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The Art of Eradicating Polio

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Science  04 Oct 2013:
Vol. 342, Issue 6154, pp. 28-35
DOI: 10.1126/science.342.6154.28

The world is close to wiping out the poliovirus, but Nigeria threatens to undo it all. Muhammad Ali Pate is on a mission to change that.

Power of example.

Muhammad Ali Pate gives oral polio vaccine to a Fulani child in Malumfashi in northern Nigeria.

CREDIT: HALLAH TASHIKALMAH

KADUNA AND KATSINA STATES, NIGERIA—The boy, who looked to be about 16 years old, was alternately defiant and tearful. His father had left early that morning with strict instructions not to let the polio vaccinators inside. So when the vaccination team came to his house on a dusty street in a town in Kaduna state in northern Nigeria, he turned them away, and he wouldn't budge when they tried to push their way through the curtain that serves as a front door. When the team left, they marked the mud wall "RX" with chalk—code word for "noncompliant."

Now the boy was being summoned into the street by a very important man, at least judging from the TV cameras and the security detail surrounding him, although he was dressed simply, in a traditional white cotton robe.

I am Muhammad, the man said in Hausa, the language of northern Nigeria, resting his hand on the boy's shoulder. He said he wanted to know what was wrong and why the boy would not let the children be vaccinated. Then he settled in to talk in the sweltering midday sun.

For at least a half an hour, the man listened as the boy vented. The vaccinators had been rude, the boy said, insulting his mother as they tried to force their way in.

I would be angry, too, if someone insulted my mother, Muhammad replied.

Why do they bring only polio vaccine when we get no help with all our other problems? And are you going to force us to take it? the boy asked querulously.

No, it is your decision. I will not force you, the man assured him. But I hope that you will change your mind. Then he patiently explained that the vaccine is safe—he had vaccinated his own kids—and it would protect them from devastating paralysis. And also, that the world has a once-in-a-lifetime chance to eradicate polio—and the boy, and Nigeria, should not stand in its way.

Then the boy's older brother, who had been listening from behind the curtain, emerged with one more question: Will you be responsible if the children are harmed? Yes, the man promised, and the brother brought the kids out to receive the polio drops. The crowd that had gathered around the house burst into applause.

And then the man, who at the time was Nigeria's minister of state for health, was back in the car as his heavily armed convoy sped off, lights flashing, sirens screaming, up the long straight highway that stretches from Abuja, the capital, through the increasingly desolate landscape of the north and then across the border into Niger.

It's a small victory, he confides later in the back seat of the Land Cruiser. But that's what it takes to eradicate polio in Nigeria. "There is science to polio eradication," he says. "But making it happen is art."

Colliding cultures

Command central.

From his office in Abuja, Pate has coordinated Nigeria's push to eliminate the poliovirus since 2008.

CREDIT: ALAMY

Muhammad Ali Pate has been trying to do what no one has been able to accomplish before him—finally drive the poliovirus from Nigeria, one of the last and most stubborn reservoirs in the world. The stakes are high: The outcome of the 25-year-and-counting effort to wipe the virus off the face of the earth rests in large part on the effort that Pate and his handpicked team have put together here in northern Nigeria.

You can't do it by fiat, Pate explains to me later during a 3-day car trip in mid-April through the north, where the virus is entrenched. Top down doesn't work in a country as complicated as Nigeria, an amalgam of colliding cultures and ethnic groups, with a discredited and powerless federal government and relentless insurgency and violence.

Instead, Pate, who hails from a Muslim village in the north, works from the ground up, persuading one boy in the streets of Kaduna North, or the next day paying courtesy calls to emirs at their palaces, or shaming local government officials who are misusing funds, or vaccinating kids in a nomadic community near the side of the road.

Campaign route.

In mid-April, Pate drove hundreds of kilometers and made dozens of stops across the Nigerian states of Kaduna and Katsina, where polio is entrenched and resistance to vaccination is high.

CREDIT: HALLAH TASHIKALMAH

He didn't always think this way. He returned from the United States in 2008 with some decidedly Western views and a wonkish appreciation of health systems management. But Pate says he soon gained a respect for Nigeria's traditional culture and power structure—at about the same time he switched from wearing tailored suits to robes.

