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Just that was revolutionary. The villagers discovered that there were well-nourished children among them, despite the poverty, and that those children's mothers were breaking with the locally accepted wisdom in all sorts of ways--feeding their children even when they had diarrhea, for example; giving them several small feedings each day rather than one or two big ones; adding sweet potato greens to the children's rice despite its being considered a low-class food. And the ideas began to spread. They took hold. The program measured the results and posted them in the villages for all to see. In two years, malnutrition dropped 65 to 85 percent in every village the Sternins had been to.
Lloyd was bitten by the positive deviance idea--the idea of building on capabilities people already had rather than telling them how they had to change. By March 2005, he and Perreiah persuaded the veterans hospital leadership in Pittsburgh to try the positive deviance approach with hospital infections. Lloyd even convinced the Sternins to join in. Together they held a series of thirty-minute, small group discussions with health care workers at every level: food service workers, janitors, nurses, doctors, patients themselves. The team began each meeting saying, in essence, "We're here because of the hospital infection problem and we want to know what you know about how to solve it." There were no directives, no charts with what the experts thought should be done. "If we had any dogma going in," Jerry Sternin says, "it was: Thou shalt not try to fix anything."
Ideas came pouring out. People told of places where hand-gel dispensers were missing, ways to keep gowns and gloves from running out of supply, nurses who always seemed able to wash their hands and even taught patients to wash their hands, too. Many people said it was the first time anyone had ever asked them what to do. The norms began to shift. When forty new hand-gel dispensers arrived, staff members took charge of putting them up in the right places. Nurses who would never speak up when a doctor failed to wash his or her hands began to do so after learning of other nurses who did. Eight therapists who thought wearing gloves with patients was silly were persuaded by two of their colleagues that it was no big deal. The ideas were not terribly new. "After the eighth group, we began to hear the same things over and over," Sternin says. "But we kept going even if it was group number thirty-three for us, because it was the first time those people had been heard, the first time they had a chance to innovate for themselves."
The team made sure to publicize the ideas and the small victories on the hospital Web site and in newsletters. The team also carried out detailed surveillance--taking nasal cultures from every hospital patient upon admission and upon discharge. They posted the monthly results unit by unit. One year into the experiment--and after years without widespread progress--the entire hospital saw its MRSA wound infection rates drop to zero.
The Robert Wood Johnson Foundation and the Jewish Healthcare Foundation recently launched a multimillion-dollar initiative to implement this approach in ten more hospitals across the country. Lloyd cautions that it remains to be seen whether the Pittsburgh results will last. It also remains to be seen if the success can be duplicated nationally. But nothing else has worked, and this is the most fascinating idea anyone has had to solve the problem in a century.
AT ONE POINT during my tour with Yokoe and Marino, we walked through a regular hospital unit. And I finally began to see the ward the way they do. Flowing in and out of the patients' rooms were physical therapists, patient care assistants, nurses, nutritionists, residents, students. Some were good about washing. Some were not. Yokoe pointed out that three of the eight rooms had bright yellow precaution signs because of patients inside with MRSA or VRE. Only then did I realize we were on the floor of one of my own patients. One of those signs hung on his door.
He was sixty-two years old and had been in the hospital for almost three weeks. He had arrived in shock from another hospital, where an operation had gone awry. I performed an emergency splenectomy for him and then had to go back in again when the bleeding still didn't stop. He had an open abdominal wound and could not eat. He had to receive his nutrition intravenously. He was recovering, though. Three days after admission, he was out of the intensive care unit. Initial surveillance cultures were completely negative for resistant organisms. New cultures ten days after admission, however, came back positive for both MRSA and VRE. A few days after that, he developed fevers up to 102 degrees. His blood pressure began dropping. His heart rate climbed. He was septic. His central line--his lifeline for nutrition--had become infected, and we had to take it out.
Until that moment, when I stood there looking at the sign on his door, it had not occurred to me that I might have given him that infection. But the truth is I may have. One of us certainly did.
The Mop-Up
People underestimate the importance of diligence as a virtue. No doubt this has something to do with how supremely mundane it seems. It is defined as "the constant and earnest effort to accomplish what is undertaken." There is a flavor of simplistic relentlessness to it. And if it were an individual's primary goal in life, that life would indeed seem narrow and unambitious.
Understood, however, as the prerequisite of great accomplishment, diligence stands as one of the most difficult challenges facing any group of people who take on tasks of risk and consequence. It sets a high, seemingly impossible, expectation for performance and human behavior. Yet some in medicine have delivered on that expectation on an almost unimaginable scale. The campaign to eradicate polio in India is just such an instance.
THE INDEX CASE was an eleven-month-old boy with thick black hair his mother liked to comb forward so that the bangs rimmed his round face. His family lives in the southern Indian state of Karnataka, in a village called Upparahalla, along the Tungabhadra River. Dry mountains of teetering rocks can be seen in three directions from the village. It has no running water and little electricity. The boy's mother is illiterate; the father can read only road signs. They are farm laborers, and they live with their three children in a single-room hut of thatch and mud. But the children are well nourished. The mother wears gold and silver earrings. Once in a while, they travel.
