In December of 2012, nine female health workers and their drivers were killed in coordinated attacks while administering the polio vaccine in Pakistan. A few weeks later, six more female vaccinators and their escort were ambushed and gunned down. Since then, more than 40 people have died while attempting to deliver polio vaccines in Pakistan. This violence has turned the world’s attention to Pakistan’s polio problem and the 100,000+ women who risk their lives to provide vaccinations to children—often for less than $5 a day.
The Lady Health Worker Program was created by the World Health Organization in 1993 to do a better job of providing healthcare to impoverished communities in rural Pakistan. In this predominantly Muslim part of the world, it would be difficult for male workers to gain access to homes during the day when the men who reside there are likely to be away, so the task is left up to women. On a typical day, A Lady Health Worker spends a few hours visiting some of the thousand or so people in her designated area doing things like distributing birth control, assisting with deworming procedures, and ensuring that tuberculosis patients take their pills. For several days each month, though, the WHO pays these women to fan out across the country, going door-to-door to administer polio vaccines.
But in the post-Bin Laden era where CIA vaccine delivery campaigns were pegged as a source of the undoing of the Taliban’s efforts, Lady Health Workers have become a target of this violence. Still they press on regardless of the risk to their personal health and safety.
Lady Health Workers range in age from about 18–45 and include a mix of both married and single women. But according to Svea Closser, an anthropologist at Middlebury College who studies the Global Polio Eradication Initiative, one trait unites them all—financial need. They typically live in small houses, have adequate food, and are able to send their children to school, but luxuries such as cars or air conditioning are out of reach; unexpected expenses like medical treatment can result in financial disaster.
Married Lady Health Workers often have husbands who are absent, handicapped, unemployed, or addicted to drugs. Unmarried Lady Health Workers tend to have deceased fathers or brothers too young to support the family. The economic pressure exerted by society on these women helps explain why they take on such a difficult and dangerous job in a country where only 20% of women are involved in the workforce at all.
For their now life-threatening work, Lady Health Workers often make less than $5 a day — roughly half what an unskilled male laborer makes. (This is less than a woman could make working at the McDonald’s in Karachi, the largest city in Pakistan.) Despite what’s required of the women doing this job, the pay is often not sufficient income to feed their families, and they are often forced to rely on help from extended family and take on additional jobs, such as sewing piecework or tutoring neighborhood kids.
“When after working so hard you get so little money, your heart breaks. And you don’t want to do the work. That’s the truth,” one woman told Closser.
To make matters worse, their wages from the government are often overdue. This November, anti-polio drives were postponed in several regions because Lady Health Workers had not been paid for months.
The violence in 2012 came after about 15 years of peaceful polio vaccine drives staffed by Lady Health Workers. In the wake of the revelation that a doctor in Pakistan had tried to aid the CIA by surreptitiously gathering DNA from the bin Laden compound under the guise of providing vaccinations, the Taliban declared itself against polio vaccinations if the West was involved. The conflation of anti-US sentiment and vaccinations has proven devastating for the women carrying out the campaign.
“Lady Health Workers are the most visible faces of the government in parts of Pakistan where nothing else in the health system really functions,” Closser said.
According to a 2011 report on polio, Pakistan risks becoming the “last global outpost of this vicious disease.” Over the years, the international community has tried shaming Pakistan into eradicating polio within its borders. This past fall, after learning that the Pakistani polio virus had spread to Syria as well as to the the sewers of Egypt, Israel, the West Bank, and Gaza, twenty-one nearby nations banded together to urge Pakistan to vaccinate its children. There are more straightforward approaches available, as well.
The issue of low pay is perhaps the easiest. “I don’t think paying the Lady Health Workers more is going to break the polio bank,” said Robert Steinglass, Immunization Senior Advisor at John Snow Inc., a public health consulting firm. On the days when these women are putting their lives on the line to vaccinate children, it seems reasonable to pay them a living wage.
Combating the violence aimed at Lady Health Workers is a more difficult problem. Here, the very involvement of the West is what has drawn the ire of militants. In an article published in PLoS Medicine this October, Seye Abimbola of the National Primary Health Care Development Agency in Nigeria and his colleagues suggested folding polio vaccines into the normal battery of immunizations a child receives, rather than delivering them as a stand-alone program. This would make the campaign (and its workers) less visible, while providing people with protection against other infections.
“The less attention we get, the less vulnerable we will be as targets for the terrorists,” Bushra Arain, chair of the All Pakistan Lady Health Worker’s Association, explained to the Christian Science Monitor last January.
This approach would address multiple health problems, so it is likely to require more resources. But combating polio while simultaneously addressing health issues like measles, mumps, and hepatitis may be what is needed to keep health workers safe and eradicate the virus.
The push to eradicate polio in low-income countries such as Pakistan comes primarily from the US and the WHO. The residents of Pakistan are typically more concerned with fighting infectious diseases with a greater death toll, such as tuberculosis, infant diarrheal infections, and malaria. This means that the WHO and western donor nations bear a large part of the burden to pay Lady Health Workers a fair wage and to keep them safe. To quote a Lady Health Worker, “There’s no work that I will shy away from—if you give me work, I will do it, no matter how difficult.” It’s the least donor countries can do to try to keep them from being gunned down.