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What Does It Take To Eradicate A Disease? Just Ask India.
As a train pulls into Moradabad, India, it is swarmed by groups of volunteers in bright yellow vests.
From outside the cars, the volunteers — from India and all over the world — begin reaching through windows and grasping at the hands of small children and infants to check their fingers. Parents willingly pass over babies through the windows onto the platform and watch patiently as the volunteers squeeze small drops out of a vial into the child’s mouth.
Other volunteers board the train, quickly moving through cars and grabbing at hands, checking fingers, and moving on until they find what they’re looking for: a young child, maybe a year or two old, who has no purple mark on her left pinky, a sign that she has yet to receive her drops. Through broken English, the volunteer, from the Netherlands, seeks consent from the young child’s parent and quickly gets it.
She tilts back the head of the small girl and squeezes two drops of her vial into the child’s mouth.
After a few minutes of this, the train conductor announces they will be pulling out, and the volunteers quickly hop off. Throughout the day, those same volunteers will repeat this process over and over.
Thus continues one of the most astonishing public health initiatives in the history of the world — India’s effort to eradicate polio.
The sheer numbers of it are incomprehensible.
In less than a week, twice a year, India will vaccinate approximately 167 million children under the age of 6. If you’re having trouble contextualizing that, consider this: there are only seven countries in the world with more than 167 million people (China, India, United States, Indonesia, Brazil, Pakistan, Nigeria). Russia, Japan, Mexico, Egypt, Germany, Iran — all of these places have less people than India has children under the age of 6.
In order to pull off this mind-boggling feat, the Indian government and its partners — such as Rotary, UNICEF, USAID, the Centers for Disease Control and Prevention, The Gates Foundation, and the World Health Organization — activate and organize 2.2 million health workers, some volunteers and some paid, to administer and track vaccinations. They have 225 million doses of the vaccine on hand, and 6.3 million ice packs or coolers to keep those vaccines from spoiling.
Health workers go through a three-and-a-half-day training that includes interpersonal communication, basic operations, how to administer drops, how to give a finger mark that denotes a vaccinated child, and how to tally the number of children they’ve vaccinated. And they’ll need all the training they can get — poliomyelitis is a crippling, contagious disease that spreads person to person and through contaminated water or food, and in many cases can leave children and adults paralyzed or dead.
Day one of the vaccination push begins with what are known as “vaccination booths,” where parents and family members can bring their children to receive a vaccine. More than 700,000 of these booths are set up all over India’s most populated cities and even exist in far-out rural areas where people live on farms or in the mountains. Politicians, Bollywood stars, religious leaders, and radio hosts advertise the booths for weeks and months leading up to immunization campaigns.
Those booths are then decorated in bright colors, outfitted with health care workers and toys in an effort to lure in any passerby who might need the vaccine. Some booths are set up near schools or outside mosques, and others are placed on the side of busy highways, which produces quite a scene. Imagine four-person families crammed onto motorcycles pulling over to the side of the road so their child can be immunized.
It takes about 30 seconds to administer the oral vaccine. A child comes in, tilts their head back, and lets a heath care worker squeeze two drops of the vaccine into their mouth. Most cry at the bitter taste. Then they will mark the child as vaccinated by coloring in his or her left pinky with a dark marker, an idea credited to Rotary. The child gets a toy, a health care worker tallies another number on the sheet that tracks total vaccinations at that particular booth, and they move on.
In the early days, only about 16 percent of the children inoculated would have their vaccine administered in a booth. Now, though, vaccinations are so popular the booths account for about 70 percent of the nearly 170 million children on the first day.
“They know,” Dr. Arif Khan, my guide for two days, told me. “By the newspapers, by the TV channels, thanks to the media, they know everything about the program.”
And when day two rolls around, things ramp up. Instead of waiting for parents and kids at prepared booths, health care workers mobilize and begin relentlessly scouring the streets for children who have no purple marking on their pinky.
