What must be done about the killings of Pakistani healthcare workers?

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f280 (Published 16 January 2013) Cite this as: BMJ 2013;346:f280
  1. Zulfiqar A Bhutta, founding chair
  1. 1Division of Women and Child Health, Aga Khan University, Karachi, Pakistan
  1. zulfiqar.bhutta{at}aku.edu

It’s time to stop trying to accommodate those who spread fear and terror

In December 2012 nine volunteer polio workers, six of whom were young women, were murdered in Pakistan.1 A day later five female education workers were murdered on their way to work in Swabi (Khyber Pakhtunkhwa). The coordinated attacks sent a chilling message to civic society that female workers and volunteers, hitherto protected by a strict Pashtun moral code, were now terrorist targets. These murders begin to fade into a background of incessant conflict and insurgency around the border areas of Khyber Pakhtunkhwa, the federally administered tribal areas, and Baluchistan. The city of Karachi is caught in a spiral of targeted killings and kidnappings for ransom.2 In Baluchistan, the law of the government has all but collapsed and the Hazara minorities have been forced to demand army rule in the main city, Quetta, to protect themselves from the threat of ethnic cleansing at the hands of a well connected and funded underground network of terrorist organisations.3 The nation is inured to reports of violent deaths on a daily basis, however, and the recent targeted killings of health workers are already off the news and public debate in Pakistan.

It is astounding that, despite these obvious hazards, health workers and vaccinators were back at work within a few weeks of the recent killings. It is a testament to the resilience and bravery of these frontline workers, who stand tall where their comrades have fallen. Pakistan has made enormous progress over the past year in restricting polio, with just 58 cases in 28 districts in 2012, compared with 198 cases in 60 districts in the previous year. Despite the current dangers inherent in polio and child immunisation programmes, polio vaccination cannot be allowed to slip. With the massive measles outbreak in Sindh claiming more than 300 lives over the past few weeks,4 it is even more important to have robust vaccination programmes in place in Pakistan.

The targeted killing of health workers in Pakistan for political or so called religious reasons is not new. Polio workers have been targeted sporadically in the past.5 In Karachi, a sprawling mega-city of almost 19 million inhabitants, 85 doctors have been assassinated since 1990, often those belonging to the Shiite sect.6 Few culprits are ever caught, and the term “hidden hands,” regularly used by those in power, has become clichéd.7 It is clear that, although these acts of violence and murder may be perpetrated by a variety of obscurantists and organisations, their motives are similar. Whether it is blowing up girls’ schools or targeting health and education workers, they aim to create a climate of maximum fear and despondency so as to impose their writ. This was the method used in the peaceful district of Swat a few years ago, which saw a virtual takeover of the population of more than two million by a few hundred hardcore followers of a religious leader, who spread his message of fear using a state approved FM radio channel.8

The ordinary Pakistani is paying the price of years of bad governance and appalling policies by successive generations of military dictatorships and corrupt civilian governments. Over the past 50 years several wars with India, ongoing political tension in Kashmir, and successive Afghan conflicts have fostered the creation of armed militant organisations that have now gone amok.9 Sadly, in both Afghanistan and much of the federally administered tribal areas and Baluchistan, a whole generation has been raised witnessing constant conflict. These “children of war,”10 often the product of a medieval education system in religious schools (madrassahs) and unemployable in a shrinking job market, are easy bait for those who would recruit them to a “holy” cause. The contribution of conflict in the Islamic world to the growth of a Jihadist mentality cannot be underestimated. Suicide bombings in Afghanistan and Pakistan were unheard of until recent years, and the advent of killing by remote control through drones has led to a veritable bonanza for recruiters to the cause of the Taliban from among the survivors, a fact well recognised by many analysts.11

Although this is all depressing and chilling, it must not detract from the need to act and support the silent majority in Pakistan who want to see progress and improvements in public health programmes. Ordinary Pakistanis are fighting for survival in a spiral of incessant energy crises, food price increases, and political insecurity that sees political forces in the country at loggerheads over rapidly shrinking geographical and regional mandates. It is inevitable that terrorist organisations and obscurantists will take advantage of crises of governance and leadership, but this cannot be allowed to happen. What we urgently need is active provision of security to health workers and a visible, vociferous condemnation of violence against volunteers and health workers by all political and religious parties.

Providing security to the civilians and frontline health workers in Pakistan must also involve active pursuit of those determined to destabilise public health and education programmes. Mere dialogue and attempts to accommodate obscurantists and murderers serves only to embolden them. The experience in the Swat valley has shown that where there is a will the state security systems can effectively take on the few who hold entire populations at ransom. It is time to accept that Pakistan is “reaping the whirlwind” of creating and nurturing those who would think nothing of taking the country back to the dark ages.12


Cite this as: BMJ 2013;346:f280


  • Competing interests: ZAB has received no support from any organisation for the submitted work; has had no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; has no relationships or activities that could appear to have influenced the submitted work

  • Provenance and peer review: Commissioned; not externally peer reviewed.