People underestimate the importance of diligence as a virtue. No doubt this has something to do with how supremely mundane it seems. It is defined as "the constant and earnest effort to accomplish what is undertaken." There is a flavor of simplistic relentlessness to it. And if it were an individual's primary goal in life, that life would indeed seem narrow and unambitious.

Understood, however, as the prerequisite of great accomplishment, diligence stands as one of the most difficult challenges facing any group of people who take on tasks of risk and consequence. It sets a high, seemingly impossible, expectation for performance and human behavior. Yet some in medicine have delivered on that expectation on an almost unimaginable scale. The campaign to eradicate polio in India is just such an instance.

 

THE INDEX CASE was an eleven-month-old boy with thick black hair his mother liked to comb forward so that the bangs rimmed his round face. His family lives in the southern Indian state of Karnataka, in a village called Upparahalla, along the Tungabhadra River. Dry mountains of teetering rocks can be seen in three directions from the village. It has no running water and little electricity. The boy's mother is illiterate; the father can read only road signs. They are farm laborers, and they live with their three children in a single-room hut of thatch and mud. But the children are well nourished. The mother wears gold and silver earrings. Once in a while, they travel.

In April 2003, the family took a trip north to see relatives. Shortly after they returned, on May 1, the boy developed high fevers and racking bouts of nausea and vomiting. His parents took him to a nearby clinic, where a doctor gave him an antibiotic injection. Two days later, the fevers subsided, but he became unable to move either of his legs. In a panic, the parents took him back to the doctor, who sent him to the district hospital in Bellary, about forty miles away. As the day progressed, the weakness spread through the boy's body. His breathing grew shallow and labored. He lay flat and motionless on his hospital cot.

A doctor at the hospital, following standard procedure in cases of sudden childhood paralysis, phoned a surveillance medical officer with the World Health Organization in Bangalore, the capital of Karnataka. The medical officer made sure that stool specimens were taken and sent for culture to a national laboratory in Mumbai (as Bombay is now called). On June 24, the laboratory results finally came back. A young technical officer with WHO in New Delhi got the call; it was a confirmed case of polio, a disease thought to have been eliminated from southern India, and it set off an alarm.

The World Health Organization is nearly two decades into its campaign to eradicate polio from the world. If the campaign succeeds, it may be mankind's single most ambitious accomplishment. But this is a big if. International organizations are fond of grand-sounding pledges to rid the planet of this or that menace. They nearly always fail, however. The world is too vast and too various to submit to dictates from on high.

Consider the other attempts that have been made to eliminate individual diseases. In 1909, the newly established Rockefeller Foundation launched the first global eradication campaign, an effort to end hookworm disease, using antihelminthic drugs, in fifty-two countries. It didn't work. Today, a billion people—a sixth of the world's population—are infected with hookworm, an intestinal parasite that feeds on human blood. A seventeen-year campaign against yellow fever, led by the Rockefeller Foundation and the United States armed services, had to be abandoned in 1932 when yellow fever was found to have a reservoir outside human beings. (The yellow fever virus persists in mosquitoes' eggs.) In 1955, WHO and UNICEF began a campaign to end yaws, an infectious disease that causes painful, purulent skin ulcers; workers screened 160 million people in sixty-one countries for the disease and treated every case they found with penicillin. A dozen years later, the campaign was dropped when it turned out that silent, subclinical infections were continuing to propagate the disease. Billions of dollars were spent in the fifties and sixties to eradicate malaria; today the disease afflicts more than 300 million people a year.

After a century of effort, the only successful attempt at eradication of a global disease has been the battle against smallpox—a mammoth undertaking that was, just the same, decidedly simpler than the campaign against polio. Smallpox, with its distinctive blisters and vesicles, could be readily and quickly identified; the moment a case appeared, a team could be dispatched to immunize everyone the victim might have come into contact with. That strategy, known as "ring immunization," eradicated the disease by 1979. Polio infections are far harder to identify. For every person who is paralyzed, between two hundred and a thousand infected people come down with little more than a stomach flu—and they remain silently contagious for several weeks after the symptoms abate. Nor is every case of childhood paralysis polio, and it usually takes weeks for stool specimens to be obtained, delivered to a laboratory, and properly tested for the disease. By the time one case has been identified, scores more people have been infected. As a result, the area targeted for polio immunization must be far larger than that for smallpox. And whereas people needed to be vaccinated against smallpox only once for immediate protection, a single dose of polio vaccine does not always take—children with diarrheal illnesses tend to pass the oral vaccine straight through. So a repeat round of immunization is required within four to six weeks. In logistical terms, it's the difference between extinguishing a candle flame and putting out a forest fire.

