( Even as more than 150 countries switch to a new polio vaccine on 18 April in order to achieve the goal of polio eradication, the virus continues to thrive in parts of Afghanistan and Pakistan. Sarah Eleazar explores these complexities in our latest quarterly.)
On 18 December 2012, the day started early for polio health workers on a routine immunisation drive. Madiha Shah, an 18-year-old mother of two in Karachi's Landhi Town, got her children ready for school, prepared breakfast for the family, and got her things in order to leave the house. It was the second day of the last three-day immunisation drive for 2012. Madiha's job as a Lady Health Worker entailed going into highly-dense, risky areas of Karachi to vaccinate children with polio drops. She reached the vaccination centre at 9 in the morning.
At the centre, Madiha and her aunt Fehmida Shah collected their immunisation kits – a blue ice-box with the words 'End Polio Now' painted in bright colours, vials of vaccine kept in the box, pipettes and permanent ink to mark children after vaccinating them. As many as 58 cases of polio had been reported in 2012 and the workers were told to step up their efforts. But amidst threats and assaults on polio workers, it was not an easy thing to do. Madiha and Fehmida had asked repeatedly for security, according to then Karachi East Deputy Inspector General Shahid Hayat Khan. But they were told not to worry as they were going to vaccinate children in Gulshan-e-Buner, their own neighbourhood.
The impoverished area of Gulshan-e-Buner is a Pashtun-populated locality in the Landhi Industrial Area. The area was infamous for harbouring Taliban militants and was popularly known as a 'No Go zone'. By 9.30, Madiha and the 44-year-old Fehmida trudged through sludge and household sewage in the narrow alleys and knocked on the first door. The chalked sign on the door indicated there were children under the age of five years living there. "Are your children home?" asked Madiha.
The start of the vaccination campaign was marked by the murder of a former colleague Umer Farooq, who had been affiliated with World Health Organisation's (WHO) polio campaigns in the past. He was shot down four kilometres away from the campaign site in the Khadim Hussain Solangi Goth area of Gadap Town. Madhiha and Fehmida focused on their work and did not spend time dwelling on the dangers of the job.
Trying to keep up the morale, Dr Elias Durry, country coordinator of the WHO, had explained that Farooq was not a part of the present campaign and chances that he had been killed because of his volunteer work for the WHO in the past were slim. The workers were told that there was no reason to worry. Yet, as the DIGs of Karachi East and West later confirmed, security had been requested for polio campaigns, even if it wasn't provided. The year 2012 had been a scary year for polio workers. On 17 July 2012, armed men in Karachi had shot at a WHO vehicle, injuring a doctor from Ghana and his driver. The doctor had been working in an inoculation campaign in Gadap Town, which was considered a major sanctuary for the polio virus. Four days after the incident, a health worker in the same area was killed.
But Madiha and Fehmida belonged to the neighbourhood where they were vaccinating children that day. The in-charge of the campaign area was their relative. The people knew them, including the cleric. In fact, when two men on a motorcycle stopped next to him in front of the mosque and pointed at their four-year-old cousin asking the cleric where they could find the polio workers, he pointed toward the lady health workers.
After administering drops to children at a house near the neighbourhood mosque, Madiha had stepped out into the warm winter sunlight; there was a loud crack and she fell down. The second bullet missed Fehmida who ran back inside the house. The two men followed her and shot her till her body, riddled with bullets, was beyond recognition. Madiha and Fehmida were among the five polio workers who were killed in separate attacks in Karachi and Khyber Pakthunkhwa on 18 December 2012. Khairunnisa Memon, presiding the All Pakistan Lady Health Workers Employees Association Sindh, recalls this as the worst period for health workers and polio volunteers in the country.
There are only two remaining polio-endemic countries in the world and they share a border. As long as wild poliovirus reservoirs along the Pakistan-Afghanistan border remain out of bounds for health workers and the rate of refusals for vaccination stay high in key areas, neither country will be able to eradicate the virus. This fear is echoed across Health Department offices in every province of the country; many believe that if things continue to go the way they are, polio virus might not be eradicated even in the next ten years.
