“A very old and frail woman was brought to the hospital in front of me. She looked like she wouldn’t make it if not given medical aid instantly,” says Nur before her voice disappears. Every time the phone connection fails, Nur calls again and starts the story from the same point. The fourth time it drops, she calls on WhatsApp and asks if it is better to just meet in person and talk.

“Who is wearing masks and staying away from one another anyway?” she asks. “Hardly anyone in the district I work in can be seen wearing one.”Nur has been a Lady Health Worker (LHW) in District South of Karachi for the past 24 years. The area is served by 12 lady health supervisors, who manage a team of 207 workers on matters of primary healthcare, family planning, vaccinations and nutrition. Working closely within their communities and neighbourhoods, community healthcare providers, including over 100,000 LHWs, are the first — and at times the only — point of contact for medical care in rural and urban slum areas of Pakistan. This relationship is developed and trusted for years.

The WhatsApp connection stays strong and Nur goes back to telling what she saw.

“A few weeks ago, my boy was sick. He had been vomiting and I had taken him to a hospital in my area,” she says. “The old woman in front of us was accompanied by a few attendants and the doctor was refusing to take her in. The doctor said he couldn’t handle her case and asked the attendants to take the patient to another hospital,” she says, hinting at a hospital that provides free-of-cost treatment in Karachi.

Nur says the patients’ attendants claimed that they were coming from the same hospital and had been asked to pay three lakh rupees upfront, so the elderly lady could be “put on the coronavirus list.” “We didn’t want to leave our mother to die there,” the attendants had said. “They would have given her an injection.”

While the doctors dismissed their fears on the spot, as a healthcare worker, Nur has heard numerous accounts of people fearing a deadly Covid-19 teeka (injection) and being ‘misdiagnosed’ with coronavirus. There was the Baba Ji in the street next to hers who had a spinal problem but then tested positive after only a few days at a hospital. Then there was a friend of her son’s who went to the city’s largest public hospitals for a “minor flu check-up”, but soon frantically called his parents. “They are coming to me with a teeka,” he apparently told them. “They have a plastic bag ready.” The boy’s parents allegedly rushed to the hospital half an hour later “to receive his dead body.” The accounts are harrowing and too many.

Nur has seen people’s mistrust regarding the coronavirus grow stronger over time. She, and thousands of community healthcare providers like her, have been going into their assigned union council neighbourhoods to provide basic healthcare to people since March, when (stricter) coronavirus-led lockdowns were enforced in the country.

“Unless things are properly investigated and communicated to the general public, people will continue to think of the coronavirus as a big drama [orchestrated by those] with ulterior motives and [conspiracy theories about] Bill Gates will keep getting popular,” she says.

Community healthcare providers, including LHWs and polio workers, like Nur are an integral part of Pakistan’s Covid-19 response and are fighting the virus head-on, often without any protective gear or even fair compensation. Many of them have been part of Pakistan’s polio drives for years and know that the introduction of a vaccine alone will not mean the end of the country’s battle against Covid-19. Indeed, these men and women understand the ground realities and the general public’s distrust of vaccines in a way few others can.

FEAR OF VACCINES

Specific guidelines were issued by the Sindh government on how fieldwork on contraceptive provision and referrals for women with babies due would continue in the coming months of life under the pandemic.

LHWs, who work as part of the government’s expanded programme on immunisation (EPI), were to continue even when everyone else was being instructed to stay at home. They were to continue vaccinating children against diseases such as tuberculosis, diphtheria, tetanus and measles, via fixed centres and door-to-door service, as LHWs working with EPI have been doing for a quarter of a century now. Over the years, various other vaccines, including the polio vaccine, have been added in the programme.

Until recently, widespread vaccination campaigns came to a halt to stop the transmission of the new virus, but primary healthcare for women and children continued. Pregnant women had to be referred for deliveries and infants had to take their timely vaccine shots.

In many parts of Pakistan, people are suspicious of these vaccine shots, and the suspicions have apparently only grown stronger during the pandemic. As the virus spread, so did this mistrust and WhatsApp voice notes of grieving families swearing that their loved ones were killed by deadly teekas. This fear is a feature of doubt and it will be present in our collective future for some time, and not just in Pakistan.

The world has had a complicated history with vaccines. Hostility toward vaccination has existed as long as the vaccines themselves. Perhaps since the early 1800s, when Edward Jenner, an English physician and scientist and the pioneer of vaccines, experimented to see if children could be protected against smallpox by being infected with lymphs from a person infected with cowpox. At that time too, the idea was taken as unholy and bizarre, giving rise to tensions between the population and the government, as people felt that their personal liberties were at stake.

