Polio vaccines—“no thank you!” barriers to polio eradication in Northern Nigeria

ABSTRACT

This article is an analysis of the boycott of the polio vaccination campaign in northern Nigeria, which has indefinitely stalled global polio eradication targets. The polio immunization drive was brought to a standstill in July 2003 as religious and political leaders in northern Nigeria responded to fears that the vaccines were deliberately contaminated with anti-fertility agents and the HIV virus. The article explores the political and cultural angles of this controversy, revealing deeper dimensions that have contributed to the rejection of polio vaccines in northern Nigeria. In doing so, it argues that there is an underlying logic to public anxieties often dismissed as ‘anti-vaccination rumours’. Although the polio vaccine boycott has proved costly in both economic and human terms, it has opened important lines of communication at global and national levels, potentially deepening dialogue, participation and sensitivity necessary for global health campaigns. Although immunization comes with countless benefits, it is a complex and difficult health strategy to enforce. Decisions on broader health as well as immunization goals are often made at a global level to be incorporated and adapted into national health plans and budgets. Evidently for immunization campaigns, the journey from the global to the local is a vulnerable and unpredictable one.

Global Health and Poverty Reduction Discourses have Recognized Immunization as one of the most affordable and effective means of reducing child mortality, and in a broader sense, as an essential contribution to poverty reduction efforts. Indeed, the global eradication of smallpox in 1977 demonstrates the great potential of immunization campaigns.

Polio (poliomyelitis) is a viral disease transmitted through contaminated food, water or faeces. In its severest form, it attacks the nervous system leading to paralysis. The Global Polio Eradication Initiative (GPEI) set its target to wipe out polio in 125 countries by mid-2005. By 2003, polio remained endemic in only seven countries, one of which was Nigeria. These targets came under threat when Muslim religious and political leaders in northern Nigeria brought the polio immunization drive to a standstill, in response to fears that the vaccines were deliberately contaminated with anti-fertility agents and the HIV virus. Under the umbrella of the Supreme Council for Sharia in Nigeria (SCSN), strong assertions were made that the Polio Eradication Initiative (PEI) in Nigeria was part of a plot by western governments to reduce Muslim populations worldwide.¹ The 16-month controversy delayed the immunization of children resulting in the spread of new polio infections within Nigeria and allegedly to other parts of western and central Africa, jeopardizing previous accomplishments of the global campaign.

The northern Nigerian case, with its high-profile reporting in the global media, is one of the latest in a long line of public controversies regarding vaccination which extend back to the earliest days of the technology. Indeed, the GPEI campaign met with similar opposition to Oral Polio Vaccination (OPV) in East Africa in the 1990s,² so the Nigerian case is a rich and recent example of more widespread occurrences. Today, global and national policymakers highlight the problem of “anti-vaccination rumours” as a major threat to vaccine demand and coverage. Policy and media commentary on such instances, and the limited social science work which has addressed them, vary in their interpretations. Some write them off as ill-founded rumours grounded in misinformation spread by a few with misguided intent, to be corrected through education. Others interpret them as collective resistance based on religion or the spread of conspiracy-type theories in (it is implied) a rather unreflective African society.³ Other commentators on vaccination “rumours” in Africa, however, address how they arise and become logical to parents, whether linked to past experiences with the state and science, or the prevailing dynamics of vaccination provision and the suspicions these arouse. Anthropological and historical works have extended such interpretations to understand anti-vaccination rumours as an idiom crystallizing valid commentary on broader political experience in colonial and post-colonial settings.⁴ Through desk and ethnographic research, this article explores the political and cultural angles of this controversy, revealing the deeper dimensions and complex factors that have contributed to the rejection of OPV in northern Nigeria. In doing so, it brings into question the roles, responsibilities and actions of global and national actors in implementing effective immunization campaigns. The article thereby suggests that there is an underlying logic to public anxieties. Rather than delegitimize these as ‘rumours’, these anxieties need to be taken seriously and their root causes addressed if the controversy is to be resolved effectively.

