No-one needed to tell Usman about the risks of polio. When the vaccination teams called at his house in one of Karachi’s poorest neighbourhoods he had no hesitation in making sure his first three children were protected from the crippling virus.
He knew the miseries of the disease. His stiff right leg bears its calling card. A lopsided stride is possible only if he uses a hand to lock the limb into place, the result of contracting poliomyelitis as a child in the early 1980s.
But when health workers arrived to administer drops to his fourth and youngest, Musharraf, two years ago, he said no. His explanation – featuring Osama bin Laden, the CIA and a fake vaccination campaign – is a symptom of the way religious hardliners, mismanagement and misconceptions have derailed Pakistan’s efforts to eradicate the disease.
“When my child was doubled up in pain, I came to know,” said Usman, who asked that only his first name be used. “We needed the doctors to confirm it. It was very difficult for us – especially for me knowing what it is like. I regretted the decision not to vaccinate him.
“Then I prayed to God for his health.”
The awkward politics of public health
Just like his father, Musharraf had contracted polio. Unlike his father, whose parents were never offered the vaccine, Musharraf’s lifetime of hardship might have been avoided.
The case has attracted widespread attention in Pakistan, serving as a case study in the awkward politics of public health. For Usman becoming one of the faces of polio prevention is a fraught business, liable to make him a target for the Taliban. Speaking four days after three polio workers were shot dead in Karachi, he is nervous, fearful of generating more headlines.
Meetings were arranged and then cancelled. Calls went unanswered or unreturned. Eventually he would tell his story only by telephone.
In 2011 Pakistan had been consumed by details of how Osama bin Laden was tracked to the town of Abbottabad. A doctor had run a fake hepatitis vaccination campaign for the CIA, offering jabs. The aim was to collect blood from bin Laden’s suspected children and grandchildren. DNA evidence would then confirm the presence of the world’s most wanted man.
Usman, like many others, suddenly thought he understood why the West was pumping millions of dollars into polio vaccinators coming house-to-house. Dr Shakil Afridi’s arrest had revealed the plot.
“Suddenly we were thinking that these forces were using community workers against us,” he said. “It was a big concern.”
Last year should have been the year that polio was eradicated from Pakistan. Instead, 91 cases were recorded – an increase on the 58 in 2012. The country is one of the last remaining reservoirs, along with Nigeria and Afghanistan, stalling global efforts to consign the crippling disease to history.
Cheap and reliable vaccines
Yet by any measure that push has been hugely successful. In 1988, when the global programme began, the disease paralysed more than 1000 children every day. By 2012, there were only 223 cases worldwide – almost half in Pakistan - a testament to cheap and reliable vaccines.
The final step, reducing that number to zero, is proving difficult and the disease has clung on stubbornly in the last three remaining countries. While polio virus circulates anywhere, there remains a risk of it seeding outbreaks elsewhere. An outbreak in Syria last year was traced back to Pakistan, for example.
Pakistan’s problem is the world’s problem.
On the front line are the vaccinators, quaintly known as Lady Health Workers. Every few months they are taken away from their routine duties to launch two or three-day vaccination drives, for which they receive a daily rate of 250 rupees ($2.50).
For that they also get the constant fear of attack as Shagufta Baig explained in a clinic in one of Karachi’s most northern neighbourhoods.
“My family are asking me to leave this job,” she said, her dark hair tucked beneath a black headscarf. “When I was called for this meeting my son asked me where I was going and said I shouldn’t go anywhere for the polio campaign.”
Their first two-day campaign of 2014 had to be abandoned when two women and a man were shot dead as they administered polio drops. No-one knows when it will resume as health workers negotiate for better pay and protection.
With time on their hands, half a dozen gathered in the Lyari Expressway Resettlement Project Dispensary, a health centre serving a poor population who lost their homes when a new road was built through the centre of the city a decade ago. They ended up in a far suburb with a measly amount of compensation with which to build new houses and a place where schools and medical facilities are few and far between.
They said concerned mothers more often cited side-effects than the CIA’s doctor spy when they refused vaccines. Many are convinced the vaccines contain contraceptives to limit population growth. That there must be an ulterior motive for the medicine sent from the West is a common doorstep theme.
