Horns blare and banana vendors tout their wares at a bus transit point in northern India. Men wearing fezzes and women in saris scurry across the busy road to get on the right bus. One woman, though, doesn't stay on the first bus she enters. Over and over, she climbs into buses and makes her way down the aisle, checking left pinkie fingers of small children.
She's searching for magic-marker ink on the pinkie. If the child has it, he or she has received the "two drops of life" proclaimed by posters that blanket this region of India. They are the drops of the oral polio vaccine.
Nearby, a motorcycle pulls up with a baby wedged between his parents—not an uncommon sight in poor countries. A health worker briefly explains to the family what the vaccine is. The mother tilts her baby's head and the drops go down. The worker marks the pinkie, and the motorcycle speeds away.
A Battle to the Finish
At bus stops and in railway stations, at rural brickmaking kilns or village schools, hundreds of health workers are fighting to eradicate the last vestiges of polio from India. Although the disease—which paralyzes children for life and sometimes kills them—is a distant memory for most in the Western Hemisphere, it is a rare but frightening reality in some developing countries.
Ten cases were reported in 2010 in the northern Indian state of Uttar Pradesh, and "for every one case identified, we assume 200 children have the virus," says Parul Ratna, CORE polio program coordinator for Catholic Relief Services in India. "Most infected children don't show signs of disease, since paralysis occurs only in 1 out of every 200 children who have it. But these carriers can pass on the virus to other susceptible kids." More than 100 children in Pakistan tested positive for polio symptoms in 2010, and cases were found in Afghanistan, Nigeria and other countries.
For Americans used to confronting epidemics by going to clean medical offices, the sight of health workers skirting banana kiosks and water buffaloes to reach toddlers is startling. The workers tote refrigerated coolers with vials of the vaccine and cough away dust and bus fumes as they work. But there's a reason they're outside where the action is: Migrants are particularly vulnerable to contracting and spreading the disease, because door-to-door health workers can't find them.
CRS has joined forces with World Vision Inc. as a partner in the U.S. Agency for International Development-funded CORE Group Polio Project, collaborating with many international and local organizations to reach at-risk people. In a government office in the city of Saharanpur, a doctor with the World Health Organization demonstrates how he uses Google Earth to find pockets of nomadic people—Van Gujjars—who tend to camp by rivers. Health workers target transit points such as railway stations to find people who aren't on any census. They also trek to brick kilns in fields outside of villages; the kilns often hire migrants.
"These high-risk groups are very important," says Parul. "If any children are missed, they could spread the virus. If any link of the chain is broken, there's a problem."
Health workers have to contend not only with distance and migration but with ingrained misconceptions about vaccines. Some families in this region of India are suspicious of vaccinations because of an aggressive vasectomy campaign launched by India's government in the 1970s. Impoverished men were often sterilized at the urging of authorities. Today, parents conflate vaccinations and sterilization, worrying that if their male or female children are immunized against polio, they will be infertile.
Other families point to anecdotal evidence, saying that a relative's child was vaccinated and got a fever, so the vaccine must cause fever. And in a culture in which boys are valued above girls, parents are sometimes only willing to "risk" giving the vaccine to a daughter—but not a son.
In traditional Muslim families, the oldest man in the family often makes decisions about health and doctors. Shabunam and Farzana, both young mothers in Saharanpur, were on the fence about vaccinating their young sons. Their father-in-law's rejection of the polio vaccine settled the matter: "At first I wouldn't allow my grandchildren to be vaccinated," says Abdul Shakur. "I thought it caused impotence."
"But [CRS staffer] Sajid and the local doctor explained the importance of the vaccine to me," he says. "They explained things and understood my feelings." He has given his consent, and his daughters-in-law now plan to immunize their children.
A handful of families are more than resistant. "They'll sharpen big knives in front of you, as a threat," says Parul. "Or they'll say, 'If you immunize my child, I'll throw him away.' "
CRS team members are careful but persevere. Rukhsana, a health worker who goes door to door in urban neighborhoods, talks about one family that resisted vaccinating their children. "I put in extra effort, visiting frequently for 3 months. Finally I persuaded them."
Most often, parents want their children immunized; it's simply a matter of getting the vaccine to every single family. In a country as vast and populous as India, it's a mindboggling challenge, but the polio teams meet it every day.
Refrigerated packs of the drops go to remote villages, and health workers are trained to administer the vaccine properly. Roaming supervisors visit the vaccination place—usually a room in a village school—to do spot checks. In a schoolroom in an area called Sarsawa, Parul scrutinizes the expiration date on the vials and clacks the ice packs together to make sure they're cold and will cool the polio vaccine properly.
On "polio days," 8- or 9-year-old sisters lug babies to the health workers' vaccination table. The babies wriggle and scream—apparently the vaccine doesn't taste good at all. In Anwarpur village, one toddler writhes so much in the health worker's arms that it's a tossup who will win this struggle. Eventually, though, he gets his drops. He walks off with other children, somewhat mollified by the small toys the health worker gives out.
Knowing the age of a child is important, because polio is most devastating when contracted in a child's first few years. The CRS program targets children under 5 because older children are at much less risk. In Saharanpur, the team meets one boy who looks about 5, but he's being raised by relatives instead of his parents, and his actual birthday is unknown. A health worker asks him to reach over his head with his right hand to touch his left ear. He can't reach it, which means he's probably under 5—and needs the drops.
Some villages have children's rallies with banners and posters. Blowing ear-piercing dayglo whistles, 10- and 12-year-old kids fan out and zoom through the village, calling children under 5 to come for the vaccine. In one village, the older kids break into girl-boy groups and run to as many houses as they can. The boys arrive back at the vaccination room after 10 minutes with no toddlers in tow. About 20 minutes later, the older girls straggle back, bringing small children they have carefully sought out.
In other areas, health teams go door to door in villages, sweating in the heat as they walk on dirt roads. The women who make up the team mark pinkie fingers with ink and house walls with chalk after a vaccination; the chalk writing tells the next team that health workers have already visited the house.
Children typically receive the drops not just once, but in rounds. "Each round lasts 7 days, and during this time the teams check the magic-marker ink or the chalk mark," says Parul. By the time it's worn off, the next round is approaching.
The teams aren't just saving one child. A polio outbreak anywhere in the world could have consequences for unvaccinated people in far-off places. "Polio spreads—people get on a train or a plane," says Sajid Parve, who coordinates CRS services to underserved populations. "If India is not free from polio, it could spread to other countries."
But knowing that a baby or toddler could escape suffering and misery—or even death—keeps the teams going strong as they seek out kids who haven't been accounted for, or work to persuade resistant parents. Community Mobilization Coordinator Baljeet Kaur knows her end goal is worth the heat, the dust and the angry parents. "If I share this information," she says, "I am saving a child's life."
Laura Sheahen is CRS' regional information officer for Asia. She is based in Cambodia.