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One scorching Monday morning in April 2019, Shahzad Khan stood at the Rashakai toll plaza in Pakistan’s northwestern Khyber Pakhtunkhwa province with a blue cooler slung over his shoulder. The toll plaza, which sits unassumingly on the broad, dusty lanes of the country’s M1 highway, is a gateway to the rest of the province and Afghanistan, which is located just two hours away. As vehicles approached the kiosk, Khan raced up to them with his icebox of polio vaccines, under the protective eye of an armed police officer. Khan was stationed here with a mandate to administer the vaccine to every child under the age of five who passed through the porous borderlands between Pakistan and Afghanistan, two of only three countries in the world where the virus has not yet been eradicated.
Around 10 a.m., a small truck carrying a wedding party of several women wrapped in white chadors pulled up. Sharp, celebratory ululations rang out from the back of the vehicle. Khan and his fellow vaccinators moved quickly: The mothers cradled their young children near their chests, and the health workers circled the van and administered oral vaccination drops to each bawling child. As they rode off, the mothers waved their children’s purple-stained fingers, the mark of a successful vaccination. The team was not always so lucky. “There are people who don’t stop,” said Khan, “but we can’t really do anything about them.”
The highly permeable border between Pakistan and Afghanistan represents one of the only places left in the world where new polio cases are being reported. So far in the first seven months of 2019, Pakistan has already logged at least 45 cases, while Afghanistan has 11. Transmitted primarily through fecal-oral contact, such as by the consumption of contaminated food or water, poliomyelitis was eradicated in the United States in 1979; in the decades since, a major international effort has been underway to uproot it from its last bastions. While these efforts have almost universally succeeded, in Afghanistan and Pakistan, health officials say the constant movement of people across the border allows children to fall through the cracks of vaccination campaigns.
Much of the traffic across the Afghanistan-Pakistan border occurs because it bifurcates the homeland of the region’s Pashtun ethnic group. Marriage and tribal ties crisscross the border, as do an untold number of individuals who regularly enter Pakistan for work, medical services, or school. As people cross the border, some carry the polio virus from one country to the other. Health officials who monitor different strains of the virus through sewage and stool samples have been able to trace its path as it spreads along two main corridors—the northern route through eastern Afghanistan and Pakistan’s Khyber Pakhtunkhwa province to its capital Islamabad, along which Khan was stationed, and a southern route from southern Afghanistan through Pakistan’s Balochistan province to Karachi, the country’s largest city.
“Pakistan and Afghanistan are considered one epidemiological bloc,” said Carol Pandak, the director of the PolioPlus program at Rotary International. “It doesn’t matter that there are two countries. There is a shared reservoir of virus.” Where people don’t obey borders, neither do viruses, making health officials mutually dependent in their fight against disease.
Shahzad Khan, far right, and a fellow vaccinator immunize a child at the Rashakai toll plaza in Pakistan
According to Pandak, extinguishing the virus partly depends on immunizing high-risk, mobile populations that move from one area to another. Normally, vaccinators carry out immunization campaigns by going door-to-door in settled areas, placing chalk markings on the door of each house they visit to reflect the number of children vaccinated that day. To reach more transient populations, health workers have established vaccination points at hundreds of “permanent transit posts” across the country. These range from highway stops like the Rashakai toll plaza to airports, bus stations, and bazaars—wherever transient populations like refugees, traders, and travelers congregate. Such permanent transit posts are made all the more essential by the fact that immunization against the polio virus requires multiple rounds of orally administered vaccinations and an injection, not just the single shot.
“Our borders are not closed,” said Ujala Nayyar, a surveillance officer for the World Health Organization, which tracks the virus’s movement. “Pakistan and Afghanistan are exchanging the virus with each other.”
Administering the vaccine is not simply a logistical challenge, however. It is also deeply interwoven in long-standing political conflicts that, like the virus, have traveled back and forth across the border. After the Soviet Union invaded Afghanistan in 1979, the United States, Saudi Arabia, and Pakistan began to funnel money and arms to the mujahideen, a segment of which later became the Taliban—Afghan students who had come to Pakistan for their religious education and were willing to return home and take up arms. The group’s success translated into political power across the border in Kabul, until it was toppled by the U.S.-led invasion of Afghanistan in 2001.
Since then, both Afghan and Pakistani Pashtuns have sought refuge across the border from military campaigns at home. In Pakistan, this has produced major refugee settlements for Afghans in Karachi and Islamabad. Despite periodic government expulsions, Afghan refugees have eked out a place for themselves in Pakistan’s metropolitan centers and, depending on political tensions, sometimes return to Afghanistan to meet with their families after long periods of absence.
