Authors: Atul Gawande
This approach, Sabin argued, could be used to eliminate polio from entire countries, even the world. The only leader in the West who took him up on the idea was Fidel Castro. In 1962, Castro's Committee for the Defense of the Revolution organized 82,366 local committees to carry out a succession of weeklong house-to-house national immunization campaigns using the Sabin vaccine. In 1963, only one case of polio occurred in Cuba.
Despite those results, Sabin's grand idea did not catch on until 1985, when the Pan American Health Organization
launched an initiative to eradicate polio from the Americas. (Six years later, Luis Fermin Tenorio, a two-year-old boy in the town of Pichinaki, Peru, became the last polio victim in the Americas.) In 1988, spurred by the campaign's growing success, WHO committed itself to eradicating polio from the world. That year, Rotary International pledged a quarter of a billion dollars for the effort. (It has since provided 350 million dollars more.) UNICEF agreed to organize the worldwide production and distribution of vaccine. And the United States made the campaign one of the CDC's core initiatives, supplying both expertise and considerable additional funding.
The centerpiece of the effort has been what are called national immunization days--three-day periods when all children under five in a country are immunized, regardless of whether they have received immunization before. In one week in 1997, 250 million children were vaccinated simultaneously in China, India, Bhutan, Pakistan, Bangladesh, Thailand, Vietnam, and Burma. National immunization days have reached as many as half a billion children at one time--almost a tenth of the world's population. Through such efforts--and a reliable network of monitors to detect outbreaks--the WHO campaign has brought the incidence of polio in the world to less than 1 percent of what it used to be.
The striking thing is that WHO doesn't really have the authority to do any of this. It can't tell governments what to do. It hires no vaccinators, distributes no vaccine. It is a small Geneva bureaucracy run by several hundred international delegates whose annual votes tell the organization what to do but not how to do it. In India, a nation of a billion people, WHO employs 250 physicians around the country to work on polio
monitoring. The only substantial resource that WHO has cultivated is information and expertise. I didn't understand how this could suffice. Then I went to Karnataka.
F
OR THE THREE
days of the mop-up, I traveled through Karnataka with Pankaj Bhatnagar, a WHO pediatrician whose job was to see that the operation was properly executed. He is in his forties, with a slight paunch and an easy, genial manner. The work can be a tricky business, he explained as we waited in Delhi for our flight south. WHO distributes much of the money for mop-up operations. UNICEF provides the vaccines. Rotary of India prints the banners and advocates locally for the cause. But the operation itself is run by people none of these organizations control: government health officials who must hire the thousands of vaccinators, train them properly, and send them from house to house.
We took a plane to Bangalore, then traveled eight hours overnight by train to Bellary, a crowded, dusty town that is the district seat for Upparahalla. At a small, strange hotel there (it had a safari theme), Pankaj convened the members of his team over breakfast. To monitor the immunization of four million children, he had just four people: three young medical officers and himself. They were the only ones available who spoke Kanada, the local language. The medical officers finished their breakfast of idli and dosa and lit up cigarettes (in India, it seems, half the doctors who work in public health smoke), and then Pankaj asked for a status report.
Since the index case was identified, he was told, four more cases of confirmed polio had appeared in the region,
including another child in Upparahalla, and four "hot" cases were awaiting confirmatory testing. Of the thirteen districts targeted for mop-ups, Bellary accounted for all but one of the cases.
"Then we must concentrate our monitoring in this district," Pankaj said. "This is now the place with the most intense transmission of polio in the world." Another doctor pulled out some figures on the area. Bellary district, he told Pankaj, has a population of 2,965,459, with 542 villages and nine urban towns. Fifty-two percent of the males and 74 percent of the females are illiterate. There are just ninety-nine doctors in the district public health system. He turned to a map. The polio cases, he said, were clustered in a triangle of villages around Siriguppa, a small, slum-ridden town about forty miles away.