From crossfire to the forefront
"Pakistan's polio programme is a disaster. It continues to flounder hopelessly, as the virus flourishes. Home to 80 percent of the world's polio cases in 2014, Pakistan is now the major stumbling block to global polio eradication," the 2014 report of the Independent Monitoring Board said in its assessment of the progress being made by the Global Polio Eradication Initiative (GPEI). In 2014, Pakistan's polio eradication efforts over the last 14 years were exposed: that year 306 polio cases were reported – the highest number of cases reported in over a decade. But the numbers plummeted the following year by 70 percent with 51 new cases being reported in 2015. The drastic change could be attributed to the fact that a large number of the polio cases reported in 2014 weren't new polio cases, but cases being reported for the first time.
Though the portfolio of health was devolved to the provinces under the 18th Constitutional Amendment in 2010, polio eradication remains a national subject. Bound by international conventions and the commitments made each year to international donor agencies and spearheading partners – the WHO, Expanded Programme on Immunisation (EPI), Rotary International, GPEI, the US Centres for Disease Control and Prevention (CDC) and the United Nations Children's Emergency Fund (UNICEF) – the federal government and district administrations are responsible for carrying out vaccination under the National Emergency Plan for Polio Eradication.
India had been declared polio-free in 2011 and global pressure was mounting for Pakistan to take decisive steps against the virus. But as they were trying to deal with the growing epidemic, health workers turned into prime targets for militant outfits and continued to be so in the coming years. Fifteen people, mainly policemen escorting health workers, were killed in an attack on a polio vaccination centre in southwestern Pakistan in January 2016.
In June 2012, tribal elders as well as warlord Hafiz Gul Bahadur banned polio drives in North Waziristan. In a pamphlet titled 'Mas'ul-o-Khadimul Mujahideen' circulated in the administrative headquarter Miramshah and surrounding areas, the Higher Council of Mujahideen warned that the onus of damage resulting in violation of the ban would be on the violators themselves. The ban was supported by the tribal elders of Asad Khel, Dhur Dhanee, Muskee and Dosalee tribes in a grand jirga held on 17 June 2012. This was followed by a ban in South Waziristan's Wana subdivision announced a few weeks later.
The pamphlets exhibited suspicion and contempt for the Pakistani state, which raises the need to examine the political context in which polio eradication efforts are opposed. But first, it is important to do away with the supposition that these demands and misgivings are irrational, fictitious and concocted in isolation.
"We have been without electricity for the last 30 years and the government is ignoring the problem," the grand jirga in North Waziristan noted. The leaders said that they had approached the Federal Government multiple times in this regard and had been turned away. Despite repeated requests the government refused to address this crucial issue, they said. "Our children are dying of scorching heat and mosquito bites. What difference will it make if they die of polio?" an elder of Dhur Dhanee tribe told The Express Tribune newspaper.
The ban spread throughout Landi Kotal, near the Afghanistan border, and surrounding tribal areas in the midst of a sweltering summer during which the residents of this tribal belt had no water or electricity for days at stretch. The grand jirga of North Waziristan had accused the local political administration of siphoning off PKR 34 million (USD 324,908) meant for a power transmission line. "We haven't had water for days," an elder of the Zakakhel tribe, told the newspaper. There was the demand to stop drone strikes as well. Hafiz Gul Bahadur, who is believed to have harboured elders of the insurgent group Haqqani Network, demanded an end to drone strikes. "Polio infects one child in a million, but hundreds of Waziri women, children and elders have been killed in drone strikes," the pamphlet read. It went on to accuse the government of using polio vaccination campaigns as a cover for espionage on behalf of the US.
