Saturday, 31 August 2019

Women Leaders in Action: Lady Health Workers’ Protests

By Komal Qidwai

A health worker vaccinates a child during a polio vaccination campaign in a rural area in Punjab.
Photo credit:
Since 2002, Lady Health Workers (LHWs) have protested against low stipends and delayed payments. The LHW Program, initiated by Benazir Bhutto in 1994, now employs over 100,000 workers. The aim of the program is to provide primary health services to women in rural and urban slum areas through LHWs, who are residents of the community they work for. Until 2012, LHWs were contractual employees. After their regularization in early 2013, they became full-fledged government employees, entitled to benefits, guaranteed payment of salaries, and a clear trajectory for career advancement through a service structure.

LHWs employ a range of protest strategies to have their demands heard. From sit-ins and marches to hunger strikes and self-immolation, these women-led protests have managed to achieve regularization, as well as increases in salaries. LHW’s protest action is one example of women’s involvement in contentious politics in Pakistan, which is currently being researched at the Collective for Social Science Research. We are conducting this study under the A4EA (Action for Empowerment and Accountability) research program, in collaboration with the Institute of Development Studies (IDS), University of Sussex.

According to Ivan Gomza, contentious politics refers to political action which operates outside of institutions, such as government bodies. Disadvantaged groups use protests to voice their demands through collective action. Our research is focused on understanding women’s role in this type of political action, including the emergence of women leaders, their demands, and protest strategies.

Along with my colleagues, I interviewed founder and president of the All Pakistan Lady Health Workers’ Welfare Association, Bushra Arain. We learned that initially she struggled for permission to join the program as she faced resistance from her in-laws, extended family and husband. Through our interviews with women leaders in other types of protest action, we found that support from male family members is important for the emergence of women leaders. The same is true for Arain, who had to convince her family to become an LHW.

After joining the program, Arain was quickly promoted to the position of a Lady Health Supervisor. She experienced harassment from male colleagues, such as a doctor who was responsible for training her. She and other supervisors protested/objected and had him removed from the program. At the same time, Arain also realized that the program was helping a large number of people, but its workers were not being paid enough or on time. By 2008, she had formed the LHW Association and in 2010, LHWs across all four provinces protested on the streets, demanding increase in wages and regularization. To mobilize LHWs for collective action, she travelled all over Pakistan, forging connections with workers in different provinces. Her leadership style matches that of many other women leaders from our other interviews – she engages in grass-roots mobilization herself, taking on responsibility and bearing high personal costs such as threats to safety and distance from her children and family.

Many of the LHW street protests are carefully staged. Describing a hunger strike in 2010 outside the Islamabad Press Club, Arain says that there were forty protesters in the sit-in, and every time one would leave, she would be replaced by another. This way, the protestors were able to maintain their numbers. In another sit-in during April, 2012, some of the protestors gave the government an ultimatum - either their demands for regularization be heard by 3 p.m., or they would self-immolate. A lack of government responsiveness pushed twenty-five protestors to sprinkle petrol on themselves, and one driver even sustained burn injuries. This compelled government officials to step in and assure the protestors that their demands would be met.

Staging protests is one of the many organizational strategies LHWs employ. They have also effectively used the courts by filing a petition in the Supreme Court in 2010 for their regularization and increase in salaries. However, it was the cruel treatment of the protestors at the hands of the police in 2011 which finally prompted then Chief Justice of the Supreme Court, Iftikhar Muhammad Chaudhry to take suo moto notice of LHWs’ demands. Even after the Supreme Court issued orders for their regularization, there were delays in implementation and LHWs continued protesting to ensure the court orders were followed through. Arain describes this combination of using courts and street protests, “The world saw that (their protest) and pressurized the government.” So creating a spectacle by staging protests induces the government to sit down with the protestors, undertake formal negotiations about their demands, and follow through with necessary action.

However, they could not have filed a petition without legal aid, and Arain claims that advocates such as Qazi Anwar, now president of the Supreme Court Bar Association of Pakistan, helped LHWs draft and file the court petition. Forging alliances, then, is also a key strategy for successful protest action. As early as 2000, before the LHW Association was formed, it was through the help of the All Pakistan Women’s Association (APWA), Aurat Foundation, and the Pakistan Paramedical Association that Arain and her colleagues had the doctor who was allegedly sexually harassing them removed from the LHW program. LHWs also form alliances with influential politicians, such as Marvi Memon. Memon was an MNA from 2008 to 2011, and her presence at their protests during those years afforded the LHWs some protection from police brutality. Even now, LHWs continue to build alliances, such as the Aurat March, and are engaging in protests to improve their conditions.

Apart from having their demands met, engaging in protest action has also led to personal empowerment for many LHWs. Arain, for instance, recalls that at the beginning of her career, she used to cry if she was chided by a person of authority. Now, after threats and beatings, she is not afraid of any backlash. Other women in the Association look at her with reverence, and her charisma certainly plays a role in marking her out as a leader. She has built this credibility over a long period of struggle. Our interviews in relation to other types of protest action reveal that many women at the forefront of protest actions have followed similar trajectories – enduring high personal costs, forming alliances, learning new organizational strategies, and emerging as leaders.