Pate is convinced that the virus can be dispatched from the country by the end of 2014, the new deadline set by the leaders of the Global Polio Eradication Initiative (GPEI), which has so far spent more than $10 billion trying to eliminate the scourge of polio worldwide. More data, more money, and more troops are being poured into the effort than ever before, thanks to the Bill & Melinda Gates Foundation and other international partners and donors, who desperately want Nigeria to finish the job so the rest of the world can, too. And they have been betting big bucks that Pate, if anyone, can pull it off. He has come close before, getting cases down to a record low of 21 in 2010.

But in an unexpected move, Pate stunned the polio community when he resigned his Cabinet position on 24 July. Pate, who won't say why he quit, insists his commitment is undiminished. He says he will continue to lead the fight against polio as chairman of the influential Presidential Task Force on Polio Eradication, as long as Nigeria's President Goodluck Jonathan agrees. And he will continue his monthly visits to the critical northern areas to keep the pressure on local leaders and vaccinators.

The top brass of the global eradication effort are optimistic that Pate has built a strong enough program that the country's recent progress can be sustained. "Pate has been absolutely crucial," writes Chris Maher, senior adviser for polio operations and research at the World Health Organization (WHO) in Geneva, who has worked extensively in Nigeria, in an e-mail. "But there is too much momentum in Nigeria for things to be easily derailed now." Maher adds: "His personal influence with the northern governors is unlikely to have diminished. If anything, he may actually end up being a more effective influencer from outside the government system."

Reinfecting the world

Vaccine advocates.

Legs paralyzed by the disease, polio survivors play an important role in persuading reluctant parents to let their children be immunized.

CREDIT: HALLAH TASHIKALMAH

Since it started in 1988, GPEI, run by a partnership of WHO, the United Nations Children's Fund (UNICEF), the U.S. Centers for Disease Control and Prevention (CDC), Rotary International, and most recently, Gates, has driven polio cases globally down more than 99%. That last 1% has proved remarkably tough, but over the past 2 years, as global cases fell to an all-time low of 233 in 2012, the end has finally seemed in sight.

Nigeria stands in the way. Last year, it had more cases than any other country, and it was the only one of the last polio strongholds where cases went up. Nigeria, along with Pakistan and Afghanistan, is one of just three so-called endemic countries that have never stopped transmission of the virus, even for a year. It is the only country in the world where all three types of the poliovirus are still circulating. It has had one of the largest and longest-running outbreaks of vaccine-derived poliovirus type 2. And of the three holdout countries, it tends to be the one that keeps GPEI officials up at night.

Nigeria has spawned more outbreaks in previously polio-free countries than the other two combined, earning its reputation as the country that reinfects the world each time the wild virus is almost gone. The latest such outbreak began earlier this year in Somalia and Kenya.

It's not that the virus circulating in Nigeria is any more dangerous. The problem lies in the lousy rates of routine immunization across a large swath of Africa, which leave huge numbers of kids vulnerable whenever the virus jumps the border from another country. By contrast, Pakistan's neighbors India and China have erected a high "wall of immunity" through strong and continuing vaccination campaigns.

Winning hearts and minds.

A UNICEF community volunteer in Kano teaches a father about polio. In the end, he agrees to let his seven children be vaccinated.

CREDIT: UNICEF/L. ANDRIAMASINORO

As in the other infected countries, polio in Nigeria is a disease of the poor and disenfranchised. By 2005, polio had been dispatched from the relatively wealthier southern half of the country, which is mostly Christian. It took up refuge in the Muslim north, which has some of the most abysmal health and development indicators in the world. More than half of the population lives in grinding poverty. According to recent UNICEF data, routine immunization rates in some parts of the north are as low as 13%. Many people there have no access to toilets and clean water, maternal and child mortality rates are off the charts, and diarrhea remains one of the country's biggest childhood killers.

The Human Development Index ranks Nigeria 153rd out of 187 countries; Transparency International places it among the more corrupt countries in the world. Understandably, there is no love lost between the poor of the North and the government they feel has abandoned them.

