"Move it or lose it." That's what my Mom used to say to me. I thought she meant my hand from the cookie jar but her wisdom far exceeded my sweet tooth. In life, to keep healthy, you've got to move. Start an early habit of walking and it could lead to aging well according to a N.Y. Times story on a study published in JAMA.

To Age Well, Walk

 

By GRETCHEN REYNOLDS

May 27, 2014 1:01 pm

 

 

Rob C. Witzel for The New York TimesMildred Johnston walking along a path in Kanapaha Veterans Memorial Park in Gainesville, Fla. Ms. Johnston participated in a large study that showed the benefits of walking for older people.

Regular exercise, including walking, significantly reduces the chance that a frail older person will become physically disabled, according to one of the largest and longest-running studies of its kind to date. 

The results, published on Tuesday in the journal JAMA, reinforce the necessity of frequent physical activity for our aging parents, grandparents and, of course, ourselves. 

While everyone knows that exercise is a good idea, whatever your age, the hard, scientific evidence about its benefits in the old and infirm has been surprisingly limited. 

“For the first time, we have directly shown that exercise can effectively lessen or prevent the development of physical disability in a population of extremely vulnerable elderly people,” said Dr. Marco Pahor, the director of the Institute on Aging at the University of Florida in Gainesville and the lead author of the study.

Countless epidemiological studies have found a strong correlation between physical activity in advanced age and a longer, healthier life. But such studies can’t prove that exercise improves older people’s health, only that healthy older people exercise. 

Other small-scale, randomized experiments have persuasively established a causal link between exercise and healthy aging. But the scope of these experiments has generally been narrow, showing, for instance, that older people can improve their muscle strength with weight training or their endurance capacity with walking. 

So, for this latest study, the Lifestyle Interventions and Independence for Elders, or LIFE, trial, scientists at eight universities and research centers around the country began recruiting volunteers in 2010, using an unusual set of selection criteria. Unlike many exercise studies, which tend to be filled with people in relatively robust health who can easily exercise, this trial used volunteers who were sedentary and infirm, and on the cusp of frailty. 

Ultimately, they recruited 1,635 sedentary men and women aged 70 to 89 who scored below a nine on a 12-point scale of physical functioning often used to assess older people. Almost half scored an eight or lower, but all were able to walk on their own for 400 meters, or a quarter-mile, the researchers’ cutoff point for being physically disabled. 

Then the men and women were randomly assigned to either an exercise or an education group.

Those in the education assignment were asked to visit the research center once a month or so to learn about nutrition, health care and other topics related to aging. 

The exercise group received information about aging but also started a program of walking and light, lower-body weight training with ankle weights, going to the research center twice a week for supervised group walks on a track, with the walks growing progressively longer. They were also asked to complete three or four more exercise sessions at home, aiming for a total of 150 minutes of walking and about three 10-minute sessions of weight-training exercises each week. 

Every six months, researchers checked the physical functioning of all of the volunteers, with particular attention to whether they could still walk 400 meters by themselves.

The experiment continued for an average of 2.6 years, which is far longer than most exercise studies.

By the end of that time, the exercising volunteers were about 18 percent less likely to have experienced any episode of physical disability during the experiment. They were also about 28 percent less likely to have become persistently, possibly permanently disabled, defined as being unable to walk those 400 meters by themselves. 

Most of the volunteers “tolerated the exercise program very well,” Dr. Pahor said, but the results did raise some flags. More volunteers in the exercise group wound up hospitalized during the study than did the participants in the education group, possibly because their vital signs were checked far more often, the researchers say. The exercise regimen may also have “unmasked” underlying medical conditions, Dr. Pahor said, although he does not feel that the exercise itself led to hospital stays. 

A subtler concern involves the surprisingly small difference, in absolute terms, in the number of people who became disabled in the two groups. About 35 percent of those in the education group had a period of physical disability during the study. But so did 30 percent of those in the exercise group. 

“At first glance, those results are underwhelming,” said Dr. Lewis Lipsitz, a professor of medicine at Harvard Medical School and director of the Institute for Aging Research at Hebrew SeniorLife in Boston, who was not involved with the study. “But then you have to look at the control group, which wasn’t really a control group at all.” That’s because in many cases the participants in the education group began to exercise, study data shows, although they were not asked to do so. 

“It wouldn’t have been ethical” to keep them from exercise, Dr. Lipsitz continued. But if the scientists in the LIFE study “had been able to use a control group of completely sedentary older people with poor eating habits, the differences between the groups would be much more pronounced,” he said.