The study draws on a range of research methods. Data were collected in the first phase through desk research, which included a literature review of media articles as well as related research papers on relevant topics and issues. The second phase adopted ethnographic research in Kano, Bauchi and Kaduna states in northern Nigeria, using participant observations, focus groups and narrative interviews with stakeholders. These include government officials, parents, members of the community, health professionals, local civil society groups, associations and health partners amongst the international development community.

The unfolding of the polio vaccine boycott in northern Nigeria

Launched in 1988, the GPEI stands as the largest on-going public health initiative in the world, led by the World Health Organization (WHO), Rotary International, the US Centers for Disease Control and Prevention (CDC) and UNICEF. The alliance with national governments and numerous institutions worldwide⁵ has made it possible to immunize two billion children around the world. The alliance launched its final drive in October 2003, aiming to immunize more than 15 million children in west and central Africa. Particular concerns were expressed about the high number of cases in Nigeria, attributed to insufficient coverage during previous campaigns. The WHO reported that more than 40 percent of the 677 new cases of polio recorded worldwide in 2002 were in Nigeria.⁶

GPEI targets, however, were to become more distant when the political leaders of Kano, Zamfara, Bauchi and Niger states in northern Nigeria brought the immunization campaign to a halt.⁷ They called on parents to not allow their children to be immunized, cautioning that the vaccine could be contaminated.⁸ The early cries against the vaccines by a number of religious leaders in northern Nigeria found a platform when taken up in July 2003 by the chairman of the SCSN, Dr Datti Ahmed. Dr Ahmed claimed that his suspicions about the vaccine did not originate from Nigeria but from reliable documents including Internet sources⁹: ‘We believe that modern-day Hitlers have deliberately adulterated the oral polio vaccines with anti-fertility drugs and contaminated it with certain viruses which are known to cause HIV and AIDS.’¹⁰

The polio campaign was concentrated in northern Nigeria where the wild polio virus¹¹ is endemic. Northern Nigeria also happens to be inhabited by a predominantly Muslim population, and this coincidence helped create a perception that Muslims were being deliberately targeted. According to the WHO, strains of the virus in Kano state were soon traceable to other parts of Nigeria, as well as several west and central African countries, raising great concerns among international health experts that ‘the world might be slipping in its efforts to wipe out polio by 2005’.¹² Despite warnings of a 30 percent increase in polio cases in January, the Governor of Kano state, Ibrahim Shekarau, in an interview stated that he viewed the boycott as ‘… a lesser of two evils, to sacrifice two, three, four, five even 10 children (to polio) than allow hundreds or thousands or possibly millions of girl-children likely to be rendered infertile …’.¹³ In other predominantly Muslim northern states where the immunization went ahead, it was not surprising to find that many families remained unreceptive and, at times, threatening towards health officials.

For many people in northern Nigeria, anxieties about OPV were not just shaped by perceptions of global religious politics. They also made sense in relation to past incidents concerning alleged malpractices in the meningitis vaccine delivery in 1996, when families in Kano accused New York-based Pfizer Inc. of using an experimental meningitis drug on patients without fully informing them of the risks.¹⁴ Pfizer Inc. is currently facing a US federal lawsuit by 20 disabled Nigerians alleging to have taken part in the study. Previously dismissed, the case has been revived by an appeals court in America.¹⁵

In addition, the SCSN claims the discovery of documents indicating that the WHO and UNICEF have been ‘actively involved’ for more than 20 years in the development of anti-fertility vaccines administered to women as part of tetanus toxoid.¹⁶ The administration of tetanus toxoid vaccines to women between the ages of 15 and 45 caused controversy in Mexico and the Philippines for this reason. Women in Tanzania and Nigeria are also alleged to have fallen victim.¹⁷

The SCSN explicitly described the polio campaign as a Western led agenda to significantly reduce Muslim communities worldwide. The controversy soon revealed a further distrust of Nigeria's federal government in facilitating tests on the allegedly contaminated vaccines. This distrust has its roots in Nigeria's turbulent political history. The struggle for leadership between Nigeria's three dominant ethnic groups has been a source of friction since independence in 1960, with rivalry between north, east and west expressed through such phenomena as disagreement over national census results, a secessionist movement leading to civil war, and, in its latest incarnation, Islamic revivalism and religious clashes in the north of the country.¹⁸