Despite the obstacles, however, the campaign against polio has made immense progress. Routine vaccination had made polio uncommon in the West, but cases continued to occur in the United States, Canada, and Europe into the 1980s, and the disease remained endemic in large portions of the world. In 1988, more than 350,000 people developed paralytic polio, and at least 70 million were infected with the virus. By 2001, only 498 cases were identified. The whole of the Americas, Europe, and the western Pacific, along with nearly all of Africa and Asia, are currently free of the disease.

In each year since 2001, however, just as the disease was on the verge of being wiped out, an outbreak has flared in some country in Asia or Africa, spilled across borders, and threatened to bring polio roaring back. In 2002, India was that country. Outbreaks in the north produced sixteen hundred polio cases. Four-fifths of all the world's cases occurred there that year. Nonetheless, the belief was that the disease had been isolated to a handful of northern states. Then, in 2003, a boy in south India developed polio—the first case in the state of Karnataka in almost three years. If the disease expanded from there, the campaign would be all but over.

 

ON JUNE 25, less than twenty-four hours after the report of the Karnataka polio case came in, Sunil Bahl, a WHO physician and technical officer in the Delhi office, sent an e-mail to key people at WHO, at UNICEF, and in the Indian government. It was his job to provide the initial assessment of the facts on the ground. "The case is in an area that has a history of being the worst in Karnataka," he wrote; it had poor routines of immunization and the most polio cases in the early years of the campaign. "Risk of establishment of virus in the area high, unless quick wide and strong measures in the form of a wide mop-up are taken." A "mop-up" is WHO lingo for a targeted campaign to immunize all susceptible children surrounding a new case. It's what is done in an area that has been rendered polio-free through routine immunization but is facing a new infection that threatens to bring the disease back. The campaigns are carried out rapidly, in just three days, to ensure that the vaccine saturates a population and to make it easier to recruit volunteers.

Sunil Bahl sent around a map of the proposed area for the mop-up operation. It covered fifty thousand square miles. Working around the summer holidays and festivals, government officials selected July 27 for the start of the first immunization round. The second round would follow a month later. Brian Wheeler, a thirty-five-year-old Texan who was the chief operations officer for WHO's polio program in India, explained the logistics to me. The Indian government would have to recruit and organize teams of medical workers and volunteers, he said. They would have to be trained in how to administer the vaccine and provided with transportation, vaccine, and insulated coolers and ice packs to keep the vaccine cold. And they would have to fan out and vaccinate every child under five years of age. Anything less than 90 percent coverage of the target population—the percentage needed to shut down transmission—would be considered a failure.

I asked him how many people that would involve.

He checked his budget sheet. The plan, he said, was to employ thirty-seven thousand vaccinators and four thousand health care supervisors, rent two thousand vehicles, supply more than eighteen thousand insulated vaccine carriers, and have the workers go door to door to vaccinate 4.2 million children. In three days.

 

POLIO IS a disease that strikes children almost exclusively—more than 80 percent of paralysis cases occur in children under age five. It is caused by an intestinal virus; the virus must be ingested to bring about an infection. Once inside the gut, it passes through the lining and takes up residence in nearby lymph nodes. There it multiplies, produces fevers and stomach upset, and passes back into the feces. Those infected can contaminate their clothing, bathing sites, and supplies of drinking water and thereby spread the disease. (The virus can survive as long as sixty days outside the body.)

Poliovirus infects only a few kinds of nerve cells, but what it infects it destroys. In the most dreaded cases, the virus spreads from the bloodstream into the neurons of the brain stem, the cells that allow you to breathe and swallow. To stay alive, a person has to be fed through a tube and ventilated by machine. The nerve cells most commonly attacked, though, are the anterior horn cells of the spinal cord, which control the arms, the legs, and the abdominal muscles. Often, so many neurons are destroyed that muscle function is eliminated altogether. Tendon reflexes disappear. Limbs hang limp and useless.

