The Central Role of Women in Polio Vaccine Acceptance Among the Pashtun in Pakistan

Pakistan and Afghanistan have ongoing poliovirus transmission, mainly in Pashtun communities. This chapter explores the intersection of gender norms and power relations with cultural norms, the marginalized social location of Pashtuns, geographic location, and age through the lens of polio vaccination. The chapter is based on data from a larger study exploring the reasons for polio-vaccine refusal, carried out during 2021–22. It draws on 153 in-depth interviews with male and female parents. Pashtun communities in Pakistan have resisted polio vaccination owing to distrust of the state machinery, which is perceived as falling short of its obligations to provide for its citizens. However, acceptance or resistance to polio vaccination is also influenced by deeper cultural and gender norms. Decision-making in Pashtun households is a complex process seeped into the hierarchy between and within genders. While traditionally, men have always had the final say in decision-making, gender norms appear to be evolving, with the mothers and mothers-in-law exerting agency in different ways to get their children vaccinated or to refuse vaccination. Vaccine hesitancy is similar for boys and girls in all refusal households. The reasons for refusal are driven by fears of sterility and infertility from the vaccine, for boys because they are responsible for carrying on the bloodline, and for girls because they cannot be married off if they lose their reproductive potential. Finally, the decision to accept/reject the vaccine varies and is impacted by the status of the vaccinator as an “insider” in the community, a status that varies by location.