Friday, 2 August 2019

HIV in Pakistan: Who knows, who cares?

By Shehrzadae Moeed and Adil Sayeed

Photo credit:

In April 2019, a doctor in Larkana’s Ratodero sub-district was arrested for allegedly passing on Human Immunodeficiency Virus, or HIV, to his patients. In the aftermath, as the Government of Sindh moved into firefighting mode, more than 30,000 individuals were screened, of which 851 tested HIV positive. More than 64% of these were under the age of six. In Kot Imrana, Punjab, the number of people with HIV increased from 1.4% in June 2018 to 13.4% in January 2019. It has been reported that over 5000 quack doctors operate in the area and 869 people have been diagnosed with AIDS. A recent report by the UNAIDS puts Pakistan on a list of 11 countries with the highest global prevalence of HIV, at 13%.

Why has Pakistan experienced sharply increased rates of HIV? In this blog, we will look at the data to assess why HIV remains prevalent and use cross-country evidence to learn lessons on tackling what is a very manageable illness.

HIV and its causes
HIV is an infectious disease that is spread through the blood, such as through used syringes, or transmitted sexually. It can also be transmitted to children if the mother is pregnant. The infection damages the immune system, and its most advanced stage develops into AIDS (Acquired Immune Deficiency Syndrome), which is life-threatening. It is a serious illness with global efforts to tackle it. However, even though it is a lifelong condition, developments in medicine mean that, with proper and regular treatment, an infected person can live a full life.

Commonly, the causes of the growth of HIV prevalence in Pakistan, similar to many developing countries, are attributed to medical negligence, a broken healthcare system, unregistered blood banks, and unlicensed practitioners, including quacks. In addition to this, the common Pakistani “penchant for receiving injections and drips as quick fix in lieu of healthy nutritional lifestyles” contributes to the inclining HIV prevalence in Pakistan.

Further, migrant labour forces open to commercial sex, and increasing man-to-man sexual activity, also contribute to this. In any other country where same-gender sex isn’t a criminal offence, governments work hard to ensure the practice of safe sex. In Pakistan, however, taboos around sexual health make it difficult for sufferers to seek help or even find a support group. If no one can talk about sex, who’s ever going to talk about safe-sex?

What does the data tell us
While the proximate causes commonly discussed in the media may have to do with unsafe sex, reusing needles, blood transfusions, and similar unsafe practices arising from quackery, medical negligence or drug use, the data suggests that the underlying cause, however, is the lack of awareness of sexually transmitted illnesses (STIs).

In the Pakistan Demographic and Health Survey (PDHS) 2017-18, only 32% of women and 67% of men reported that they had heard of AIDS. In Sindh, this is even lower, with 26% of women and 49% of men reported being aware of AIDS. These figures are very low.

Furthermore, out of every 100 women, less than 4 are aware of the fact that there is a treatment for HIV and less than 3 know where to receive HIV treatment. Similarly, less than 33% of men are aware of the fact that there is a treatment for HIV, and less than a quarter have any knowledge of treatment centers. Comprehensive knowledge about HIV is abysmally low, with only 4% women and 10% men being familiar with the details of this illness.

A lack of awareness of this public health challenge is thus endemic – a flip side of the same coin, however, is the discrimination among those who are aware. In the same survey, more than 50% of the respondents said they would not buy fresh vegetables from a shopkeeper who has HIV. Similarly, 46% of women and 48% of men who are aware of AIDS said they would not want HIV positive children to go to a school with those unaffected by this illness.

Discrimination in a population acts as a disincentive for people to get tested and treated. It is the taboo associated with HIV and AIDS that also leads to less people being open about it, thereby reinforcing the lack of awareness.

Way forward
What is clear is that the Government of Pakistan’s National AIDS Control Programme (NACP), which was established in 1986-87 and has received significant donor financing, has been ineffective in tackling the social causes of HIV/AIDS prevalence. Perhaps there is a need to learn from other countries – after all, Pakistan is not the first country facing this issue.

In Brazil, for example, massive reduction in cases can be largely attributed to a massive awareness program (prevention) coupled with widespread distribution of free medication (treatment). Their ministry of health also utilized social media in a 2014 awareness campaign. This also assisted in reducing the population growth rate which currently stands at a relatively low 0.8% as compared to Pakistan’s 2% annual growth rate. The success of Brazil’s AIDS campaigns is evident today as 84% of the population with HIV is aware of their condition as compared to just 15% in Pakistan.

In sum, Pakistan needs to rethink its strategy to fight HIV and AIDS. HIV, if caught and treated, can yield a normal life for those infected with it. If not treated properly, however, HIV can quickly develop into AIDS, which is life-threatening and a miserable condition to be in for someone infected with it. The spreading of STI’s and the chances of HIV developing into its last stage of AIDS are particularly high because of the lack of awareness and stigma associated with them in Pakistan. The NACP needs to tackle these head on, perhaps by talking about these issues from an early age, including sexual education in school, as other countries, including Brazil, have done. As long as there is a lack of awareness regarding the issue, these epidemics will continue to prevail and the people will continue to suffer.

The authors were interns at the Collective in July 2019.