1. Introduction
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1 Chapter 1 Introduction It’s so frustrating! We know [what] is going to happen and can do nothing to stop it! —World Health Organization (WHO) official, Islamabad The Polio Eradication Initiative, a twenty-year, six-billiondollar 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 door-to-door (World Health Organization 2002). Polio eradication may also prove to be one of public health’s most spectacular failures. The program is in trouble. After twenty years of work, the goal of eradicating polio has not been met. The program has made dramatic progress, reducing the number of new polio cases from hundreds of thousands per year in 1988 to around eight hundred in 2003. However, in the last few years the project has been unable to make significant headway in reducing the case count to zero; in fact, the number of new polio cases seen each year has increased.1 In 2008, there were around 1,600 cases of polio in the world. Polio transmission stubbornly persists in four countries: Nigeria, India, Pakistan, and Afghanistan. With the two target dates set for eradicating polio already missed—2000, and then 2005—the possibility may be slipping away. This book is an ethnography of the Polio Eradication Initiative as it played out in Pakistan in 2006 and 2007. It examines power relations and the politics of decision making in this major global health project, and describes the cultures of health systems from Geneva to the Pakistani Punjab. The central question this book asks is: Why does the effort to eradicate polio seem to be failing in Pakistan? I thought I might already know the 2 Chasing Polio in Pakistan answer to this question when I began my research. I thought that polio eradication officials would know little about local cultures, and I thought they would use local cultural beliefs as a scapegoat for failures of implementation . But as it happened, my preconceived ideas were wrong. Knowledge of Local Culture It is a truism in medical anthropology that health projects often fail because they are based on insufficient knowledge of the cultures of the people they aim to assist. A common theme throughout the medical anthro­ pology literature is the necessity of understanding local culture and beliefs in order to successfully implement health projects and effect behavior change (e.g., Hahn 1999; Paul 1955). Judith Justice’s Policies, Plans, and People (1986) is justifiably a classic in the anthropology of global health and is the book that in large part inspired my own work. A central thesis of her work—one that holds true in many health projects I have observed in South Asia—is that the effectiveness of many health projects is limited by their failure to take local realities into account. But the difficulties the Polio Eradication Initiative faces cannot be blamed on a lack of local knowledge. I was consistently impressed and humbled by how well Polio Eradication Initiative officials in Islamabad, and even Geneva, understood the complexities of local communities’ attitudes toward polio immunization and the knotty dynamics of vaccination campaign implementation in district health systems in a variety of contexts across Pakistan. I had ingratiated myself into the project by offering to provide anthropological information that would expand planners’ understanding of the people whose children they aimed to vaccinate, but I soon found I could tell them nothing that they did not already know. Part of the reason people working on polio eradication had such deep knowledge is because of the structure of the project. Polio vaccination takes place in mass campaigns carried out over the course of about a week about eight times a year. During the campaigns, the World Health Organization offices in Islamabad emptied out save for a single employee charged with collecting the data arriving via phone, e-mail, and fax from various districts. World Health Organization and UNICEF employees fanned out across Pakistan, directly monitoring campaign activities in every district where cases of polio were still occurring. A highly developed and sensitive surveillance system told planners exactly where polio cases were still occurring and thus where vaccination Introduction 3 coverage was less than perfect, so they could focus their attention on places where quality was subpar. Because vaccination was not an ongoing activity but...