Pankaj made his assignments. For the mop-up, he would check on progress in at least Upparahalla, a village called Sirigere where polio had appeared, the two urban areas with hot cases, and a mine in Chitradurga, where vaccinators might have particular difficulties gaining entry because the housing was on the property of a private company. He assigned the remaining villages to the others and asked them to follow up behind him for a second check in Upparahalla and the urban areas. The group then split up. By eight thirty in the morning, Pankaj and I were on the road.
W
E HAD A
rented four-wheel-drive Toyota and a betel-nut-chewing driver who waited until we were an hour down a pitted road to tell us that the battery was dead. Whenever the
engine was turned off, he said, we'd need to push-start the car. Pankaj thought this was funny.
The terrain outside the windows was baked by the hot sun, and the hills were desert-lizard brown. The monsoon had failed to come this year. Only the few fields that had drip irrigation looked green. It took us about two hours to travel the thirty-five miles to Sirigere, a village of mud-walled huts jammed up against one another. There was garbage in the alleyways, and dust-faced children were playing everywhere. Pankaj had the driver stop at a group of dwellings seemingly at random. Marked in chalk on each door was a number, a "P," and that day's date. The number was the house number. The "P" meant that the vaccinators had come, identified all the children under the age of five who lived in the house, and vaccinated them--that very day, according to the date marked. Pankaj took out a pad of paper and strode over to one of the huts. He asked the young woman at the door how many children lived there. One, she said. He asked to see the child. When she found him, Pankaj took his hand and noted the black ink mark on the nail bed of his little finger--it's how the vaccinators tag the children who have received polio drops. Was any other child in the fields? Away at a relative's? No, she said. He asked if her boy had received routine immunizations before today. No, she said. Had she heard about the polio case in town? She had. Had she heard about the vaccination team before the workers arrived at the door? She had not. He thanked her and wrote all the information down on a form before moving on.
Several houses later, Pankaj said that, so far, the workers
had done their job. But he was disturbed that no one knew the vaccinators were coming that day. In addition to putting up banners (we'd seen a couple hanging as we came into the village), workers were supposed to use "miking" to reach the illiterate--auto-rickshaws with loudspeakers playing tapes announcing the upcoming campaign. Without that warning, some people would turn away the vaccinators knocking on their doors.
Going around to a few more huts, we bumped into a vaccination team--a social welfare worker wearing sandals, a blue sari, and a flower in her hair, and a younger, college-student volunteer with a flower in her hair, too, and a square blue cold box of vaccine slung over her shoulder. They were standing in front of a hut they'd marked with an "X" instead of a "P"--the woman of the house had said that three children lived there, but one was absent and could not be vaccinated. Pankaj asked the vaccinators to open their cold box. He checked the freezer packs inside--still frozen, despite the heat. He inspected the individual vaccine vials--still fresh. There was a gray-and-white target sign on each vial. Did they know what it meant? That the vaccine was still good, they said. What does it look like when the vaccine expires? The white inside the target turns gray or black, they said. Right answer. Pankaj moved on.
We went to the home of the village's recent polio case. The girl was eighteen months old and silent. The mother, pregnant and with a three-year-old boy clinging to her side, laid her down on her back so that we could examine her. Neither leg would move. Lifting each one, I felt no resistance in
the child's hips, her knees, her ankles. Only four weeks had passed since she was stricken. She almost certainly was still contagious.
Pankaj found three children visiting the house. He checked each of their hands. None had received polio drops yet.
W
E GAVE THE
four-wheel drive a push and made our way to Sirigere's primary health center, a few miles outside the village. It was a drab, unpainted, three-room concrete building. The center's medical officer met us at the door. About forty years old, with ironed slacks, a buttoned short-sleeve shirt, and the only college education in the area, he seemed eager to have our company. He offered tea and tried to make small talk. But Pankaj was all business. "May I see your microplan?" he asked before we had even sat down. He was referring to the block-by-block plan drawn up by each local officer. It is the key to how the operation is organized.
