Better (6 page)

O
NE DIFFICULT QUESTION
came up repeatedly--from local doctors, from villagers, from workers trudging house to house. The question was: Why? Why this huge polio campaign when what we need is--fill in the blank here--clean water (diarrheal illness kills 500,000 Indian children per year), better nutrition (half of children under three have stunted growth), working septic systems (which would help prevent polio as well as other diseases), irrigation (so a single rainless season would not impoverish farming families)? We saw neighborhoods that had had outbreaks of malaria, tuberculosis, cholera. But no one important had come to visit in years. Now one case of polio occurs and the infantry marches in?

There are some stock answers. We can do it all, goes one.
We can eradicate polio and do better on the other fronts. In reality, though, choices are made. For that whole week, for instance, doctors in northern Karnataka had all but shut down their primary health clinics in order to carry out the polio vaccination work.

Pankaj relies on a somewhat more persuasive line of argument: that ending polio is in itself worthwhile. In one village, I watched a resident demand to know why the government and WHO weren't combating malnutrition there instead. There was only so much they could do, Pankaj said. "And if you're starving, becoming paralyzed certainly isn't going to help."

Still, you could make the same claim for almost any human problem that you decide to tackle--blindness or cancer or, for that matter, kidney stones. ("If you're starving, kidney pain certainly isn't going to help.") And then there is the issue of money. So far the campaign has cost three billion dollars worldwide, more than six hundred dollars a case. To put that in perspective, the Indian government's total budget for health care in 2003 came to four dollars per person. Stopping the very last case of polio, one official told me, might cost as much as two hundred million dollars. Even if the campaign succeeds in the eradication of polio, it is entirely possible that more lives would be saved in the future if the money were spent on, say, building proper sewage systems or improving basic health services.

What's more, success is by no means assured. WHO has had to extend its target date for eradication from 2000 to 2002 to 2005 and now is having to extend it again. In these last years of the campaign, more and more money has been spent chasing
the few hundred cases that keep popping up. A certain weariness is bound to settle in. Around twenty-four million children are born in India each year, creating a new pool of potential polio victims the size of Venezuela's entire population. Just to stay caught up, a mammoth campaign to immunize every child under the age of five has to be planned each year. The truth is, no cost-benefit calculus can assure us just now that the money is well spent.

Yet for all these reservations, the campaign has averted an estimated five million cases of paralytic polio thus far--a momentous achievement in itself. And although erasing the disease from the world is a grand, perhaps even absurd ambition, it remains a feasible task and one of the few things we as a civilization can do that would benefit mankind forever. The eradication of smallpox will last as an enduring gift to all who are to come, and now, perhaps, the eradication of polio can, too.

But this means we must actually get down to that final polio case. Otherwise, the efforts of the hundreds of thousands of volunteers, and the billions spent will have amounted to nothing--or maybe worse than nothing. To fail at this venture would put into question the very ideal of eradication.

Beneath the ideal is the gruelingly unglamorous and uncertain work. If the eradication of polio is our monument, it is a monument to the perfection of performance--to showing what can be achieved by diligent attention to detail coupled with great ambition. There is a system, and it has eradicated polio in countries with far worse conditions than I was seeing in India--for example, in Bangladesh, in Vietnam, in Rwanda, in Zimbabwe. Polio was eradicated from Angola in the midst of a civil war. An outbreak in Kandahar in 2002 was halted by
a WHO-led mop-up operation despite the Afghan war. In 2006, new mop-ups took place in northern Nigeria, where polio remains endemic and periodically spills into neighboring countries. In India, Pankaj told me, there have been campaigns on camels in the Thar Desert of Rajasthan, in jeeps among the tribal communities of the Jharkhand forests, on power boats through flooded regions of Assam and Meghalaya, on Navy cruisers traveling to remote islands in the Bay of Bengal. During our own mop-up, we covered about a thousand miles in the three days of going town to town. Pankaj worked his mobile phone almost constantly. Armed with the information he provided, state officials arranged deliveries from ice factories to teams at risk of running short of ice packs and extended the mop-up by an additional day in one area where the local officer had severely underestimated the population to be vaccinated. Four miles outside the village of Balkundi, we came upon a cluster of makeshift shanties for migrant laborers, not seen on any maps. When we checked the children, though, they all had the vaccinators' ink marks on their pinkies. At Chitradurga, we found the mines in decay, but state officials had made sure that the company gave the vaccinators access to the workers' compound. With some searching, we discovered a few children here and there. Every one of them had received the vaccine, too.