The World Health Organisation (WHO) included hesitancy towards vaccines in a list of top 10 threats to global health last year. But despite opposition — historical and prevailing — vaccinations are considered one of the top achievements of the 20th century.

With the Covid-19 pandemic, the vaccine challenge has multiplied, owing to conspiracy theories and general distrust. In the United States alone, an Associated Press-NORC poll indicated that one in five Americans would refuse a Covid-19 vaccine, whenever the trials are completed and it is ready to be injected. Pakistanis don’t feel much different.

“I can’t even say that I would like to be vaccinated against Covid-19 in the first place,” says Nur, scoffing at the idea of difficulties she might face if the anti-Covid vaccine is made part of the routine immunisation. “It would be very hard to work with this vaccine. Who would want it when there are so many stories with the coronavirus disease?”

Seven months after the virus first took the world in its grip, Pakistan’s population is seemingly torn between fear of the virus and a denial of its existence. There is outright refusal to wear masks and to follow standard operating procedures of social distancing. In these circumstances, fear of the virus is also felt by community healthcare providers when they go for immunisation work in their communities. And even their routine work is made more difficult because many believe that hospitals are giving Covid-19 patients fatal injections.

“How am I to trust you with any injection? Who knows what’s in there?”

“We don’t have any food or money and you care about injections?”

Community healthcare providers have heard these too often in the past three months. They know vaccination against Covid-19 is going to be tough.Over the years, vaccines that have eradicated diseases from the world haven’t had the same success in Pakistan. A polio surge was reported last year, when 100-plus infections were reported. And the expensive vaccines package that, so far, has vaccines that deal with 10 diseases, keeps expanding. Millions of rupees are invested into these and any Covid-19 vaccine would be a new addition.

THE NEED TO ACT FAST

The good news is that many doctors say that the vaccine is coming. The government assures that efforts are underway for Pakistan to receive the vaccine when it is ready. Shipment logistics and the setting up of a scientific team to target high-risk populations — such as patients with co-morbidities, pregnant women and healthcare workers, including those working in communities — are among its priorities.

“The Covid-19 vaccine is not far into the future,” Dr Rafiq Khanani, professor and chairman of pathology and microbiology at the Dow University of Health Sciences and the president of the Infection Control Society Pakistan tells Eos. “In the first quarter of 2021, Pakistan would have been past phase two of the vaccine trial. The work of misconception eradication and positive opinion building towards it needs to start now.”

The WHO lists 25 Covid-19 vaccines in clinical evaluation around the world, while 139 are listed to be in preclinical evaluation. Pakistan is not working on any vaccine development but, so far, has been invited by a Chinese pharmaceutical company to conduct trials of its inactivated vaccine, and will likely be doing more in the near future as global trials see the light of day.

“Pakistan will also conduct trials as the virus has shown mutations in different parts of the world and since the genetic makeup of populations is different around the world, the response is gauged accordingly,” says Dr Khanani. “If virus transmission becomes slower in the future and there is a time lapse until a vaccine arrives, it will get tough to conduct trials in the country and for people to become more receptive towards the vaccine,” he adds.

Hesitancy over vaccines is prevalent and may have been increasing since the influenza pandemic of 2009, according to studies. At that time too, there were beliefs that the response to the pandemic had been influenced by commercial interests, planting the seeds of further doubt towards vaccines. While the general population’s reluctance towards vaccines is driven by concerns of safety and belief in alternative medicine, a UK-based literature review of over a thousand scientific articles cited the same reasons for healthcare professionals too. It was believed by some that the pandemic-influenza vaccine contained dangerous additives, thought to trigger allergies. The critical review conducted in the UK cites a lack of knowledge among healthcare workers about national guidelines on vaccinations as one of the reasons behind their reluctance to use the vaccine. Even those who were aware, didn’t feel confident in advising in favour of the vaccine and had their own doubts about it.

But despite opposition, microbiologists and epidemiologists have crusaded over decades to keep pushing for vaccines, to the extent that they have now become the most cost-effective measure for public health globally. “The fact that in the last 100 years humans have experienced a rise in life expectancy of up to 40 years is because of the impact of vaccines,” says Dr Rana Safdar, chief of disease surveillance at the National Institute of Health, Islamabad.

SPREADING THE WORD

Awareness is clearly key.

“In Pakistan, people listen to doctors, nurses and paramedical staff and, in rural settings, lady health workers,” says Dr Khanani. “People are not as stupid as some believe them to be ... Right awareness has to be spread through the right people.”