In April 2003, the family took a trip north to see relatives. Shortly after they returned, on May 1, the boy developed high fevers and racking bouts of nausea and vomiting. His parents took him to a nearby clinic, where a doctor gave him an antibiotic injection. Two days later, the fevers subsided, but he became unable to move either of his legs. In a panic, the parents took him back to the doctor, who sent him to the district hospital in Bellary, about forty miles away. As the day progressed, the weakness spread through the boy's body. His breathing grew shallow and labored. He lay flat and motionless on his hospital cot.
A doctor at the hospital, following standard procedure in cases of sudden childhood paralysis, phoned a surveillance medical officer with the World Health Organization in Bangalore, the capital of Karnataka. The medical officer made sure that stool specimens were taken and sent for culture to a national laboratory in Mumbai (as Bombay is now called). On June 24, the laboratory results finally came back. A young technical officer with WHO in New Delhi got the call; it was a confirmed case of polio, a disease thought to have been eliminated from southern India, and it set off an alarm.
The World Health Organization is nearly two decades into its campaign to eradicate polio from the world. If the campaign succeeds, it may be mankind's single most ambitious accomplishment. But this is a big if. International organizations are fond of grand-sounding pledges to rid the planet of this or that menace. They nearly always fail, however. The world is too vast and too various to submit to dictates from on high.
Consider the other attempts that have been made to eliminate individual diseases. In 1909, the newly established Rockefeller Foundation launched the first global eradication campaign, an effort to end hookworm disease, using antihelminthic drugs, in fifty-two countries. It didn't work. Today, a billion people--a sixth of the world's population--are infected with hookworm, an intestinal parasite that feeds on human bloo
d. A seventeen-year campaign against yellow fever, led by the Rockefeller Foundation and the United States armed services, had to be abandoned in 1932 when yellow fever was found to have a reservoir outside human beings. (The yellow fever virus persists in mosquitoes' eggs.) In 1955, WHO and UNICEF began a campaign to end yaws, an infectious disease that causes painful, purulent skin ulcers; workers screened 160 million people in sixty-one countries for the disease and treated every case they found with penicillin. A dozen years later, the campaign was dropped when it turned out that silent, subclinical infections were continuing to propagate the disease. Billions of dollars were spent in the fifties and sixties to eradicate malaria; today the disease afflicts more than 300 million people a year.
After a century of effort, the only successful attempt at eradication of a global disease has been the battle against smallpox--a mammoth undertaking that was, just the same, decidedly simpler than the campaign against polio. Smallpox, with its distinctive blisters and vesicles, could be readily and quickly identified; the moment a case appeared, a team could be dispatched to immunize everyone the victim might have come into contact with. That strategy, known as "ring immunization," eradicated the disease by 1979. Polio infections are far harder to identify. For every person who is paralyzed, between two hundred and a thousand infected people come down with little more than a stomach flu--and they remain silently contagious for several weeks after the symptoms abate. Nor is every case of childhood paralysis polio, and it usually takes weeks for stool specimens to be obtained, delivered to a laboratory, and properly tested for the disease. By the time one case has been identified, scores more people have been infected. As a result, the area targeted for polio immunization must be far larger than that for smallpox. And whereas people needed to be vaccinated against smallpox only once for immediate protection, a single dose of polio vaccine does not always take--children with diarrheal illnesses tend to pass the oral vaccine straight through. So a repeat round of immunization is required within four to six weeks. In logistical terms, it's the difference between extinguishing a candle flame and putting out a forest fire.
Despite the obstacles, however, the campaign against polio has made immense progress. Routine vaccination had made polio uncommon in the West, but cases continued to occur in the United States, Canada, and Europe into the 1980s, and the disease remained endemic in large portions of the world. In 1988, more than 350,000 people developed paralytic polio, and at least 70 million were infected with the virus. By 2001, only 498 cases were identified. The whole of the Americas, Europe, and the western Pacific, along with nearly all of Africa and Asia, are currently free of the disease.
In each year since 2001, however, just as the disease was on the verge of being wiped out, an outbreak has flared in some country in Asia or Africa, spilled across borders, and threatened to bring polio roaring back. In 2002, India was that country. Outbreaks in the north produced sixteen hundred polio cases. Four-fifths of all the world's cases occurred there that year. Nonetheless, the belief was that the disease had been isolated to a handful of northern states. Then, in 2003, a boy in south India developed polio--the first case in the state of Karnataka in almost three years. If the disease expanded from there, the campaign would be all but over.
