Sajid Azam, 30, belongs to the minority Christian community in Karachi, Pakistan. He has two children, and his only source of income: cleaning the city's sewers.

"I feel suffocated while working in the manhole. Sometimes I find pieces of glass or used syringes during manual cleaning. I have no medical support from the government. I am compelled to do this work as I have no other option to earn a livelihood," Sajid Azam, a sanitary worker in Karachi, told DW.

For 10 years, Azam has worked without proper safety gear. "I have an iron rod, hammer, chisel, bucket and rope to clean the sewerage hole. We do not have masks for safety purposes," he said. 

Manual cleaning comes at a cost. Skin diseases now affect Azam and his family.

A sanitary worker died during manual sewer cleaning.

Medical experts also say that sanitary workers are at serious risk due to exposure to solid waste. "Most of them are Hepatitis - A, E and B and C also. After that skin fungal infection and then scabies and then HIV - so among infections these are the major causes of all the infections in the sanitary worker," Shamail Zia, a dermatologist, told DW.

Government officials claim safety kits are provided — but many workers don't follow the procedures. "The government and municipalities ensure the safety of sanitary workers. However, unfortunately, many staff members do not comply with safety measures or follow the rules. That's why some incidents occur," accordiong to Daniyal Alishan Siyal, a spokesperson for the Karachi Metropolitan Corporation.

Officials say machines are being introduced to replace manual sewer cleaning, but it's unclear if this shift will truly improve conditions — or leave some workers behind. 

Sanitation work in Pakistan is deeply stigmatized — seen as a caste-based job tied to religious minorities like Christians and Hindus. 

"We are Christians, and we cannot escape that. The only jobs available to us are sweeping roads or cleaning sewer holes. No white-collar job is written in our fate here," Azam said. 

Pakistan lacks an anti-discrimination law — despite its international human rights obligations. Article 25 of the Constitution omits caste as a protected category. Amnesty International found 44% of sanitation workers face discrimination because of their profession.

Despite the hardships, Azam believes his struggle will lead to a better future for his children. "We inherited this work from our forefathers. But I want my children to have a bright future — even if mine is destroyed."