Nowshera, Khyber Pakhtunkhwa province – At 11am on a Saturday, Tayyaba Gul and her team of polio campaign workers enter a school in Nowshera, a city in Pakistan’s northwest.
A week earlier, agitated parents had instructed teachers to block vaccination teams from immunising their children against the polio virus, claiming the vaccine was harmful and capable of poisoning their children.
Gul, a polio eradication activist, was hopeful she could restore their trust.
Today, Pakistan is one of the last countries with the wild poliovirus, reporting at least 15 cases this year.
While the poliovirus has been eradicated around the globe, it remains endemic in Nigeria, Afghanistan and Pakistan, where it still cripples children every year.
In recent years, however, Pakistan has been able to celebrate a precipitous drop, after recording more than 300 cases in 2014. Much of this success has been driven by more than 250,000 polio workers who have ventured into remote and inaccessible patches of the country to administer vaccinations to children under the age of five.
However, recent eradication efforts have been stymied by suspicion from parents and the public at large that the vaccine is unsafe, driven by misinformation spread on social media.
In April, one female polio worker in Balochistan and two policemen escorting vaccinators in Khyber Pakhtunkhwa were shot dead. In another incident, an impassioned mob set a health facility on fire in Pakistan’s northwest city of Peshawar, claiming that scores of children were sickened by the vaccine.
As videos purporting to unmask the vaccine’s dangers gained traction online, more people refused it and attacks on polio workers mounted, pushing the government to temporarily halt the polio campaign’s activities.
There are public fears that the polio campaign might be a front for nefarious actors, a myth that has its roots in a fake vaccination campaign orchestrated by the CIA in 2011 to track down Osama bin Laden in the country.
The lingering mistrust has pushed health workers such as Gul to work overtime to bring accurate information to the public, organising awareness sessions in public schools and religious seminaries.
Gul’s team is also engaging influential community members – imams, teachers, local politicians, and powerful landlords to spread the message that the vaccine is safe.
In Nowshera, approximately two hours from the capital Islamabad, refusals jumped to more than 88,000 cases in April, up from just 256 refusals in March, according to Waqar Ahmed Khan, district coordinator at the Youth Catalyst Pakistan (YCP).
Led by Gul, YCP runs a network of health centres in Pakistan focusing on fighting the polio virus.
Working in high-risk areas for polio transmission in Nowshera, Gul and her team at YCP, are careful to approach the vaccine as part of a broader health initiative.
“Some of the teachers were asking me, ‘Why are you only focusing on polio?’,” Gul told Al Jazeera. “‘Why not other diseases? Why is this one more important?’ They were saying, ‘This vaccine is made by America, it’s not locally made’.”
Haseena Bibi, a 23-year-old working at YCP, says one way of fighting vaccine denial is to inform people that they can also find medicine for common ailments such as fever and the flu at the centre.
“Some have misconceptions that it causes infertility, others say they have other medical concerns that we are not addressing,” said Nageena Arshad, one of the government’s polio vaccinators in Nowshera.
Given entrenched poverty and substandard healthcare infrastructure, the community’s initial faith in a vaccine is often low.
Many see the lack of public spending on basic health services as emblematic of wider neglect and are therefore suspicious of free vaccines.
In short, people are unsure why the government would intervene in one health emergency while ignoring several others.
Hansa Bibi, a 30-year-old mother-of-two in Nowshera refuses the vaccine for her children.
“America is our enemy, why are they giving us a free vaccine?” she told Al Jazeera.
“They put ingredients [forbidden in Islam] in the vaccine to sterilise the Muslim population. They put things in this that are making all the children vomit,” Bibi said. “My in-laws took the vaccine, but I will not give it to my children.”
Bibi says most of her opinion is formed by Facebook posts and Urdu-language TV channels.
She is angry with the Pakistani government for promoting the vaccine, which she says causes impotence and may harm children.
“In the mosques, imams say that these vaccines are from a foreign laboratory … We are poor, and people say ‘take this free thing’, but we are saying we don’t want it.
“Why do Americans send vaccines instead of flour?”
“The government always sends a polio team to our house with oral drops, but we don’t know why they are always coming so much.”
It's not an easy situation. We did a lot of hard work on polio in the last seven to eight years in Nowshera. If we stop this programme, it means that we start from zero again.
Faisal Khan, a Nowshera district health spokesperson for CHIP Training and Consulting, says every refusal is analysed and discussions are held with families who cite multiple reasons for rejecting the vaccine, including the notion that it is is not permissible in Islam or effective, or that it may even sterilise the population.
The government should make receiving the vaccine mandatory, he suggests.
Earlier this year, the Khyber Pakhtunkhwa government announced it would block the ID cards of parents that refuse the vaccine for their children.
To build trust, YCP also provides free medical services, such as antenatal and postnatal care for pregnant women and routine immunisations for women and their children.
During a recent polio campaign inside the Nowshera centre, Nihar Bibi, a health worker, was approached by two young visitors – aged eight and 10 – requesting medicine for a skin problem.
The area has no government hospitals, and the centre often functions as the neighbourhood’s only health facility.
Most patients are not there with the polio vaccine in mind; they are concerned about pneumonia, a UTI, or a fever.
Naeem Ullah, who works on the immunisation programme and trains religious leaders, says that raising awareness of the vaccine’s efficacy is paramount.
“When people know its benefit, only then can they give the benefit to their children.”
Last week, a father of an unvaccinated child in Nowshera threatened to kick out Ullah when he knocked on their door. Claiming he needed food, not vaccines, the father expressed doubt about the vaccine’s safety.
“I said to him, ‘I will drink this right in front of you, and I will go with you to the mosque if you have any religious opposition to the vaccine’,” said Ullah.
Later, the man accepted the oral drops for his child.
“This was a very tough polio campaign,” says Zubair Shah, monitoring and evaluation officer at YCP.
Usually Shah spends the post-polio campaign period with vaccinators revisiting homes where parents denied access to children; however, the suspension of these follow-up visits has redirected YCP’s efforts.
Now, the centre is trying to mobilise influential community leaders.
“It’s not an easy situation,” Gul says. “We did a lot of hard work on polio in the last seven to eight years in Nowshera. If we stop this programme, it means that we start from zero again.”