Over all, Dr. Lipsitz said, “it’s an important study because it focuses on an important outcome, which is the prevention of physical disability.”

In the coming months, Dr. Pahor and his colleagues plan to mine their database of results for additional followup, including a cost-benefit analysis. 

The exercise intervention cost about $1,800 per participant per year, Dr. Pahor said, including reimbursement for travel to the research centers. But that figure is “considerably less” than the cost of full-time nursing care after someone becomes physically disabled, he said. He and his colleagues hope that the study prompts Medicare to begin covering the costs of group exercise programs for older people.

Dr. Pahor cautioned that the LIFE study is not meant to prompt elderly people to begin solo, unsupervised exercise. “Medical supervision is important,” he said. Talk with your doctor and try to find an exercise group, he said, adding, “The social aspect is important.” 

Mildred Johnston, 82, a retired office worker in Gainesville who volunteered for the LIFE trial, has kept up weekly walks with two of the other volunteers she met during the study. 

“Exercising has changed my whole aspect on what aging means,” she said. “It’s not about how much help you need from other people now. It’s more about what I can do for myself.” Besides, she said, gossiping during her group walks “really keeps you engaged with life.”

Scoliosis is a pronounced curvature of the spine that can be painful and lead to arthritis, difficulty breathing, and other organic dysfunction. It most often begins to occur as a toddler, and is often treated with bracing that is not always effective. Now a new report demonstrates the efficacy of an exercise regimen called The Schroth Method, citing dozens of successful research studies, and the Scoliosis Research Society is taking notice. If you know someone with scoliosis, perhaps they should too.

Body

 

Hope for an S-Shaped Back

By RACHEL RABKIN PEACHMAN

May 12, 2014, 3:53 pm

 

 

 

Andy Manis for The New York TimesBeth Janssen, a physical therapist, instructs Tylene Dierickx, 15, who has scoliosis, in a Schroth Method stretching exercise to help correct the curvature of her spine.

I wore a hard plastic brace around my torso from ages 8 to 16 to treat scoliosis, or spinal curvature. Bracing has been standard treatment in children for the past five decades, and I wore my brace diligently, if awkwardly, in the hope that it would contain my S-shaped curvature and stave off the need for spinal fusion surgery.

By the time I was 16 and full-grown — and no longer considered at high risk for curve progression — my most prominent spinal curve had stabilized at 45 degrees. I’d narrowly escaped surgery and the complications that can accompany it. My orthopedist told me my treatment was done.

I’ve discovered in the years since that scoliosis is not something you endure and outgrow, like pimples and puberty. Significant curves often grow throughout adulthood, and can cause deformity, arthritis, pinched nerves, herniated discs, muscle spasms and reduced mobility and lung capacity.

Now, at the ripe age of 38, I find myself with a 55-degree upper curve, a 33-degree lower curve, consistent pain — and no standard treatment to follow.

Some orthopedists have recommended surgery; others have suggested conventional physical therapy. None can say whether either protocol will eliminate pain, and until recently these were my only options.

Now there may be another: an exercise regimen called the Schroth method. Developed in the 1920s in Germany by Katharina Schroth, the technique is a standard treatment for scoliosis in children and adults in several European countries.

The therapy, tailored to each patient’s curves, focuses on halting curve progression, reducing pain, and improving posture, strength and lung function. The exercises include stretching, strengthening and breathing techniques that counteract the rotation of spinal curvatures. Patients are supposed to do them at home and incorporate postural corrections into their daily lives.

Dozens of studies from abroad have found that the Schroth method and variations of it improved patient outcomes and reduced the need for surgery in people of all ages. In one study, patients who didn’t do Schroth exercises saw their spinal curves progress up to nearly three times more than those of patients who did practice the exercises. In another study, 813 Schroth patients increased their ability to expand their chests to breathe by an average of 20 percent.

None of these studies were large, randomized controlled trials, and the Scoliosis Research Society, which influences guidelines for care in the United States, does not officially recognize physical therapy as a treatment option. “But the mind-set of the American scoliosis practitioner is shifting,” said Dr. Michael Mendelow, an orthopedic spinal surgeon at Shriners Hospitals for Children in Greenville, S.C.

Boston Children’s Hospital and Hospital for Special Surgery in Manhattan are among the health-care institutions that now have Schroth therapists. Insurers are starting to cover the treatment and the braces favored by Schroth experts, and certified practices have popped up across the country. 

