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Chasing Polio in Pakistan

Why the World's Largest Public Health Initiative May Fail

Svea Closser

Publication Year: 2010

The number of global polio cases has fallen dramatically and eradication is within sight, but despite extraordinary efforts, polio retains its grip in a few areas. Anthropologist Svea Closser follows the trajectory of the polio eradication effort in Pakistan, one of the last four countries in the world with endemic polio. Journeying from vaccination campaigns in rural Pakistan to the center of global health decision making at the World Health Organization in Geneva, the author explores the historical and cultural underpinnings of eradication as a public health strategy, and reveals the culture of optimism that characterizes--and sometimes cripples--global health institutions. With a keen ethnographic eye, Closser describes the complex power negotiations that underlie the eradication effort at every level, tracking techniques of resistance employed by district health workers and state governments alike. This book offers an analysis of local politics, social relations, and global political economy in the implementation of a worldwide public health effort, with broad implications for understanding what is possible in global health, now and for the future. This book is the recipient of the annual Norman L. and Roselea J. Goldberg Prize for the best project in the area of medicine.

Published by: Vanderbilt University Press

Title Page

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Table of Contents

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List of Illustrations

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pp. ix

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pp. xi-xiii

I am deeply grateful for the extraordinary openness of people working at all levels of the Polio Eradication Initiative. The World Health Organization staff in Islamabad was particularly welcoming, and my work benefited enormously from the help and support of everyone there, particularly Dr. Obaid ul Islam, Dr. Nima Abid, and Dr. Javed Iqbal. I offer heartfelt thanks to these people for allowing me to work inside polio eradication, and ...

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1. Introduction

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pp. 1-22

The Polio Eradication Initiative, a twenty-year, six-billion-dollar project that has employed over two million people, is history’s largest coordinated mobilization in the cause of public health. In 2001 alone, the Polio Eradication Initiative vaccinated about 575 million children against polio in ninety-four countries, most of them multiple times, and most by teams going ...

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Bus Number 11

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p. 23-23

Fatima is a lady health worker in Kaifabad. Because she lives in an area of Pakistan where no new polio case has been seen for several years, she works on three to five door-to-door polio campaigns a year. In areas with ongoing transmission, lady health workers work on six to eight polio campaigns a year; in ...

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2. Polio Eradication in Policy

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pp. 25-52

Eradication, the permanent obliteration of a disease, is a powerful ideal.1 Its supporters are impassioned and eloquent. It also has a number of clear advantages as a public health strategy. Because the goal is unambiguous and progress toward that goal is measurable—the case count—monitoring performance and ensuring accountability are relatively ...

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The Moving Target

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pp. 53-54

Nasrin lives in a small thatch compound on the edge of a settled neighborhood on the outskirts of Kaifabad. I am at her house because her family is seminomadic, raising goats for a living. What polio eradication planners call “mobile populations” appear to be spreading poliovirus across Pakistan and Afghanistan. I want to ask her about ...

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3. Polio Eradication in Practice

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pp. 55-92

I was the arbiter of the meaning of the faint brown mark on the three-year-old’s fingernail. The doorway of her house, a nearly windowless brick-and-cement building sharing three of four walls with other homes, was dark, so I asked her to come out into the bright, dusty, narrow dirt street. There in the sunlight, I squatted down to look at her finger. Four people leaned over me to get a look: the lady health worker responsible ...

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Public Buses

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pp. 93-94

Reema is a lady health worker who lives in a small village outside Kaifabad. I visit her in the very early spring, when the mustard is in bloom; the fields around the cluster of cement buildings that make up her village are brilliant yellow. Reema’s supervisor leads me up the narrow, muddy alleyway to her house. After warmly welcoming her supervisor, who leaves ...

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4. Kaifabad

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pp. 95-120

Tanveer and I spoke several times about what drove us crazy during monitoring in Kaifabad and in other districts we visited. “The thing is,” one of us would say, “that if people working in Kaifabad spent half as much energy planning and executing a good campaign as they did evading the monitors, the vaccination coverage would be perfect.” We ...

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Land Cruisers

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pp. 121-122

Ahmad is a driver for the World Health Organization office in Islamabad, and Tanveer befriended him as they were both waiting in the parking lot one day. The WHO office has a huge fleet of white Toyota Land Cruisers and Hilux pickup trucks (twins of U.S. Tacomas), all of them operated by drivers. Whenever anyone working for the ...

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5. Islamabad

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pp. 123-149

Polio eradication in Pakistan was officially a government program with support from international organizations like WHO. In certain times and places, this was how things actually worked. Since hundreds of thousands of Pakistani government employees did the work of vaccinating children, polio eradication was a government program in a very real sense. As one WHO official noted, the progress made in greatly ...

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Air Travel

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pp. 150

The heat in Kaifabad is torrid in early June. Each evening the always weak electricity in my windowless house gives out entirely, and I can only pray there is enough water to stand in the shower with my clothes on in order to cool off enough to fall asleep. I board a crowded plane from Kaifabad to Abu Dhabi filled with migrant workers and give a huge sigh ...

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6. Geneva

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pp. 151-170

I began a master’s program in international health in 2003 but graduated in 2005 with a degree in global health.2 The change in the moniker of my department reflected a larger trend: the term “global health” is replacing the previously dominant “international health” in the language of academics and bureaucrats working toward improving health ...

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The End of the Line

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pp. 171-172

I walk to Zainab’s house from my house in Kaifabad through streets not wide enough for a car, redolent with raw sewage from the open gutters that run down both sides of the road. None of the houses in her neighborhood has a yard. They all share three walls with other homes, the ...

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7. Conclusion

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pp. 173-194

The field of global public health is currently in an era of unprecedented funding and ambitious goal making.1 The global financial crisis of 2008– 2009 is likely to have some effect on aid (McNeil 2009), but it takes place in the context of historically high levels of funding for global health initiatives: $21.8 billion in 2007, compared to $5.6 billion in 1990 (Ravishankar et al. 2009). ...


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pp. 195-208

Works Cited

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pp. 209-223


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pp. 225-232

E-ISBN-13: 9780826517104
Print-ISBN-13: 9780826517081
Print-ISBN-10: 0826517080

Page Count: 248
Publication Year: 2010