In the midst of the significant concerns being expressed by the Muslim community, there was equally a sense of urgency around a health dilemma that was becoming less manageable with each new infection in the region. Having made much progress in battling polio over a number of years, and understanding the critical implications of allowing the virus to spread further, the GPEI partners were greatly concerned. The Nigerian federal government was faced with the major challenge of asserting its limited constitutional authority over the defiant Sharia state governments and pacifying the Muslim communities, without much success. In the early days of the controversy, Carol Bellamy, UNICEF's Executive Director, obtained the commitment of President Obasanjo and the Health Minister to eradicating polio by the end of 2004.¹⁹ The confidence that was displayed publicly by the federal government did not speak of the great hurdles they faced in trying to convince the Muslim community of the safety of the vaccines. By January 2004, Nigeria was identified as ‘the number one reservoir and polio transmitting country in the whole world’.²⁰

When it became abundantly clear that the SCSN would not back down from its position regarding the suspension of the PEI, the National Assembly mandated a special committee in August 2004 to carry out a more thorough and transparent investigation of the polio vaccines. This investigative process was expected to respond most importantly to questions about whether there were indeed undeclared agents in the polio vaccine. If, in actual fact, anti-fertility agents in the form of oestradiol hormones were detected, the immediate question would be: ‘What is the scientific explanation for these quantities?’ and ‘What impact, if any, do they have on the female reproductive system?’²¹ Further key questions regarded whether there was ‘basis for suspicion in the stupendous spending on polio by donor agencies in spite of the presence of more destructive diseases’.²² Unhappy with the alleged lack of transparency in the National Assembly's investigation, the SCSN formed its own investigative team. When the National Assembly returned with results that re-affirmed the safety of the polio vaccines, the Kano team returned with opposing test results, alleging the contamination of the vaccines with traces of oestradiol.²³ The leader of the National Assembly house committee investigations, Dr Lawal Alhassan Bichi, acknowledged the SCSN test results stating, ‘I believe there is polio, I believe we must vaccinate our children, but where polio vaccine is seen to contain something that has not been declared, then I find it unethical to recommend that the vaccine be used.’²⁴ Explanations about the quantities and scientific impact of the oestradiol present in the vaccine were not provided by the committee and therefore the investigations were either not thorough, or there were aspects that were not revealed to the general public.

Following these developments, a number of groups and individuals expressed their opinions either in support of or against the SCSN's stance. The SCSN is perceived by a great many to be waving the flag of Islam in a polarized world where the West is thought to be at war with the Muslim world. Ali Guda Takai, a WHO doctor, suggested that there is a link between the protest in northern Nigeria and what is happening in the Middle East. ‘If America is fighting people in the Middle East, the conclusion is that they are fighting Muslims.’²⁵ A Kano-based pharmacist suggested direct links between the polio campaign, the September 11 attacks and the US invasion of Iraq and Afghanistan. According to him, ‘…some radical Islamic groups see opposition to polio vaccination as a means of expressing their anti-Western feelings. The best known of these organizations is the SCSN’.²⁶

In efforts to challenge some of these perceptions, the WHO enlisted the support of the Organization of the Islamic Conference (OIC), the African Union and the Arab League to urge a resumption of the Nigerian immunization drive.²⁷ In November 2003, the OIC adopted a resolution to pressure Islamic countries to make greater efforts to eradicate polio.²⁸ Nigeria is one of 17 OIC member states in Africa. Similarly, a segment of the international Muslim community, as represented by the International Fiqh Council, declared its strong disapproval of the stance of the SCSN in Nigeria. Scholars attending the 15th annual conference of the Islamic Fiqh Council²⁹ in Muscat spoke strongly against the northern Nigerian boycott of the polio vaccines. The prominent Muslim scholar Sheikh Yusuf Al-Qaradawi expressed his disappointment, stating: ‘Should the scholars of Kano refuse to follow the advice of their fellow scholars in the Muslim ummah [community]—which I doubt they would—I would turn to the people of Kano themselves and call upon them to vaccinate their children against polio.’³⁰

Strong opinions about the controversy resound locally and internationally, including views that a lack of Western education amongst northern Nigerians has contributed to the severe rejection of polio vaccines.³¹ Other voices rally around the opinion that bringing to question the safety of the vaccines is a positive sign, indicating the society's awareness of democratic and human rights principles and a willingness to pursue them. Furthermore, a mixed bag of opinions, globally, shows opposing views of the WHO: on the one hand it is seen as a neutral and respected international health care institution, but on the other as an agent of Western domination. In this case, it is glaring to see how Western medical science in the form of an international health campaign has the potential to lose its cloak of neutrality, acquiring significant political and cultural meanings reflective of a global political climate.

