The final frontier

How one town nestled between Afghanistan and Pakistan is crucial to the fight to end polio

The town of Torkham, on the border between Pakistan and Afghanistan, is crucial to hopes of eradicating polio in two of its last strongholds.

The border town of Torkham more resembles a bustling marketplace than Afghanistan’s busiest crossing point. It is early, but gaudily painted trucks are already fighting for with buses, cars and carts for space, as crowds of Afghans jostle to pass through to Pakistan. The town in the eastern Nangarhar province is a vital gateway to the subcontinent for the 30,000 people that cross back and forth every day. It is also the staging ground for one of the last battles against polio, a scourge that as recently as 1988 raged across the region, paralysing or killing thousands of people each year.

Vast vaccination drives have herded the virus into only three countries: Afghanistan, Pakistan and Nigeria. Fewer than 250 cases were reported worldwide in 2012, but that is not enough to declare victory. Just one in each 200 cases of polio leads to paralysis, with the remainder causing feverish, flu-like symptoms or no signs of illness at all. For every paralysed child, then, a further 199 may be spreading the virus.

Until polio is wiped out in these final three nations, the risk of it infiltrating other states remains high. In Egypt, which has been free of the disease since 2004, a strain of wild poliovirus was found swirling in Cairo’s sewers in January. The World Health Organisation (WHO) believes it was likely imported from north Sindh, Pakistan.

Torkham is a microcosm of the fight to extinguish this disease. Afghanistan and Pakistan repeatedly re-infect one another with polio strains carried silently across the border by throngs of migrants. The crossing has become a focal point for vaccinators, who work exhaustively to stop transmission. Health workers, some wearing World Health Organisation armbands, can be seen weaving among clusters of veiled women to stop girls in bright shawls and small boys in baggy salwar kameez. Those found without a black ink stain on their finger, the mark used by field workers to denote vaccination, are inoculated on the spot. Around 2,000 children are immunised each day, scouted out by teams on both sides of the border.

Government backing

Governments in both countries have thrown their weight behind this final push to eradicate polio, ensuring a depth of support that was lacking before. Afghanistan’s President Hamid Karzai signed a national polio eradication plan in September, assigning a focal person to deliver updates directly to him. In Pakistan, the daughter of President Asif Ali Zardari is an ambassador for the eradication effort. Asifa Bhutto Zardari spoke out in December after the murder of field workers in Karachi and Peshawar by suspected militants, pledging to ramp up security to ensure planned vaccination drives could continue.

“We cannot allow these people to dictate what we can and cannot do,” she said. “The polio vaccine can save millions. It is not against Islam to promote healthy children.”

It is an uphill battle. To reach pockets of unimmunised children, workers must go door-to-door in the mountainous tribal lands surrounding the border, chalking fractions on doors to show how many of the household’s offspring have been inoculated. Not all are made welcome. Rumours of vaccines being a Western plot to sterilise Muslim children, or a front for Western spying networks, can scare some families into refusing the vaccine. In Pakistan, more than 70 per cent of polio cases can be traced to the country’s Pashtun community, a conservative ethnic group with a high rate of vaccine hostility. Health workers have learned to lobby religious leaders and tribal elders for support: with their approval, doors open.

Progress is slow but steady. Pakistan saw 35 cases of polio in 2012, according to the Global Polio Eradication Initiative (GPEI), down from 89 the year before. Afghanistan’s caseload fell to 17, down from 27 cases in 2011.

It is expensive work. Each dose of oral polio vaccine costs around $0.14, but the medical costs of transporting and distributing it are far higher. The Islamic Development Bank recently pledged $227m in financing to Pakistan to fight the virus but more is needed. The GPEI calculates that an annual $1bn spent wiping out the last traces of the virus over the next few years could save up to $50bn over the long term, eliminating the burden of treatment costs and the need for huge immunisation campaigns.

For now, Torkham’s field staff must keep the pressure on, vaccinating intensely to reduce the pool of unprotected children vulnerable to infection. If they, and others like them, succeed, polio will join smallpox as the only other virus in human history to be wiped out in the wild. Millions of lives may depend on it.