KARACHI // One morning last week, dozens of families stood quietly in the white-tiled waiting room of a small clinic in one of Karachi’s innumerable slums; small children and their parents in a queue that spilt down rough concrete steps out onto the dirt lane below.

The parents were there to vaccinate their children against a number of diseases — including, crucially, the polio virus — and waiting for free medicine, another incentive offered by Pakistan as a tactic to win the country’s battle to eradicate polio.

“This camp covers only three per cent” of the local union council (UC), the smallest administrative unit, “and is expected to cover 600 children”, said Abdul Maboob, a Pakistani health official overseeing the day’s efforts. “In most other parts of the UC people are refusing to host these camps out of fear of the Taliban in the area.”

Six police officers stood watch in the narrow lane, nervously eyeing passersby emerging from adjoining alleyways and holding their automatic weapons high up by their chests.

The vaccination drive coincided with an ongoing operation in Karachi against Pakistani Taliban (TTP) militants, and over the past 18 months, a dozen police officers have been killed here in the city’s Qaidabad slum by members of the group’s Swat and Mehsud factions.

Last year in Qaidabad alone, a health clinic where polio vaccinations were being given was attacked with a grenade, and two polio vaccinators were shot dead by militants. Sixty-six polio workers have been killed in Pakistan since 2012.

The country’s latest polio vaccination campaign was launched last week and will continue across Pakistan through the end of the month, but the effort has so far been halting and inconsistent, marred by continued attacks, government dysfunction and political gridlock, persistent anti-vaccination propaganda, and operations against TTP militants and other extremists in the two areas of the country most crucial to eradicating the disease — Karachi and the north-west.

Despite promises by prime minister Nawaz Sharif that then newly dedicated federal and provincial government cells would carry out a coordinated campaign to stamp out the virus, new cases reached record levels in 2014, giving Pakistan the humiliating distinction of being the world’s largest incubator and exporter of the resurgent virus, despite it nearly being eradicated in 2012.

Health officials, however, say the vast majority of children have been vaccinated and that the new cases are confined to insecure areas in the north-west, Karachi and Balochistan.

Millions of vaccinations were administered across the country last year with the help of international aid, including from the UAE.

Over 13 million children in the north-west Khyber Pukhtunkhwa province and the adjacent Federally Administered Tribal Areas (FATA) were vaccinated between June and September during a campaign led by the UAE-Pakistan Assistance Programme, which was established by Sheikh Mohammed Bin Zayed in 2013.

But despite this increased focus, the WHO declared a global health emergency over the virus’ spread in May. Polio traced to Pakistan was found in Egypt, Israel, China and in Syria, where there had been no new cases since 1999.

After six cases from December were confirmed in Pakistan last week, the total number of new cases rose to 303 in 2014, up from 93 in 2013, according to WHO data. For every 200 carriers of the virus that paralyses children, only one person will exhibit symptoms, health officials say, so even one new case is considered an emergency.

Pakistan also faces economic consequences and a travel ban for its citizens over the virus, and the government now requires those who have spent over four weeks in the country to produce vaccination certificates before departing. But according to travellers at Karachi’s airport, certificates can be bought there without having taken the vaccine.

There were 23 new cases in Karachi last year, all coming from a handful of the highest-risk UCs where TTP groups have increased their control of ethnic Pushtun neighbourhoods. The largest proportion of new cases in the country were from Khyber Pukhtunkhwa and the FATA.

Over a million people have been displaced from the North Waziristan tribal area since the Pakistan military launched an offensive against TTP strongholds there, most of whom had never been vaccinated.

Their homes destroyed, they settle in cities and towns in the north-west and in slums like Qaidabad in Karachi, where TTP militants have formed shadow governments. The extremists attack the vaccination teams because they are a symbol of the state they are fighting to overthrow and discredit, and out of suspicion that vaccinators gather information for the police and intelligence agencies, according to health workers who have spoken with TTP commanders.

The targeting of vaccinators began in 2012 after it became public that the CIA had used a fake hepatitis vaccination campaign led by a local doctor, Shakil Afridi, to try and collect DNA from Osama bin Laden’s family members at the late Al Qaeda leader’s Abbotabad home.

In Karachi, an operation launched in September by police and federal paramilitary forces against TTP militants and criminal gangs has badly hampered the vaccination efforts, say both police and health officials. Already this year, campaigns in Karachi’s high-risk neighbourhoods have been cancelled because of a lack of available police protection or because of raids in the same areas.

“The morale of the campaigners has been affected,” said Durenaz Jamal, a provincial health official who oversees the anti-polio drive in Karachi. “You are not going to achieve targets [with the operation ongoing].”

In Karachi, the campaigns – protected by police officers – go into the most militant-infested areas and present the TTP with easy targets.

“We encounter [kill] the militants in the same area where they do polio campaigns,” said a police constable from the TTP-stronghold neighbourhood of Sohrab Goth, who requested anonymity to speak freely. “So obviously they will take revenge [on the vaccination teams].”

The latest attack came on Monday in the city’s Orangi Town area, when a police detail protecting a vaccination team was attacked by gunmen on a motorcycle, severely injuring one police officer.

Local people, many of whom have received few health or education services from the government and who face a hostile police force that has killed many innocent Pushtuns along with militant suspects, are extremely wary of the frequent follow-up campaigns.

Back at the clinic, Mr Mahboob said that along with the security threats, UN-designed communications efforts to convince religious clerics to support the vaccinations and convince families that the vaccine is not part of a western conspiracy against Muslims have not been effective.

Unicef has compiled fatwas from conservative clerics of the Deobandi sect — adhered to by most Pakistani Pushtuns — in favour of the vaccinations, and organised televised events where clerics themselves take vaccination drops and administer them to children.

“But no one is talking to the low-level mosques or madrassah students in these areas,” said a health worker with an NGO that works with Unicef on campaigns to convince people to vaccinate their children.

In Qaidabad, local health officials were only able to get a decent turnout by using a makeshift tactic to publicise the campaign, telling the local imam to announce free routine vaccinations and medicine, without mentioning to him that polio vaccinations – which have developed a particular stigma for being part of a western conspiracy – would be included.

Unending political crises and the fight against extremist terrorism have also compounded the inadequacy of the government’s response. Vaccinators, who have only been paid around US$2 (Dh7.3) per day, were promised higher salaries but those never materialised – and many say they are never paid at all or have to wait for weeks – causing a high turnover and low morale, along with poorly run campaigns.

Meanwhile, according to English-language daily, The News, the incompetence of officials appointed to the new provincial and federal Emergency Operation Cells has led to international organisations refusing to work with some of them, and there appears to be little coordination with on-the-ground organisers about how to tailor strategies to fit the unique conditions of each community.

“The new government polio committees don’t come to the area to talk with local health workers about strategies,” said the NGO worker. “They’re not working properly.”

tkhan@thenational.ae