The medical officer's microplan was a sheaf of ragged paper, with marker-drawn maps and penciled-in tables. The first page said that he had recruited twenty-two teams of two vaccinators each to cover a population of 34,144 people. "How do you know this population estimate is right?" Pankaj asked. The officer replied that he'd done a house-to-house survey. Pankaj looked at the map--the villages in the area were spread out over more than ten miles. "How do you distribute the vaccine to the vaccinators who are far away?" By vehicle, the officer said. "How many vehicles do you have?" Two, he said. "What are the vehicles?" One was an ambulance. The other was a rented car. "And how does the supervisor get out to the
field?" There was a pause. The officer shuffled through the microplan. More silence. He did not know.
Pankaj went on. Twenty-two teams would require about a hundred ice packs per day, or three hundred ice packs altogether. "Why did you budget for only a hundred and fifty ice packs?" We are freezing them overnight for the next day, the officer explained. "Where?" He showed Pankaj his deep freezer. Pankaj opened it up and pulled out the thermometer, which revealed that the temperature was above freezing. The electricity goes out, the officer explained. "What is your plan for that?" He had a generator. But when pressed to show it he was forced to admit that it wasn't really working, either.
Pankaj is not a physically imposing man. He has a boyish mop of thick black hair, parted almost down the center, and sometimes it sticks up. He has programed his cell phone to play the James Bond theme when it rings. When we're driving, he points out the monkeys we pass. He makes jokes. He laughs with his head tilted back. But in the field his demeanor is grave and taciturn. He doesn't tell people if their answers are good or bad. He keeps everyone on edge. I had an impulse to tell the medical officer that he was doing okay. But Pankaj seemed to make a point of saying nothing to fill the silences.
In Siriguppa, where two of the hot cases had appeared, we walked the neighborhoods with another medical officer. Siriguppa is a dense, urbanized town of windowless concrete-block tenements, rusting corrugated-metal lean-tos, and some forty-three thousand people. We had to fight our way through narrow streets crowded with water buffalo, motorcycles, braying goats, and fruit sellers. There was electricity here, I noticed, running through wires that drooped from scattered
utility poles, and the sound of televisions poured out from some of the houses.
The two hot cases, we found, were in a small Muslim enclave that had sprouted up a few months earlier. Going door to door, Pankaj learned that almost none of the enclave's children had received routine immunizations. Some of the families seemed suspicious of us, answering questions tersely or trying to avoid us altogether. We found one boy whom the vaccinators had missed. Pankaj was concerned other children might have been hidden. The previous year, rumors had circulated among Muslims that the Indian government was giving different drops to their male children in order to make them infertile. The rumors were thought to have been quashed by an education campaign and greater Muslim involvement in the immunization program. But one had to wonder.
Later, walking with a local doctor and a vaccination team through a village called Balkundi, we came to the home of a small, pretty woman who had rings on her toes and a baby held loosely on her hip. Another child, a boy of about three, stood nearby, staring at our little crowd. Neither child had been vaccinated, so Pankaj asked if we could give them the polio drops. No, she said. She did not appear angry or afraid. Pankaj asked if she knew that a case of polio had appeared in her neighborhood. Yes, she said. But she still didn't want the drops given. Why? She would not say. Pankaj said OK, thanked her for her time, and moved on to the next house.
"That's it?" I asked.
"Yes," he said.
The local doctor had stayed behind, however, and when
we looked back he was shouting at the mother: "Are you stupid? Your children will become paralyzed. They will die."
It was the one time I saw Pankaj angry. He walked back and confronted the doctor. "Why are you shouting?" Pankaj demanded. "Before, she was listening, at least. But now? She's not going to listen anymore."
"She is illiterate!" the doctor shot back, embarrassed to be rebuked so openly. "She doesn't know what is right for her child!"
"What does that matter?" Pankaj replied. "Your shouting doesn't help anything. And neither will a story going around that we are forcing drops on people."
So far, few were refusing the drops, and that was good enough, he told me later. A single nasty rumor could destroy the whole operation.