My article criticizing certain rituals in the Shi'a Muslimtradition in Pakistan's Express Tribune on December 8 spurred a firestorm ofcontroversy, as a number of commentators deemed it inappropriate or worse. Myargument was that religious adherents need to repudiate rituals that infringeon collective rights, and which can escalate sectarian conflict; these includethe rituals during the commemoration of Muharram, that can involve men and evenchildren flagellating  themselves withknives on chains, and processions of bleeding men as a display of adoration forthe martyred Imam Husain (this is byno means reflective of all Shi'a practice, but is widely practiced amongSouth Asian Shi'a).

The controversy grew more intense on Twitter, and evennotable commentators such as NasimZehra asked for an immediate apology from the Tribune on grounds that thearticle was "outrageously offensive."To her credit, Ms. Zehra later noted thatafter the apology the matter should be closed. However, hate mail from all over followed,including several messages to the president of the University of Vermont (whereI teach) asking for my dismissal, a surprising torrent against free speech evenfrom highly educated writers. The university noted that the article was wellwithin the confines of free speech and was in fact condemning violence. Insteadof admonishing me, the university offered me police protection.

Under pressure from sponsors and amid fears that other mediahouses would use this episode to spur a consumer boycott, Tribune decided tofirst edit and then completely remove the article, and noted that I was"banned" from writing in their pages again. My intention was never to rebukeShi'ism itself, but rather such rituals whose practice further leads toacrimony between Shi'a and Sunnis. Furthermore, a ritual with so much bloodbeing spilled in a procession can be a public health issue, and has been repeatedlyquestioned and curtailed in Iran, Syria, and Lebanon.

Ireposted the article on my site with a clear apology for specificstatements which were, in retrospect, inflammatory for Pakistan's religioussensibilities. The newspaper's "ban" on my writing was later edited out of the apology statement posted onthe Internet, but this episode left me deeply troubled about the state ofjournalistic independence in Pakistan. The country has a vibrant civil societyand promising career track for journalists and independent writers, but therehas been a rapidrise in abductions and murders of journalists whose views were consideredantithetical to certain religious perspectives.

This episode highlighted for me a larger issue of mediafreedom in a country which often prides itself in having private TV channelswith fiery talk shows blasting politicians. Yet religious debate, often socontentious and even violent in Pakistan, remains off limits. Pakistan as asociety needs to understand that the right to offend in journalism is afundamental right. I don't mind getting hate mail despite the norms of freespeech, but what surprised me was that educated people questioned my right tocriticize a cultural practice by referring to it as "hate speech." I wasrepeatedly asked what my point was if criticism could further cause conflict. Stillanother asked, "could you criticize Jewish rituals the same way in America?" Thiskind of reaction could have taken place in many Muslim societies -- and Sunnisare equally culpable on such matters as Shi'a.

Pakistan's infamous blasphemylaws are a result of exactly this kind of oversensitivity and pattern ofraising ire following any hint of criticism about religious rituals or edicts.The valorization of extreme religious edicts by the State has unfortunatelybeen successful in co-opting the sensibilities of even many educated citizens. Thisin turn has strengthened the religious establishment's efforts toinstitutionalize a radical inertia within the political system.  Perhaps unwittingly, liberal commentators whowould rather avoid tougher issues of dissent scorned my article, and by doingso strengthened the same kinds of arguments that fanatics use to marginalizeminorities or their opponents.

Ironically, in my article, I clearly stated that lawsagainst hate speech must be enforced. Speech that directly urges violence towardsany particular person or group of people must be avoided at all costs. Yet tounderstand sectarian conflict, which is often compared to "cancer," we have tolook at both proximate and systemic causes. Just as one treats cancer withchemotherapy, groups like Lashkar-e-Jhangvi(LeJ) need to be hunted down for terrorist crimes. But we also need to searchfor systemic causes of sectarian strife, which in Pakistan can be traced totheology in both Shi'a and Sunni doctrines as well as political interventionand alleged statesupport for sectarian groups like LeJ or Sipah-e-Sihaba Pakistan (SSP).

In a pluralistic society, the limits of what is allowed insuch cases can be debated and questioned, and laws can be passed and changedthrough democratic processes. For example, there are laws in some Europeancountries against questioning the historical validity of the Holocaust, but inthe United States, such historical questioning is protected by the firstamendment to the U.S. constitution (despite the repeated accusations by many Pakistanisthat American law and politics reflect undue Jewish influence). While Idisagree with the limitations on free speech in Europe, there is at least aworkable legislative pathway for repeal of these laws. In Pakistan, the prospectof any legislative change to errant laws is stifled by precisely the kindof bullying about religious sensitivity exhibited in this episode.