The first effective vaccine for polio was introduced in 1955, after the largest clinical trial in history. (Jonas Salk's vaccine, made from killed poliovirus, was given to 440,000 children; 210,000 received a placebo injection, and more than a million served as unvaccinated controls.) Five years later, Albert Sabin published the results of an alternative polio vaccine he had used in an immunization campaign in Toluca, Mexico, a city of a hundred thousand people, where a polio outbreak was in progress. His was an oral vaccine, easier to administer than Salk's injected one. It was also a live vaccine, containing weakened but intact poliovirus, and so it could produce not only immunity but also a mild contagious infection that would spread the immunity to others. In just four days, Sabin's team managed to vaccinate more than 80 percent of the children under the age of eleven—26,000 children in all. It was a blitzkrieg assault. Within weeks, polio had disappeared from the city.

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.

 

* * *

 

FOR 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.

 

WE 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.

 

* * *

 

WE 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 programmed 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.

 

One difficult question came up repeatedly—from local doctors, from villagers, from workers trudging house to house. The question was: Why? Why this huge polio campaign when what we need is—fill in the blank here—clean water (diarrheal illness kills 500,000 Indian children per year), better nutrition (half of children under three have stunted growth), working septic systems (which would help prevent polio as well as other diseases), irrigation (so a single rainless season would not impoverish farming families)? We saw neighborhoods that had had outbreaks of malaria, tuberculosis, cholera. But no one important had come to visit in years. Now one case of polio occurs and the infantry marches in?

There are some stock answers. We can do it all, goes one. We can eradicate polio and do better on the other fronts. In reality, though, choices are made. For that whole week, for instance, doctors in northern Karnataka had all but shut down their primary health clinics in order to carry out the polio vaccination work.

Pankaj relies on a somewhat more persuasive line of argument: that ending polio is in itself worthwhile. In one village, I watched a resident demand to know why the government and WHO weren't combating malnutrition there instead. There was only so much they could do, Pankaj said. "And if you're starving, becoming paralyzed certainly isn't going to help."

Still, you could make the same claim for almost any human problem that you decide to tackle—blindness or cancer or, for that matter, kidney stones. ("If you're starving, kidney pain certainly isn't going to help.") And then there is the issue of money. So far the campaign has cost three billion dollars worldwide, more than six hundred dollars a case. To put that in perspective, the Indian government's total budget for health care in 2003 came to four dollars per person. Stopping the very last case of polio, one official told me, might cost as much as two hundred million dollars. Even if the campaign succeeds in the eradication of polio, it is entirely possible that more lives would be saved in the future if the money were spent on, say, building proper sewage systems or improving basic health services.

What's more, success is by no means assured. WHO has had to extend its target date for eradication from 2000 to 2002 to 2005 and now is having to extend it again. In these last years of the campaign, more and more money has been spent chasing the few hundred cases that keep popping up. A certain weariness is bound to settle in. Around twenty-four million children are born in India each year, creating a new pool of potential polio victims the size of Venezuela's entire population. Just to stay caught up, a mammoth campaign to immunize every child under the age of five has to be planned each year. The truth is, no cost-benefit calculus can assure us just now that the money is well spent.

Yet for all these reservations, the campaign has averted an estimated five million cases of paralytic polio thus far—a momentous achievement in itself. And although erasing the disease from the world is a grand, perhaps even absurd ambition, it remains a feasible task and one of the few things we as a civilization can do that would benefit mankind forever. The eradication of smallpox will last as an enduring gift to all who are to come, and now, perhaps, the eradication of polio can, too.

But this means we must actually get down to that final polio case. Otherwise, the efforts of the hundreds of thousands of volunteers, and the billions spent will have amounted to nothing—or maybe worse than nothing. To fail at this venture would put into question the very ideal of eradication.