Tariq Suleman, a senior researcher at Bloomsbury Pakistan Social Science Research and Advocacy, says hidden between conspiracy theories are facts with which people build a superstructure of myth, with plausibility. The pamphlets distributed in Wana and Miramshah accused the authorities of introducing a "spy network" disguised as polio workers in their areas. This fear was not unfounded. Decisions that subvert public health activities can damage decades of efforts to gain the trust of a people otherwise suspicious of foreign interests in public health programmes. The US' Central Intelligence Agency's (CIA) decision to conduct a covert operation in the guise of an inoculation programme against Hepatitis B did just that. In the midst of the struggling polio vaccination campaign in 2010, the CIA enlisted the services of a Khyber health officer to collect DNA samples from Osama bin Laden's family in Bilal Town, Abbottabad while administering Hepatitis B vaccine bin Laden's children. Dr Shakil Afridi enlisted the services of low-ranking Health Department officials, by passing the Abbottabad administration, and held a vaccination drive in Bilal Town, inoculating entire neighbourhoods without official permission.
Afridi did not inoculate anyone against polio, Dr Bashir Ahmad, Expanded Programme on Immunisation (EPI) Additional Director explains. "His job was to collect DNA samples. You cannot do that when administering oral polio vaccine." In this case, he says, the ends did not justify the means as it was the polio vaccination campaign that ended up bearing the brunt of Afridi's espionage.
Aziz Memon, a representative of Rotary International in Pakistan, explains the gravity of the setback. Recalling his interviews with parents who had refused to get their children inoculated, Afridi's role as a CIA spy was presented as a key argument by almost every one of them. When tribal elders boycotted vaccination drives in the Waziristan region, they said on the one hand, America had killed hundreds of their people in drone strikes and on the other hand, was trying to 'protect' their children by initiating vaccination campaigns. "Wolf in sheep's clothing" is the term the pamphlet distributed in South Waziristan uses for the US, the largest donor for polio eradication efforts in Pakistan.
In an interview with the International Crisis Group in July 2015, a high-ranking government official said it wasn't that militant outfits or tribal elders believed that there was anything un-Islamic about vaccinating children against polio. "We reached out to some religious leaders to help us with the bans because they have linkages with the militants, they share the same school of thought, but it soon became clear the issue wasn't ideological. The militants were using this as a bargaining chip. They said, 'we are open to being convinced to allow [immunisation], but what will we get in exchange?' the official said.
Why children are missed?
The streets of Pashtoon Abad are narrow and the mud walls and the splintered wooden doors of single-storey houses on either side speak for the families living in them and the children who will not be vaccinated today. Two sisters, covered head to toe with a white scarf covering their faces, hold on tight to their blue polio vaccination kits as they shuffle past a shop where a group of men are having tea. A few of them sneer. The sisters are not welcome here.
Pashtoon Abad, one of the most conservative neighbourhoods in Quetta District of Balochistan, has been a high-risk trouble zone for several years. It is also home to nearly 10,000 families, many of whom regularly refuse to have their children vaccinated. A four-year-old child was diagnosed with polio in 2015. Dr Syed Saifur Rehman, coordinator of the Balochistan Emergency Operations Cell, says the child's parents had refused vaccination despite multiple requests.
On an average, the number of chronic refusals is 4000 families in every campaign in Balochistan, Rehman told the media in August 2015. The number appeared to have dropped significantly – almost by 91 percent – since November 2014, claimed Dr Aftab Kakar, another officer at the Balochistan Emergency Operations Cell. The 'mop-up' campaign (WHO term for a targeted campaign to immunise susceptible children surrounding a new case) in Pashtoon Abad was considered a success even though there were no records detailing how many people had travelled to other places since the polio case was reported.
However, Oliver Rosenbauer, communications officer at the Global Polio Eradication Initiative (GPEI), does not think refusal is a main reason as to why polio persists in Pakistan. "Pakistan has one of the lowest refusal rates anywhere in the world, less than two per cent. In my country, Germany, refusal rates are approaching 10 percent."