ON JUNE 25, less than twenty-four hours after the report of the Karnataka polio case came in, Sunil Bahl, a WHO physician and technical officer in the Delhi office, sent an e-mail to key people at WHO, at UNICEF, and in the Indian government. It was his job to provide the initial assessment of the facts on the ground. "The case is in an area that has a history of being the worst in Karnataka," he wrote; it had poor routines of immunization and the most polio cases in the early years of the campaign. "Risk of establishment of virus in the area high, unless quick wide and strong measures in the form of a wide mop-up are taken." A "mop-up" is WHO lingo for a targeted campaign to immunize all susceptible children surrounding a new case. It's what is done in an area that has been rendered polio-free through routine immunization but is facing a new infection that threatens to bring the disease back. The campaigns are carried out rapidly, in just three days, to ensure that the vaccine saturates a population and to make it easier to recruit volunteers.
Sunil Bahl sent around a map of the proposed area for the mop-up operation. It covered fifty thousand square miles. Working around the summer holidays and festivals, government officials selected July 27 for the start of the first immunization round. The second round would follow a month later. Brian Wheeler, a thirty-five-year-old Texan who was the chief operations officer for WHO's polio program in India, explained the logistics to me. The Indian government would have to recruit and organize teams of medical workers and volunteers, he said. They would have to be trained in how to administer the vaccine and provided with transportation, vaccine, and insulated coolers and ice packs to keep the vaccine cold. And they would have to fan out and vaccinate every child under five years of age. Anything less than 90 percent coverage of the target population--the percentage needed to shut down transmission--would be considered a failure.
I asked him how many people that would involve.
He checked his budget sheet. The plan, he said, was to employ thirty-seven thousand vaccinators and four thousand health care supervisors, rent two thousand vehicles, supply more than eighteen thousand insulated vaccine carriers, and have the workers go door to door to vaccinate 4.2 million children. In three days.
POLIO IS A disease that strikes children almost exclusively--more than 80 percent of paralysis cases occur in children under age five. It is caused by an intestinal virus; the virus must be ingested to bring about an infection. Once inside the gut, it passes through the lining and takes up residence in nearby lymph nodes. There it multiplies, produces fevers and stomach upset, and passes back into the feces. Those infected can contaminate their clothing, bathing sites, and supplies of drinking water and thereby spread the disease. (The virus can survive as long as sixty days outside the body.)
Poliovirus infects only a few kinds of nerve cells, but what it infects it destroys. In the most dreaded cases, the virus spreads from the bloodstream into the neurons of the brain stem, the cells that allow you to breathe and swallow. To stay alive, a person has to be fed through a tube and ventilated by machine. The nerve cells most commonly attacked, though, are the anterior horn cells of the spinal cord, which control the arms, the legs, and the abdominal muscles. Often, so many neurons are destroyed that muscle function is eliminated altogether. Tendon reflexes disappear. Limbs hang limp and useless.
The first effective vaccine for polio was introduced in 1955, after the largest clinical trial in history. (Jonas Salk's vaccine, made from killed poliovirus, was given to 440,000 children; 210,000 received a placebo injection, and more than a million served as unvaccinated controls.) Five years later, Albert Sabin published the results of an alternative polio vaccine he had used in an immunization campaign in Toluca, Mexico, a city of a hundred thousand people, where a polio outbreak was in progress. His was an oral vaccine, easier to administer than Salk's injected one. It was also a live vaccine, containing weakened but intact poliovirus, and so it could produce not only immunity but also a mild contagious infection that would spread the immunity to others. In just four days, Sabin's team managed to vaccinate more than 80 percent of the children under the age of eleven--26,000 children in all. It was a blitzkrieg assault. Within weeks, polio had disappeared from the city.
This approach, Sabin argued, could be used to eliminate polio from entire countries, even the world. The only leader in the West who took him up on the idea was Fidel Castro. In 1962, Castro's Committee for the Defense of the Revolution organized 82,366 local committees to carry out a succession of weeklong house-to-house national immunization campaigns using the Sabin vaccine. In 1963, only one case of polio occurred in Cuba.
Despite those results, Sabin's grand idea did not catch on until 1985, when the Pan American Health Organization launched an initiative to eradicate polio from the Americ
as. (Six years later, Luis Fermin Tenorio, a two-year-old boy in the town of Pichinaki, Peru, became the last polio victim in the Americas.) In 1988, spurred by the campaign's growing success, WHO committed itself to eradicating polio from the world. That year, Rotary International pledged a quarter of a billion dollars for the effort. (It has since provided 350 million dollars more.) UNICEF agreed to organize the worldwide production and distribution of vaccine. And the United States made the campaign one of the CDC's core initiatives, supplying both expertise and considerable additional funding.
The centerpiece of the effort has been what are called national immunization days--three-day periods when all children under five in a country are immunized, regardless of whether they have received immunization before. In one week in 1997, 250 million children were vaccinated simultaneously in China, India, Bhutan, Pakistan, Bangladesh, Thailand, Vietnam, and Burma. National immunization days have reached as many as half a billion children at one time--almost a tenth of the world's population. Through such efforts--and a reliable network of monitors to detect outbreaks--the WHO campaign has brought the incidence of polio in the world to less than 1 percent of what it used to be.