The duty of any socially conscious writer is to push theenvelope and challenge people to question their assumptions. This will makepeople uncomfortable, but incremental social change always happens through sucha dialectical process. If people were always trying to stray from controversy socialchange would never take place. Cultural sensitivity is far too often used as anexcuse for maintaining the status quo in places like Pakistan, and this needsto change if the country is ever to overcome the polarization that continues toimpede communitarian peace.

Saleem H. Ali is professor ofenvironmental studies at the University of Vermont's Rubenstein School ofEnvironment and Natural Resources and the director of the Institute forEnvironmental Diplomacy and Security at the James Jeffords Center for PolicyResearch. He can be followed @saleem_ali

The monsoon rains have historically brought mixed fortunes to Pakistan. While they help spur the cultivation of crops, changing demographics and population distribution have given rise to recurring catastrophes the rains leave in their wake. As Pakistan suffers from another cycle of floods in both rural and urban areas, recent weeks have seen the explosion of a dengue fever epidemic in central Punjab. In the past two weeks alone, more than 6,000 cases have been reported, with the majority occurring in Lahore. At least 40 deaths  have now also been reported. The extent of the epidemic is such that schools in Punjab have been closed for the last ten days.

Dengue fever is a mosquito-borne viral infection. While most cases present with non-specific symptoms such as fever and muscle aches, in about 1 percent of cases, the disease progresses to a more dangerous condition called "dengue hemorrhagic fever." In this condition, the normal human clotting process becomes deranged, resulting in spontaneous bleeding in patients, leading in some cases to death. In the appropriate context, dengue can be diagnosed without the help of any advanced laboratory tests. However, treatment options are limited only to supportive measures, such as providing anti-fever and pain medication, as well as using transfusions to combat platelet deficiency, though no "cure" or vaccine exists.

Dengue fever epidemics have become a cyclical nightmare in Pakistan over the last several years. The infection was quite rare in South Asia before the turn of the century, but starting in the last decade, dengue epidemics have become a regular occurrence, usually peaking in September and October. As the population in Pakistan grows or people move around in search of economic opportunity or safety from militant violence, settling in many places into overcrowded urban slums on the outskirts of cities like Lahore.

These slums are hotbeds of contamination, given that the proliferation of these ramshackle neighborhoods outpaces that of adequate infrastructure development. With hygienic practices already poor, they grow worse in such settings, where public sanitation is often subpar. The best measure to prevent dengue can be by halting the reproduction of mosquitoes or preventing mosquito bites. Mosquitoes reproduce in stagnant water, and unless widespread measures are taken to drain such collections or fumigate mosquito-prone areas, the insects continue to proliferate, helping spread infections.

The current armed conflict in Pakistan has also been a key driver of disease. The plains of Punjab provide a home to millions of internally displaced refugees who have moved away from the war-torn northeastern and tribal regions, bringing with them an increase in disease. Furthermore, war itself is known to be one of the most potent fomenters of infectious disease: Studies have shown that "complex emergencies" can cause a several-fold increase in infection rates.

But aside from these direct environmental factors fueling the spread of dengue, another potential cause of the infection's appearance might well be climate change. Like most other infections spread by an intermediary organisms (like mosquitoes), dengue transmission increases with atmospheric temperature and humidity, since higher temperatures and moisture optimize mosquito breeding.

Complicating this problem further is emerging evidence that Pakistan's mosquitoes are developing resistance to insecticide that is used to eliminate them.

Unfortunately, many of the factors contributing to dengue outbreaks, from poor hygiene and sanitation to climate change, are risk factors common to most infectious diseases. If no major changes occur, Pakistanis could be exposed to a host of epidemics, such as measles, pneumonia, and cholera.

One important reform would be to empower public health specialists to develop overarching strategies to reduce factors leading to transmission. However, the medical community in Pakistan is focused on other things, with young doctors in Punjab on strike for long periods of time this year protesting low wages. Given that there is such resentment among trainees, who form the backbone of the clinical work force, it is likely that these protests are also adversely affecting the response to the current epidemic, as there are fewer doctors available to try and stem the crisis.

Since neither cure nor vaccine exists for dengue fever, prevention is the only option to control the human and economic cost of the epidemic. While the local media has criticized the government's response, one has to consider that they are over whelmed by several public health crises spanning the length and breadth of the country simultaneously, such as the widespread floods, ongoing polio transmission and rampant malnutrition. Nevertheless, improving hygiene and sanitation, in addition to helping better-manage public infrastructure development and population growth, remain the only long term solutions for preventing dengue, and other infections, from breaking out.

