Late last year, in Karachi’s Metroville Colony, Sadia Rizwan went door-to-door administering a two-drop oral polio vaccine to children. She visited dozens of homes each day, calling on more than 350 households in just ten days. The COVID-19 pandemic was raging across Pakistan, and Rizwan was acutely aware of the risks she was taking to carry out a polio vaccination campaign—risks that were deepened by the unwillingness of some families she visited to wear masks or maintain social distance. But as a longtime resident of Metroville, she also knew firsthand the havoc polio wreaks when left unchecked.
Rizwan is one of over 100,000 female vaccinators, known in Pakistan as “Lady Health Workers,” who represent the frontline in the fight to eradicate polio. Working in their own communities, they are familiar faces that help reduce vaccine reticence and skepticism. And being women, they can access parts of society and the household that are ignored by, or off-limits to, their male counterparts. As the world gears up for the mammoth task of vaccinating billions of people around the globe against COVID-19, the lesson from polio is clear: in many conservative communities, vaccination success will depend on women.
THE ENDLESS FIGHT
Humanity is not good at eliminating diseases. Only one—smallpox—has ever been completely eradicated. But since 1988, vaccination programs have progressed a remarkable 99 percent of the way to wiping out polio, a viral disease that disproportionately impacts children, infecting their central nervous systems and leaving some paralyzed for life. The persistent one percent is found in Pakistan and Afghanistan, where polio eradication efforts have faced a range of obstacles, including social and religious barriers, challenging vaccine delivery logistics, and tenuous government partnerships with nongovernmental organizations.
COVID-19 made things worse in these last redoubts of disease. At the onset of the pandemic, the World Health Organization (WHO) paused all polio vaccination campaigns worldwide, resulting in an estimated 80 million vaccinations being missed in 2020. Campaigns slowly resumed in Pakistan in August of last year, but much ground was already lost. In late 2020, 74 percent of sewer samples taken across the country tested positive for the polio virus, up from just 13 percent of sewer samples in early 2018.
If Pakistan ever succeeds in eradicating polio, it will be thanks to its Lady Health Workers. The WHO, Rotary International, and Pakistan’s government are jointly in charge of polio vaccination efforts in the country, but women like Rizwan shoulder the day-to-day responsibility of delivering doses. The work they do is intimate. They enter homes, discuss private health matters, and persuade families of the benefits of vaccinating their children. In conservative northwest Pakistan, where misinformation proliferates and vaccine hesitancy is common, this work is impossible without women who hail from the communities they serve.
Much of the vaccine hesitancy has its roots in religion. Just as some conservative Christian leaders in the United States have sown doubts about the safety of vaccines among their congregants, religious figures such as imams in Pakistan have often stood in the way of immunization efforts, wielding outsize influence over the health decisions of community members. Tayyaba Gul, a longtime polio eradication activist in Nowshera, a city in Pakistan’s Khyber Pakhtunkhwa Province bordering Afghanistan, understands this well. For years, she has worked with imams to organize health seminars after Friday prayers in which she and her team dispel misinformation and encourage parents to have their children vaccinated.
Not all religious leaders have welcomed female polio eradicators, however, and relations between communities and health workers are often strained. Some of Gul and Rizwan’s colleagues have been killed, while others regularly face violent threats. But because religious hard-liners are responsible for so much of the anti-vaccination rhetoric in Pakistan, winning over imams is vital for both the success of vaccination drives and the safety of the health workers.
NETWORKS OF EMPOWERMENT
Getting women involved in health outreach has other benefits as well. “These women are entrepreneurs, supporting their families and themselves to continue their education,” said Sadia Shakeel, who works with Rotary International and Pakistan’s government to train female vaccinators. According to the United Nations Development Program Gender Inequality Index, Pakistan ranks a dismal 135th out of 162 countries and women have few job prospects. The female vaccinator program provides employment, money, freedom, and a rare opportunity to influence community decision-making.
“Women don’t have [social or economic] mobility without men,” explained Gul, the activist. Often, women in Pakistan need the permission of men to work at all, which goes some way toward explaining why, in Gul’s home province of Khyber Pakhtunkhwa, only 14 percent of adult women participate in the labor force compared with 60 percent of men. Women who become Lady Health Workers don’t just empower themselves; they help mobilize other women in their communities to become decision-makers in their own households, starting with choices about their children’s health and well-being.
Walking the streets and knocking on doors, the female vaccinators have become deeply knowledgeable about community needs far beyond polio. As a result, they have become involved in a range of activities, such as organizing health camps, procuring water filtration equipment, and responding to typhoid outbreaks. As members of the communities they serve, the women know that vaccination campaigns cannot succeed unless the underlying social determinants of health—such as economic stability and environmental safety—are first addressed. And their holistic approach to public health has paid dividends: according to Pakistan’s Demographic and Health Survey, regions that are served by female vaccinators have better health outcomes in areas such as family planning, neonatal care, and immunization than regions that are not.
MODEL PUBLIC HEALTH
When COVID-19 cases started to spike in Pakistan last May, it was female vaccinators who scrambled to distribute masks to their communities and to run outreach campaigns to promote hand washing and social distancing. Now, according to Gul and other Lady Health Workers, they stand ready to play a leading role in COVID-19 vaccine distribution, even though the government has yet to announce plans for them to do so.
Pakistan’s Lady Health Worker program is far from perfect. Female vaccinators are underpaid, suffer from discrimination, and receive insufficient government support. But they have much to teach the world when it comes to effective vaccine distribution. To date, just shy of two billion vaccine doses have been administered worldwide—one dose for every four people. High- and middle-income countries have received 85 percent of those doses, however, while low-income countries have received just 0.3 percent. This glaring inequality will likely persist for years to come, but there are reasons for mild optimism that the rate of vaccination in the developing world will improve. The United States has pledged to donate half a billion doses to COVAX, the international vaccine-sharing initiative that aims to administer two billion doses before the end of the year, half of them in low- and middle-income countries. It has also backed a push to waive intellectual property protections for vaccines and, along with other developed countries, promised direct vaccine transfers to developing nations. As a result, there is hope that even the poorest countries can reach the WHO’s goal of having at least ten percent of every country vaccinated by September.
But the higher COVID-19 vaccination rates inch up in the developed and developing world alike, the more important it will become to address intracountry distribution disparities as well as intercountry ones. That is where outreach programs modeled on Pakistan’s Lady Health Workers come in. Strong female community health worker programs can help advocate for and deliver vaccines to rural and marginalized communities, especially in conservative or religious societies, bridging the gap between formal and informal health-care institutions and ensuring that the privileged and wealthy are not the only ones who receive doses. They can also help to dispel misinformation and overcome vaccine hesitancy within their communities, helping to close the gap between rural and urban, as well as rich and poor, vaccination rates over time.
Even in the United States and other countries with higher vaccination rates, teams of female vaccinators modeled off of Pakistan’s Lady Health Workers could help reduce vaccine hesitancy in communities with low uptake and assist individuals who lack the resources to navigate the health-care system or secure vaccine appointments. The need for such workers is not theoretical. According to the UN High-Level Commission on Health Employment and Economic Growth, there was a shortfall of 18 million community health workers around the world even before the pandemic. The success of the Lady Health Worker program in Pakistan, coupled with the unique demands of the global COVID-19 vaccination drive, suggests an obvious path for meeting that shortfall: invest in women so they can invest in the health of their communities.