He agrees that the rate of refusal in some parts of Pakistan is higher than others, and even the WHO has encouraged the government to identify "area-specific" hurdles. "The 'missed child' approach allows health workers to identify area-by-area why children are being missed. Is it due to refusals? Or due to insecurity and hampered access? Or because of the threat of attacks on health workers? Are there difficulties in reaching mobile population groups? Is there a lack in proper micro-planning, not having sufficient amount of vaccine, not having fully trained vaccinators/supervisors? There are many questions to be addressed," says Rosenbauer.
He says the reasons vary greatly area by area. "For the most part, it's actually an issue of properly planning the campaign and effectively implementing it. That has been the main problem why children are missed," he claims. "It's not enough to address just refusals. We have to address all the reasons why children are missed – refusals tend to be the smallest of the reasons."
Bringing down refusal rates seemed to be the priority of the Balochistan government as it changed its tactic on how to approach 'refusing parents' in 2013, says Muhammad Zafar, a journalist from Quetta. The term 'polio volunteer' was changed to sehat muhafiz (an Urdu phrase meaning guardian of health). Every sehat muhafiz is accompanied by a local prayer leader, a tribal elder or some other influential reason. The endorsement of polio vaccine by respected members of a community makes locals more open to engaging with the sehat muhafiz, says Zafar. In some of the more high-risk areas, a polio team takes along screening equipment to show residents a documentary on polio.
Furthermore, polio workers often take polio drops themselves, in front of people who appear hesitant about getting their children inoculated. Though it is too early to say whether or not this has helped changed perceptions, he says the questions and answers session after the documentary screening creates room for deeper engagement with the residents.
The suspicions remain, however. One question that leaves even the most dedicated sehat muhafiz stumped is: "Why is it that every other medicine is priced exorbitantly and is out of our reach, but this polio vaccine, prepared and distributed by Americans, is brought to us in our houses for free?"
Despite a lumbering health services bureaucracy at the top, healthcare at the grassroots is almost non-existent in impoverished areas in Pakistan. Last year, Dawn reported that only 10 out of 27 EPI centres in Qilla Abdullah district were functional and the situation was not much different in other 31 districts of Balochistan. The question of why residents are denied basic health facilities but given free polio drops at their house speaks volumes of deprivation and resentment towards the state itself.
Researcher Tariq Suleman points out that as of now, the government outreach campaign appears to be structured around the premise that cultural and religious beliefs are mainly responsible for the refusals and if the government can, somehow, dispel these fears, the road to eradicating polio will be a smooth one.
Looking for perspective
The 20th century is the age of vaccination, Harris Coulter says in his book Vaccination, Social Violence and Criminality. The turn of the 19th century saw the creation of a new field – immunology – and with it, come its supporters, advocates, financiers, corporate interests and the detractors. World health leaders initiated seven global eradication campaigns in the last century – against hookworm, yaws, malaria, smallpox, poliomyelitis, guinea worm and yellow fever but succeeded in eradicating only smallpox.
In 1909, the Rockefeller Foundation's Sanitary Commission launched a hookworm eradication programme in the US South. The disease is spread through faecal contamination of the soil and is contracted by people walking barefoot in contaminated soil. The campaign involved mass awareness campaigns directed at doctors, teachers and the general public. Large meetings were called where people were diagnosed and vaccinated on the spot. In her book Chasing Polio in Pakistan: Why the World's Largest Public Health Initiative May Fail, Svea Closser discusses the eradication campaign launched by the Rockefeller Foundation over 100 years ago and draws attention to initiatives that may well mirror the state of polio eradication campaign in Pakistan.
The Rockefeller Foundation's awareness campaigns, writes Closser, included detailed information about the importance of toilets and sanitation. But it did not become involved in building toilets, she notes. In fact, the campaign raised eyebrows within government health circles. "There are many who feel it is dangerous for outside agencies to initiate and direct the activities of state and municipal officials," an evaluator is quoted to have said about the campaign in 1915.