Having halted the PEI for 16 months, Kano state and the SCSN came under increasing pressure to reach a compromise. Procuring vaccines from reputable companies in Muslim parts of Asia seemed a viable solution. Demonstrating the purity and safety of vaccines produced in a Muslim state would further justify the political position that informed the boycott. Satisfied by the quality and process of production of polio vaccines, the Kano state team returned with a seal of approval for Biopharma, an Indonesian company, which was to become the new source of polio vaccines for the predominantly Muslim states.³² They were soon to discover that Biopharma was already one of the companies licensed to contribute to the pool of polio vaccines produced and supplied to the GPEI for global redistribution. With this finding, and with the increasing intensity of advocacy involving some of the most prominent Muslim leaders in northern Nigeria, Kano state eventually approved the resumption of the polio eradication campaign. In opposition to their decision, the SCSN continues to maintain its primary position on the dangers of OPV to Muslim families in northern Nigeria.³³

Ultimately, however, the campaign was resumed. The re-launch in Kano came to symbolize the end of the polio controversy in the country, with the Emir and the Governor publicly immunizing their own children to demonstrate the safety of the vaccines.³⁴ A very significant polio eradication resolution was made in June 2004 at the 10th session of the conference of the OIC. Apart from influencing member states to work harder at eradicating polio, some OIC member states have begun to make financial contributions in support of global polio eradication efforts in 23 West African countries, 17 of which are OIC members including Nigeria.³⁵ Such efforts demonstrate significant solidarity amongst Islamic states towards polio eradication and more importantly confirm their belief in the safety of the polio vaccines procured through this global initiative. An intense advocacy campaign was coordinated by Dr Ezio Murzi, UNICEF's representative in Nigeria. State and local government officials were urged to work hand-in-hand with religious and community leaders to ensure the success of the campaign.

Old and current challenges to Nigeria's polio immunization campaign

An introduction to Nigeria's immunization activities through the lens of the political controversy leaves one with the impression that it stood as the sole impediment to what would otherwise have been a smooth-running immunization programme. However, field research has revealed that beneath the high-profile political turmoil of the controversy, there exist different layers of challenge to polio eradication and routine immunization. These challenges in turn bring into question the commitments made by the federal government to eradicate the virus by 2005.

Indeed it has become evident that the steady increase of polio cases in northern Nigeria started long before the boycott of polio vaccines by northern Muslim states. In 2000, reported polio cases were below 50 and by 2003 they had risen to above 350.³⁶ More broadly, national coverage rates for full childhood immunization have been on the decline since the 1980s with current rates as low as 13 percent in Nigeria, as reported in the Nigerian Demographic Health Survey³⁷ and the Nigeria Immunization Coverage Survey-2003. Nigeria's coverage has been reported to be one of the lowest in Africa and indeed in the world. The same studies indicate that current immunization coverage in some states in northern Nigeria is below 1 percent, and the average for the north west zone where Kano is situated is as low as 4 percent.³⁸ Shortly after the resumption of the polio campaign, UNICEF reported that independent monitoring by health workers and volunteers confirmed that nearly 75 percent of children were vaccinated against polio in northern Nigeria—the highest numbers ever recorded for the area.³⁹ Dialogue with communities, however, does not suggest enthusiastic uptake of polio vaccines.

It is to community perspectives that we now turn, drawing on fieldwork to examine the meanings of Nigeria's PEI in local terms and how both local officials and parents reflect on the boycott and its aftermath.