Haider Warraich, MD, is a research fellow at Harvard Medical School. He is a graduate of the Aga Khan University in Karachi, Pakistan, and the author of the novel, Auras of the Jinn.

United States-Pakistan relations have been in free fall since the successful raid by Special Operations Forces on May 2nd  killed Osama bin Laden and several others in Abbottabad, Pakistan. Now an investigation by the Guardian has revealed details of an intelligence operation in the months prior to the raid that attempted to use a fake vaccination campaign to confirm the terrorist leader's whereabouts. The operation, which reportedly failed, attempted to use the pretext of a free Hepatitis-B vaccination to collect DNA on those living inside Bin Laden's suspected compound, hoping to match it with the DNA of his relatives. However, while few details about the operation are known, one thing is certain:  its existence will cause serious damage to legitimate domestic and international health campaigns in Afghanistan and Pakistan. 

Immunization programs in Pakistan already have a hard time convincing many to get vaccinated. In 2007, a polio-vaccination campaign in northern Pakistan failed to immunize 160,000 children, due to rumors that the vaccine was an American attempt to sterilize children. The rumors were at least partially spread by local clerics, who claimed that the polio-immunization drive was "a conspiracy of the Jews and Christians to stunt the population growth of Muslims." Some vaccination teams were even beaten after locals heard the rumors. In another case, a Pakistani doctor was killed in 2007 after working to fight anti-vaccine propaganda in Bajaur agency. And the risk to health workers has increased drastically in recent years. According to the Aid Worker Security Database, which tracks attacks against national and international humanitarians, only two aid workers working in Pakistan reported being the victim of attacks in 2004,  while by 2010 that number had risen to 28. Furthermore, the Red Cross claimed this month to have observed a spike in attacks against humanitarians, fueled in part by anger over the Abbottabad raid. Simply put, it has never been more dangerous to be a health worker in Pakistan.

Similar distrust towards health workers exists in Afghanistan. Taliban fighters have always had an uneasy relationship with vaccination teams and aid workers, suspecting they are government or Western spies. In 2007, Taliban fighters kidnapped one vaccination worker in Uruzgan province during a polio-vaccination campaign. They beat him and only released him after he promised to stop vaccinating children. It is not just vaccination efforts that are harmed by the rumors: less than a year ago a group of international and Afghan aid workers were hiking back from a three-week medical mission in the Hindu Kush mountains when they were captured and executed by gunmen. A Taliban spokesman took credit for the attack, claiming that the aid workers were spies.

Insecurity has a serious negative effect on health care in rural communities. The greater the personal risks, the greater the appeal for both national and international health workers to stay within the safety of major cities, venturing out only in large convoys. This so-called "bunkerization" diminishes the ability of health campaigns to target rural communities -- often those most in need of primary health care. The best way to overcome bunkerization is through building relationships with communities and local elites, allowing for the free movement of health workers in a region -- exactly the kind of thing undermined by the CIA's apparent operation.

Given the precarious relationship between health workers, militants, and civilians in many areas of both Afghanistan and Pakistan, the existence of a fake vaccination program ran by the CIA is likely all the evidence many need to accuse all vaccinators and health workers of spying. The end result will be fewer families willing to have their children vaccinated, and more attacks on health workers providing any manner of medical care to communities. Some people will no doubt say that the operation was a reasonable and necessary attempt to confirm bin Laden's location, and that nobody was directly put at risk as a result. Tell that to the next vaccination team in Abbottabad.

Christopher R. Albon is writer and researcher on public health in armed conflict, health diplomacy, and human security. Writes at Conflict Health, UN Dispatch, the US Naval Institute, and elsewhere.

Last December, I traveled to Peshawar, ground zero in Pakistan's fight against polio. As the capital of Khyber-Paktunkhwa (KP) and the Federally Administered Tribal Areas (FATA), this is where the debilitating disease needs to be stopped in order to prevent an explosive outbreak, one that can nonetheless be easily prevented by a cheap and safe vaccine. Of the 144 children across Pakistan paralyzed by polio in 2010, over half were from FATA, and 17 percent were from KP.  As a senior program officer at the Bill and Melinda Gates Foundation, my goal in going to Peshawar was to hear firsthand what was being done to bring polio under control, and see what more could be done to ensure that it disappears altogether, as it has in much of the rest of the world.

Over the past two decades, polio has been reduced by 99 percent globally. Yet the disease continues to paralyze children in Pakistan because the vaccine is not getting to every child. Why? In KP and FATA there are two main reasons. First, more than 25 percent of children in FATA are not being reached consistently because of a protracted and deadly conflict with insurgents. Another 10 percent of children are missed either because vaccinators fail to reach every home or parents refuse to immunize their children.

