In November 2022, a truck carrying police personnel was targeted in a suicide attack in Quetta, Balochistan, killing four people and wounding another 27. The target were police personnel, en route to provide security to polio workers.

Polio teams, which largely comprise lady health workers (LHWs), have been the target of scores of attacks over the last decade or so. Although there are no official records on the number of health workers’ lives lost to terrorist attacks, media reports claim that over a 100 persons associated with vaccination campaigns have been killed since 2012.

In August 2012, the World Health Organisation (WHO)’s Regional Director to the Eastern Mediterranean, Dr Ala Awan urged the Pakistani government to provide and ensure safety for polio vaccination teams.

Armed police escorts were directed to accompany polio teams, but despite this, many teams still came under attack, killing both polio workers and police personnel.

The polio virus

“Polio, or poliomyelitis, is a disabling and life-threatening disease caused by the polio virus. The virus spreads from person to person and can infect a person’s spinal cord, causing paralysis,” according to the Centres for Disease Control and Prevention (CDC).

Since January 2021, all polio cases in Pakistan have been reported from seven polio-endemic districts in Southern KP. In 2022, 20 polio cases were detected in Pakistan. The number of cases has significantly decreased from last year due to the relentless work of LHWs. Until March this year, no new cases had been reported. However, on March 15, a new case of a three-year-old boy diagnosed with polio emerged from Bannu district — one of the seven polio-endemic districts in KP.

While the reduction in case numbers is relatively good news, polio remains a difficult battle for the country.

Stories from the field

Besides the deadly terrorist attacks, LHWs face a multitude of problems and impediments in the field, the biggest being resistance from families against vaccinating their children. This resistance sometimes becomes dangerous for the immunisations teams.

“Our teams and colleagues have been attacked while doing fieldwork, some of them have been injured and others have lost their lives,” said SA*, an LHW who works in Sindh (SA’s name has been withheld on request — most LHWs, afraid of backlash, do not wish to be named).

Many LHWs are vulnerable to health issues as they work on the frontline to administer vaccines to the public. Even while working through the most deadliest pandemics we have seen during our lives, they were not provided with protective gear.

Read more: UNDERVALUING THE LINCHPINS

“We are the first to be affected from any disease, virus or illness as we are sent to vaccinate people,” said Uzma*, an LHW from Sindh. “We may not be infected but we can become carriers and become the source of virus transmission to our families. It was extremely stressful for us as we were afraid our families would be infected during the pandemic.”

Harassment faced by LHWs

Apart from these issues, LHWs often face harassment, including sexual harassment, in the field. They often have no one to turn to.

No one in their department takes any action against harassment complaints, while they fear that confiding in their families would result in restrictions being imposed upon them. In such times, the LHWs turn to each other, try to give each other support, and cope however they can.

“LHWs face many issues on a daily basis in the field. Some of these may not be as serious as targeted attacks but they do leave a lasting impact. Sometimes it becomes difficult to continue working in the circumstances, but we have to keep working,” said SA*.

“We work on many different campaigns including family planning. We visit homes to talk to women about family planning but their families, especially husbands and mothers-in-law don’t want us to talk to the women. When men open the door and find out why we are there, they sometimes shout and even abuse us.”

She recalled that “once I went to a house and the man who opened the door was shirtless. When I told him who I was and why I was there, he began using innuendos and making obscene gestures. I was quite stressed and left as quickly as I could.”

Other LHWs also shared similar stories of how men tried to harass them and, in some instances, tried to lure them into the house. Often, these LHWs make these home visits alone, so they have come up with a system to keep themselves safe.

“We try to keep in touch with each other via phones, informing each other where we are,” said Safia*, an LHW who works in the suburban areas of Karachi. “It is the only thing we can do … it makes us feel safer.”

LHWs working in other cities face similar problems. “We face harassment daily,” said Saima*, an LHW who works in Hyderabad. “When we visit homes to discuss family planning, sometimes we are not allowed to talk to the younger women. Mothers-in-law question our intentions and sometimes refuse to let us meet their daughters-in-law. Sometimes they accuse us of trying to make women sterile. If the younger women are allowed to talk to us, it is always under the watchful eyes of the matriarch.”

Farhat Sultana, a health worker and member of the All Lady Health Workers Programme Union lamented that LHWs had to face pressures on the job as well as in their own homes. “They face so many things from family and in-laws, who have no idea about the challenges LHWs face such as harassment, sexual harassment, and other threats.”

Adding to this, Farah*, another LHW who works in the suburban areas of Karachi, elaborated on the threats she has received during door-to-door polio campaigns.

“Once I went to a house and a man opened the door. He asked me to come in as his children were asleep and he would wake them,” said Farah*. “I refused and asked him to send his wife. He got angry and started abusing me. I felt scared because it was apparent there were no women or children in the house and this man would cause harm to me. I turned around and left quickly, while he kept abusing and threatening me.”

