Two young women burst through the door of a health center in a Pakistani slum. One woman sobs. The other tries to explain what just happened.
Nida, 21, and Sahar, 19, are front-line vaccinators — a small but essential role in Pakistan's enormous effort to eradicate the virus. They were going down alleys knocking door-to-door, administering polio vaccine drops to children, when a man pulled out a gun, slammed Nida over the head, snatched her bag and ran away. (Nida and Sahar asked that their last names not be used to protect their safety.)
This slum, in the working-class city of Rawalpindi, is "a high-risk area," says Nosherwan Khan, a member of Pakistan's National PolioPlus Committee, which is affiliated with Rotary International.
"It might be criminal activity. It might be a vaccination attack," says Khan.
The violence aimed at vaccinators, whatever the cause, is partly why Pakistan is one of the world's last holdouts against polio, alongside Afghanistan and Nigeria.
Targeting 38 Million Kids
For the past few years, Pakistan has undertaken an enormous anti-polio campaign to vaccinate 38 million children. There are some 260,000 polio vaccination workers who fan out across the country, accompanied by 100,000 to 200,000 security personnel to protect them.
This all began after the country reported 306 cases of polio in 2014. That's when the newly-elected government declared polio a national health emergency, says Ayesha Raza Farooq, the prime minister's point person for polio eradication. The government, and the U.N. unfurled an ambitious campaign to eradicate the virus, supported by Rotary International and the Bill & Melinda Gates Foundation (which is a supporter of this blog.)
There's excellent progress: Last year there were just 8 polio cases. This year, there was one. But getting to zero cases is elusive. And it's a key milestone toward Pakistan proclaiming itself free of the virus. The current ruling government made eradicating polio one of the country's top three priorities.
Even more important than getting down to zero, Pakistan needs to stop the wild polio virus from circulating. "Even if you have zero cases – the risk is there," says Dr. Jamal Raza, president of the Pakistan Pediatric Association and an advocate for vaccination.
Raza said that only 1 percent of polio cases lead to paralysis. But other children who display no symptoms can spread the virus – potentially infecting kids whose immune systems are vulnerable.
Pakistan has an extensive surveillance system, and the country's most recent Polio Eradication Update listed 12 sites where the virus is still circulating. It is still present in parts of the port city of Karachi, slums around Rawalpindi and through a corridor of towns that lead from the Pakistani border to Afghanistan.
What They're Up Against
There are dramatic obstacles to eliminating polio. Violence aimed at vaccinators make headlines — like the mother-and-daughter vaccination team who were gunned down in Quetta, a garrison town near the Afghan border, on January 18. The attacks are inspired in part by preachers who claim vaccines are a Western conspiracy to make Muslims infertile. Others claim vaccinators are spies, a lingering legacy of the CIA using a fake vaccination campaign to find Osama bin Laden in Pakistan nearly a decade ago.
The anti-vaccine activists not only fuel violence but also prompt parents to refuse vaccines.
And then there's vaccination fatigue, as health workers repeatedly immunize children.
The Centers for Disease Control recommends four doses of oral vaccine. But Dr. Raza says that's not the case in Pakistan. He said Pakistani children are particularly vulnerable because many of them are undernourished "and have a poor local immunity."
"In those children, three or four doses doesn't do it," he says, referring to cases where children had received the four doses and still contracted the virus.
Walter Orenstein, associate director of the Emory Vaccine Center, agrees. In an email to NPR, he wrote: "More doses are needed in developing countries to reach herd immunity thresholds than in industrialized countries. How many doses are needed is unclear. Ten to 14 doses seems like a lot. But given the need for wiping out the last chains of transmission, better to err on the side of more doses than you need than fewer."
He adds: "There is no harm at all from extra doses if you are already immune."
But the regular campaigns have a downside.
Refusal Rates And Viral Protests
In high-risk areas for polio like the Fauji slum in Rawalpindi, vaccinators visit once a month. The virus is circulating in the sewage in the area – suggesting that some residents have the virus but haven't shown symptoms.
"I am not surprised that people are fatigued," says Farooq. "Our teams are knocking doors in our high-risk areas at least once every month."
Farooq said scientists told her the refusals "are not worrisome, it is only when there is a cluster of refusals, blocks of refusals," she said. "We don't see that right now."
Refusal rates are in fact quite low — "from 0.1 percent to 0.15 percent, says Rana Safdar, coordinator for the national Emergency Operation Center for Polio in Pakistan.
But Raza says even one refusal is a potential risk because a child could have the virus without displaying symptoms and spread it through the sewage system.
Interviews with health workers and parents suggest that even though refusal rates are low, they appear to be underreported.
Safdar says one of the biggest challenges is that people advocate against vaccines on social media.
"Whenever something is posted which is negative against the program or against the vaccination, it gets viral," he says. Even material prepared by Western anti-vaccination activists is spread around in Pakistan.
In March, three children died in Nawabshah, a city in Pakistan's hinterlands. Raza says the children died after receiving an expired measles vaccine.
In the days after the report of the measles story, thousands of parents refused the polio vaccine.
"That really derailed the whole process of measles vaccination – and of vaccinations in general," Raza says.
For the most part, though, parents oblige.
Dealing With Danger
Before the two young women were attacked, Nida and Sahar marched through the Fauji slum, armed with clipboards and a cooler box of polio vaccine, banging confidently on flimsy doors.
At one, a woman answered, smiling.
She rounded up her children, who were chasing a chicken that quickly scurried under a day bed in the living room. One little girl, Jannat-Noor refused to open her mouth.
"Come on, it's sweet," Nida purred. "Bravo!"
Jannat-Noor burst into tears. Nida colored Jannat-Noor's finger with a sharpie to indicate she'd been vaccinated.
"It's nail polish," she said smiling.
Once finished, the women chalked notes on the wall outside – notes for the next vaccination team. Nida and Sahar estimated they earned $16 for five days work like this. It is not a lot of money
"We serve community – that's why we feel happy," Nida said.
But after the attack on NIda and Sahar, another health worker looks grim. He's just watched Nida burst into the health center. "I am very much concerned about my security," says Dilbar Khan, from the World Health Organization, who oversees polio vaccination in this area. "We have families. We have children. We are as concerned about these front-line polio workers as we are for ourselves."
For a few tense minutes, the health workers aren't sure if the attacker will follow the women to the center. Police arrive to take details.
As for Nida, somebody has bandaged her head. She lies on a gurney
I ask her if she's still willing to work as a vaccinator. She shakes her head – no. That refusal, of a health worker to go back to the front line also chips away at Pakistan's ambitious goal of zero.
With additional reporting by freelance reporter Hina Javed in Karachi