Firozabad, INDIA — A team of women picks its way down narrow laneways and up steep stone staircases, stepping over the occasional indifferent goat along the way. They are multi-denominational, the bright saris of the Hindus a contrast to the black hijabs of their Muslim colleagues.
The women carry ledgers, chalk and a Styrofoam cooler. Everywhere they go they bend to peer at the left hands of the smallest children in what seems like a sea of children. They check the nail bed of the pinky finger for a slash of purple, the mark of those already vaccinated against the virus they are trying to drive out of India, polio.
The setting is Firozabad, a sprawling, bustling city in Uttar Pradesh, India’s most populous state. Carts pulled by camels, oxen and horses or pushed by people share the chaotic roads with cars, motorcycles, bicycles and more people. Everywhere you see bricks and bangles, bangles and bricks. Here, it seems, nearly everyone is either making one or the other or moving one or the other from one place to the next.
The area’s rich clay soil molds well into the red bricks that India makes and uses by the millions. And the city is famous for the thin glass bracelets that clink and cluster on the wrists of married women in India. The workers of both industries pose particular challenges for the polio eradication effort.
In recent years Uttar Pradesh — or UP as it is commonly known — and the neighboring state of Bihar have been the source of all the polio viruses that have crippled children in India. As such, they are considered high-risk areas, marked for more frequent vaccination rounds than states where polio appears to have been quelled.
Nearly every month the effort is mounted. An army of vaccinators tries to find every child five and younger. Teams visit each house, shanty and tent on their routes, dripping orange polio vaccine into grimacing mouths. In some homes, they meet parental resistance. To those homes they make repeated calls, trying to work through the fear, dispel the misinformation.
The team marks its progress on house doors in chalk. The markings look like hieroglyphics to the uninformed, but to those on Team Polio, there is much to be learned from the chalk scratchings.
Dr. Suhasini More — her surname rhymes with foray — is the World Health Organization’s polio team leader for the Agra sub-region, into which Firozabad falls. She deciphers the chalk marks on one door across from an open lot where water has pooled and garbage festers.
“T means team number. Team Number 7. X is because maybe one or two or all the children are not vaccinated due to any reason. Maybe he’s not at home. Maybe he’s sick. And this,” says More, pointing to an arrow that punctuates the markings, “is the direction the team in going.”
An X can also mean a parent has refused to let a child be vaccinated. That has traditionally been a problem among some in UP’s sizeable Muslim minority. But More says the number of families that reject vaccine for their children has been declining.
Muslim women vaccinators are meant to help overcome what remains of this resistance. In some cases, a community leader — a person of influence — also trails around with the team, a presence meant to persuade those wary of the vaccine that it’s OK from a religious point of view.
The local eradication team has even reached out to the union that represents bangle makers, says Dr. Rakesh Vishwakarma, officer on special duty for the UP region for the National Polio Surveillance Project, a joint Indian-WHO effort. Vishwakarma explains that the thinking is if union organizers tell Muslim members that letting their kids be vaccinated is a good thing, then more will agree to do so.
Brick kiln workers pose their own obstacles for the vaccination teams. Whole families are drawn to the kilns for work, leaving homes in rural India for the better paying work at kilns. But brickmaking operations shut down during the annual monsoons, prompting the migrants to scatter back to their homes.
Because they move around, these families often don’t fall under the responsibility of a specific jurisdiction. This means vaccinators need to know where the kilns are and how many families, how many young children, are living on their grounds. These are people who won’t bring their children to vaccination clinics. The vaccine has to come to them. Firozabad is about 25 miles from Agra, but it feels light years away from that city’s glistening Taj Mahal. Smallish by Indian standards, the city has a population of about 350,000, though many thousands more live in villages and hamlets dotting the surrounding countryside.
The standard of living here is not high. According to India’s 2001 census — the most recent from which statistics are available — 35 percent of families in UP were comprised of six to nine members. And just over 60 percent of families in the province lived in dwellings consisting of one or two rooms.
In 2001, most homes did not have electricity, running water or indoor bathrooms; 63 percent got their water from a communal hand pump, 67 percent lit their houses by kerosene and 68 percent did not have indoor latrines.
Some improvements have occurred over the past five years, but sanitation here is still very poor, Vishwakarma says. That lack of infrastructure helps explain why polio has been so hard to root out here. Polioviruses travel from one person to the next via what’s known as the fecal-oral route. In places where people defecate in the open or dump feces into gutters or drains, there are many ways for polio viruses to leach into water and make their way into the guts of the vulnerable — especially during the monsoon season, which is now underway.
India is one of four countries in the world where polio is still endemic, though it appears it may be on the cusp of finally halting transmission. There has been only one case of paralytic polio reported in the country this year, in West Bengal.
Helen Branswell is a Nieman Global Health Fellow. Her travel was supported by the Pulitzer Center on Crisis Reporting as part of its partnership with Harvard’s Nieman Foundation for Journalism, designed to strengthen global health reporting. See her related reporting on Sewage Science: Stalking a Threat to Polio Eradication in the World’s Sewers.