Perspectives on polio immunization since the resumption of the PEI

The political campaign that resulted in allegations that the polio vaccines were contaminated with anti-fertility agents was very successful in creating lasting fear in the minds of a great number of Muslims in northern Nigeria. Despite the polio controversy resolution at a statutory level, its impact continues to linger within communities. This is reflected in the harsh manner in which vaccinators continue to be treated as they carry out the door-to-door PEI campaign, particularly in remote rural communities. Fear of the vaccines pervades the words of even traditional and religious leaders, many of whom remain sceptical of vaccine safety even while they publicly stress their roles as advocates for the polio campaign. Within communities, however, perspectives on the vaccine differ from house to house and amongst individual household members.

A female vaccinator in Kano described the reactions to the vaccines as diverse, but emphasized the rejection of OPV amongst a majority of households since the resumption of the PEI. In Bauchi, a female health worker commented:

Even some of the religious leaders do not agree to have their kids immunized let alone us. They say it is harmful to families.⁴⁰

Although a majority of households have turned down the vaccine, some have allowed their children to be vaccinated. A barber commented:

If the White man really wanted to destroy us, there are many other easier ways to do it. They can poison our coca-cola, the biscuits we buy, the sweets and even panadol that you can buy in the kiosks for headaches.⁴¹

Some respondents distinguished between the vaccines found in post-natal clinics during routine immunization sessions and those administered by roaming vaccinators who go to homes, emphasizing their trust in the former but not the latter.⁴² Indeed, senior male members of the household such as husbands, brothers and uncles tend to have the final say as to whether a child is vaccinated. However, some female respondents stressed their role in persuading their husbands to approve that their children be vaccinated. A mother of two stated: ‘Like everything else, you must at least negotiate with your husband, especially when it concerns your children.’⁴³ Beyond rural communities, there are a number of Western educated professionals who harbour similar fears about the polio vaccines. A female banker in Kaduna speaks of her initial scepticism but re-echoes the theme of trust when asking her private doctor for advice on whether to give her son the vaccine.⁴⁴ When asked whether she would allow her son to be vaccinated by the door-to-door vaccinators, as opposed to having her son vaccinated in a private clinic, she said she would not take that risk with her son.

Local and international media suggest that the response to the polio vaccines is born out of a lack of education, illiteracy and ignorance. Rejecting these suggestions, a Muslim leader and elder in Minjibir (Kano) stated: ‘It is as a result of education that we ask questions as to what medicine is being brought into the country, what it contains and how it will affect us.’⁴⁵ In a contrary view, Hussain Abdu, coordinator of the Centre for Development Research and Advocacy in Kaduna, responded to these comments, stating:

Yes it is true, an enlightened society is one that asks questions, however this does not absolve northern governments of their total neglect of education. Yes Quranic education is also education and it is important for development, but equally so is Western education which broadens awareness and enables our diverse society to be integrated. If the rate of education in the north was higher, the polio problem will not have gone to this extreme.⁴⁶

Also very prominent in the local communities are traditional healers, some of whom resent the polio vaccines and are thus promoting traditional cures to polio.⁴⁷ Indeed, what became apparent in the course of various discussions was an almost irreconcilable difference between Hausa and biomedical definitions of polio. These differences have led to clashes of perspective, which have significantly contributed to worries about the polio vaccines.

The Hausa⁴⁸ name for polio is Shan-inna. The understandings and meanings given to this disease differ between Western science/biomedicine and Hausa culture. In biomedical terms, polio is caused by a virus and is preventable through scientific methods of immunization. In Hausa culture, Shan-inna is an ailment of the spirit world.

Amongst Hausa communities, it remains a strong belief that Shan-inna is a powerful female spirit that consumes the limbs of human beings. Traditional healers are greatly respected in the Hausa community and are believed to have special powers that enable them to interact with the spirit world. They are usually the first point of call when one has been affected by Shan-inna. For many, particularly those living in the rural areas, traditional healers are the only doctors they have. Estimates have shown that 80–85 percent of Nigerians and Africans as a whole rely on traditional healers for health education and health care.⁴⁹ They greatly outnumber modern health practitioners and usually play leadership roles within their communities.⁵⁰ Their thorough understanding of the local culture and their role in issues of governance, family and health issues place them in variable positions of influence. It is not surprising to find, therefore, that notions around Shan-inna are defined and sustained by traditional healers. This is particularly so in remote communities where primary health care is inaccessible due to inadequate supporting infrastructure such as roads, water, electricity, effective communication and administrative systems,⁵¹ all necessary for the efficiency of health care delivery.⁵²