The disease wasn't eradicated, but its burden was reduced. By 1920, the Rockefeller International Health Division had made global hookworm eradication a goal of the organisation. Huge sums were spent on treatment of the disease, but the Foundation was unwilling to spend on improving sanitation in the countries it was involved in.
Resistance towards vaccination is not just a Pakistan phenomenon. Paul Greenough, in his paper 'Intimidation, Coercion and Resistance in the Final Stages of the South Asian Smallpox Eradication Campaign', 1973-1975, discusses the violence incorporated in the latter stages of smallpox eradication in India as well as Bangladesh. He quotes Lawrence Brilliant, a WHO physician-epidemiologist:
In the middle of the night an intruder burst through the door of the simple adobe hut. He was a government vaccinator, under orders to break resistance against smallpox vaccination. Lakshmi Singh awoke screaming and scrambled to hide herself. Her husband leaped out of bed, grabbed an axe, and chased the intruder into the courtyard. Outside, a squad of doctors and policemen quickly overpowered Mohan Singh. The instant he was pinned to the ground, a second vaccinator jabbed smallpox vaccine into his arm. Mohan Singh, a wiry 40-year-old leader of the Ho tribe, squirmed away from the needle, causing the vaccination site to bleed. The government team held him until they had injected enough vaccine; then they seized his wife… After seeing his family vaccinated, Mohan Singh addressed the medical team and his fellow villagers, who had been assembled, in the following terms: "My dharma [moral duty] is to surrender to God's will. Only God can decide who gets sickness and who does not. It is my duty to resist your needles. We must resist your needles. We would die resisting if that is necessary."
Greenough notes that such coercive means have forbidding repercussions for other health initiatives being run parallel to or succeeding campaigns.
Drops and bullets
The Islamabad government has been innovative in finding opportunities to immunise children. In the first half of 2014, the Pakistan Army launched a military operation in South Waziristan forcing millions to leave their homes. "The temporary displacement of the population of South Waziristan provided us a scope to immunise children who polio teams had been unable to reach for over two-and-a-half years. Mobile and fixed teams were established at all 1075 transit points and at camps for the internally displaced people to ensure that every eligible child was administered polio vaccine," said Senator Ayesha Raza, the prime minister's focal person for polio eradication.
In Khyber Pakhtunkhwa, the government introduced the Sehat Ittehad Programme in February 2015, which made local rather than foreign agencies run the vaccination campaign. This was done to remove suspicions of the residents towards the motives of foreign governments. A month later, police registered cases against more than 1400 people in Peshawar for refusing to vaccinate their children against polio and arrested 471 parents. The move was lauded in government circles and a month later, Senator Raza introduced a bill to make refusals in the Islamabad Capital Territory punishable by fines and imprisonment. Bill Gates, whose foundation has poured in billions into the polio eradication campaign, called up Pakistan Tehreek-i-Insaf chief Imran Khan and congratulated him on the success of the Sehat Ittehad Programme.
This is "brute force" researcher Tariq Suleman notes in his article 'Winning Against Polio' for the News on Sunday. He says such coercive tactics deepens the gap between the campaign and the community. More than anything, it deepens resentment and exposes the weakness of the government's communications strategy, writes Suleman.
Whose fault?
Gadaap Town's Union Council 4 in Karachi looked like a war zone when Sameer Mandhro, a reporter for the Express Tribune, was there to cover the first day of a routine polio drive in June 2015. "The area was completely cordoned off," he recalls. Residents had been told to stay indoors and cooperate with polio teams. Anyone walking in the streets was either frisked or eyed with great suspicion. The unrelenting sun beat down upon workers as they went door-to-door and the journalists following their every move. Within a few hours of working in the area, which none of the polio workers there belonged to or were familiar with, they had started feeling faint. "No one even offered them water. I asked how they felt about the conditions they worked in and they stared at me, refusing to say a word," Mandhro says.