Beneath the ideal is the gruelingly unglamorous and uncertain work. If the eradication of polio is our monument, it is a monument to the perfection of performance—to showing what can be achieved by diligent attention to detail coupled with great ambition. There is a system, and it has eradicated polio in countries with far worse conditions than I was seeing in India—for example, in Bangladesh, in Vietnam, in Rwanda, in Zimbabwe. Polio was eradicated from Angola in the midst of a civil war. An outbreak in Kandahar in 2002 was halted by a WHO-led mop-op operation despite the Afghan war. In 2006, new mop-ups took place in northern Nigeria, where polio remains endemic and periodically spills into neighboring countries. In India, Pankaj told me, there have been campaigns on camels in the Thar Desert of Rajasthan, in jeeps among the tribal communities of the Jharkhand forests, on power boats through flooded regions of Assam and Meghalaya, on Navy cruisers traveling to remote islands in the Bay of Bengal. During our own mop-up, we covered about a thousand miles in the three days of going town to town. Pankaj worked his mobile phone almost constantly. Armed with the information he provided, state officials arranged deliveries from ice factories to teams at risk of running short of ice packs and extended the mop-up by an additional day in one area where the local officer had severely underestimated the population to be vaccinated. Four miles outside the village of Balkundi, we came upon a cluster of makeshift shanties for migrant laborers, not seen on any maps. When we checked the children, though, they all had the vaccinators' ink marks on their pinkies. At Chitradurga, we found the mines in decay, but state officials had made sure that the company gave the vaccinators access to the workers' compound. With some searching, we discovered a few children here and there. Every one of them had received the vaccine, too.

By the end of the mop-up, UNICEF officials had distributed more than five million doses of fresh vaccine through the thirteen districts. Television, radio, and local newspapers had been blanketed with public service announcements. Rotary of India had printed and delivered 25,000 banners, 6,000 posters, and more than 650,000 handbills. And 4 million of the targeted 4.2 million children had been successfully vaccinated.

In 2005, India had just sixty-six new cases of polio. Pankaj and his colleagues believe that they're finally closing in on their goal of eradication in India. And as India goes, so might the world.

 

STILL, THERE IS no denying the dimensions of what Pankaj and his colleagues are up against. Pankaj says that he has seen more than a thousand cases of polio in his career as a pediatrician. When we drove through the villages and towns, he could pick out polio victims at a glance. They were everywhere, I began to realize: the beggar with two emaciated legs folded under him, rolling by on a wooden cart; the man dragging his leg like a club down the street; the passerby with a contracted arm tucked against his side.

On the second day of the mop-up, we reached Upparahalla, the village where the Karnataka outbreak had started. The first, index case of polio was now a fourteen-month-old boy with a healthy, almost muscular thickness about his upper body; after the first few days of his infection, his breathing had returned to normal. But when his mother put him down on his stomach you could see that his legs were withered. With the exercises the nurses had taught her to do with him, he had regained enough movement in his left leg to be able to crawl, but his right leg dragged limply behind him.

Making our way around the open sewage in Upparahalla, the mud-covered pigs, the cows resting curled up like cats with their heads on their hooves, we found the neighbor girl who had come down with polio after the boy. She was eighteen months old, with a big, worried face, perfect white teeth, and short, spiky hair. She was wearing small gold earrings and a yellow-and-brown checked dress. She squirmed in her mother's arms, but her legs only dangled beneath her dress. Her mother wore an impassive expression as she stood before us in the sun, holding her paralyzed child. Pankaj gently asked her if the girl had ever received polio drops—perhaps she'd got the vaccine but had not taken it. The mother said that a health worker had come around with polio drops a few weeks before her daughter became sick. But she had heard from other villagers that children were getting fevers from the drops. So she refused the vaccination. A look of profound sadness now swept over her. She had not understood, she said, staring down at the ground.

Eventually, Pankaj continued onward, checking on the vaccinators going door to door. Then, when he was finished, we left. The road heading out of the village was a red dirt track and we rattled over it with our wheels in the ruts that the bullock carts had made.

"When will you do when polio is finally gone?" I asked Pankaj.

"Well, there is always measles," he said.

 

From the book Better: A Surgeon's Notes on Performance by Atul Gawande. Reprinted by arrangement with Metropolitan Books, an imprint of Henry Holt and Company, LLC. Copyright © 2007 by Atul Gawande. All rights reserved.

 

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