So when vaccination teams come around with nothing to offer but drops of oral polio vaccine (OPV), many people are suspicious and fall prey to rumors that the vaccine is contaminated with the AIDS virus or infertility drugs, part of a Western plot to decimate the Muslim population. Rumors and misinformation reached such a frenzy in 2003 and 2004 that four northern states banned all polio vaccination outright, sending cases soaring to 1122 by 2006.

The challenges now are as great as ever. This year, the antipolio vaccination movement has resurged, with opponents circulating CDs and texting people in advance of campaigns, warning of the supposed dangers of the vaccine. The country's violence and terrorism took on a chilling new dimension with the murder of 10 polio workers in Kano in February.

Linchpin.

Nigeria is critical to the global effort to eradicate polio. It is just one of three countries, along with Afghanistan and Pakistan, where transmission has never been stopped. Since 2003, Nigeria has accounted for a significant share of cases worldwide, and virus originating there sparked outbreaks in 25 previously polio-free countries.

SOURCE: WHO

That's why Pate is on the road for 3 days in April, as he has been every month since October 2012, visiting the worst places and using his signature brand of diplomacy to try to turn things around. The grueling trip shows, stop by stop, how he has again managed to bring cases down in 2013; it also gives a taste of the political and social complexities of working in a region that is so critical to the outcome of the global eradication initiative itself.

On the road: Saturday, 13 April

Progress.

Under Nigeria's new emergency eradication plan, polio cases in the country have dropped about 45% from this time last year. Nigeria had 122 polio cases total in 2012; so far this year there have been 47, compared with 90 this time last year. Cases have shifted to the eastern half of the country, where the insurgency is intense and it is difficult to reach children during polio vaccination campaigns. There have been no cases of type 3 polio, showing gains against one of the two remaining wild serotypes.

SOURCE: WHO

EN ROUTE FROM ABUJA TO KADUNA STATE: The first thing you notice about Pate are his eyes: Wide set in a round face, they have such dark circles that they appear bruised. He looks perpetually tired. He is soft-spoken, with a kind voice, and despite his many years in the West, speaks English with a heavy Hausa accent.

When he picks me up at the Rockview Hotel in Abuja, where about half the guests seem to be aid workers or U.N. employees, he is wearing a plain white cotton robe, as he will throughout the trip. His fula, the traditional round cap, is next to him on the seat. His black socks and lace-up shoes add an oddly Western touch.

We are going to Kaduna and Katsina states, which last year had about 40% of the polio cases in the country and where, despite the country's stepped-up effort, vaccinators are still missing too many kids. As we set out, Pate talks about the murders in Kano, another of the high-risk states. At about 9 a.m. on 8 February, gunmen on motorcycles stormed two clinics in rapid succession, killing 10 health workers and one client, all women. The vaccinators had just assembled before heading out for their "mop-up" day, when they try to find and vaccinate kids missed during the previous 3-day door-to-door campaign.

Half a continent away.

A young girl receives polio vaccine drops at a school in Mogadishu, where a new outbreak is raging, seeded by virus from Nigeria.

CREDIT: UNICEF/KATE HOLT

Violence and terrorism in Nigeria are nothing new. The Islamist insurgency is so intense that the president in May declared a state of emergency in three northern states and sent in troops. Schools have been burned, students murdered, villagers massacred. Aid workers have not been immune. In August 2011, 23 were killed and scores injured when the Islamist insurgent group Boko Haram bombed U.N. headquarters in Abuja. But polio workers had never before been directly targeted. No one has claimed responsibility.

President Jonathan and Pate immediately condemned the killings, and Pate visited the grieving families in Kano. Vaccination rounds continued as scheduled the next month. "We are not going to stop or the militants will have gotten what they wanted, so we forge ahead," he says. Asked whether he feels in personal danger, Pate concedes, "sometimes, yes. I am a visible target for those who don't want the program to succeed. Boko Haram is not against polio per se, but it is a high-profile program, high visibility. If you want to attack the government, it is an easy target."