In Pakistan, these right people include community healthcare providers. Since March, these workers have been working on spreading awareness about Covid-19. Following the Global Polio Eradication Initiative guidelines, Pakistan was among 39 countries where campaigns came to a halt. The polio eradication programme realigned the polio workforce — at all levels from provincial to divisional — to support the government response to the coronavirus, through communication and community engagement.

Workers designed pamphlets, banners and videos and shared messages through WhatsApp and Facebook groups. Some of the male workers prepared panaflexes in neighbourhoods, installed loudspeakers on trucks and went around their assigned union councils, calling out the threats of the disease and asking people to stay indoors. Women polio workers went from home to home with brochures, informing people about the virus, what they needed to do to remain safe, and referring people with symptoms for testing, similar to the duties assigned to LHWs.

They helped in other efforts too. “I was asked to make a list of households in my union council who had daily wagers and were deserving of ration in the lockdown,” says Sumiya, a polio workers’ supervisor in North Karachi. “We visited houses, collected all the data within five days and shared it with them. Not that any ration was actually provided to the deserving families.”

Anti-polio vaccine opposition may be high in some parts of the country, but many experts are of the belief that infectious disease and microbiologists’ advocacy groups are much better placed to advocate for the use of a Covid-19 vaccine and awareness in communities. With a little training, community healthcare providers can also be real assets in the coming battle, they believe.

COMMUNITY HEALTHCARE PROVIDERS TO THE RESCUE

“Whenever there is an issue of infection control in Pakistan, LHWs can play a huge role in surveillance, as they are the primary link for people in the health system,” says Dr Ali Mir, a public health specialist and an associate at the Population Council, Pakistan. “Unfortunately, they lack training and education, proper equipment supplies of disease surveillance and personal protective equipment, otherwise they could be involved in contact tracing and curbing. But it’s not too late as yet,” he adds.

Since the outbreak, in addition to their primary healthcare work, community healthcare providers have indeed become part of Covid-19 contact tracing. The supervisors send in daily reports of people in their communities who have a travel history or are experiencing symptoms. “We didn’t have a disease surveillance system as such for Covid-19 so we adapted the one for polio to monitor the risk of spread,” says Dr Safdar, who is also the national coordinator for polio eradication.

As the virus spreads deeper into communities, it hasn’t spared community healthcare providers who have been going into the communities without any protection, despite district health offices being mandated to provide masks, sanitisers and gloves.

Following Eidul Fitr, one day after returning from work in Karachi’s District East, Wajiha* could feel her body aching all over. Thinking it was just tiredness after a long day at work, she ignored it. Sometime later, she started feeling feverish and, much to her surprise, couldn’t taste anything she was eating. A young widow and a mother of two teenagers living with her mother in Chanesar Goth, Wajiha started expecting the worst — Covid-19 had reached her.

She feared that if she would go to a hospital, doctors would admit her. What would she do then? She had no money for all that. And what if the government got to know and made her quarantine at home? All the neighbours would know and would blame her for spreading the virus. No. This simply could not happen.

Wajiha shared her concerns with her manager, a lady health supervisor.

A few days later, she mustered the courage to go to the Dow University of Health Sciences and got herself tested. As expected, the result came back positive. She experienced constant fevers and had difficulty in breathing. But more than anything else, she was extremely worried for her two children and her mother. The house she lives in is small and total self-isolation was not an option.

Workers like Wajiha are even ostracised for catching the virus. “Our clients in the communities yell at us for bringing the virus into their homes,” says a lady supervisor, who manages a team of 15 workers. She says that workers vaccinate children, interact with pregnant women and move from one home to the other. “It is hard to know the exact source from where anybody contracted the virus.”

Any protective gear these workers have, they bought on their own. In late Ramazan, a few workers in Hyderabad protested this lack of gear and refused to go on duties. Their colleagues were getting infected and they didn’t feel safe. “We were then given tiny bottles [of sanitiser], that some got and many others didn’t,” Mahwash, a supervisor in Hyderabad tells Eos. “Nothing since then.”

District health officers in Karachi stress on the safety of all healthcare workers. “Lady Health Workers are our own, just like doctors and nurses. They report symptoms to us immediately and we get them tested, as we don’t want to risk any transmission from healthcare workers,” says Dr Shafique Ahmed, the District Health Officer, District West.

But Bushra Bano Arain, chairperson of the All Pakistan Lady Health Workers Association, says that workers are in no position to get treatment if they contract the virus. “They are scared,” she says. “We are now openly resisting going into the field and asking our communities to seek consultation over phone/WhatsApp. But there are emergencies and, in the current times, people need all kinds of medical help.”

