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Twenty-three years after it was eradicated in the United States, polio still stalks Pakistan, one of three countries left in the world where the devastating disease remains endemic. Prevention should be easy – all it takes is two drops of the vaccine, administered three different times, for a child to become immune. For years, polio has hovered on the brink of extinction in Pakistan, thanks in part to a 25-year effort by UNICEF, WHO, the CDC and Rotary International that has established a system of nationwide vaccinations that take place every six weeks. In 1988 there were 350,000 cases of polio in 125 different countries; today, that number is down to 176 cases in Pakistan, Afghanistan and Nigeria.

Hopes that polio could be knocked out for good in Pakistan faltered this summer when a pair of militant commanders in the ungoverned tribal areas along the border with Afghanistan banned the program, saying no vaccination teams should come to the area until the drone campaign against militants came to a halt — essentially holding the nation’s children hostage. The militant ban has spread amongst Pakistan’s Pashtun population, reaching as far as Karachi, in the country’s south.

There were 48 cases of paralytic polio last year in Pakistan, down from 154 in 2011. And while the cases are concentrated in the Pashtun speaking populations of Khyber Pakhhtunwa Province and the tribal areas, many of them have direct links to Gadap Town, Karachi’s biggest slum. Home to more than 400,000 people, of which 60,000 are children under the age of five, the tightly packed warren of concrete-block low-rise apartment buildings and small family compounds has become something of a black hole for government services. There is only one basic health clinic to serve the entire population, no sanitation services, no water treatment and a high likelihood that waste water is mixed with drinking water. For polio, it is the perfect storm, combining limited access, bad hygiene, low education levels and severe malnutrition: the polio virus has recently been found in water samples collected from the fetid stream that runs through the slum, a popular playground for area children. One polio worker recounts watching young children play tea party there, sipping stream water from the lids of water bottles scavenged among the heaps of rotting refuse lining the banks.

Pashtun-speaking migrants from the tribal areas dominate the area, and militant networks have made inroads among the population. Local officials call Gadap town “mini Waziristan,” in reference to an area near the Afghan border that is home to both the Pakistani Taliban and al-Qaeda linked militants. It’s not much of an exaggeration. In Gadap town, women, if they are seen at all, wear the trademark shuttlecock burqa of the Pashtun heartland. A recent survey conducted in Karachi by the World Health Organization noted that Pashtuns account for 75 percent of Pakistan’s polio cases even though they are only 15 percent of the population. Pakistan will never be free of polio, concluded the report, until a way is found to persuade poor Pashtuns to vaccinate their children. The Pakistani government is working with local communities on an education campaign, and making sure that every child on a public bus coming into or out of Karachi gets the drops. Still, some families have had to learn about the value of the vaccine the hard way.

Not so long ago, every child in Muhib Banda, a Pashtun village not far from the provincial capital of Peshawar, was vaccinated each time the polio teams came through. Local shopkeeper Saiful Islam says that he made sure his sons were first in line. But in late May, rumors swept through the town, as vicious and quick as a virus. “Some people were saying that the polio vaccine was made of pig urine, or monkey urine,” says Islam. “They said that it was a conspiracy to make Muslim children infertile. I believed them.” When the vaccinators came through a few days later, he refused to answer their knock. He refused again in July. And then his six month-old daughter Sulaim came down with a fever. When she recovered, she could no longer move her legs. It’s likely that she will never be able to walk. “Our ignorance made her paralyzed,” says Islam. He has pledged to join the fight against the disease, praying that Sulaim will be its last victim.

Diego Ibarra Sánchez is a Spanish documentary photography based in Pakistan.

Aryn Baker is the Middle-East bureau chief for TIME.

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Athar Hussain / Reuters

Eight-year-old Sumayya, whose uncle, Imran Ali, was injured in a shootout by unidentified gunmen, looks at him as he is brought to a hospital for treatment in Karachi, Pakistan, on August 23.

Athar Hussain / Reuters

A man rides a donkey-cart on the deserted streets during a strike in Karachi on August 23. Karachi faced a complete shutdown on Tuesday after the Muttahida Qaumi Movement (MQM) announced that a day of mourning would be observed against the ongoing wave of violence that has claimed nearly 100 lives in less than a week, local media reported.

David R Arnott writes

Karachi, a city of 18 million people, ground to a halt Tuesday, with most residents staying off the streets after a political party called a strike to protest the deaths of at least 96 people killed in the past week, the AP reported.

Yet the violence shows few signs of abating. Police chief Saud Mirza told the AP that the bodies of 10 more people were found overnight, some of them stuffed in bloody sacks. Read the full story.

Also on PhotoBlog: August 18 - Wave of violence in Karachi kills 39 in two days.

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niqab_115.jpg Two women wearing niqab pass through a broken street. 115 is the number to call an Edhi ambulance. The number is imprinted over all Edhi paraphernalia.

I wanted to share some notes on what we (Omar Mullick and I) have been doing in Karachi. Abdul Sattar Edhi, the main subject of our film, is primarily known for his ambulance service in Pakistan. He started out with a small blue van in the 1950's called the "Poor Man's Van" and went around Karachi transporting the dead and sick to their fated destinations. Little did he—or anyone in Pakistan—know that he was the first and only ambulance in the entire country. To this day, Edhi is at the forefront of providing first response care to Pakistanis while the local city and provincial governments lag far behind.

The ambulance service is the largest and most well known program the Edhi Foundation provides. There are about 30 check posts around Karachi that have at least three ambulances for dispatching around their designated area.

It's important to note that these ambulance drivers aren't paramedics. They are only required to have a driver's license and be able to read and write in Urdu. Many of them don't know CPR and are taken only through a very basic training before becoming a driver. The main job of an Edhi ambulance driver is to transport patient X from point A to point B. The lack of qualifications is a little frightening since there of road side accidents and shooting casualties an ambulance picks up in a day.

I remember feeling a little uneasy watching a live stream of a terrorist attack in progress because the police were nowhere in sight. A minute later I heard sirens and saw an Edhi ambulance pull up. The driver exited his van and ran off camera with a stretcher. The police showed up ten minutes later. The importance of the Edhi ambulance in Pakistan goes without saying.

The photos in this blog post were taken during our time with the Edhi ambulance drivers and dispatchers in Korangi Town.

asad_head.jpg Asad, an Edhi ambulance driver, sticks his head out during a sweltering day in Lala-abad. Most ambulances don't have an A/C unit. The Edhi Foundation has to keep costs down to maintain their affordable RS 100 ($1.20 USD) fee for transport.

Asad waits for a patient in the back of his van. The back contains only a stretcher and an oxygen tank.

korangi_smiles.jpg An ambulance driver rests on a table at the Korangi dispatching center. The Edhi driver's shift is 24 hours. Drivers take many breaks throughout the shift. They work every other day, 15 days a month.

korangi_crotch.jpg Mahmood, an ambulance dispatcher, talks to a friend on the phone during a blackout. The Korangi center loses electricity about five times a day. During some night shifts, the electricity doesn't come back till the morning. A small generator powers the phones and a tiny bulb -- just enough to keep the work day moving.

police.jpg Two police officers ride on a bike. In Karachi, it is illegal to have a passenger on your motorcycle (except for women, children and the elderly). Clearly, those who enforce the law aren't around to follow it.

Notes on the Edhi Ambulance

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