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At Lahore's train station, four-year-old Khayam Zahid gets his pinky finger marked by polio worker Imtiaz Ahmed to signify he's received vaccination drops.

Photography by Saiyna Bashir/The Globe and Mail

It was 10 a.m. and an argument was already breaking out at Lahore’s central train station.

A man seated at the platform with his wife and infant son didn’t understand why workers wanted to administer yet another polio drop. His child had already been given the drop multiple times in previous months, and he was worried.

Imtiaz Ahmed, the polio worker administering the drops, calmly explained that several doses are required for the vaccine to be effective, and it is largely safe.

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The father, still unimpressed, eventually let Mr. Ahmed administer the drop.

“It’s his son, and he’s a father, so in a way, it’s good he’s arguing,” said Mr. Ahmed, who has been volunteering as a polio vaccinator for a decade.

“But we’re not wrong either, and we can’t just leave them alone, and we have to try and explain.”

Arguments on the subject have become violent in the past. Lahore is generally safer for polio workers than areas near the border with Afghanistan, but one worker was assaulted in the city this year.

“This is just a part of our work,” he said, adding that it’s worth the risk. “This work is for a good cause. It’s to help people, and so we feel good because of it.”

Polio workers were mobilized in Lahore shortly after Eid celebrations because new cases had showed up in the city for the first time since 2011. The virus was detected in water reservoirs, meaning a city-wide polio drive was needed.

When a new case of polio is found, vaccination teams target only the neighbourhoods near the infection. But with polio detected in reservoirs, the teams had to immunize every child in a city with an estimated population of 11.3 million.

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Mr. Ahmed and his colleague Zakaya Sarwar, left, continue their rounds through the Lahore train station. Workers like them were mobilized in August after Eid festivities, when new polio cases emerged in the city.

Ms. Sarwar gives polio drops to Alina Batool, 5. Transit points are an ideal place for workers to vaccinate every child in a family and improve immunity before disease can spread to other cities.


Propaganda and mistrust

Lahore’s first case of polio in eight years is a notable setback in a long-fought battle that has faltered this year. Pakistan has had 76 cases of the disease as of early October, up from 12 last year and eight in 2017.

Leaders in the global fight to eradicate polio say misinformation in the digital age is their biggest problem, and the spread of anti-vaccine propaganda on Facebook and WhatsApp has exacerbated an existing mistrust of polio workers in Pakistan, which, along with Afghanistan and Nigeria, is one of the last places where the virus exists. Misinformation can quickly lead to violence and murder.

The Canadian government has invested heavily in global anti-polio efforts, and has disbursed more than $600-million since 2000. The funding programs aim to support the World Health Organization’s (WHO) anti-polio program by training community-based vaccinators in remote areas in Pakistan.

The South Asian country faced enormous challenges in the past decade with the rise of the Pakistani Taliban, a terrorist group (separate from the Afghan Taliban) that destabilized the country and believed polio programs were part of foreign conspiracies. Major terrorist attacks rocked the country’s largest cities, and the Taliban banned polio vaccinations.

“They used to openly come and kill workers,” said Aziz Memon, who directs anti-polio efforts in Pakistan for Rotary International, an aid organization. He says 187 workers have been killed in the past four years, and five in 2019.

“There was one day in Karachi where 18 vaccinators were killed. Another day nine were killed in Peshawar.”

Mr. Ahmed's cases of vaccine. Polio vaccinations were once banned in some parts of the country by the Pakistani Taliban.

The worst days of the Taliban militancy in Pakistan are gone, but Mr. Memon says mistrust and anti-vaccine propaganda persist. Much of that propaganda stems from a fake vaccine scheme the U.S. government used to aid the search for Osama bin Laden in the Khyber Pakhtunkhwa province – a region that accounts for more than half of new polio cases this year. The fact that vaccine workers were part of a foreign operation stoked current rumours that vaccine programs are a Western plot to sterilize Muslim children.

The first national vaccination drive of the year had to be cancelled in April after a video circulated on Pakistani social media falsely claiming children were suffering after being given expired polio drops. The video showed children in a hospital performing seizures on command by a person off-screen, and rumours quickly spread that it was real. Data from the WHO show refusals for polio drops spiked as a result of the video. Refusal rates had hovered around 0.2 and 0.3 per cent in the previous two years, but shot up to 2.5 per cent in April.

Thousands of concerned parents rushed to hospital as a result of the video, worried their children might have similar symptoms. A national health emergency was declared in April after medical staff couldn’t deal with the crowds, and the vaccination drive was called off. “We were expecting to immunize 39 million children and it ended up being about 37 million, so there was a gap,” explained Palitha Mahipala, the WHO representative in Pakistan. “Since then, we have been working very strongly on our social media campaign.”