On January 25, however, the federal government stepped up its fight to end polio. Pakistan's President Asif Ali Zardari launched a National Emergency Action Plan for Polio Eradication, laying out a national blueprint to eliminate polio from the country. This includes formal plans for tracking progress on polio objectively and regularly, setting up national and provincial task forces, and engaging Pakistan's leadership in polio eradication activities. Two days later, His Highness Sheikh Mohammed bin Zayed, Crown Prince of Abu Dhabi, and Bill Gates announced a partnership to help polio vaccines reach 32 million children in Pakistan. Then, British Prime Minister David Cameron announced that his country would double its contribution to polio eradication, helping vaccinations reach an additional 45 million children around the world.

Despite all this good news, however, eliminating polio in Pakistan is not going to be easy. An incident that occured January 22nd offered a stark reminder of why, when a health worker in North Waziristan was kidnapped and killed while returning home from promoting polio immunization, demonstrating that security remains a daunting challenge to anti-polio efforts. And even a few small gaps in the vaccination campaign can undermine progress across the board. To keep the disease in check, Pakistan needs to achieve and sustain high levels of immunity in the population; any pockets that are left unvaccinated will serve to re-ignite the epidemic. Avoiding such holes requires that health workers who administer the vaccine are well trained and supervised, that vaccines arrive on time, and that immunization activities are closely monitored. When coverage falls below 90 percent, special efforts will be needed, either to re-vaccinate a given area or determine which children were left out the first time around.

One key component in both these efforts will be political will at all levels. In FATA and KP, I've seen important progress as the top political and administrative leadership have come solidly together behind a plan to stop polio. In FATA, the Pakistani Army's medical corps is closely involved in helping to support immunization activities, and committees have been set up to liaise with other civilian health workers. The next step will be to lay out detailed micro-level plans that get vaccinators into areas where they could not go before. In areas controlled by insurgents, their leaders are also being approached in the hopes that they will allow vaccinators to safely and easily access children.

The Pakistani government and its U.N. partners are also working closely with religious leaders to ensure polio vaccines and other immunizations are accepted by the population. Some parents have refused polio vaccines because of misconceptions about the effects of polio vaccination -- for example that they could cause infertility. But the outreach is yielding results: The proportion of families in accessible areas who refuse vaccination dropped from 3 percent to 0.06 percent in the December 2010 campaign.

The benefits of the polio program go beyond preventing the spread of just this crippling disease. Following the "super flood" in Pakistan last year, polio eradication staff and resources helped track and prevent the spread of communicable diseases such as cholera in affected areas. Polio teams also help prevent other diseases, communicating with families on why immunization can save their children's lives. As more children get immunized from diseases such as measles, hepatitis and pneumonia, thousands of lives are saved each year.

Globally, there is also quite a bit at stake. Fighting polio is like fighting a fire. If it is not completely put out, it can spread fast and reappear in places where it was previously eliminated. Afghanistan, which faces similar challenges to those in Pakistan, has made tremendous progress on eliminating polio, so we know it can be done even in the most challenging environments. Since December 2010, vaccinators in Afghanistan have reached 25,000 more children who were previously inaccessible. The number of polio cases country-wide is down to a near record low, and contained within just two provinces - Helmand and Kandahar.

Launching an aggressive effort to finally eliminate polio in Pakistan is a necessary precondition to a polio-free world. The tools and strategies are in place, now more than ever, and Pakistan has the opportunity to build on international support to eliminate polio once and for all.

Michael Galway is senior program officer at the Bill & Melinda Gates Foundation.

The floods in Pakistan in 2010 were massive. The rains affected the length of Pakistan, maximally impacting the provinces of Khyber-Pakhtunkhwa (KPK), Punjab, and Sindh as well as parts of Baluchistan. Flooding displaced more than 20 million people and covered about one fifth of Pakistan's arable lands -- an area roughly equal to the U.S. eastern seaboard. This flood affected more people than the 2005 Kashmir earthquake, Hurricane Katrina (2005), Hurricane Nargis (2005), the Indian Ocean tsunami of 2004, and the 2010 Haiti earthquake combined. Irrigation systems were destroyed, crops ruined, and seed stockpiles devastated. More than six million heads of livestock (including poultry) were killed. Yet, amazingly, only 1,985 people perished while another 2,946 were injured.

Given the population density of the affected regions, the poor infrastructure, and the baseline level of poverty, these figures are astonishingly low. In spite of the physical destruction, the fact that fewer than 2,000 Pakistanis died suggests that the Pakistani government did something very well last summer. Amidst numerous ongoing internal security crisis, political challenges and shortfalls of international assistance, Pakistani agencies continue to manage this crisis well despite the serious challenges that remain.

Read on