By the end of the mop-up, UNICEF officials had distributed more than five million doses of fresh vaccine through the thirteen districts. Television, radio, and local newspapers had been blanketed with public service announcements. Rotary of India had printed and delivered 25,000 banners, 6,000 posters,
and more than 650,000 handbills. And 4 million of the targeted 4.2 million children had been successfully vaccinated.

In 2005, India had just sixty-six new cases of polio. Pankaj and his colleagues believe that they're finally closing in on their goal of eradication in India. And as India goes, so might the world.

S
TILL, THERE IS
no denying the dimensions of what Pankaj and his colleagues are up against. Pankaj says that he has seen more than a thousand cases of polio in his career as a pediatrician. When we drove through the villages and towns, he could pick out polio victims at a glance. They were everywhere, I began to realize: the beggar with two emaciated legs folded under him, rolling by on a wooden cart; the man dragging his leg like a club down the street; the passerby with a contracted arm tucked against his side.

On the second day of the mop-up, we reached Upparahalla, the village where the Karnataka outbreak had started. The first, index case of polio was now a fourteen-month-old boy with a healthy, almost muscular thickness about his upper body; after the first few days of his infection, his breathing had returned to normal. But when his mother put him down on his stomach you could see that his legs were withered. With the exercises the nurses had taught her to do with him, he had regained enough movement in his left leg to be able to crawl, but his right leg dragged limply behind him.

Making our way around the open sewage in Upparahalla, the mud-covered pigs, the cows resting curled up like
cats with their heads on their hooves, we found the neighbor girl who had come down with polio after the boy. She was eighteen months old, with a big, worried face, perfect white teeth, and short, spiky hair. She was wearing small gold earrings and a yellow-and-brown checked dress. She squirmed in her mother's arms, but her legs only dangled beneath her dress. Her mother wore an impassive expression as she stood before us in the sun, holding her paralyzed child. Pankaj gently asked her if the girl had ever received polio drops--perhaps she'd got the vaccine but it had not taken. The mother said that a health worker had come around with polio drops a few weeks before her daughter became sick. But she had heard from other villagers that children were getting fevers from the drops. So she refused the vaccination. A look of profound sadness now swept over her. She had not understood, she said, staring down at the ground.

Eventually, Pankaj continued onward, checking on the vaccinators going door to door. Then, when he was finished, we left. The road heading out of the village was a red dirt track and we rattled over it with our wheels in the ruts that the bullock carts had made.

"What will you do when polio is finally gone?" I asked Pankaj.

"Well, there is always measles," he said.

E
ach Tuesday, the U.S. Department of Defense provides an online update of American military casualties from the wars in Iraq and Afghanistan. According to this update, as of December 8, 2006, a total of 26,547 service members had suffered battle injuries. Of these, 2,662 died; 10,839 lived but could not return to duty; and 13,085 were less severely wounded and returned to duty within seventy-two hours. These figures represent, by a considerable margin, the largest burden of casualties our military medical personnel have had to cope with since the Vietnam War.