KADUNA STATE BORDER: As we cross the border into Kaduna state, the convoy is flagged down by a dozen or so cheering men by the side of the road, emissaries of the governor and deputy governor, who will join us for the day. Donning his fula, Pate jumps out of the car to thank the welcoming committee, and the political drama begins.

Meeting with senior state officials a few minutes later, Pate explains: "I am here as the chairman of the Presidential Task Force on Polio Eradication to encourage you to see every child is immunized, that this be the best round of 2013. When I looked at the results [from last month], there has been a lot of progress, but in Kaduna state, there is lots of room for improvement." Then it is off to see the rounds.

The convoy stops in the middle of a narrow street in the market in Kaduna South, and Pate is out, working the crowd. The ramshackle market, with its stalls stacked high with grains, fruits, and vegetables, is one of the "fixed posts" to vaccinate kids who aren't home—or whose parents say they aren't—when the teams go door-to-door.

Pate is there to see the polio survivors, wearing their bright green vests emblazoned with "Kick Polio out of Nigeria forever," courtesy of Rotary International, which has volunteers in all the endemic countries and has so far contributed more than $1 billion to the cause. The men, whose legs are paralyzed, pull themselves along the street with their strong arms, using flip-flops as shoes on their hands. They smile broadly when the minister meets them, proudly showing Pate a shiny blue motorcycle they built as part of a rehabilitation program to give the survivors jobs. "Polio has left you with paralysis of the body, but your minds are active," Pate says as he thanks them for their help.

At a time when polio has become all but invisible and few people have seen how it can ravage the body, the survivors are some of the program's most effective advocates. "Parents don't want their kids to be like that," Pate tells me when we are back in the car.

KADUNA NORTH TOWN: There is no shade at the next stop, where Pate persuades the boy and his brother to let the kids be vaccinated, and the heat has easily topped 105. The car feels almost indecently cool when we climb back in.

Pate is pleased. "This is important diplomacy." He concedes that in the grand scheme of things, one or two missed kids won't make a difference—and you certainly can't spend half an hour with each one. "But this family was contaminating the atmosphere," he says. And besides, he adds, he wanted to demonstrate the art of persuasion for the vaccinators.

"I was very conciliatory. I feel the pain of poor people," Pate tells me. "They need so much. Why is it only polio we offer, why do we keep going back?" They may want vaccine against a deadly measles outbreak, or a new road that the government has promised. Refusing polio vaccine is the only leverage they have.

That's why one of Pate's signature programs is called Saving One Million Lives. The goal is to avert 1 million deaths by 2015 by offering basic services such as routine immunization, rehydration salts and zinc for diarrhea, bed nets for malaria, and antenatal and newborn care—"Who could be against maternal and child health?"—and also polio vaccination. "It is not either or, polio or other health needs. We do both. It works very well."

MEETING HALL, KADUNA NORTH DISTRICT: After opening prayers, Pate begins to speak, commending the district chairman, the equivalent of a mayor in the United States, and assembled officials for their efforts. It's a tough spot to work, he concedes; rumors are rife, refusals are high, the large migrant population is hard to reach.

But then the gloves come off. Despite a "surge" of about 150 additional staff members from WHO, CDC, and UNICEF for this critical last stage (Science, 3 August 2012, p. 514), the district missed some 30% of kids in the last round. "With all these boots on the ground, why is there no progress in Kaduna North and Kaduna South?" Pate asks.

"I don't want Nigeria to be forever remembered as the last country in the world with polio—it is an issue of shame. Even in Nigeria, there will be a last state and a last local government. I don't want Kaduna North to be the last local government."

It's a drama he will enact repeatedly over the next couple of days—praise and then pressure. It's the only way he can work in the districts, which are autonomous and have long been the Achilles' heel of the program, he says. "I can't sanction them," he says. "So I have to cajole and influence."

"It is up to you to see the funds are used prudently," says Pate, who has learned that the chairman has not yet released the district's contribution to the campaign and has not been attending the requisite planning meetings. "If money is diverted … you will have blood on your hands."