Overworked and undervalued

Many LHWs spoke of job insecurity, long working hours, and unpaid overtime. Sometimes they are required to work on public holidays or face show-cause notices if they don’t.

“We are sometimes asked to stay late to complete a report or are called in to work on Sundays and other public holidays,” explained Safia*. “We are not given overtime or anything for this. We worked during the Covid-19 pandemic and worked during elections — which is not part of the LHWs’ job description, but we have to. We got an allowance to do Covid-19 duty but nothing for election duty.”

In a country that has a vacuum when it comes to public healthcare for the masses, healthcare workers, especially lady health workers are an extremely important link. For thousands across the country, especially in rural areas, LHWs are the only health facility that they have access to.

“We are not only health workers. For many, we also act as counsels, therapists, and even as social workers as people come to us with problems like domestic violence, sexual harassment etc. We try to help them as best as we can,” said Saima*, an LHW working in Karachi.

Such incidents have a lasting impact on the psychological well-being of LHWs, but they persist and continue to work. “Lady health workers are filling in for other professionals, from vaccine administration, to providing family planning, delivering babies, and counselling. We don’t have health insurance or any protection despite the hazards of our job … we are just pushed into the field with little training or proper equipment,” said Uzma, a member of the All Lady Health Workers Programme Union.

“During [the] Covid-19 [pandemic], we were given a [risk] allowance, but we were not given masks, hand sanitisers or PPEs to protect us from the virus when we visited homes. The allowance, which was quite helpful as our income is quite low, stopped when the campaign stopped. We should be given regular increments as this job is hazardous not only to the LHWs but to our families as well.”

In 2022, members of the All Lady Health Workers Programme Union organised protests across the country which lasted for more than a month. Things became serious when the authorities cracked down on the protesters sitting outside the Karachi Press Club (KPC). LHWs were baton-charged by police and water cannons were used; several were taken into custody.

“Our union has been working hard for the rights of LHWs and as you saw we were brutalised in Karachi when we were protesting in front of Karachi Press Club,” said Noor Fatima, an LHW and union member. “Not only were our members beaten and dragged, their clothes were torn and water cannons were used on us. Many were injured and many more were taken into custody. We were only asking for our rights.”

Earlier in February 2023, Bushra Arain, president of the All Lady Health Workers Programme Union, was also manhandled in Karachi. It did little to dampen her spirit.

“We will continue to fight for our rights — we are an important part of the healthcare system in Pakistan,” Arain told Dawn.com. “LHWs provide the much-needed medical care that people need especially in rural areas and in low-income areas but what do they get in return? Their role is vital, but it is under-appreciated. We only ask for what is our right.”

Working through the floods

The recent floods did not discriminate. They caused destruction across Pakistan, including in towns, villages and in the homes of many LHWs. Despite being affected, and despite the poor and risky working conditions, the LHWs did not stop working.

“During the floods, our LHWs have also been affected. Many lost their homes, but they carried on trying to help people. Many only had painkillers which they provided to the people,” said Arain. “They carried on doing their duties even though their own lives, like others, had been washed away by the floods.”

Recalling cases from the floods, she added, “Many women did not have an extra set of clothes and had to keep wearing the same clothes even after they had helped deliver a child. This is the dedication of LHWs … who are ignored when they ask for their rights, but are considered important when they have to fill in for others.”

She continued, “They did not have any sanitary products and with no change of clothes, it was quite difficult for them [the LHWs]. On top of that, there was no clean water in many areas to wash up properly. It is inhumane not to provide them with the basics of life.”

Many LHWs living in flood-affected areas lost their homes and some areas were still flooded months after the flood. Arain said the money that was provided by the authorities for rehabilitation was given without proper assessment. Homes that were partially damaged, crumbled over the months as the flood water receded and buildings revealed more damage. She asked the Sindh government to re-evaluate the damage and provide aid accordingly.

It is about time the government recognises and values the work of LHWs in Pakistan. This goes beyond just words of thanks; it requires listening to their concerns and providing robust, holistic solutions.

This includes putting in place security mechanisms for LHWs who go out for door-to-door campaigns and are solely dependent on each other for safety. It includes valuing the labour or LHWs and providing better wages and working hours. It also requires a focus on providing capacity-building training sessions, along with mental-health counselling or sessions for LHWs who face stress, trauma and fatigue in their work.

Apart from this, prioritising the Sustainable Development Goals (SDGs) that Pakistan is already a signatory to can improve the working conditions of LHWs.

Out of 17 SDGs, at least eight directly affect LHWs including poverty, zero hunger, good health and well-being, quality education, gender equality, clean water and sanitation, decent work and economic growth, and strong institutions. Working towards these goals for all would go a long way in improving the lives and working conditions of LHWs.

The names of some LHWs have been changed or withheld to protect privacy

Header Image: Female polio worker marks a house as visited after vaccinating children at a Christian colony slum in Lahore, 2012. — Photo: A.M Syed/Shutterstock