For healthcare workers, Torkham border crossing connecting eastern Afghanistan to neighbouring Pakistan straddles one of the most important regions in the world: Close to the border are some of the world’s few remaining reservoirs where the polio virus is endemic.
While Afghanistan is seeing fewer cases than its much larger neighbour, the country faces an uphill struggle because of large unvaccinated populations just over the border in Pakistan’s Federally Administered Tribal Areas (FATA).
Since the beginning of 2014, three polio cases have been registered in Afghanistan - one more than in the same period last year. The genetic lineages of all three cases, according to the UN World Health Organization (WHO), indicate that the three children were infected by viruses which are currently circulating in Pakistan.
This past week alone, according to the Global Polio Eradication Initiative, six new polio cases were registered in FATA and Khyber Pakhtunkhwa Province - putting Pakistan’s total number of cases this year at 21.
The mountainous terrain, an open border where tens of thousands cross daily, poses a big challenge for those trying to ensure that each and every child under five is vaccinated, according to Kshitij Joshi, the UN Children's Fund (UNICEF) press officer.
He says their main aim is to nip potential outbreaks “in the bud” and clamp down on cross-border infections “so it does not spread, or, more proactively, make sure there is enough immunity in Afghanistan that even that does not happen.”
Here on the Afghan side of the Torkham border crossing, teams of vaccinators work around the clock. Young porters pushing carts carrying women and children are directed off the main border crossing walkway and into a small enclosure. Every child under the age of five is given two drops of the vaccine; they get a mark on the finger to confirm that they have been vaccinated and then they are free to go.
According to WHO figures, 2,700 children are vaccinated at the crossing each day.
“All the families here know that the vaccine is good for the health of their children,” a mother of five from Jalalabad told IRIN. “Those who oppose it don't know about its benefits. If they did, they wouldn't oppose it.”
Still, one man carrying his child pushes his way through the line, refusing the vaccine.
An emerging hotspot
In previous years, according to a Centers for Disease Control and Prevention report (CDC), provinces in the volatile southwest of the country such as Helmand and Kandahar were the main areas of concern in the fight against polio.
After 80 cases were registered nationwide in 2011 there was an upsurge in staff numbers, training events and campaigns.
The investment in the south bore fruit. “Despite continuous insecurity”, says the National Focal Point for Polio Eradication (NFPPE) 2013 annual report, “Afghanistan succeeded to interrupt transmission of wild polio virus in the southern provinces for a period of nearly one year (November 2012 to December 2013) and in the south-eastern provinces throughout 2013 up until the present.”
However, according to CDC, while the percentage of unreachable children in the south decreased by 43 percent, it increased by 122 percent in the east.
While challenges remain, one of the greatest successes in eastern Afghanistan so far, health workers say, has been the ability to maintain neutrality or de-politicize the vaccination programme.
“The achievement of the whole programme has been the neutrality aspect and that is how we have been able to gain assess into these [insecure] areas,” Joshi told IRIN.
“The way we have positioned the programme is just for the children of Afghanistan. There is no differentiation between what party you belong to, or what ideology you follow - it is purely about the health and well-being of the children.”
Yet, eastern Afghanistan is still home to a multitude of militant groups. The Pakistani Taliban or TTP, who publicly banned polio vaccinations in Pakistan in 2012 in response to the killing of civilians in drone attacks, holds sway in many areas.
As Nangarhar grows increasingly insecure, many districts have become inaccessible even to those from the province. Residents who spoke with IRIN said they have moved from their villages in the districts to the main city, Jalalabad, because of insecurity.
“The government does not even go there,” said one resident from Achin bordering Pakistan. “There is no government, it is all Taliban and these people [militant groups].”
“Even in my village there is no government. It used to be safe, but now foreign fighters have come in from over the mountains.”
According to Dr Shahla, who like many Afghans only has one name, the provincial communication officer in charge of the polio section in the Afghan Ministry of Public Health, the vaccinators do see refusals, but these eventually get dealt with by the Immunization Communication Network (ICN).
“The campaign is implemented in all 22 districts of Nangarhar. We have one small problem area, Lal Pura. We have one small cluster there that is inaccessible for us, otherwise all other districts in Nangarhar don't have any problems.”
The ICN - in nine of the 22 districts - works with community elders and leaders, sharing information and explaining the importance of polio vaccinations.
Tapping into the community through dialogue with local `shuras’ [councils], and `shura’ members, has proved successful in getting into the problematic areas, said Joshi.
“It is a slow and gradual process but, yes, eventually they do understand the importance of vaccinators and vaccinations in the area and we are given access into those areas as well,” said Shahla.
“However, it keeps changing, it shifts. It's not that there is only one area that remains inaccessible permanently; it keeps on changing, and it’s not the entire district as well, it’s only a few clusters here and there, and that also keeps shifting. So we get access in a couple of rounds and then it may stop one fine day, and then again, a few months later the same area will be open to you again.”
According to reports, last year nine of the country's 34 provinces saw a 40 percent increase in security incidents involving public health facilities, staff and patients.
However, unlike Pakistan, where vaccinators have been continuously targeted, abducted and killed, teams here told IRIN they have not come under any threat.
“I have worked here for around five years,” said Rana, the sub-district coordinator for the Afghan Ministry of Public Health “and no, we have not had any problems yet - we have not had any security incidents.”
However, the murder of two polio immunizers on their way back from an awareness campaign in Afghanistan’s central Uruzgan Province last year underscores the dangers.
Despite growing insecurity across the country, the number of polio cases has dropped, unlike in neighbouring Pakistan. Last year, according to UNICEF, 14 new polio cases were recorded in Afghanistan, compared to Pakistan’s 93, although the latter has a far larger population of 182 million compared to Afghanistan’s 31 million. In 2012, 37 cases were registered in Afghanistan as opposed to 58 in Pakistan.
Now, with anti-polio campaigns every six weeks and vaccination teams permanently located at Torkham, healthcare workers here are hoping to stop transmission of the virus in Afghanistan by the end of this year.