A medical officer, who did not want to be named, adopts a saccharine tone. "These areas used to be very dangerous once upon a time, but that's not the case anymore." Security threats in Karachi's no-go zones are isolated from one another, he says. "It's not like in Waziristan where a jirga or council of mujahideen will declare war on polio workers and citizens will follow… the issues here are specific to each neighbourhood we go to." Polio workers are at the greatest risk, he concedes. "They put their lives at risk for a meagre salary… it's extortion."
Khairunnisa Memon of the Lady Health Workers Association says it is not difficult to find people who will risk their lives for a few hundred rupees a day: "Our polio volunteers come from extremely financially-distressed backgrounds." The workers are told to visit at least 200 houses every day. WHO pays half of a polio volunteer's salary and the rest is matched by the provincial government. "The WHO is prompt with its payments but it can take up to four polio campaigns for the government to release its half of the salary." She talks about her own struggle to get her services regularised and raise her salary above the minimum wage level.
While journalists, government officials and donor agencies wax lyrical about the bravery and dedication of polio workers, says a member of the Punjab Young Doctors Association. There are all sorts of irregularities on the ground. He says, "But you get what you pay for." Svea Closser points out in her book: "District employees resisted the directives of their superiors in a number of ways, including refusal to work, falsification, corruption, false compliance, and direct confrontation."
In 2006, Raees Khan, a 14-month-old boy was diagnosed with polio despite having been administered 11 oral vaccine doses. The child, belonging to the Sulmankhel tribe, was from Dera Ismail Khan district. The case created a furore in the country. For the first time, the health services apparatus was set to question the efficacy of polio vaccine administered to children. Several officials suggested that the paralysis could have been induced by live attenuated polio vaccine.
Sona Bari of the GPEI dismisses this report as a fabrication. "There is one in two million chances of that happening. No way had that child been vaccinated 11 times," she says. To further the point, requesting anonymity, a polio volunteer in the Rahim Yar Khan district of Punjab, admits she has marked children as vaccinated even if they are not. "This has happened twice," she mumbles sheepishly. "On being threatened with physical assault if I did not leave the house, I have sometimes asked the family members to let me mark the child so I wouldn't get into trouble."
The Final Push
The world will be declared polio-free in 2018 if the GPEI's Polio Eradication and Endgame Strategic Plan 2013-2018 is to be believed. Out of the three types of poliovirus, type 2 was certified eradicated in September 2015, and there have been no type 3 cases globally for three years. For any disease to be declared eradicated, it must not rear its head in a country for at least three years. There have been six polio cases reported in 2016 in Pakistan. Although the country may not be able to help the GPEI in its endeavours to declare the world polio-free by 2018, it can push for zero transmission by the end of 2016. "That is what we're aiming for," says Rosenbauer. Has there been progress? Yes, definitely, he says. "It's probably never looked as strong as at the start of this year [2016]."
But the price of inactivated polio vaccine (IPV) has been a challenge for the GPEI, he says. Through UNICEF and the GAVI Alliance, preferential pricing and bulk purchasing agreements with manufacturers reduced the cost of IPV to less than USD 1 per dose from USD 2.50. Rosenbauer says that while this is encouraging, but more needs to be done to further reduce the per-dose cost.
The more prevalent oral polio vaccine (OPV) is considered generally safe, but the weakened virus it contains can, on rare occasions, mutate into vaccine-derived poliovirus. Dr Bashir Ahmad of the EPI says one of the ways to avoid this is to introduce IPV, which is injected into the bloodstream. This vaccine does not cause vaccine-derived poliovirus and boosts immunity when administered alongside OPV. Furthermore, it reduces the number of shots required to be completely vaccinated against the disease. However, overall the benefits of OPV outweigh those of IPV. "We use OPV to eliminate the virus in a community as the vaccine remains active in the sewerage even after it is passed in stool. IPV will only protect the recipient," she says. Also, at USD 0.14 OPV is more affordably priced.