For a time, traditional healers were challenged by the modern health sector but gradually reclaimed their relevance with the collapse of Nigeria's economy in the 1980s, which meant that health care was not only no longer free but also declining in accessibility and quality.⁵³ Currently, even though there is little standardization and regulation, the private sector and the traditional medicine settings are very important and jointly account, in one estimate, for 60–80 percent of service provision.⁵⁴

A significant number of Nigerians use a combination of both Western and traditional cures depending on factors including cost, accessibility and the effectiveness of a particular treatment. Those with a Western-style education, however, are in the minority and amongst the lowest users of traditional methods of healing. It is, however, very difficult to assess to what extent cultural beliefs, specifically or generally, influence the response towards western health initiatives for they are usually accompanied and impacted by a combination of other factors. In the case of polio in Nigeria, it is evident that both polio and routine immunization coverage rates started to decline around 1990, long before the political dilemma.⁵⁵ The rapid increase in polio cases since 2001 prior to the political boycott of 2003 can be attributed to numerous factors related to issues of health systems and service delivery as well as culture.

Primary health care and immunization in Nigeria

Polio immunization began as a national programme in 1996. Since 1988, however, National Immunization Days (NIDs) and sub-NIDs for the eradication of the virus became the centre of attention for the National Programme on Immunization (NPI) for several years.⁵⁶ The enormous human and financial resources consumed by the PEI have taken their toll on the already-limited capacity of the NPI and wider primary health care system.

The central role of the PEI in Nigeria's immunization programme is no doubt a creation of the GPEI and subsequently a key objective of the Millennium Development Goals' (MDG) aspiration to reduce child mortality by two-thirds by 2015. It is expected that immunization will play a key role in achieving this objective, with targets set for national immunization coverage at 90 percent for every country by 2010, including certified polio eradication. The Global Alliance for Vaccines and Immunization (GAVI) has pledged its support towards the achievement of these targets.⁵⁷ With ‘health systems and services too weak to support such targeted reduction in disease burden’,⁵⁸ this represents a very distant goal for Nigeria and Africa at large.

In 1996, the NPI was re-established as a sister arm to the Ministry to compensate for the failures of previous immunization programmes.⁵⁹ The NPI acquired the power to have a direct relationship with communities in supporting immunization programmes nationally. Despite volumes of international and local support, the NPI failed to reverse the rapidly declining coverage of childhood immunization; indeed, coverage rates have worsened since its establishment. At the rate of $56 per fully immunized child, Nigeria spends double the amount of money that other developing countries spend per child on immunization and yet coverage rates are lower than in poorer neighbouring countries including Mali, Togo, Ghana, Niger, Cameroon and Benin, and even war-torn countries such as the Democratic Republic of Congo (DRC).⁶⁰ At the current coverage rate of 13 percent in Nigeria, up to 200,000 children die from vaccine-preventable diseases each year (22 percent of childhood deaths).⁶¹

Despite the NPI's primary responsibility to ensure the supply of vaccines and equipment to states and local governments, the most prominent complaint amongst communities is the unavailability of vaccines, followed by the great distances people must travel to reach the nearest vaccination posts for routine immunization services.⁶² Indeed, immunization services have been inaccessible to a significant proportion of rural communities where 80 percent of Nigeria's population resides. Jummai, a mother of four, walked for two hours with her baby on her back from Goda village to Minjibir local government area to attend the weekly immunization session only to find that the measles vaccine was unavailable.⁶³ This occurred during a severe measles outbreak in the region. In an attempt to resolve the issue of availability, in 2003, UNICEF took over responsibility for vaccine procurement for the NPI;⁶⁴ however, distribution remains in the hands of the NPI. To address the persistent problems associated with accessibility, President Obasanjo has requested a review of the NPI's distribution system.

