Targeted Violence Against Community Health Workers: A Critical Barrier to Pakistan's Polio Eradication Goals

"[T]argeted violence against community health workers in Pakistan poses a significant barrier to polio eradication goals and highlights deeper societal issues such as mistrust and misinformation surrounding vaccination."

Workplace violence is a significant occupational risk faced by healthcare personnel in community-based settings, posing a global public health threat. Pakistan, one of the few countries where polio remains endemic, has faced targeted violence against polio workers, hindering its progress in eradicating the disease. This article examines the nature, extent, and implications of this problem, proposing the use of community-based approaches to improve worker safety, promote vaccine acceptance, and ensure sustainable progress toward a polio-free Pakistan.

The article describes specific events that have significantly influenced the interplay of trust, cooperation, and the achievement of goals in global security and public health. The disclosure of information in 2011 that the United States' Central Intelligence Agency (CIA) had conducted a fake hepatitis B vaccination programme in Pakistan to obtain DNA from Osama bin Laden's alleged hideout not only sparked violent resistance from militants but also triggered a series of targeted killings and attacks on polio healthcare workers involved in immunisation drives. This initial breach of trust resulted in the first attack in July 2012, involving a Ghanaian World Health Organization doctor and his driver in Gadap Town, Karachi. These violent incidents led to the deaths of several polio workers, restricting the use of supplementary immunisation activities (SIAs) and post-SIA surveys in high-risk regions.

A timeline provided in the article highlights the more recent incidents of violence faced by polio vaccination teams and their police escorts in Pakistan, underscoring the persistent challenges. For example, on November 1 2024, a bombing near a girls' school in Mastung, Balochistan, claimed nine lives, including five schoolchildren, and injured 29 others. This attack was carried out with an improvised explosive device attached to a police vehicle escorting polio workers, aimed at impeding national eradication campaigns.

As reported here, this violence has profoundly impacted vaccination campaigns, leading to a resurgence of polio cases and the death of over 200 polio vaccination workers and security officials in recent years. Such violence not only endangers lives but also hampers vaccination initiatives, creating fear among workers and reducing immunisation coverage, particularly in high-risk areas. The history of these attacks intensified by a breach of trust has compounded resistance from militant groups and the spread of misinformation. The figure above illustrates some of the factors contributing to targeted violence against community health workers in Pakistan. These factors are categorised into misinformation and misconceptions, lack of community engagement, cultural and religious sensitivities, political and social unrest, socio-economic factors, and resistance to change.

To look at one specific factor in more detail: Female healthcare workers often face resistance due to the low acceptance of women in such roles and negative perceptions, with some believing they are part of a hidden agenda to dismantle traditional social structures. In certain conservative communities, these women are viewed as agents of Western influence, involved in activities considered anti-Islamic. This resistance stems from the strict gender roles prevalent in tribal areas, where individuals are expected to adhere to norms and behaviours associated with their gender. In contrast, some families restrict male polio workers, particularly when the male head of the household is absent, creating barriers to successful immunisation campaigns in conservative regions with stringent gender standards. These opposing views hinder vaccination campaigns, highlighting the critical need for culturally sensitive strategies to increase vaccination rates.

Examples of possible strategies discussed in the article include employing voluntary community mobilisers (VCMs) to enhance public trust and vaccination coverage, establishing polio immunisation centres in vulnerable areas, strengthening multi-sectoral partnerships and advocacy strategies , involving local influencers to address community concerns, and implementing safety measures and incentives for health workers.

In conclusion: "The interplay between violence and polio eradication efforts in Pakistan highlights a significant challenge. Violence incidents targeting community health workers emphasize the urgent need for global health and humanitarian organizations to reassess their strategies. Ensuring the safety of these workers is essential for fostering stability and advancing public health initiatives, which are critical for reaching eradication goals."