Teaching centers such as Columbia University and Morgan Stanley Children’s Hospital of NewYork-Presbyterian are sponsoring Schroth-related conferences.

“If you look critically at the body of literature, there is evidence that, when properly done in the right situation, with the right therapist and the right patient, Schroth can change the chance of curve progression,” said Dr. Michael Vitale, chief of pediatric orthopedics at Morgan Stanley Children’s Hospital.

Christa 

Lehnert-Schroth, Bad Sobernheim, GermanyA 5-year-old boy with a case of scoliosis caused by poliomyelitis, before treatment, left, after three weeks of in-patient Schroth treatment, center, and after six weeks of Schroth treatment, right.

 

Even the Scoliosis Research Society is taking a second look.

“We’re primarily using Schroth on people who are being braced — I think it will make bracing more successful,” said Dr. M. Timothy Hresko, chairman of the research society’s nonoperative committee and associate professor of orthopedic surgery at Harvard.

At the University of Alberta in Canada, researchers recently completed a randomized pilot study of Schroth, financed in part by the research society. The six-month study showed that adolescents with scoliosis who did these exercises fared better than teenagers who didn’t with regard to curve progression, pain and self-image. A larger multicenter randomized trial, funded by the SickKids Foundation and the Canadian Institutes of Health Research, is now enrolling adolescents.

Many scoliosis patients, in increasing discomfort, aren’t waiting for new study results. At age 15, Rachel Mulvaney of Mount Sinai, N.Y., went to a clinic run by Beth Janssen, a Schroth therapist, in Stevens Point, Wis. Her 42-degree curve was progressing, and orthopedists had told her she needed surgery.

“Within the first three days there, I was out of pain for the first time in five years,” said Ms. Mulvaney, now 19. After eight months of Schroth exercises, her curve decreased to 30 degrees, and it has since dropped to 22 degrees — a reduction extremely rare in patients her age.

Her orthopedist, Dr. John J. Labiak, clinical assistant professor of orthopedic surgery and neurosurgery at Stony Brook University, said he was “shocked and happily surprised” by her progress. He has begun recommending the method to other patients.

As for adults with scoliosis like me, who are beyond bracing yet hoping to avoid surgery, Schroth may be the last best chance. We can’t turn back time and change the progression of our curves, but maybe this therapy can make carrying groceries a little less painful or breathing a little easier — for us and those who grow up after us.

A version of this article appears in print on 05/13/2014, on page D6 of the NewYork edition with the headline: A Braceless Option for Scoliosis.

Metabolic Syndrome, a combination of high blood pressure, being over-weight, and diabetes, affects millions of people. A new study finds that the casual link between these three conditions is, instead, genetic. That also lends focus to obesity being genetic, rather than just eating too many calories, and may well lead to new treatment approaches to the Syndrome.

Select News Peer Review By:

Endocrinology

Metabolic Syndrome: Genetic Trigger?

Published: May 14, 2014 | Updated: May 14, 2014

By Crystal Phend, Senior Staff Writer, MedPage Today

 

 

Reviewed by F. Perry Wilson, MD, MSCE; Instructor of Medicine, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

Genetic mutations causing an inherited form of the metabolic syndrome have been found, with implications for drug development across diabetes, heart disease, and obesity.

A substitution error in the gene DYRK1B tracked exactly with early-onset coronary artery disease, abdominal obesity, hypertension, and type 2 diabetes running in three large families in Iran, Arya Mani, MD, of Yale, and colleagues found.

A second substitution mutation in the same gene was found in affected, but not unaffected, members in a fourth family of a different ethnic background, the group reported in the May 15 issue of the New England Journal of Medicine.

The specific mutations found are likely rare, but genome-wide association studies have also linked DYRK1B to type 2 diabetes and traits associated with the metabolic syndrome, which may implicate common variants in the general population, the group noted.

While there have been plenty of causative mutations found for individual cardiovascular risk factors, that hadn't been the case for susceptibility genes for clusters of cardiovascular risk traits, such as those in the metabolic syndrome, the researchers noted.

Approximately 3% to 4% of the population may carry these mutations impacting metabolic syndrome risk, Mani predicted, although there does appear to be an interaction with environment.

Now with these results, it's time for a search into mechanisms that could be exploited to treat the whole gamut, he told MedPage Today.

"With a single drug, one may actually find treatment for different metabolic risk factors, such as high blood pressure, in certain instances, and hypercholesterolemia and reduce the risk for coronary artery disease and diabetes," he said.

