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195 Notes Chapter 1 1. More information on the history and progress of the Polio Eradication Initiative is in Chapter 2. 2. The World Health Organization valued employees who were aware of local realities. At all levels of the organization, there was an emphasis on understanding the particularities of specific situations—the motto in Pakistan for 2007 was “local solutions to local problems.” Perhaps five decades of anthropological harping on this point has had an impact. 3. Most of the conversation quoted in this chapter took place in Urdu, or in a local dialect of Punjabi. (In this particular case, the exchange took place in a mixture of Urdu and English.) The translations into English are my own. Throughout the book, speech in quotation marks or in block quotes (such as this one) represents either a direct quote recorded at the time or a conversation reconstructed immediately after it took place. 4. Minority groups across Pakistan and India were consistently less well vaccinated than the general population. This was in many cases due to prejudice on the part of the lower-middle-class, mainstream-culture vaccinators, an issue I discuss in more detail in Chapter 5. 5. District-level health staff were supposed to carry out a variety of tasks for “social mobilization,” including visiting teachers and religious and community leaders on a regular basis to secure their support for immunization activities. Overall, refusals were a concern but not a major barrier to the elimination of polio from Pakistan; by the WHO’s best estimates, they never amounted to more than 1 percent of the overall population. 6. The Global Alliance for Vaccines and Immunizations (GAVI); the Global Fund to Fight AIDS, Tuberculosis, and Malaria; the Stop TB Partnership; and the Measles Initiative are notable examples of large projects similar in these respects to the Polio Eradication Initiative. The projects are of course not exactly alike—the Global Fund, for example, uses a much wider array of implementing organizations in recipient countries than the Polio Eradication Initiative does—but my discussion of the challenges that the Polio Eradication Initiative faces likely applies to some extent to these other large projects. 196 Notes to Pages 9–15 7. I am aware that what, exactly, constitutes success and failure is often a deceptively simple question. David Mosse argues that in some projects, attribution of “success” or “failure” depends less on what actually happens on the ground than on whether planners are able to cast the achievements of a project in terms of their donors’ dominant paradigms (Mosse 2005). In the culture of optimism that I argue characterizes global health, projects that are failures by their original criteria may be recast as successes (Brown 1998). Also, projects that succeed in their stated goals may have few wider impacts (the eradication of polio, for example, would not significantly change the overall burden of disease in Pakistan). These nuances must be grappled with—but discussing them should assist with, rather than detract from, the goal of analyzing whether and how development projects are making concrete improvements in the lives of the poor they aim to assist. 8. The Polio Eradication Initiative does a genetic sequence of the poliovirus obtained from every child with polio, which enables analysis of the patterns of transmission of the virus. 9. Eight to ten million people fled in both directions across these newly drawn lines in the Punjab and Bengal, and between half a million and a million people were killed (Menon and Bhasin 1998, 35). Bangladesh, formerly East Pakistan, became an independent nation after a civil war in 1971. 10. The government estimated that as of 2000–2001, 32 percent of the population was surviving on less than Rs 748 (about $13) per person per month, the poverty threshold “derived by valuing the minimum required caloric intake of 2350 calories per capita with a minimum expenditure required for non-food needs” (Government of Pakistan Planning Commission 2005, 7). It should be noted that the economic situation in Pakistan as a whole has improved since this estimate was made in 2000. 11. I attended a lower-middle-class wedding within earshot of the bombs exploding at Lal Masjid during the “operation,” and conversation at the wedding centered on this topic. While there was widespread condemnation of the actions of the militants—most people felt that their using the children of the madrassah as a human shield was reprehensible, and that their lack of respect for private property was a serious...


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