Polio Doesn’t Respect Borders — But Neither Do Vaccines

Author: Lynzy Billing

Ebrahim Noroozi/AP

Jibran Khan has been a polio vaccinator on the Pakistani side of the Torkham border crossing for the past 10 years. It’s a key crossing, connecting Pakistan’s Khyber Pakhtunkhwa province with Nangarhar province in Afghanistan.

In early October, Pakistan announced that it would arrest and deport foreigners it said were in the country illegally, giving a deadline of Nov. 1 for a return to their native homes. This meant that more than 1.7 million Afghans would need to leave.

Since October, almost half a million Afghans have left Pakistan, flooding into Afghanistan.

34-year-old Khan and his fellow cross-border vaccinators were vaccinating as many as 27,000 people a day at the time, he told Global Citizen.

“This week, it's been about 4,000 a day,” he said.

Vaccinators stationed at the Torkham border have administered 1,318,718 polio vaccinations this year, according to the Pakistan Polio Eradication Programme. 

Of those, a total of 386,206 vaccines were administered to Afghans returning from Pakistan to Afghanistan from the beginning of October to Dec. 7.

Since it was launched in 1988, the Global Polio Eradication Initiative (GPEI) has made steady progress on eradicating polio. Afghanistan and Pakistan are the only countries in the world where wild polio remains endemic and where the final push towards eradication has proven the most difficult. 

In 2023, Pakistan reported six cases of wild type 1 poliovirus infections. Afghanistan also reported six casesall cases were detected along the Pakistan border. Pakistan reported 20 cases in 2022, and Afghanistan reported two.

While Pakistan has moved forward in its fight against polio over the past year, vaccinators at the border are concerned that polio cases could rise again with Afghans returning to Afghanistan after Pakistan’s announcement to deport them.

Taliban fighters stand guard as Afghan refugees wait to register in a camp near the Torkham Pakistan-Afghanistan border in Torkham, Afghanistan, Saturday, Nov. 4, 2023
Image: Ebrahim Noroozi/AP

In March 2019, GPEI introduced a new tactic in its effort to defeat poliovirus circulation, with Afghanistan and Pakistan introducing all-age polio vaccination for travelers crossing the international borders. This program was launched to increase general population immunity against polio and to help stop the cross-border transmission.

Khan is a lead supervisor at the Torkham border. He is one of 13 leads working with 60 teams, made up of three vaccinators each, who are stationed across four points on the Pakistan side of the Torkham border. On the other side of the border, there are another 48 teams, operating out of 12 sites. The number of teams working each day varies.

Khan and his team screen everyone going into Afghanistan from Pakistan, looking for children’s finger marks (that would indicate they were vaccinated) and checking adult vaccination cards. Even if they have been vaccinated before, anyone over the age of 10 must be vaccinated again at the border crossing, Khan explained.

People — And Polio — Travel

GPEI is midway through its 2022-2026 polio eradication strategy, which aims to eradicate all poliovirus transmission in endemic countries, stop cVDPV transmission (vaccine-derived polio), and prevent outbreaks in non-endemic countries.

A vaccinator holds up the polio vaccine as she prepares to vaccinate a child in Kabul, Afghanistan.
Image: Photo by Lynzy Billing

But the battle to beat polio, once and for all in Afghanistan and Pakistan, is complicated by the fact that travelers go between two infected communities, Hamid Jafari, director of the World Health Organization’s regional polio eradication program, told Global Citizen.

However, the recent influx of people traveling between the countries also provides an opportunity. Vaccinators at border crossings now have the chance to screen and vaccinate moving populations, Jafari explained. 

“Catching these travelers means you’re bringing down the risk of cross-border transmission of the highly infectious viral disease,” he said.

He points out that this is not only about offering protection for someone crossing the border, who may end up in a community that is infected.

“If somebody is infected with wild poliovirus, the vaccine is not going to kill the virus, they will continue to excrete the virus,” Jafari said. “The idea is that it's not about this one individual — it's about everybody crossing the border, so that if this one infected individual crosses the border and visits or settles in a community of migrants, at least people who have been moving (and back and forth between these communities) are protected, and the virus doesn't begin to circulate in these communities.”

When it comes to eradicating polio, Jafari says that the final infection is likely going to be among mobile and hard-to-reach populations.

A vaccinator marks a child’s hand after they receive the polio vaccine at a hospital in Kabul in November 2022. Vaccinators at the Torkham border screen people crossing, looking for children's finger marks and checking adult vaccination cards.
Image: Photo by Lynzy Billing

“This is such a long border with millions of people crossing each year, so it's also an important opportunity to improve vaccination of those people who are harder to reach, living in remote or inaccessible areas,” he said. 

As well as being stationed at international border crossings like Torkham, vaccination teams — sometimes known as transit teams — are also at major inter-provincial borders, district borders, and locations like checkpoints and bus stops, with the goal of catching people on the move.

Cross-border vaccination teams work on both sides of the Torkham border, giving polio vaccinations as a supplementary dose to the routine childhood immunizations given at 6, 10, and 14 weeks old.

Jafari said that the vaccinators stationed at the border are used to vaccinating tens of thousands of people crossing weekly, but they have had to add teams to help with an increase in vaccinations since Pakistan started deporting people back to Afghanistan.