There are broader implications for how we view obesity too, Chin Jou, PhD, a science historian at Harvard, wrote in an accompanying editorial.

"These studies, of course, reinforce what some physician-researchers have been insisting for more than a century: that obesity is innate, that weight regulation is not governed by a uniform tally of 'calories in-calories out,' and to quote Jules Hirsch, that 'there is a biochemical or basic biological element in what it is that we call 'willpower,'" she wrote.

That's not a view shared by the majority of Americans, Jou noted.

He cited a 2012 online poll by Reuters and the market research firm Ipsos that found 61% of U.S. adults believed that "personal choices about eating and exercise" were responsible for the obesity epidemic.

While they, "it seems, remain unaware of or unconvinced by scientific research suggesting that 'personal choices' may not account for all cases of obesity," she noted, "...weight is clearly far from being entirely within an individual's control. Genetic predispositions, in tandem with the development of food environments that facilitate overeating and built environments requiring minimal energy expenditure, may help explain why so many Americans are obese today."

The study examined three unrelated families in a community in southwest Iran on the basis of an "unusual constellation" of juvenile-onset abdominal obesity and other aspects of the metabolic syndrome.

"These families were considered to be outliers because of the low prevalence of early-onset coronary artery disease and obesity in the local community," Mani's group noted.

In these families, 25 members (21 with genetic samples) had the metabolic syndrome not explained by neurohormonal activation and early-onset myocardial infarction or coronary artery disease. Onset was at a mean age of 45 in men and 44 in women.

Each of them had a mutation substituting cysteine for arginine at position 102 in the highly conserved kinase-like domain of DYRK1B, the gene encoding dual-specificity tyrosine-phosphorylation-regulated kinase 1B.

None of the 12 unaffected family members had the mutation, dubbed R102C.

Nor was the mutation found in 2,000 DNA samples from ethnically-matched Iranian controls, 3,600 U.S. white controls, 2,500 persons of diverse ethnic backgrounds in the Allele Frequency Database (ALFRED), 5,000 exomes from the Yale Center for Genome Analysis database, or 5,400 exomes in the NHLBI ESP5400 database.

Linkage analysis and whole-exome sequencing showed that all three affected families shared identical haplotype markers, "indicative of their common ancestral origin," although no family member was homozygous for this haplotype.

"In each family, affected members could trace their descent from a common ancestor," the researchers noted. "The familial clustering and pattern of inheritance of these clinical features were consistent with the effect of a highly penetrant autosomal dominant trait and suggested that the affected family members might share a common founder mutation."

Functional characterization of the disease gene revealed that normally the "nutrient-sensing" protein encoded by DYRK1B boosts fat formation via inhibition of the SHH (sonic hedgehog) and Wnt signaling pathways.

The gene also appeared to kick up generation of glucose by increasing expression of the key enzyme glucose-6-phosphatase.

The R102C mutation discovered in the families was a gain-of-function allele that boosted both effects.

"Our findings suggest that DYRK1B plays a central role in the biologic pathways that are disrupted in the disorder known as the metabolic syndrome," the researchers concluded.

No other genetic variant was found in more than five affected family members, and some were found in unaffected members.

The study was funded by the National Institutes of Health.
Mani disclosed NIH grant support but no relevant relationships with industry.
Jou disclosed no relevant relationships with industry.

Many people have difficulty falling asleep, particularly women. There are a number of reasons for the problem, including how light effects one's circadian rhythms. While I don't often post about gadgets, this inexpensive one may be of assistance to some as it functions to start the body's clock moving toward sleep...assuming you use it correctly.

CNET -

Sleeping under an artificial sunset: Hands-on with the Drift Light bulb

Can a light bulb with a microprocessor help you sleep better? Crave's Amanda Kooser tucks in with the Drift Light, a high-tech Sandman.

by Amanda Kooser, May 7, 2014 9:39 AM PDT

The Drift Light wants to ease you to sleep. Amanda Kooser/CNET

There are all sorts of apps out there you can use to track your sleep. Sometimes they involve keeping your phone or a fitness wristband in bed with you to pick up on all your tossing and turning. If apps and hardware accoutrements just aren't your thing, then you might like Saffron's Drift Light, a smart light bulb that is also incredibly simple.

The 40W-equivalent LED Drift Light has a built-in microprocessor. No app, no extra hardware, and no fuss. You just screw the bulb into a light fixture. In my case, I used the bedside lamp I always have on before bed. Turn it on once and the Drift acts like a regular light.