KADUNA STATE GOVERNMENT LODGE: "Very few people upset me. I don't think there are difficult people, just different people. But he upsets me," Pate says over lunch at the government lodge. He is talking about Haruna Kaita, a professor of pharmacy at Ahmadu Bello University in Zaria and one of what Pate calls the "pseudoscientists" who have spread rumors about the polio vaccine. In 2004, Kaita announced he had analyzed samples of OPV and found traces of estradiol and other contaminants, feeding into the furor that led to the vaccination ban of 2003 and 2004.

The ban was lifted only after intense national and international lobbying, with then-President Olusegun Obasanjo assembling several delegations to test the vaccine, and GPEI providing assurances that only vaccine made in Indonesia, a Muslim country, would be used in Nigeria.

In January this year, Kaita teamed up with an influential cleric and made a CD, widely distributed, repeating many of the earlier assertions. Kaita alleged that the polio vaccine "contain[s] birth control and birth defect-causing substances … [and] that children could contract other diseases through the [vaccine], it could be cancer, HIV, or mad cow disease …" The cleric, Ibrahim Ahmad Aliyu, said, according to a translation: "Forceful oral polio vaccinations are an American-planned genocide against the Muslim populations in Nigeria."

When Pate first came back to Nigeria, he debated the skeptics. "I thought I could reason with them scientist to scientist," he says. But since the February killings, Pate's stance has hardened. "They have gone too far," he says. He blames the opponents for indirectly inciting violence. Now, Pate says, instead of reasoning with them, "We will engage them one by one."

With Kaita, Pate says he has some leverage: "If he is a professor at a public university, he is a government employee." In late April, Kaita released a two-part statement carried in the newspapers "clarifying" his position "following attempts in high and low places to ridicule my painstakingly cultivated reputation." He recognized "the existence of the polio epidemic and the mechanism of administering appropriate vaccines to prevent its spread in Nigeria" and backed off some of his more inflammatory claims. But he also complained that agents of the State Security Service had visited his home several times and the police had called him to Abuja in an effort to intimidate him.

EVENING MEETING, KADUNA NORTH: The sun is down, but the heat is still insufferable in the packed room where the day's vaccination efforts are being reviewed. Even Pate is sweating.

One by one, the supervisors report how many houses their vaccination teams visited, how many kids were in each, the number immunized, the number missed, why, and so on. One team leader says the women have no power. Another says some mothers want to vaccinate their kids but tell her that their husbands will divorce them if they do. It is hard to know how much is the truth, how much excuses. But it is clear many kids were missed, and many teams will be sent back into the field to mop up the next day. Similar meetings take place across the northern states after each vaccination day, part of a massive effort Pate has put in place to pinpoint trouble spots, where more effort is needed.

HOTEL SEVENTEEN, KADUNA: It's late when we reach the hotel, an incongruously modern building that just opened and is still working out the kinks. As we wait for my room to be readied, Pate tells me the circuitous route that brought him to polio.

The oldest of 10 kids, Pate, 45, grew up in a small town in Bauchi state. His father is Fulani, the largest nomadic pastoralist group in West and Central Africa; his mother is part Fulani and part Hausa, the main ethnic group in northern Nigeria. His father was the first in the family to graduate from university, and Pate remembers him telling him as a boy: " 'I can't give you wealth or cattle. All I can give you is an education. You have to go to school, that is your path.' "

Pate took the advice to heart—as did his siblings, who have multiple advanced degrees among them—putting himself through college and medical school at Ahmadu Bello University in Zaria, Nigeria's ancient center of learning. He was restless—"my nomadic genes," he says—and wildly ambitious.

He landed a job as medical officer for the British Medical Research Council in The Gambia in 1993, then in 1995 went on to a residency in internal medicine at Howard University in Washington, D.C., followed by a fellowship in infectious disease at the University of Rochester in New York. Along the way he decided clinical work was "too reductionist." So while in Rochester he earned a master's in health systems management long distance from the London School of Hygiene & Tropical Medicine. Recruited to the World Bank in 2000, he worked his way up the ranks, ending up as country sector coordinator for human development in the East Asia/Pacific region in 2006. While at the bank, "I got the itch again," he says, so he commuted from D.C. to Duke University in North Carolina on the weekends and earned a master's in business administration.

