Rebellion against the polio vaccine in Nigeria: implications for humanitarian policy

Abstract

Polio eradication has been top on the agenda of various international humanitarian organizations since 1988. Caused by a virus that enters through the mouth, poliomyelitis attacks the nervous system, and can lead to irreversible paralysis or death. Children under five years of age are most at risk, and the oral polio vaccine, OPV, is administered as a drop often on a lump of sugar placed in the child's mouth. Given multiple times, the vaccine may protect a child for life!. In this essay, the Nigerian scenario serves as a case study of community involvement and trust in international humanitarian policy. The underlying causes of the rebellion and its long term impact on immunization programs in the region as well around the world are of interest and relevance to students, teachers and practitioners of public health.

Information about the epidemiology of polio and its eradication policies was obtained primarily from the website of the World Health Organization web site, while knowledge of the rebellion in Nigeria is based on the British Broadcasting Corporation (BBC) news reports and follow-up articles. I am also drawing ftom library research of peer-reviewed journal articles and my course work and notes on community participation in public health.

‘Rebellion’ against the polio vaccine

Since the beginning of the WHO's global polio eradication initiative in 1988, the prevalence of polio has fallen by 99 per cent. However, polio remains endemic in certain regions of the world. The Americas, Europe, and many parts of Asia had been declared polio-free, but some parts of Africa and Asia continue to report polio cases. With 2005 as the new target for polio eradication, immunization efforts have specifically focused on Nigeria and India. This is because the polio epidemics that struck Nigeria and India had contributed to increased numbers of polio cases worldwide between 2001 and 20022. Nigeria is the country with the second highest risk of ongoing polio transmission in the world. Fearing that the epidemics may cause polio to spread into neighboring countries and regions that had previously been declared polio free, humanitarian agencies stepped up immunization efforts in Nigeria!.

The Global Polio Eradication Initiative (GPEI) is spearheaded by the WHO, Rotary International, the United States Centers for Disease Control (CDC), and the United Nations Children's Fund (UNICEF). GPEI consists of four main strategies: immunization of infants for life during their first year, immunization of children under 5, surveillance for outbreaks, and targeted “mop-up” campaigns when an outbreak occurs!. Immunization programs usually consist of workers administering OPV and vitamin A supplements to children. Since 2001, the number of polio cases in Nigeria has quadrupled to encompass almost half of the world's polio cases². In mid-October 2003, the WHO began an emergency campaign to immunize fifteen million children in Nigeria over the course of three days³.

However, the immunization drive was brought to a halt in three counties after Islamic community leaders claimed that the vaccines were unsafe and might even cause the spread of. disease^3,4. Leaders requested that the vaccines be doublechecked for safety. One leader, Datti Ahmed, a doctor and president of Nigeria's Supreme Council for Sharia Law stated, “There were strong reasons to believe that the polio immunization vaccines was contaminated with anti fertility drugs, contaminated with certain viruses that cause HIV / AIDS, contaminated with Simian virus that are likely to cause cancer”³. In addition to the contamination allegations, rumors spread in the area that the contamination was part of a US plot to limit Nigeria's population by spreading AIDS and increasing infertility. The WHO continued to assert that the vaccines were completely safe, and although it eventually agreed to test the vaccines to confirm their safety, the campaign was set back significantly - unti12004^5,6.

Analysis and implications

Learning about this scenario led me to ask the basic question, Why did this occur? While it is too early to know for sure, it is possible for me to examine the causes within the frameworks of community participation and trust in humanitarian projects and the historical relationship between Africa and the West.

Undoubtedly, the lack of trust of the humanitarian agencies, directly reflecting a distrust of the Western countries, by the Nigerian communities was a major factor in the extent to which the rebellion gained momentum. In any context, trust is an important part of the relationship between aid workers and recipients. Community trust is affected by previous relationships with the provider. Points of contact between the community and the provider serve as points where trust is increased or decreased. The provider's trustworthiness is judged based upon the community's understanding of provider's announcement and the final outcome of the situation7. Directly related is the importance of providing communities with information and ensuring that they accurately understand the information provided. Misunderstandings about the purpose of the vaccinations could dramatically affect the level of trust within the community. As Das and Das (2003: 100) concluded, “households often carry out vaccinations based on their trust in the [provider] rather than the merits of the immunization per se.” Within the context of Nigeria, the trust of humanitarian agencies within the communities was quickly overcome by the beliefs of influential religious leaders. The fact that the claims of the leaders had such a sweeping effect across the country illustrates that trust of humanitarian agencies was low to begin with.

In addition to lack of trust, the immunization campaigns demonstrated the WHO's top-' down approach to polio eradication. Although the published literature about polio eradication stresses the inclusion of ‘political, community and religious leaders’, in practice the WHO did not involve them effectively. The GPEI typically trains local volunteers to administer OPV and vitamin A to children. Local community organizations and leaders were not involved in the planning or development of immunization campaigns. Prior to the rebellion, the WHO met with the Nigerian Minister of Health, who declared the federal government's support of the immunization programs ^1,8. However, local political and religious leaders who have a greater influence in their communities were not included. By utilizing a top-down approach, the WHO normally controls how immunization programs were implemented without consulting with the community⁹. Exclusion of community members and leaders translates to communities' lack of share in ownership of the program. As a result, questions of vaccine safety could take a firmer hold because communities are not invested and the program is imposed by outside agencies.

Finally, it is important to recognize the historical relationship between Africa and the West and the implications of that history. Historically, Africa was dominated by European countries during the Age of Imperialism and experienced the exploitation of its resources and its people. This history has created a lasting resentment of the Western world and may call into question the underlying motives of Western actions on the continent. Humanitarian agencies may be seen as the vehicles through which Western countries seek to impose their policies on non Western countries resulting in increased level of distrust of these organizations. In addition to the history of imperialism, events in African American history, such as the Tuskegee Study ¹¹ (Pg 4) caused many contemporary African Americans and Africans to distrust and to question the underlying motives of the US government. The lasting impacts of the Tuskegee Study extend beyond the boundaries of the United States. Around the world, people of African descent have come to believe that HIV/AIDS is a form of government-led genocide on African people¹⁰. Such severe issues of distrust ultimately impact other health issues, as in the case of OPV.

Fundamental changes must occur in the WHO's planning and implementation of future polio immunization campaigns. While it is crucial to continue efforts to immunize at-risk children worldwide, the program needs to take a more community-based approach in order to ensure that a similar rebellion does not happen again. Before re-implementation, two important steps must be taken. First, an in-depth examination researching the implications of the historical, political and religious influences must begin. This research must recognize and address Africa's colonial history, the implications of the AIDS epidemic and events like the Tuskegee Study, and the significance of religion and religious leaders in the region. This research will provide aid workers with a deeper understanding of the context in which they are functioning. Similarly, it will enable them to work more effectively with community by understanding and recognizing the experiences of the Nigerian community.

Second, the community must be included in the conception, development, and implementation of the new immunization campaign and program. It is necessary for the WHO to shift away from the top-down approach to a more bottom-up approach where there is equal collaboration on both sides and the community is empowered⁹. Local community organizations would provide stable anchoring points within the community to encourage immunization. In addition, local organizations would provide valuable information and insight into the community. Local political and religious leaders must be included in the development of programs as well. Particularly since the rebellion against polio was sparked by a religious leader, it is particularly important in regions where religion plays a major role in the lives of the people to include local religious leaders as consultants. Unlike the earlier program where local people were only involved as trained assistants, people, particularly leaders, will be more invested and probably more trusting of the program because they will have played a role in the development. By involving the community throughout all the stages of the planning process, hopefully another rebellion may be avoided.