In recent years, the Pakistani government has responded to criticism that the permeability of those borderlands has facilitated the flow of militants by beginning a project of building 1,600 miles of fencing between the countries. It was in part that porousness that allowed Osama bin Laden to slip into Pakistan and evade immediate U.S. capture for nearly 10 years. As part of the effort to eventually apprehend him, the CIA used a fake hepatitis vaccination campaign as cover, going house to house to ferret out information. In recent years, the legacy of this duplicity is a paranoia that’s hard to shake, complicating efforts to conduct an actual polio campaign in both Afghanistan—where the Taliban is resurgent—and neighboring Pakistan. Although the two countries synchronize immunization days each month, sending technical teams back and forth, for the past several years, the Afghan Taliban has intermittently suspended the vaccination program in key areas of the country. Most recently it has banned door-to-door vaccinations primarily in southern and eastern Afghanistan under the pretext that spies might be behind the project.
The Taliban’s antivaccine stance has the potential to create its own deadly consequences. In Pakistan, there has been a fear of a spillover effect: health officials worry that unvaccinated Afghan children might end up in Pakistan, or children in Pakistan might travel to Taliban-controlled areas of Afghanistan where they would miss routine immunization. According to Aziz Memon, the chairman of the Pakistan National PolioPlus committee for Rotary International, missing even one dose of the required rounds of the vaccine will jeopardize a child’s path to immunity against the virus.
A child shows his hand after being vaccinated in northwest Pakistan.
The problems raised by such suspicions extend well beyond border regions and transit posts, reaching into the heart of the country’s settled areas. In the narrow, muddied gulleys of an Afghan refugee camp on the outskirts of Pakistan’s capital, Islamabad, a 40-year-old polio vaccinator named Asiya Shazadi said that she plays a cell phone video, shared on government social media platforms, if she encounters resistance. Misconceptions about the vaccine are rife: Some residents believe the vaccine is made with pork or un-Islamic ingredients, and that it induces nausea or death.
Indeed, a mixture of religious and political fears have not only stoked parental resistance to vaccination but also directly endangered the lives of health workers. At the Rashakai toll plaza, Khan said that rumors still swirl among Afghans and Pakistanis that the vaccine is a Western project to sterilize Muslims. “We explain to them that it won’t cause any disease and it’s beneficial for children,” he said. But like Afghanistan, Pakistan has been roiled by opposition to the vaccine, with militant groups openly pledging to attack vaccinators. In 2012, a Pakistani Taliban fatwa proscribed the vaccine, sparking a campaign of violence. This past April, several health workers and security officials were killed, pushing the tally to more than 90 since 2012.
Still, health workers like Shazadi have been able to build some trust with the communities where they work. She used to work as a teacher in the refugee camp; many of her students still recognized her when she knocked on their doors. Those relationships have been essential to the success of Pakistan’s vaccination campaign, which has managed to whittle down cases from a high of more than 300 cases in 2014 to more than 45 today. Pakistan’s team of a quarter million vaccinators are exclusively local and overwhelmingly female. Their gender allows them to enter domestic spaces that are off-limits to men, and the reliance on local vaccinators has helped calm suspicion about the vaccine being a foreign-backed project.
Asiya Shazadi, a polio vaccinator, visits an Afghan refugee camp on the outskirts of Islamabad, Pakistan, during a polio campaign this past April
Still, for health experts, Pakistan’s halting polio eradication campaign has suffered setback after setback, with the target date for eradication shifting each year. “The way the polio virus is in Pakistan is completely out of control,” said Nayyar. This year, Pakistan even exported a strain of the virus to neighboring Iran. Though it was detected only in sewage samples there and did not present in a human case, the event was worrisome because it indicated that Pakistan’s uncontrolled borders were still allowing the virus to move, despite a stringent travel regimen that requires every traveler leaving Pakistan to brandish proof of vaccination at airports.
Sitting in the refugee camp, 35-year-old Khair Muhammad gave an honest assessment of the fears that come with the decision to vaccinate. “We know that the vaccine is good for our children,” he said. During this year’s April immunization campaign, however, Pakistani social media was afire with misinformation that the vaccine was poisoning children, sparking a public panic that saw a health facility in Peshawar attacked and destroyed by a mob. “My wife was scared,” said Muhammad, whose family hails from Afghanistan’s Laghman province. Despite their anxieties, they vaccinated all four of their children.
“The people from Afghanistan are understanding the problem and accepting the vaccine,” said Muhammad Shah, a policeman who trailed behind the vaccinators in the refugee camp. As they stopped at one door, a vegetable-cart puller named Imanullah picked up his 1-year-old son, Rehmanullah. Imanullah, who goes by only one name, said he came to Pakistan from Tagab, Afghanistan, to earn money and work in the country. “We are happy here,” he said. “We are giving the vaccine to children because it’s good for their health.”
As for polio, Imanullah believes both countries can vanquish the common threat. “I am praying that the polio virus will be eliminated soon, but God knows better than I do about when that will happen.”
If you want more border stories, check out this additional package which explores how the borders that divide and surround Europe affect the lives of the people living near them.