dint of their massive scale and need to reach deep inside conservative societies, end up grappling with more than just medical challenges. In other campaigns in Africa and South Asia, vaccinators have grappled with natural disaster, virulent opposition from conservative clerics and sudden outbreaks of mysterious strains of the disease. Their natural first reaction is frustration. But then, each time, vaccinators have optimistically predicted that, with enough donations and a redoubled effort, they would get the situation under control. “This isn’t over, not by a long shot,” Sarah Crowe, a spokeswoman for the United Nations Children’s Fund, said after the killings. “There’s still great energy in the campaign.” Still, Pakistan needs all the help it can get. One of just three countries in the world where the disease is still endemic, Pakistan counted 198 new infections last year — the highest rate in the world. Militant commanders have been criticizing polio vaccination campaigns — a prominent yet weakly protected sign of government presence in far-flung areas — since 2007 when Maulvi Fazlullah, a radical preacher on a white horse, strode through the northwestern Swat Valley. Mr. Fazlullah claimed that polio vaccines were part of a plot to sterilize Muslim children, but in recent years Taliban commanders in the militant hub of North Waziristan have come up with a more political complaint: they say that immunization can resume only when American drones stop killing their comrades. Suspicion of vaccination has also intensified since the Central Intelligence Agency used a Pakistani doctor, Shakil Afridi, to run a hepatitis B vaccination scheme in order to spy on Osama bin Laden’s house in Abbottabad in 2011. Heidi Larson, an anthropologist at the London School of Hygiene and Tropical Medicine who analyzes local support for vaccines in different countries, believes the C.I.A.’s use of Dr. Afridi has hurt the polio drive more than the Pakistan government or the eradication campaign itself will admit. “We’re risking people’s lives here,” she said. “More people are dying as vaccinators than have from polio. There’s something wrong with that equation.” But Oliver Rosenbauer, a spokesman for the W.H.O., said that only 1 to 2 percent of Pakistani families refuse polio vaccines, and that has not changed substantially since the C.I.A. ruse was exposed. It may be too soon to accurately assess the impact of this week’s violence on eradication in Pakistan or globally. In any event, the rest of the world had a banner year — not a single case in India, which once had more than any other country, and no outbreaks outside the virus’s two persistent epicenters of northern Nigeria and the nearby Sahel regions of Niger and Chad, and the Pakistan-Afghanistan border region. Where immunization has worked, it has often included the work of female volunteers — which can have other public health benefits, too. Ms. Crowe, the Unicef spokeswoman, said that in Pakistan, “every encounter a vaccinator has with a mother delivers other messages about breast feeding, hand-washing or encouragement to take children to health centers for other immunizations.” The anti-polio drive has tried to integrate itself so deeply into the country’s faltering public health system that an attack on vaccinators is seen not as a blow against the West, but as a blow against the lives of local women and children. “This is not about polio,” said Dr. Bruce Aylward, who heads polio eradication at the World Health Organization. “This is someone attacking health care workers who are delivering basic interventions.”