In 2008, he got a call: Then-President Umaru Yar'Adua wanted to see his resume.

Nigeria had just been roundly condemned by the World Health Assembly for derailing the global eradication program. That year, Nigeria had some 800 cases. Humiliated, the president wanted to clean house. He offered Pate a job as CEO of the country's National Primary Health Care Development Agency, the equivalent of the U.S. CDC, in October. There was no question. "I wanted to be a player," Pate recalls. In November, after 15 years abroad, Pate was on the job in Abuja.

Two years later, polio cases had dropped to 21, the lowest ever. In 2011, the president appointed Pate the minister of state for health. With Pate's attention diverted by his broader portfolio, cases began to climb, setting off alarm bells within the international community. By October 2012, Pate was back in charge, this time as chairman of the Presidential Task Force on Polio Eradication, and on the road.

On the road: Sunday, 14 April

THE PALACE OF THE EMIR OF ZARIA, KADUNA: The gate to the emir's palace is a bright mosaic of greens, reds, blues, and golds, a stark contrast to the mud architecture of the rest of the old city.

Resplendent in an intricately embroidered, cream-colored robe and gauzy tufted headdress, the emir receives Pate on his red throne while his councilors sit cross-legged on the floor. After prayers, Pate offers his condolences for the recent death of the emir's older brother. The emir, like other traditional leaders across the north, is a big supporter of the polio program, and Pate is full of praise and gratitude.

It's the same drill the next day when Pate meets with the emir of Malumfashi. "You see the drama," Pate says later of the pageantry, the elaborate robes, and the effusive praise. You have to be an artist to move between Nigeria's traditional and modern worlds, he adds. "And for a long time the community will remember that the government, the minister came to them. And he is here for polio. That is the influence that is so vital to the global effort."

"I used to have a different view of the emirs. I thought sometimes our traditions were holding us back," he tells me. That changed soon after his return when he went to a meeting called by a district chairman and almost no one was there. When he went to the emir's palace, it was packed. "That made clear the dysfunction of the [district] system," he says. "The district officials have the money, legal authority to tax. But they have no moral authority. The emirs have moral authority and a formidable network that you ignore at your own peril."

Pate had another revelation soon after his return, when he decided to ditch his expensive suits for traditional garb. "I hadn't worn a robe since '95 when I got married. I came back here and wore suits. But then I realized I had to be part of the culture." And besides, he says, the suits were way too hot.

EN ROUTE FROM ZARIA TO KATSINA STATE: Pate is something of a data geek. During the long car ride, he recalls having lunch with Bill Gates a couple of years ago. "He asked really tough questions" about our data. "I had questions, too, I felt like I was flying blind."

Gates brought in the Seattle group Global Good to develop a model to assess population immunity, or what proportion of the population is adequately vaccinated against polio. With foundation support, Nigeria introduced geographic information systems and global positioning systems, and satellite mapping found thousands of settlements no one knew existed. It turned out that polio cases were increasingly concentrated along the borders between states and districts, where everyone thought it was someone else's responsibility, and along nomadic routes. Soon, digital maps replaced vaccinators' hand-drawn plans.

Gates bankrolled the spiffy new Emergency Operations Center in Abuja, which now has offshoots in several high-risk states. For the first time now, the partner agencies work in the same building, where data feed in from the districts and states. "Now we have data so we can make decisions in real time," Pate exults.

As we are talking, the convoy pulls over at a boisterous nomadic settlement near the side of the road in Malumfashi. Pate jumps out of the car and launches into Fulani, one of his native tongues. The crowd is thrilled as Pate vaccinates a baby and then good-naturedly lets himself be vaccinated. Laughing, he declines the candy given to the kids after their drops.

He is pleased to see the encounter broadcast later on TV.

KATSINA STATE GOVERNMENT LODGE: At dinner, Pate is tired, the circles under his eyes even more pronounced. He runs his hands across his face and close-cropped hair, then takes off his shoes and rubs his feet. Over chicken and fried rice, he tells me what keeps him on the road each month.