Thanks to a WHO recommendation, most teams have a woman so they can comfortably enter homes without objection. Across the country, teams will visit more than 209 million homes to try and administer the vaccine. If a child isn’t there, they will come back. Some teams go door to door in the same villages for five straight days. By leaving chalk markings on the front of homes, health care volunteers let others who may come after them know whether the children have been vaccinated or not.
Of course, not all homes are created equal. Some require four-wheelers, jeeps with four-wheel drive, motorcycles, or bikes to access.
Simultaneously, the workers move onto public transportation, a key element of their success. Between 75,000 and 100,000 children will be immunized inside running trains alone, a strategy that — if not executed — would risk leaving thousands who were in transit without vaccines simply because they were on a vacation during an immunization week. Volunteers relentlessly scour train stations and bus stations all over the country for children who are missing the purple-colored mark on their pinky.
On top of that, there are two subnational campaigns focused on close to 400,000 high-risk communities where migrants or particularly poor sanitation exists. In those campaigns, another 75 million children will be vaccinated. Children in India are vaccinated for polio at birth, again at 6 weeks, again at 10 weeks, and again at 14 weeks, leaving them with four doses in their first year of life. Some, according to Dr. Khan, will be immunized upwards of 20 times by the age of 6.
But it wasn’t always like this.
If there’s anything as astounding as vaccinating 167 million children in a week, it’s the challenges India overcame to get there.
When Dr. Pankaj Bhatnagar of WHO got involved in fighting polio in the late 1970s, the country was seeing 150,000 to 200,000 new cases every year.
“I was hopeful, but I must confess, when I got involved, I was a pediatrician working in a hospital, and I had not seen all the challenges that lay before us,” Dr. Bhatnagar said. “Only when we started implementing the polio campaigns and got out to the field, you realize what a challenge it is to reach each and every household in the country.”
Perhaps the challenge that was hardest to overcome was the suspicions and concerns of the Muslim community in India.
After all, there are more Muslims in India than any country in the world, save Indonesia and Pakistan. Moradabad, with a population of 1 million people and once considered the polio capital of the world, is about 75 percent Muslim. Conspiracies that the oral vaccines were a push to make the Muslim community impotent, or that they violated strict Muslim dietary restrictions, were rampant.
Deepak Kapur, the Rotary India PolioPlus Committee chair, told me a frightening story that illustrated just how resistant some people were. He and his team had heard about a strict Muslim family that wouldn’t let any of the volunteers vaccinate their children. This, despite the fact that they already had a daughter who had been paralyzed after contracting polio.
When they arrived, Kapur asked the mother if she would allow them to vaccinate her newborn child. After initially saying no, she seemed convinced by the team’s coaxing and indicated that she would let the worker administer the vaccine. But Kapur said her body language “looked all wrong.”
Sensing something was amiss, he pressed her before administering the vaccine. “What will you do when we leave?” Kapur asked. Her answer shocked him: she would kill the baby before her husband got home. Why? She said that her husband had promised to kill her if he found out that she had allowed health care workers to give her child this “potion,” a vaccine many in her rural community suspected was part of a government effort to make the religious Muslims impotent.
Two years later, that same health care worker went back to the same home, approached the same family and administered the same vaccine with no resistance. What changed?
Well, for one, the Indian government and its partners helped push Imams to come out and support the vaccination push. One of the first, and most popular, was a famous Imam named Hakeem Syed Masoom Ali Azad, who went to the medical college at Aligarh Muslim University for advice after members of his Mosque began asking him questions about the vaccine. Azad’s family has held the position of Moradabad’s Shaher Imam — or chief cleric — for the last 200 years. His word was gospel.
Through the Muslim universities, he learned that the vaccine was effective, did not violate haram, and did not contain anything that would make a child impotent or unable to have children. So Azad — with his more than 1 million followers in India — began promoting the vaccine at services during major holidays. Once, he took it in front of his congregation. Another time he administered the vaccine to his grandchildren.