Turn it on, off, and back on, and it blinks to let you know it's entered midnight mode, in which it fades to dark over the course of 37 minutes, mimicking the light change involved in a real sunset. The third option is called moonlight mode and it fades the bulb down to a gentle glow to act as a nightlight.

The idea behind the artificial sunset is to encourage your body to react like humans did before we had electricity, laptops, tablets, and phones to keep us occupied way into the wee hours. Saffron says the bulb is meant to promote relaxation and increase melatonin to encourage good sleep.

I've been testing out the $29 Drift Light for the last week. I'm notoriously bad about falling asleep. I shuffle around looking for a comfortable position and listen to podcasts when I really can't get into dreamland. The first night I used the Drift Light in midnight mode, I really noticed it moving silently down through the dimness settings and ultimately turning off. Over the next few nights, it got to the point where I never caught it turning off because I was already asleep.

It helps when you can really dial in the timing for the bulb. Knowing it takes 37 minutes to count down to blackness, you can time it to turn off right about when you would normally be going to sleep.

There is something soothing about the world dimming around you. It's like being a kid with an early bedtime, sensing the sun set outside your window.

My one-week trial run is hardly a huge sample size. I still woke up a few times during the night, but most of that was due to a 12-pound cat weighing down my knees. Your experience with a product like this may vary, but it's a temptingly simple alternative to a lot of the other, more complex sleep-aid technologies out there.

The Drift Light in residence in a lamp. Amanda Kooser/CNET

Lest we take things for granted, the return of Polio to the world population is a reminder that there is still much to do in making the world safer and healthier. With the announcement by the WHO, declaring a health emergency that polio is spreading through 6 countries, will the rest of the world respond again to combat the debilitating disease?

Health

Polio’s Return After Near Eradication Prompts a Global Health Warning

By DONALD G. McNEIL Jr.MAY 5, 2014

 

Health workers vaccinate a child in Afghanistan. Credit Diego Ibarra Sanchez for The New York Times

Alarmed by the spread of polio to several fragile countries, the World Health Organization declared a global health emergency on Monday for only the second time since regulations permitting it to do so were adopted in 2007.

Just two years ago — after a 25-year campaign that vaccinated billions of children — the paralyzing virus was near eradication; now health officials say that goal could evaporate if swift action is not taken.

Pakistan, Syria and Cameroon have recently allowed the virus to spread — to Afghanistan, Iraq and Equatorial Guinea, respectively — and should take extraordinary measures to stop it, the health organization said.

“Things are going in the wrong direction and have to get back on track before something terrible happens,” said Gregory Hartl, a W.H.O. spokesman. “So we’re saying to the Pakistanis, the Syrians and the Cameroonians, ‘You’ve really got to get your acts together.’ ”

The declaration, which effectively imposes travel restrictions on the three countries, represented a newly aggressive stance by the health organization. In the past, it has often bent to pressure from member states demanding no consequences even as epidemics raged inside their borders and sometimes slipped over them.

Sakhina, a 3-year-old girl from Kabul, has contracted polio, the first confirmed case in the capital in 12 years. Her family previously lived in Pakistan and her father is a taxi driver who travels frequently to the tribal areas. Credit Diego Ibarra Sanchez for The New York Times

“This is a fundamental shift in the program,” said Dr. Bruce Aylward, the organization’s chief of polio eradication. “This is the countries of the world signaling that they will no longer tolerate the spread of the virus from the countries that aren’t finished.”

The emergency was declared though the total number of known cases this year is still relatively small: 68 as of April 30, compared with 24 by that date last year.

What most alarmed experts, Mr. Hartl said, was that the virus was on the move during what is normally the low transmission season from January to April.

“What we don’t want is cases moving into places like the Central African Republic, South Sudan or the Ukraine,” said Rebecca M. Martin, director of global immunization for the Centers for Disease Control and Prevention, which has provided money and expertise to the eradication campaign since it began in 1988.

Fighting the virus normally includes several rounds of vaccination of all young children in a target country. But, in an unusual step, the agency also said that all residents of Pakistan, Syria and Cameroon, of all ages, should be vaccinated before traveling abroad, and that this restriction should be retained until one year after the last “exported case.”

It also said another seven countries should “encourage” all their would-be travelers to get vaccinated. Those are Afghanistan, Equatorial Guinea, Ethiopia, Iraq, Israel, Nigeria and Somalia.