FIGHTING A PANDEMIC AND FOR THEIR RIGHTS

While many healthcare professionals in Pakistan acknowledge how essential the services of community healthcare providers are, these essential workers have been struggling for even their basic rights for a decade. As they fight a pandemic on the one hand, they also continue to fight injustice and demand their rights.

In the first week of July, raised voices could be heard outside the DG Health Sindh Office in Hyderabad. With their heads covered with colourful dupattas and chadars, and a few wearing masks and others wearing veils, a group of LHWs gathered in the 40C scorching heat of Hyderabad. “Jeena hoga marna hoga, dharna hoga [We will protest, come what may],” they shouted in unison. They demanded that they be paid and given fuel allowances as promised. Forty-one LHWs in Hyderabad haven’t been paid in the past 18 months. Supervisors aren’t getting their petrol allowances for the past year and a half.

The protest wasn’t a one-off, but part of a decade-long struggle that has been happening in the country. In the past, LHWs have held demonstrations from Karachi and Dera Ismail Khan to Islamabad and Peshawar, demanding salaries. Over the years, the top court has taken notice and ordered the provincial and federal authorities to clear payments, but dues still remain unpaid for around 1,500 workers in Sindh alone. “Salary rates are not the same for workers across provinces either,” says Arain.

“For the longest time, our salaries have been our means of returning loans to each other, our neighbours and family members,” says Nur. “We borrow money from others and return whenever we get paid. This has been accepted as part of the LHWs’ struggle ever since the programme came into being. We have kept our profession alive for the health of people. Salaries never came to us easy,” she says.

THE OTHER VACCINE

Community healthcare providers have been busy and an active part of Pakistan’s Covid-19 response since March.

For two months, the polio workers received their dues as usual; some of them also got text messages about contract renewals for May. But in the middle of Ramazan, they received another text, stating that everything was being done to ensure that the workers received their May salary before Eid, and for that to happen, all logistical equipment that they had needed to be returned to the office. What the text message failed to mention was that many of the workers were being laid off.

As many as 11,000 community-based vaccination (CBV) workers in Karachi and Peshawar were affected by the termination of polio campaigns. The numerous others who were affected included area managers and managerial-level staff ensuring smooth execution of polio campaigns. A few hundred were transferred, while some were allowed to stay on. The reason given for this was that funding for the project had come to a grinding stop because of the Covid-19 pandemic.

Late last month, the polio immunisation drive finally resumed in Pakistan. The drive will focus on high risk areas throughout the country. The government plans to start the campaign in these areas on a special mobile teams (SMTs) model, where campaigns run on a five-day format and workers are paid daily wages.

“We will be hitting 23 union councils of Karachi in addition to selected UCs in other provinces and, as per the revised modalities, we will start and, based on the feedback, will go for a full-blown campaign later,” says Dr Safdar. “District-level training of workers is in progress for that.”Reportedly, the workers have been asked to ensure the use of masks, sanitisers and avoid close contact with people.

But the drive has not resumed in many of the UCs where many polio workers were fired. “If there are no funds for polio vaccines, then how will polio work resume in the [other] union councils of Karachi?” asks a polio worker association representative, not wanting to be named.

The fact that the layoffs happened during a pandemic, at a time when many of these health workers were risking their lives every day, only adds insult to injury.

Polio workers report that contractor companies have been changed numerous times in the past. During these transitions, all the workers were transferred to the new group accordingly. This is the first time mass firings have taken place, overnight, with no preamble.

The government claims that the previous model of community-based vaccination was not proving to be effective in these specific UCs. “The new approach [the SMT model] is to try to address the spread,” says Dr Safdar.

LIVES ON THE LINE

“Some of my [former] colleagues have been going to houses offering to clean them,” says Ghous, one of the laid-off workers. “Our kids expectedly look at our faces for food.”

The frontliners of one of the country’s major vaccination campaigns are suffering and the diseases are waiting for no one. In June, Multan issued an alert when the polio virus was found in sewage water. So far this year, 63 wild poliovirus cases have been reported in Pakistan. The country is also among the 15 countries with the highest number of detected Covid-19 cases in the world.

The battle against coronavirus has only just begun. Community healthcare providers are a massive workforce that’s most likely to be involved in the upcoming, huge challenge of Covid-19 eradication in the next few years. Being part of vaccination drives in Pakistan is a dangerous job in which workers have been shot, faced abuse and denied fair compensation. The workers doing these jobs are the ‘other’ frontliners, who require the attention of the public sector. They’ve been asking for their rights for years, but their pleas have not been heard. Maybe their efforts during the pandemic will finally amplify their voices.

Header photo by Arif Ali/White Star

*Name has been changed to protect identity

The writer independently reports on labour and environment. She can be reached at haniyajaved1@gmail.com