Karachi, Pakistan - Sitting at his worktable in a ramshackle hut in one of Karachi's poorest districts, Muhammad Aslam makes clothes for a living. The 17-year-old never went to school, but has been a tailor since he was 12, making about $20 a month from sewing men's shalwar kurtas - a traditional dress.
"I can walk on it, but it hurts. My leg is wasted away from the knee down," he says, steadying his left knee with his hand as he leads me through the dusty, labyrinthine streets to his home.
Aslam is one of hundreds of people in Pakistan who suffer from polio, a crippling virus that attacks the body's central nervous system.
In the last 25 years worldwide polio cases have dropped by 99 percent, but the highly contagious disease, which is passed on through infected water and food contaminated with the faeces of an infected person and thrives in areas with poor sanitation and incomplete vaccination efforts, remains endemic in Pakistan, Afghanistan, and Nigeria.
Of those, it is Pakistan that remains the most at risk, suffering 166 cases already this year, compared to just 10 in Afghanistan and six in Nigeria, according to the World Health Organization (WHO).
It is an alarming uptick from the 93 cases reported in total last year, and the 58 cases in 2012, as Pakistan's efforts to control the disease appeared to finally be bearing fruit.
While the lack of uniform hygiene standards is one reason for the disease's spread, health workers told Al Jazeera that the biggest issue in Pakistan is opposition to vaccination by parents - often with the "justification" that the vaccine is part of a conspiracy to sterilise Muslims, as advocated by the Pakistani Taliban - and subsequent attacks on polio vaccination workers.
While the majority of Pakistan's polio cases are found in the tribal areas, where the government writ is tenuous and the Pakistani Taliban hold sway over large areas, that ideology has been exported to other parts of the country, too, creating reservoirs where the disease can spread across geographical boundaries.
Nowhere is the threat more visible than in Karachi, Pakistan's largest city, and one where a complex mix of ethnic, political and religious conflicts has resulted in a city where violence itself is endemic.
'Creating fear by killings'
"[The Taliban] have been living in some areas, engaging in criminal activities and killing polio vaccinators," says Aziz Memon, chairman of Pakistan's national Polio Plus committee, referring to the Karachi areas of Sohrab Goth, Baldia, Landhi, and Bin Qasim, where even police officials told Al Jazeera they often feared to tread.
"Now if you start killing people, then [vaccinators] will not be able to go there. When they are not able to go there, it will become a polio reservoir."
|Aslam, 17, says that he does not let his disabled leg affect his daily work as a tailor [Asad Hashim/Al Jazeera]
The threats from Karachi-based groups allied with the Pakistani Taliban is based on a perception that the polio vaccination drops administered to children are meant to harm them as part of "a foreign conspiracy".
This perception was only strengthened by the CIA's use of Dr Shakil Afridi during a similar immunisation drive in Abbottabad to ascertain the location of Osama bin Laden, polio workers say, citing arguments made by those who refuse to take the vaccine.
"No one used to care about the conspiracy theories before Dr Shakil Afridi, but now people have started caring. And they have started creating fear by killing vaccinators," says Memon.
Since July 2012, 58 people have been killed in attacks on polio vaccination teams in Pakistan, including at least 24 health workers, according to data compiled by UNICEF. In the latest attack, on September 10, in the tribal area of Bajaur, a paramilitary soldier who was providing security to a team was killed by a group of masked gunmen.
"We take our lives in our hands when we work in these areas, the danger is very high," says Mashook Ali, 20, a polio vaccinator who works in the Quaid-e-Azam Colony area of Karachi. "But we do this for the children, so that they are saved from the virus."
Vaccination teams in Karachi are often deployed with security cover from the police. On Monday, a four-day polio vaccination drive in Karachi kicked off amid tight security. But vaccinators said that the police protection was often more superficial than meaningful.
"We have seen incidents where vaccinators have been fired upon, especially in Pashtun areas, where we work, so we do feel afraid," says Saddam Hussain, 18, another vaccinator. "But we do this work for the betterment of Pakistan. We have made an oath to eliminate polio from Pakistan."
'Militants are like kings'
Reports of polio cases in Karachi coincide with the areas of influence of the Taliban, according to police officials with whom Al Jazeera spoke. It is in these areas that environmental samples consistently test positive for the virus, too, according to the WHO data.
Karachi is the only Pakistani city, other than Peshawar, where such environmental tests consistently bring up positive results for polio, according to the data.
Sheraz Aslam, a coordinator for polio vaccination efforts in Karachi, says: "There are areas where you cannot go at all. If they want vaccinations there, they have to come outside their area, to us."
Waqar Gill, 19, an area coordinator for vaccination efforts in an area under threat, said that the vaccinators are more concerned about refusals, however, than the threat of attack.
"Those who refuse say that the vaccine reduces male potency, or that it is a US conspiracy. Some even say it is made from the urine of foreigners," said Hussain.
Gill added that there were also concerns about short-term ill-effects as a result of the vaccinations, which immunise children by giving them a very small dose of the infection.
Those who refuse say that the vaccine reduces male potency, or that it is a US conspiracy. Some even say it is made from the urine of foreigners.
The lack of immunisation coverage, combined with the influence of the Taliban and the constant flow of migrants into the city has turned Karachi into a reservoir for the disease, says Memon, which is of major concern in terms of worldwide polio eradication efforts.
"From North Waziristan, when these terrorists went to Syria, they move with their families," he said, pointing to the detection of a Pakistani strain of polio in Syria last year. "Until you do not achieve total elimination, the whole world is unsafe. Because the virus is just a flight away."
While country-wide coverage rates for Pakistan's polio immunisation drives are relatively high, they remain far from perfect, with an average of 11 percent of children being missed in vaccination drives, either due to security reasons or refusals, according to the WHO. In Karachi, that number stands at 21 percent.
"If the community is willing to hold a dialogue with you, then you can ask them, and perhaps even convince them [to allow vaccinations]," says Azfar Ali, the country manager for PolioPlus. "But in certain areas of Karachi, like Sohrab Goth, you can't even talk about it. Militants are like kings there."
Aslam, the tailor, lives in an area where there are a large number of migrants from the South Waziristan tribal area, and, consequently, a large number of refusals.
"I feel like if I had gotten the drops, then today I would be able to walk, I'd be able to play. I feel like I am less than these other kids," he says.
"This disease ruins a person's life. The people who don't give their children these drops, they must be idiots."
Follow Asad Hashim on Twitter: @AsadHashim
Source: Al Jazeera