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Before sunrise, Shameema slips on her worn rubber sandals and checks the insulated box – the ice packs inside must maintain the crucial cold chain at between 2C and 8C (35.6-46.4F). She hoists the container on one shoulder and steps out into the dark.
Tanzeela follows with her own pack, after quickly retying the laces of her canvas shoes. Both women live in Pulwama, a district where summer temperatures climb to 37C. Their destination lies higher, out of the valley where asphalt turns to dirt track and then to a barely distinguishable footpath along the floor of the mountain pine forests.
Shameema, 45, has worked as a vaccinator for more than a decade, while Tanzeela, 28, joined the programme three years ago. They form part of India’s army of 2.5 million frontline health workers – the human machinery behind the world’s largest immunisation campaign.
Shameema estimates she has administered polio drops to more than 3,000 children during her years as a vaccinator. She remembers a boy in her village who limped with a deformed leg, the legacy of a polio infection before India had fully eradicated it. It is this memory that keeps her going.
“I saw that child struggle to walk to school,” Shameema says during a pause near a stream. “His mother held him on her back until he grew too heavy. [People in] these mountains need protection too – the children here deserve the same health as those in the cities.”
This morning, they are walking towards Namblan, a meadow ringed by pine trees where nearly 50 dhokas, the seasonal mud-and-stone homes of Gujjar and Bakarwal nomadic families, are scattered over the hillsides.
Even before the paved roads end, the electricity lines stop far below these settlements. Horses are the primary transport for the families who spend the summer months with their livestock in these highlands.
The women climb more than 12 miles (20km) with the heavy insulated cool boxes, which hold vials of the oral vaccines, ice packs and the thick paper registers that document the day.
Tanzeela has given polio drops to about 800 children since she joined the programme. She wears the same shoes she uses for farm work. The soles have worn thin, but they grip the rocky paths better than the sandals of some colleagues, she says. One fellow worker walks barefoot for parts of the trail.
“The payment is small and the paths are steep,” Tanzeela says. “I think about my own nephews when I climb. The drops take seconds, but they change a life for ever.”
Their compensation is 125 rupees a day – about £1 – from the state government for the two-day vaccination campaigns, which happen four to six times a year during the national immunisation drives that target all children under five.
India’s polio programme represents a triumph of planning, vigilance and human endurance. The country has been certified polio-free since 2014 – with the final confirmed case in January 2011 in West Bengal – largely thanks to a surveillance network of 60,000 health workers, who monitor 40,000 reporting sites for acute flaccid paralysis, the signature symptom of wild poliovirus.
The oral polio vaccine uses a live but weakened form of the virus developed by a Polish scientist, Albert Sabin, in the late 1950s. The two drops placed on a child’s tongue stimulate antibodies in the intestinal lining that destroy the virus before it can enter the bloodstream and attack the nervous system.
The same gut immunity reduces viral shedding in infected children, ending the chain of transmission in communities where clean water comes from streams and springs. The oral formula creates communal immunity, protecting whole clusters of children who share courtyards and water sources.
This biological shield proves especially vital in the disputed region of Indian-administered Kashmir, where 73% of the 14 million population live in rural areas, with hundreds of thousands of children under six living in far-flung villages and mountain settlements.
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Seasonal migration routes take the Gujjar and Bakarwal pastoral communities of about 1.2 million people far from clinics and hospitals during the summer. Reaching them requires coordination between state health departments, local panchayats (village councils) and the frontline workers who know the mountain trails.
The national immunisation effort targets 27 million children under five, and up to 1.7 million vaccinators can be deployed during a single day of a national immunisation drive. Those workers staff 750,000 booths, then fan out with mobile teams into forests, deserts and urban slums.
The scale of this operation dwarfs most military logistics exercises. Insulated boxes travel by foot, bicycle, boat and bus, but in regions such as Kashmir, the final leg of this journey is always down to women travelling on foot.
The dhokas sit miles apart, sometimes separated by ravines and streams that swell with melted snow. A mother might walk two hours to meet the vaccinators halfway, her baby strapped to her back. The workers record these encounters in their paper registers, marking the child’s name, age and the date of the dose.
Shameema and Tanzeela know the terrain and the communities, and time their ascent to reach the first dhokas as the families finish their morning prayers.
“The families welcome us with tea and bread,” Shameema says. “They know the value of these drops. Some remember the days prior to full eradication, when children in neighbouring villages fell ill.”
India’s greatest public health victory still depends on these health workers willing to make such critical journeys for little reward, dedicated to maintaining the country’s protection against the devastating disease.
By late afternoon, the final dhoka receives the vaccinators. A child opens their mouth, gets two drops on their tongue, another name goes on the register and the insulated box is a bit lighter as the women begin their descent down the same tracks they climbed hours earlier. It will be dark by the time they reach home.
