KARACHI, Pakistan — For Pakistan's primarily female polio workers, the job has always been about life or death. They're quick to remind parents they speak to during eradication campaigns that polio doesn't just cripple its victims — if left untreated, the disease will eventually kill children.
In the last week, however, "life or death" has taken on a new meaning for their work. Over several days, nine polio workers across the country were shot and killed during a nationwide campaign to immunize children. It's been said that at this point, more vaccinators than polio victims are dying in Pakistan.
"There’s something wrong with that equation,” Heidi Larson, an anthropologist at the London School of Hygiene and Tropical Medicine, told The New York Times.
The multi-billion-dollar immunization campaign is an attempt by the international health community to add Pakistan to the list of the countries that are polio-free.
Along with Afghanistan and Nigeria, Pakistan is one of the last frontiers for polio. Political unrest, poor health infrastructure and government negligence have all impeded eradicating the disease.
But the number one reason polio hasn't been eradicated, health workers and government officials say, is ideological opposition to vaccines.
In Pakistan, the Taliban issued a decree claiming that vaccinations of any kind are part of a Western plot to sterilize Muslim populations. Resisting vaccines has been encouraged; some Islamic clerics have even issued fatwas that give anyone crippled by polio automatic "martyr" status.
After the Taliban discovered that the CIA used a Pakistani doctor and the pretense of a polio vaccination drive to locate Osama bin Laden, polio eradication campaigns became even more dangerous in Pakistan.
These realities are well-known by the workers, mostly women, who walk Karachi's afflicted neighborhoods, carrying clipboards and refrigerated vaccine boxes. Every time they successfully immunize a child, they mark the door of the household with a large chalk X. (After interviews conducted by UNICEF revealed that parents didn't want strange men giving polio drops to their children, Pakistan moved to employing mostly women for their eradication campaigns. In fact, health workers in Pakistan are referred to as LHWs, for "lady health workers.")
The health workers say though they wear no uniforms, their actions have made them sitting ducks for militants. And they're starting to reconsider whether the job is worth the risk.
"It's not hard to figure out who the polio workers are," said one, who'd been working as a community health worker for three years. "We get paid only PKR 250 ($2.50) per day. This is not enough for us to continue this work."
"For this little money, I can't afford to leave my children as orphans," said another worker.
The women refused to use their names out of fears that they would be targeted.
In Pakistan, 75 percent of all polio cases occur within the Pashtun community. Pashtuns are the largest ethnic group in neighboring Afghanistan — where polio is also still endemic — and have migrated to Pakistan in large numbers in pursuit of economic opportunities. For this reason, the Karachi workers said polio won't be eradicated in Pakistan as long as there is instability in Afghanistan.
Most new infections in Pakistan occur in the country's remote tribal belt, where clashes between militants and soldiers are frequent. People fleeing the fighting and drone attacks in the area often seek refuge in Karachi — the country's largest city — where the disease has been making a comeback in recent years.
According to a recent report by the World Health Organization, polio in Pakistan will never be eradicated unless workers can convince the Pashtun elders that accepting the vaccine is in their best interest.
"We try and locate whoever is the most important person in the neighborhood," said one health worker, "and then we convince them that polio is important." However, she expressed concern that if militants continued to target health workers administering vaccines, elders and religious clerics might stop vocalizing their support.
"In Karachi, you always have to worry about being killed," she said.