“They get this information from their elders, religious leaders and at the mosques,” said one health worker, who asked that she be known only by her first name, Sohana. “There’s a perception that the US is the enemy of Muslims. Why would it want to help us for free? It’s not their problem.”
"They said ther were going to kill us"
Other concerns are rooted in recent health scares. At the end of last year, during another polio push, a three-year-old boy was taken ill after being given a vitamin capsule that had passed its use-by date. He developed a skin allergy and fever. His family took him to hospital when he fell unconscious. Then they called the media.
Sohana was with 11 other lady health workers in one of the neighbourhood’s narrow, rubbish-strewn streets when they were hunted down and surrounded by locals.“They said they were going to kill us,” she said.
The terrifying stand-off was defused only when she telephoned her manager, who arrived to talk down the crowd and let the women leave. The boy eventually made a full recovery but the suspicion lingers that health workers are dishing out vaccines which are past their best, and Sohana admits that they have twice been sent out with expired vials.
They also say their two-day campaign is not long enough. In pairs they are supposed to cover 600 homes, returning during a catch-up session to houses where the children were out or where parents initially refused. Factor in time spent explaining the programme, checking expiry dates and examining ingredient lists with parents and the job becomes a rush.
If Karachi is one of the frontlines, then Pakistan’s tribal areas – the semi-lawless, militant infested mountainous regions that border Afghanistan – are another. The government has only a tentative hold on its territory and insecurity is rife.
Then in 2012 a senior Taliban commander ordered an end to vaccinations in his territory until the CIA halted its controversial drone campaign, cynically using child health as a political tool. Other commanders followed suit putting North and South Waziristan off limits to vaccination teams.
The result is that 300,000 children have not been immunised, according to Dr Shamsher Khan, Unicef’s co-ordinator for high risk populations in the country. That is the biggest problem facing eradication efforts, he said.
Tackling the problem means winning over the clerics that spread lies, he added.
“We are engaging religious leaders. If you look at religious leaders at the national, provincial and even up to the district level there is no opposition,” he said.
“The issue is at the grassroots level.”
The approach has brought mixed results. Health officials’ biggest coup has been to sign up Sami ul-Haq – one of the country’s most influential scholars, nicknamed the Father of the Taliban for his madrassa’s role in turning out militant commanders. At the end of last year he recanted his earlier criticism and issued a fatwa urging parents to have their children immunised against polio and a string of other diseases.
“The suspicions and doubts created or spread out among people regarding these vaccinations are baseless,” he said.
His change of heart did not last long. Within a month, apparently angered that his words were appearing without his permission in local newspapers, his madrassa released a statement claiming the fatwa was being used to drive a wedge between him and the Taliban leadership at a time when he was supposed to be helping broker peace talks. And it accused unnamed “powers” of using immunisation for personal gain and demanded reassurance from the UN that any health drive not be used for spying.
The suspicion of new technology – in this case vaccines – has long been a feature of clerical teaching in South Asia, according to Raza Rumi, of the Jinnah Institute thinktank, dating back to the days when mullahs rejected the railway brought to India by the British.
That changed in the 1990s when Benazir Bhutto used her position as prime minister to launch polio initiatives but has seen a resurgence after 9/11, he said. Where once the opposition was political, in today’s Pakistan awash with weapons and terrorist havens, it is now violent.
The result is a country losing the ability to function in a broad range of areas, not just vaccinations.
“This problem is ultimately about the capacity of the Pakistani state to deliver basic services in the areas of public health and security,” said Mr Rumi.
For the time being that means seeking a pragmatic solution. When the next push is launched in Karachi there will be no advertising or publicity. In Peshawar the vaccine will be bundled into other health drives, in an attempt to reduce opposition.
That might help protect the lady health workers risking their lives for $2.50 a day, but will it help change attitudes to a life saving vaccine?
Lifelines: The Quest for Global Health profiles the extraordinary work of global health workers in their quest to rid the world of the deadly, neglected diseases and conditions that keep millions of people in poverty. "The Last Drops" explores polio in Pakistan and will air on Al Jazeera English from 20h00 GMT on 29 May 2014.