Senator Ayesha Raza feels the government's "progressive and innovative" programme which focuses on 'accountability' at every level will provide the ground support required to eliminate transmission once and for all. "This year, we have received allocation of USD 328 million for the next three years." The final push, however, will come in May when the weather takes a scorching turn and the virus is at its most active. How that plays out will determine where Pakistan stands in terms of its commitment to eradicating polio.
However, there is criticism from various quarters that the government at the centre pays mere lip service to the GPEI while its commitments lie elsewhere. One official in the Punjab EPI says that they have funds from 2011 that still have not been spent. "There is a lack of an accountability mechanism. There's a lot of fancy talk at the top about monitoring polio officials, but who will hold the government accountable?" he asks.
One argument that is for Pakistanis to trust the campaign, the government needs to indigenise the whole affair. Foreign involvement in the campaigns needs to be downplayed as much as possible while taking lessons from their organisational skill. The mistrust over foreign agency in inoculation drives has led to a war of jurisdiction over the child. In this tug of war between the parents and the state, the child is the one who loses. But foremost, it needs to be remembered that the lacunae in basic healthcare services makes the government's fight to eradicate polio such a challenge.
Give him four drops
Two-year-old Musharraf was the first polio case reported in 2013. Aziz Memon of Rotary Polio Plus recalls the day he visited their house in Karachi. "I walked into the two-room rented house seething with anger," Memon recalls. "How ridiculously ignorant does one have to be to deny their own child polio drops, I thought." Then he saw Musharraf's father.
Usman, 49, hailed from Bajaur and was a polio survivor. His crutches lay next to him as he gestured Memon towards a chair. They exchanged pleasantries but the words rang hollow for Memon. "Musharraf is my youngest child," Usman said, his head bowed the whole time. "I was crippled as a child. When my first child was born I swore I would never let that happen to him. My other three children are vaccinated."
Musharraf, unlike Usman's other three children, was born at Karachi's Jinnah Hospital. For all intents and purposes, the hospital should have monitored the infant's vaccination regimen.
Usman's wife coughed loudly indicating that tea was ready. Usman got to his feet, using the crutches, and hobbled over to a flimsy curtain separating the kitchen from the living space. He brought in two cups of steaming tea and biscuits that he carried in one hand as he tried to balance himself.
"I run a tea stall at a petrol station," he said, making an attempt at small talk.
"How much do you make?" Memon asked.
"Almost 30,000 rupees a month."
They sat in silence sipping tea and then Memon eyes fell on the newspaper. "Are you educated," he asked. Usman put his cup down slowly his eyes narrowed. "You walk in to our house all high and mighty, judging me, thinking I'm some illiterate ignorant fool."
Memon remained unfazed by the sudden hostility. "For someone who knows how to read, refusing your child vaccination is pretty ignorant, is it not?"
Angry and shaking all over, Usman got up wagging a finger at Memon, "Who do you think you are interrogating me like this? Go ask Dr Shakil Afridi that American stooge these questions."
Memon stood his ground. "As your guest, I would rather that I didn't raise my voice. But tell me this, why punish your child for a crime someone else committed?"
A sob rose from behind the curtain. It was Musharraf's mother. Her voice high-pitched and quivering cut through the curtains. "I told him to get my child vaccinated. My child will be a cripple for the rest of his life. You ruined his life, you ruined his life."
Usman sat down, his head in hands. "Can you give my child four drops so he can walk again?"
Memon explained that it wouldn't work. "We can help get him a physiotherapist and implements to aid him in walking. He will never run like the rest of your children, but he will be able to walk."
The parents thanked Memon and Usman gave him his phone number. The next time they would meet, Usman would be a polio team facilitator in Bajaur. "No one from my village will be a cripple as long as I live," was the last message he sent Memon.
***
~ Sarah Eleazar is a Lahore-based journalist.