Gates Package — page 549

populations, and over 27 million children born every year--more than in all of sub-Saharan Africa --who need to be vaccinated. Stopping the circulation of the virus everywhere in the country was the eradication initiatives biggest accomplishment in the past decade. Vaccine team preparing to vaccinate children against polio at Patna Railway Station (Bihar, India, 2011). There are now just three countries that have never eliminated polio: Nigeria, Pakistan, and Afghanistan. I visited Northern Nigeria four years ago to try to understand why eradication is so difficult there. I saw that routine public health services were failing: Fewer than half the kids were getting vaccines regularly, and there were no reliable figures for how many children lived in each area. Also, the normal process of quality monitoring done as part of each polio campaign was not working. Statistics about the quality of coverage varied greatly. We decided we needed to invest heavily in another layer of quality monitoring to understand what was going wrong. This involved picking random locations on the map and randomly checking children in those places to see if they had been vaccinated. The work required specially trained staff working independently of the people implementing the vaccination campaigns. That impartiality was crucial. One huge problem the polio program found was that many small settlements in the region were missing from vaccinators' hand-drawn maps and lists documenting the location of villages and numbers of children. As a result, children weren't getting vaccinated. Often villages on the border between two maps weren't assigned to any team. To make matters worse, the estimated distance between villages was sometimes off by miles, making it impossible for some vaccinators to do the job they were assigned. To fix this, the polio workers walked through all high-risk areas in the northern part of the country. Step by step, they explored these areas and spoke with people, adding 3,000 communities to the immunization campaigns. The program Shabida Bibi holding her daughter, Rushkar_ Khatoon, who had the last known case of polio in India (West Bengal, India, 2011). 2013 Annual Letter from Bill Gates