Health workers vaccinated children in Jalalabad, Afghanistan. Credit Diego Ibarra Sanchez for The New York Times

Israel has had no confirmed human cases of the disease, but a Pakistan strain of the virus has been detected in sewage in Tel Aviv and elsewhere.

While the W.H.O. has no enforcement power, the regulations are part of a 2007 global health treaty saying all parties “should ensure” that steps it recommends are taken. That applies to Pakistan, Syria and Cameroon. The other seven only need to “encourage” those steps.

But countries could use the document to refuse to admit migrants, visitors or even business travelers who lack vaccination cards.

Polio, short for poliomyletis, is a highly contagious virus spread in feces; although only one case in 200 causes symptoms, the hardest-hit victims can be paralyzed or killed. With so many silent carriers, even one confirmed case is considered a serious outbreak. There is no cure.

Unlike influenza or other winter viruses, polio thrives in hot weather. Cases start rising in the summer and often explode when the monsoon rains break the summer heat, flooding sewage-choked gutters and bathing the feet of romping children with virus, which they pick up by touching their feet or a ball and then putting a finger in a mouth.

Though the disease primarily strikes children, evidence has mounted that it also crosses borders in adult carriers, such as traders, smugglers and migrant workers.

Health officials recommend immunization for people traveling to or from 10 countries affected by polio.

With 54 of this year’s 68 new infections, Pakistan is by far the riskiest country, Dr. Aylward said. Polio has never been eliminated there, Taliban factions have forbidden vaccinations in North Waziristan for years, and those elsewhere have murdered vaccine teams.

Syria has had only one confirmed case of polio this year, but it had 13 cases last October, the first in the country since 1999.

Before the uprising began in 2011, Syria had a 90 percent vaccination rate, but it fell rapidly in war-torn areas. About 300,000 children are in areas blocked off by the government or too dangerous to reach, according to the United Nations Children’s Fund.

The Syrian cases from last year were of the Pakistan strain, which was found in Egypt last year, then moved into Israel, first in a largely Bedouin desert town, then elsewhere. How it reached Syria is unclear, but in April it was found in a Syrian refugee camp in Iraq, despite extensive vaccination campaigns in camps in Lebanon, Jordan, Turkey and elsewhere.

“Fortunately, it’s pretty easy to do in refugee camps,” Mr. Hartl said.

With Syrians fleeing massacres and bombings, it seems absurd to make them stop and produce vaccination cards, critics said.

Annis Gul contracted polio in March. Credit Diego Ibarra Sanchez for The New York Times

Cameroon’s outbreak is of a strain from Nigeria, which previously had more cases than any country in the world but which has had only two so far this year. As in Pakistan, Islamic terrorist groups in Nigeria have killed vaccinators. Nonetheless, multiple vaccination rounds have reduced the problem.

Cameroon, Equatorial Guinea and other African countries are all vulnerable because their routine immunization rates are so low; in Equatorial Guinea, only 26 percent of all children are protected, Dr. Martin said

It is unclear whether the new travel restrictions will hurt the economies of the affected countries. Pakistan already has vaccination booths where its highways enter Afghanistan, China and Iran.

Pakistan’s health minister, Saira Afzal Tarar, said her office had recommended vaccinating travelers at the country’s five international airports before they board. (The W.H.O. calls for vaccination at least four weeks before traveling, except in emergencies.)

She expressed her disappointment at the restrictions, saying, “We have been doing whatever we can, but due to the law and order situation in our country, especially in the two tribal regions, we are facing extraordinary challenges.”

Until 2012, the world was making enormous progress toward eliminating polio. India, which once had millions of cases, had its last three years ago. Monday’s emergency was declared both to alert donors and to pressure the affected countries to organize vaccination drives, Mr. Hartl said.

That means recruiting and training hundreds of thousands of vaccinators, and sending them into the field with millions of doses of vaccine, which must be kept cold, usually by packing them on ice in a foam plastic box each vaccinator carries on a shoulder strap.

It is a huge logistical undertaking. Vaccinators go door to door in village and cities, approach passengers at railway stations and on buses, and walk up to cars at toll plazas and in traffic circles. The ideal is to vaccinate every child in the country several times, with a month or so between each round.

It also entails many conflicts. Even when there is no local opposition, there are struggles over issues including who gets the vaccinator jobs, which usually pay $2 to $5 a day, and who controls the gas money for minibuses taking teams to villages.

Reporting was contributed by Anne Barnard, Dan Bilefsky, Rick Gladstone and Salman Masood.