“I have convinced a lot of Imams and community leaders,” he told A Plus through an interpreter. “I used to visit people’s houses also, we’d go with workers into Muslim homes. I was happy to go convince them.”
It’s tough to overstate how important Azad’s support was. In 2002, more than 80 percent of children who contracted polio were boys or Muslims, according to UNICEF.
But challenges in Moradabad went way beyond just religious resistance, and many are replicated in other cities throughout the country. Population density, dirty water, lack of sanitation, and malnutrition among children made enteric stomach diseases incredibly common and thus made vaccinations nearly impossible. Human feces in open drains, or humans bathing and defecating in the same rivers as buffalos and cows, created incredible problems.
“Imperial College of London did a study, and enteric diseases are six times more common in Moradabad than any area in the world,” Kapur said. “Which meant if you look at a kid as a bucket of water, if you keep pouring a vaccine in, it has this hole in the bottom, it doesn’t stay in long enough to keep.”
Of course, getting the vaccines to the people in the first place was a struggle.
Bureaucracy and government hurdles made funding difficult. The government, with help from donations, is paying for the entire vaccination push. But in order to do that, health care professionals first had to convince politicians it was worthwhile. Skepticism about whether India could eradicate polio at all left many leaders wondering if it was worth diverting so much money into the issue. Rotary alone has raised close to $200 million for UNICEF and WHO to fund eradication activities.
According to Kapur, Rotary’s value went beyond the financials. They also helped cut through the bureaucratic red tape.
“Because we have 130,000 Rotarians who live here, eat here, work here, have families here, whenever you want to go to a political leader’s office or a bureaucrat’s office or a religious leader’s mosque, there is somebody that knows somebody that will get that door open for you,” Kapur said.
Issues came up you would never consider. Once, a railway minister refused to spend money shipping vaccines through the country on trains. Health care workers had to lead a six-hour demonstration outside his office to change his mind.
One man who took the vaccine 17 times still contracted polio. Displeased with the United Nations and the polio vaccine, he got the health minister of Uttar Pradesh — India’s most populous state with more than 200 million people — to call a press conference. His story could have been devastating for the campaign, but minutes before he went live on television, health officials convinced him the vaccine didn’t work because it didn’t take, not because it wasn’t effective.
Migrating populations who would move between vaccine pushes also created problems. Health care workers would have to find people in the slums or living in construction sites to administer the vaccines.
Finally, there is what some believe is the most perplexing problem of them all — the risk of the actual vaccine.
Until last year, what’s known as the trivalent oral vaccine was most common for children. Trivalent oral poliovirus vaccines (OPV) addressed Type 1, Type 2 and Type 3 viruses, but they come with a caveat: it’s a live virus, which in very rare cases causes vaccine-associated paralytic poliomyelitis. In cases when the vaccine doesn’t take, live polioviruses will end up in the sewage system, and has the potential to mutate and spread.
In many ways, this is just another challenge overcome. In the event of a poliovirus outbreak, “micro plans” are activated that deploy emergency response teams to deliver vaccinations in the surrounding areas. Last April, because Type 2 polio had been eradicated worldwide, the entire country moved away from trivalent to bivalent vaccines, which only includes Type 1 and 3 vaccinations. They plan to stop using live cultures all together once polio is eradicated worldwide.
And recently, there’s been no need to activate an emergency response team, because India hasn’t seen a new polio case since January 13, 2011.
Humans have only eradicated one disease from the face of the earth: smallpox. But after a long journey, polio might become No. 2.
Even after the first polio vaccines became accessible in the 1980s, India still saw as many as 50,000 new cases every year. In 1985, there were 385,000 polio cases worldwide.
Dr. Matthew Varghese, who works at St. Stephen’s Hospital in New Delhi, is running one of the last polio wards in the country. People come from hundreds of miles away to receive corrective surgery and physical therapy for paralytic polio. His hospital, incredibly, offers their services to patients for free.