Dr. Mahipala said the virus likely got to Lahore through migrants from Pakistan’s worst-affected areas near the Afghanistan border. Those regions, such as the Khyber Pakhtunkhwa province, still account for more than half of the country’s new polio cases, and have the strongest anti-vaccine sentiments.

“No country faces the challenges we are facing,” Mr. Memon said. “If you go in the mountains, you won’t find a soul, but you’ll find 4G. Everyone knows how to make a video and send it across [the internet].”

While many of those regions in Pakistan’s eastern borders are in lower-density cities, Lahore is Pakistan’s second biggest city, and new cases have workers scrambling to react. “We rush to respond when a new case of polio is found,” said Faheem Asghar, a polio worker who manages Rotary International’s field workers in the city. “It’s very serious, there are announcements made at the mosque and at schools.”

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At Allied School in Lahore, three-year-old Abish Sidique shows his vaccination mark. Schools are another ideal location for vaccinations because parents are able to sign consent forms ahead of time.

Muhammad Saleh, 11 months old, is one of the children Mr. Ahmed vaccinated at the Lahore train station. Muhammad is heading for Rawalpindi with his mother, Fazeela Tariq.


Trains and classrooms

For a week in August, volunteers like Mr. Ahmed were scattered throughout Lahore’s urban sprawl. Densely packed neighbourhoods where several children and families live in one home make for difficult work compared to smaller cities near the Afghan border.

At the Lahore Junction railway station, Mr. Ahmed squeezed through the cramped quarters of trains that were about to depart for cross-country journeys, on which families of 10 might share a four-bunk compartment. Despite the claustrophobic feel and lack of air conditioning in Lahore’s 30-degree weather, transit points like train stations give workers a chance to vaccinate every child in a family, and to prevent the disease from reaching other parts of the country.

The classroom is another ideal setting. In many cases, parents have signed consent forms.

Mr. Asghar spent most of his time at one school, where he taught kindergarten children to chant anti-polio slogans about “chasing away” the polio virus from Pakistan.

Children at Allied School raise their marked fingers after being vaccinated.

Perhaps one of the most risky assignments is going door to door. Many residents look nervous at the arrival of two or more polio workers, and are often worried about side effects.

Recently, the task has been assigned mainly to women. Much of the violence or rejections in previous campaigns happened because households were uncomfortable with an unknown male presence, especially when only women were at home with their children.

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“We can’t feel nervous,” Rehana Begum, a polio volunteer for two decades, said when asked about the nature of her work. “If we’re nervous, how is this work going to be done? We have to do this work like we’re their sisters or brothers, with care.”

She says that people always have many questions about the vaccine, but rejections are rare in Lahore. But reluctance turns up even in wealthier neighbourhoods and where people are educated. Most are concerned about the need for repeated doses.

Polio worker Zakaya Sarwar vaccinates three-month-old Inza Batool. Many door-to-door vaccination jobs have been assigned to women to ease mistrust about visits from male strangers.

Ayesha Noor, a resident of Defence, one of Lahore’s upscale neighbourhoods, thought there had been a mistake last time polio workers came to her home. It was their fourth visit in two months, and she said the spread of misinformation left her unsure who to trust about whether to allow her daughter to take the vaccine again, especially after the girl happened to fall ill after the second vaccination.

So she refused the drops. But later that day, she said, several workers showed up and pressed her to go through with the vaccination. Reluctantly, she agreed, although she said she felt forced.

Today, she realizes several rounds of the vaccine are needed, but said authorities need to address misinformation.

“If even we’re not sure about the facts, how is a person in a village in Khyber Pakhtunkhwa going to know?” she asked.

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Some in Lahore have found nonconfrontational ways to avoid the polio drops. Parents throughout the country have acquired the polio markers that are used to put a spot on a child’s pinky when they’ve been vaccinated, and are marking their children.

The WHO and Rotary International say social media campaigns will become part of their anti-polio efforts. The Pakistani government also plans to launch an “aggressive” online campaign to shift public perceptions, Mr. Mahipala said.

Moreover, they say they have to find a way to end transmissions of the virus in three major cities: Quetta and Peshawar, which are near the Afghan border, and Karachi, the country’s largest city, which struggles with crumbling infrastructure, a dense population and widespread poverty.

The fight in those cities has never managed to stop new transmissions, and vaccinating enough children there will be the key to stopping polio from appearing elsewhere in the country.

“We knew that the last few steps of polio eradication would be the hardest,” Mr. Mahipala said. “But we are committed to continuing vaccination campaigns until this disease is eradicated for good.”

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