"We passed the Rubicon when cases were so low in 2010," he adds. "We knew we could do it, so there is no excuse not to do it. It is a moral imperative." And beyond Nigeria, "eradicating polio will be huge for the global health community, like going to the moon. It will unleash a huge momentum."

It is 10:30 when the protocol chief finds us a suitable motel and Pate quits for the day.

On the road: Monday, 15 April

KATSINA DISTRICT: "We are in a difficult area," Pate says the next morning as we begin our long last day in Katsina, Nigeria's barren, northernmost state. Polio opposition is strong in this area; Kaita is from here, and the CD is circulating widely.

Pate meets briefly with the governor, then heads to the big event of the day: a ribbon-cutting ceremony for seven new buildings at the Federal Medical Centre in Katsina. Pate is the guest of honor, along with the emirs of Katsina and Daura, whose guards in their bright red and green turbans stand out among the sea of light-colored robes and who jostle with Pate's nattily clad security detail. The guards with their leather whips sit at the emirs' feet. Pate's crew, along with federal police armed with AK-47s, spread out among the crowd.

Pate cuts the ribbon for a new laundry room that holds two new washing machines for the 515-bed hospital and the new intern housing, named the Muhammad Ali Pate Officers Quarters.

Then the convoy departs for a dozen farflung districts—from Baure in the north to Funtua in the south. At each of the stops, Pate tells the local officials that he and 457 other scientists from around the world have just signed a declaration supporting GPEI's new plan to wipe out the virus by 2018. Nigeria should not be backwards, he says.

Pate and I part ways at 6 p.m. He is heading back to Abuja. I am staying in the north to observe vaccination campaigns. He insists I keep a car, a driver, and an armed guard. "It is not that dangerous," he assures me. "But people sometimes take advantage of foreigners."

Outbreak

On 9 May, the inevitable happened. A case of wild polio was confirmed in a 32-month-old girl near Mogadishu—the first there since 2007. Genetic analysis showed the virus came from Nigeria. A week later, another case was reported in Kenya in the Dadaab refugee camp near the Somalia border, the first wild case in that country in almost 2 years. Just when cases globally were at a record low, Nigeria had once again reinfected the Horn of Africa. By the end of September, cases in the Horn had soared to 191, more than double the number in Nigeria, Pakistan, and Afghanistan combined. The outbreak, spreading fast because the conflict has left so many kids unvaccinated, is a devastating blow and a tough test of GPEI's recently announced plan to stamp out any new outbreak within 120 days. This time, they won't, program officials conceded in September.

Nigeria itself seems back on track. The program took a hit in March after the killings in Kano, when vaccination coverage stagnated or declined in some places. The influential Polio Eradication Independent Monitoring Board, which has often been scathing in its reviews, in May 2013 gave the country high marks, noting that "[t]he pace of improvement in Nigeria's Polio Programme over the last six months has been greater than at any other point in its history." Cases are down 45% from this time last year.

In the light of these successes, Pate's abrupt resignation as health minister on 24 July was met with an outpouring of praise and regret. "Pate has made a fantastic contribution … and it's disappointing to see him move on from his position as Minister of State for Health," wrote Michael Galway, Gates's point person for Nigeria, in an e-mail. "But I feel confident the program will continue to move in the right direction."

Speaking on the phone on 21 August from his house outside Washington, D.C., where his wife and six kids now live, Pate declined to say why he quit. "I want to avoid speculation. … I feel the time for the transition had come, it was the right time in a way that doesn't hurt the program."

Pate, who is an adjunct professor at Duke University, will likely take a new position advising the Gates Foundation. He says there's no reason to worry that the eradication will lose momentum. He points out there is a strong team in place, led by the executive director of the primary health care agency, the position Pate held when he first began to turn polio around.

"It is not only one person" he says. "It is the role one plays on the team. I can continue in that role even though I am not minister and help to complete eradication." He expects to remain closely involved in the campaign and plans to spend time each month in Nigeria.

Indeed, the day we spoke on the phone he was flying back to Abuja for another road trip to the areas where polio cases are now centered and the insurgency remains intense. Since our April visit, Kaduna and Katsina states have remained polio-free.

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