When U.S. combat deaths in Iraq reached the two-thousand mark in September 2005, the event captured worldwide attention. Combat deaths are seen as a measure of the
magnitude and dangerousness of war, just as murder rates are seen as a measure of the magnitude and dangerousness of violence in our communities. Both, however, are weak proxies. Little recognized is how fundamentally important the medical system is--and not just the enemy's weaponry--in determining whether or not someone dies. U.S. homicide rates, for example, have dropped in recent years to levels unseen since the mid-1960s. Yet aggravated assaults, particularly with firearms, have more than tripled during that period. A key mitigating factor appears to be the trauma care provided: more people may be getting shot, but doctors are saving even more of them. Mortality from gun assaults has fallen from 16 percent in 1964 to 5 percent today.

We have seen a similar evolution in war. Though firepower has increased, lethality has decreased. In the Revolutionary War, American soldiers faced bayonets and single-shot rifles, and 42 percent of the battle wounded died. In World War II, American soldiers were hit with grenades, bombs, shells, and machine guns, yet only 30 percent of the wounded died. By the Korean War, the weaponry was certainly no less terrible, but the mortality rate for combat-injured soldiers fell to 25 percent.

Over the next half century, we saw little further progress. Through the Vietnam War (with its 153,303 combat wounded and 47,424 combat dead) and even the 1990-91 Persian Gulf War (with its 467 wounded and 147 dead), mortality rates for the battle injured remained at 24 percent. Our technology to save the wounded seemed to have barely kept up with the technology inflicting the wounds.

The military wanted desperately to find ways to do better.
The most promising approach was to focus on discovering new treatments and technologies. In the previous century, that was where progress had been found--in the discovery of new anesthetic agents and vascular surgery techniques for World War I soldiers, in the development of better burn treatments, blood transfusion methods, and penicillin for World War II soldiers, in the availability of a broad range of antibiotics for Korean War soldiers. The United States accordingly invested hundreds of millions of dollars in numerous new possibilities: the development of blood substitutes and freeze-dried plasma (for infusion when fresh blood is not available), gene therapies for traumatic wounds, medications to halt lung injury, miniaturized systems to monitor and transmit the vital signs of soldiers in the field.

Few if any of these have yet come to fruition, however, and none were responsible for what we have seen in the current wars in Iraq and Afghanistan: a marked, indeed historic, reduction in the lethality of battle wounds. Although more U.S. soldiers have been wounded in combat in the current war than in the Revolutionary War, the War of 1812, and the Spanish-American War combined, and more than in the first four years of military involvement in Vietnam, we have had substantially fewer deaths. Just 10 percent of wounded American soldiers have died.

How military medical teams have achieved this is important to think about. They have done it despite having no fundamentally new technologies or treatments since the Persian Gulf War. And they have done it despite difficulties with the supply of medical personnel. For its entire worldwide mission, the army had only about 120 general surgeons available
on active duty and two hundred in the reserves in 2005. To support the 130,000 to 150,000 troops fighting in Iraq, it has been able to put no more than thirty to fifty general surgeons and ten to fifteen orthopedic surgeons on the ground. And these surgeons and their teams have been up against devastating injuries.

I got a sense of the extent of the injuries during a visit to Walter Reed Army Medical Center in Washington, D.C., in the fall of 2004, when I was invited to sit in on what the doctors call their "War Rounds." Every Thursday, the Walter Reed surgeons hold a telephone conference with army surgeons in Baghdad to review the American casualties received in Washington. The case list for discussion the day I visited included one gunshot wound, one antitank-mine injury, one grenade injury, three rocket-propelled-grenade injuries, four mortar injuries, eight improvised explosive device (IED) injuries, and seven with no cause of injury noted. None of these soldiers was more than twenty-five years of age. The least seriously wounded was a nineteen-year-old who had sustained extensive blast and penetrating injuries to his face and neck from a mine. Other cases included a soldier with a partial hand amputation; one with a massive blast injury that amputated his right leg at the hip, a through-knee amputation of his left leg, and an open pelvic wound; one with bullet wounds to his left kidney and colon; one with bullet wounds under his arm requiring axillary artery and vein reconstruction; and one with a shattered spleen, a degloving scalp laceration, and a through-and-through tongue laceration. These are terrible and formidable injuries. Nonetheless, all were saved.