“We don’t charge a penny from any of these patients,” Dr. Varghese said, noting that the most at-risk polio patients are impoverished. “It is our responsibility as a society to ensure that they’re able to realize their dreams.”
One good sign, though, is that Dr. Varghese has been seeing a lot fewer patients in recent years. Dr. Bhatnagar has noticed the same phenomenon.
“In the peak seasons, we’d get multiple cases of polio and wards would be full of children suffering from weakness of the limbs or respiratory issues,” Dr. Bhatnagar said. “Some would die or be paralyzed for life. If you go out to the roads of India, you will see the remains of it, some people are still suffering from post-polio paralysis. What you will not see now is children who have recently been paralyzed, because for the last six years there has not been a single case of polio in the country.”
At the end of 2009, successful vaccination pushes brought the number of new cases that year down to 741. By 2010 that number was 42. And by 2011 it was zero.
“It’s been dramatic,” Dr. Varghese said. “In fact, to tell you the truth, I never expected this could happen in my lifetime.”
And yet, it did.
Despite vaccine skepticism, religious resistance, conspiracy theories, unfathomable risk of contagious disease, political roadblocks, financial challenges, and a mutating virus, India persisted and — for now — has tallied a remarkable victory.
Albertine Perre, a Rotary member from the Netherlands who has been a leader in fundraising for the PolioPlus Fund, said the important part is not stopping. Despite many believing the end of polio in India would mean worldwide eradication, there were still 36 cases of polio outside India last year. Pakistan, Afghanistan, and Nigeria are all considered endemic.
“We didn’t win the battle yet, as long as there is polio in Pakistan and Afghanistan and Nigeria, there is still a risk,” Perre said. “To keep people motivated is difficult. You see how many people have to work in this campaign? That’s not easy.”
Since Pakistan borders India, the risk of polio there gives India’s health workers nightmares. Pakistan and Afghanistan might not have the same kind of population density as India, but both have trouble attracting volunteers because of terrorism and political violence. Unfortunately, it only takes one virus to cross over and begin infecting people, and it’s sometimes hard to notice: less than 1 percent of polio infections cause paralytic symptoms, so if one person exhibits signs of paralytic poliomyelitis, that could mean as many as 200 are already infected before a response team can get on top of the outbreak.
Still, most people are optimistic. The simple fact that each national immunization campaign covers more than 98 percent of India’s children keeps everyone relatively safe, even in the event an outbreak occurs. India’s drop from 42 new cases in 2010 to zero in 2011 also gives people hope that with just 36 new cases worldwide last year, they are about to cross the finish line in global eradication.
“I am very optimistic and hopefully we can finish the job,” Dr. Bhatnagar said. “I think even in Pakistan, Afghanistan, and Nigeria it’s working through the processes and strengthening all these aspects of the program. Strengthening planning, communication, social mobilization, reaching every child, accountability at various levels, and working closely with community leaders. Clearly, we have the tools to eradicate polio in the rest of the world.”
For India, they now have their eyes on the next step: routine immunizations for all children that cover diseases like rubella, measles, hepatitis B, pneumonia, tetanus and typhoid, diseases other developed countries are already ridding themselves of. And, of course, helping Afghanistan, Pakistan, and Nigeria finish the job. Dr. Sanjeev Yadav, the chief medical officer of Moradabad, hosted a listening session with volunteers after day one of the immunizations in the city. In attendance were health care workers from Pakistan and Afghanistan, who said they were planning to bring the idea of vaccination booths back to their country.
Dr. Yadav, for his part, was not shy about having pride in what India had done.
“This is a public health program — I think — that can be a study in itself for any program in public society that’s for the community,” he said. “This is one of the most wonderful things that has happened in public health. I don’t think there is any other example of any success, anything comparable to this.”
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