Mapping a Population on the Move

Afghan refugees settle in a camp near the Torkham Pakistan-Afghanistan border, in Torkham, Afghanistan, Nov. 3, 2023.
Image: Ebrahim Noroozi/AP

“A lot of movement happens at the border, but people actually eventually land somewhere and getting to them there is very, very important,” Jafari noted. 

Once they have crossed the border, the next important step is mapping where people settle to ensure that they are included in future vaccination campaigns.

Jafari says that in close coordination on the Afghanistan side with the International Organization for Migration (IOM), UNHCR (the UN Refugee Agency), and the Afghan government, they have established registration centers, where they process everyone coming in and screen them for health services.

“Some travelers are going to UNHCR camps and WHO and other partners are cooperating with them to make sure that the children there are vaccinated and the registration is giving an indication of where people are headed,” Jafari said.

Borders Offer New Opportunities

While the borders allow health workers to reach more people, educating travelers about polio and the benefits of its vaccine remains the greatest challenge for the vaccinators, according to Khan.

He says that the vaccinators hand out pamphlets printed in Urdu and English, but often find that they need to explain them in Pashto.

Afghan refugee children warm themselves with fire in a camp near the Torkham Pakistan-Afghanistan border in Torkham, Afghanistan, Nov. 4, 2023.
Image: Ebrahim Noroozi/AP

Five to 10 children the vaccinators see each day at the Torkham border have never received any polio vaccination, he said. Some people refuse the polio vaccine because they come from a remote rural area and have not yet been reached by house-to-house vaccinators, or they turn it down due to religious reasons. Khan also said that some think the vaccination is not good for their health.

There are still communities far from the border thar are anti-vaccination, he says, and vaccinators face an uphill battle to reach and convince these isolated communities about the benefits of immunization.

“Some say, ‘There are dozens of other diseases that we see, why do we need a polio vaccination,’” he said.

“The reality is that at the border crossing, there isn't much time for explaining the polio vaccination,” Jafari acknowledged. “That's not the place to create awareness. You just don't have time for that kind of a conversation.”

“Informing the general public about polio and why it's important to vaccinate their children happens during house-to-house vaccination on both sides of the border,” he says. “Except for in a very few pockets of specific migrant communities, who are not from the local area, we don't really see a lot of rejection and refusal of vaccination when we do house to house.”

While visual posters saying that vaccination is required to cross the Torkham border are seen by travelers, Jafari notes that not everybody can read.

Still, despite this, he argues that most people do not resist getting the polio vaccine at the border because the Torkham border is not generally the first time travelers have encountered a polio team. 

“They encounter them in their neighborhood, their households … at other crossing points, so it's not something that they are completely unfamiliar with,” he says. “This has been going on for years now, so many of the people who frequently cross the border are very familiar with it, they have their vaccination cards ready … and are accepting and see this as part of the process that they have to go through to cross the border.”

While not everyone Khan is seeing has been reached by house-to-house vaccination teams and awareness campaigns, the teams at the border are doing their best to fill in the gaps.

“Obviously the situation is complex and it would be unrealistic to expect that you'll get 100%,” Jafari said. “But I think we are getting the vast majority of these families that are moving back [to Afghanistan], about 90% in a massive wave of people.”

Reaching Beyond the Borders

On Dec. 5, Shaista was waiting to enter Afghanistan with her 2-year-old son. She had been living in Peshawar and was leaving to avoid arrest or deportation, she told Global Citizen.

They arrived that morning in the cold, bundled in the back of a truck with one small bag of belongings.

The young woman originally came from Achin district of Nangarhar province, long a poliovirus hotspot, but she had moved to Pakistan a year earlier.

Her son had never been vaccinated. A single mother household, there was no male family member to accompany her to a health center when she was living in Achin, she says, and no vaccinators came to her home.

At the crossing, she was told that the baby would be vaccinated.

“I let them do it,” she said. “But I don’t understand. I can’t read the book they gave me.”

Shaista is not alone. Afghanistan’s illiterate population (age 15 and above) has been estimated at 12 million — of which 7.2 million are female.

Afghan refugees return to Afghanistan through the Torkham Pakistan-Afghanistan border, in Torkham Afghanistan, Friday, Nov. 3, 2023.
Image: Ebrahim Noroozi/AP

Women make up 80% of Afghan returnees, according to a November report by Gender in Humanitarian Action (GiHA), which also notes that women-headed households may be harder to locate in their areas of return because they are largely isolated in their homes and risk being excluded from assistance. 

Shaista does not know where she will go after crossing the border. She has no relatives to return to and there is no proper shelter at Torkham border to starve off the near-freezing temperatures. Families in makeshift camps at the border with nowhere to go face limited access to drinking water, no toilets, lighting, or heating source other than open fires.

Pakistan’s expulsion of Afghans has placed a heavy burden on the cross-border teams to reduce the threat of growing virus transmission between the two countries. Khan said that the vaccinators are working around the clock to cater to an influx of people they have not seen so high since 2016.

Khan feels that cross-border teams are filling their most critical role yet so that their progress in fighting the virus is not lost. 

“For polio, there is no compromise,” he said. “We must vaccinate everyone.”

Disclosure: This article is part of a polio content series that was made possible with funding from the Bill and Melinda Gates Foundation.

Produced and edited by Jackie Marchildon and Olivia Kestin