On the second floor of a local dispensary in Peshawar, Dr. Sheda Hussain stands in front of a 50-person immunization team of female health workers and technicians. Flicking through three Power Point presentations, he guides them through the process they must follow during their visits to homes around the city.
In two weeks, the government-funded Lady Health Workers will take part in a provincial immunization campaign against measles. As the women go door to door, they will also distribute polio drops to unvaccinated children and newborn babies for the first time, Mr. Hussain says.
Peshawar is on the front-lines of Pakistan’s polio battle. Ninety percent of Pakistan's polio cases were genetically traced to the city earlier this year, according to the World Health Organization (WHO). The WHO called the city the “world’s largest reservoir” of the virus.
Two years ago, polio was nearly eradicated across the globe. On Monday, the WHO declared a global health emergency, saying those gains could be lost if Pakistan, Syria, and Cameroon did not crack down on the virus, which has spread across their borders this year.
Pakistan is especially problematic: 86 percent of the 68 global polio cases registered in 2014 stem from Pakistan, and the majority of re-infected areas can trace the virus back to the country within the last 12 to 18 months.
Local health workers in Peshawar are concerned that they may not be able to address the root causes of the current outbreak.
The city’s proximity to the country’s tribal belt, its constantly mobile population of refugees and migrants, and pockets of deep resistance from locals make the job incredibly difficult.
Teams like Hussain’s, along with a slew of volunteers, managed to immunize almost every one of the more than 700,000 children that are registered on government lists in Peshawar during its last polio vaccination campaign this spring.
It’s an enormous feat, but one that may ultimately fail to make a significant dent in the explosion of polio cases registered in Pakistan this year. Peshawar, the capital city of Pakistan's northern Khyber Pakhtunkhwa Province (known as KP), is located next to FATA, the Federally Administered Tribal Areas. The remote mountainous area along the Afghanistan border is known for a spotty state presence, drone strikes, and Al-Qaeda and Taliban fighters.
Every time a conflict breaks out in FATA – such as a drone attack or Army operation against militants – thousands of locals flee to other areas within Pakistan.
“As a large city, Peshawar inevitably receives a huge influx of these internal refugees,” most of whom have not been vaccinated, says Jan Baz Afridi, a doctor and deputy director in charge of immunization in KP. "FATA is a major cause of the disease’s spread to Peshawar.”
FATA has little health infrastructure, and is largely inaccessible to immunization workers and volunteers, Mr. Afridi says.
There have not been any polio immunization campaigns in FATA's North Waziristan district in the last two years, says Khalid Aziz, the former chief secretary of KP Province who has studied FATA. Other districts within the FATA tribal belt have not seen visits from vaccination teams for four years.
Security risks are only one part of the polio problem. Another factor is the colonial-era policies adopted by the Pakistani government that have kept FATA historically marginalized, says Mr. Aziz.
With no local representation, courts, police stations, or basic state infrastructure including schools and hospitals, the government fails to carry out its role as a service-provider in the area.
"This has created an environment where an entire segment of the Pakistani population is cut off from the rest of the country and the rest of the world. Myths flourish, and the state fails to meet the most basic needs of its citizens," says Aziz.
One of the myths circulating among those who deny vaccinations is that the drops may cause infertility. Another persistent rumor is the fear of immunization workers serving as spies for foreign governments.
After the CIA organized a fake Hepatitis B and polio vaccination drive through a Pakistani doctor to help identify Osama bin Laden, militant groups banned polio workers from accessing areas under their control – mostly in FATA.
The ban has resulted in direct attacks on health workers, including an attack in March on polio workers in KP that killed at least 11.
Volunteers ready for dangerous work
In Peshawar, Hussain struggles with finding enough volunteers for his immunization campaigns. Government-hired health workers can only cover a third of registered children who need to be vaccinated. There is likely a far larger number of unregistered children.
Volunteers have a tendency to stop showing up whenever there is an attack against one of the health workers.
Shazia Bibi, one of the Lady Health Workers working under Hussain, is acutely aware of her job’s risks.
At the end of March, one of her colleagues was kidnapped and brutally tortured, her dead body dumped a few kilometers from her home.
“Sometimes, we're afraid that they'll come for us," says Ms. Bibi. “But so far, my own experience has been wonderful, and we're happy that we're getting the opportunity to serve our people, and hope to win this jihad.
"We need more resources, and more security, to do our job," says Hussain.