During fieldwork, community members identified another issue, expressing considerable concern about the age and competence of vaccinators.⁶⁵ People across Bauchi, Kaduna and Kano states expressed alarm that girls ranging between the ages of 9 and 14 were selected to administer OPV to babies. This was discouraging to many otherwise willing parents, who rejected the polio vaccines on the grounds that vaccination is a task for qualified health professionals. To a number of parents, the employment of such girls for the task of immunization was disrespectful on the part of the health authorities and a relegation of a very important service. Members of the community were also quick to point out that the door-to-door campaign is beneficial to acts of patronage. Girls employed as vaccinators are paid just a fraction of their dues, whereas the remainder is shared amongst coordinating NPI officials at the local government level.⁶⁶ In their defence, NPI officials argue that the young girls were employed specifically for their ability to freely go into homes that do not permit the entry of men, in accordance with Muslim culture.

One of the NPI's responsibilities is to provide adequate support to the states and local governments for them to run continuous awareness-building initiatives, as an important aspect of community mobilization. But rather than provide support, NPI often exceeds its mandate, subjugating the important role of the communities as leaders in this process. The poor impact of these grassroots awareness-creating interventions is reflected in the limited knowledge and understanding of immunization amongst parents. The NPI can boast a media campaign that saw influential political and religious leaders raising awareness and encouraging polio immunization. However, the radio, which is the greatest medium for news in northern Nigeria, has become a luxury in very poor rural communities. This is accompanied by recurring complaints of a lack of resources to conduct outreach awareness campaigns at the local government level. A nurse working in a local government clinic stated:

I feel they should do it as in the past when professional health workers will go to the traditional leader, gather people and do it out in the open. This way people can discuss and ask questions and all will be explained to them. We do awareness sessions when the women come here for immunization, but really we need more resources to reach those in the village who are not coming.⁶⁷

Studies have shown that mothers with Western education are more likely to have a fully immunized child. Nevertheless, it is evident that amongst uneducated as well as educated parents, there are varying levels of understanding as to the types of immunization available and their frequency.⁶⁸ Not surprising, therefore, are prevailing notions that one vaccine serves as prevention for all potential diseases, that vaccines prevent diseases such as malaria, pneumonia and cholera and that one dose of a vaccine is quite sufficient for any one disease. Such misconceptions serve to create distrust and confusion when they prove not to be true.

In relation to the polio campaign, it was therefore not surprising to find parents complaining that their child had already been vaccinated for polio once, questioning how many times vaccinators wished to administer the same vaccine? For those more aware, there was confusion as to whether a child can receive more than four doses of the oral polio vaccine, particularly those who had already received doses of the vaccine as part of the routine immunization service at their local clinic. Many were told by door-to-door vaccinators that there is no limit to the number of doses a baby can receive. A number of parents, however, spoke of their resentment of such medical advice coming from child vaccinators. There are conflicting views as to potential harm caused by too many doses of OPV. However, the immunization programme should, as an obligation, make parents/carers aware of the ‘recommended’ number of doses for all vaccines.

Awareness, understanding and clarity on immunization amongst communities are undoubtedly essential for the success of the polio campaign and for wider immunization delivery. The centrally driven nature of the NPI, however, does not encourage community-driven approaches. State governments have strongly expressed the need to have a leadership role over their immunization programmes, complaining that the NPI's excessive control of the immunization services has rendered state governments as mere assistants.

Economic and political patronage has also influenced the campaign. A closer look at local government primary health care services signifies a low capacity to carry out functions effectively. The high levels of patronage associated with the relatively well-resourced health sector are very pronounced. Political appointments and the frequent cabinet re-shuffles at federal, state and local government levels have significant implications on who has access to what resources and in which ways. This has been particularly significant in the well-funded PEI NIDs and sub-NIDs, where key appointments such as NPI managers and cold chain officers⁶⁹ at the local government level are central to the chain of patronage. The large number of health workers taken away from their posts to serve as supervisors and vaccinators during NIDs and sub-NIDs for up to 35 days at a stretch, six times a year, takes a heavy toll on an already poorly staffed primary health care system. The NIDs and sub-NIDs are a very lucrative source of patronage in that they consume massive administrative costs, particularly in the form of daily allowances. It is common knowledge that beneficiaries of the polio immunization view the PEI as a windfall that will hopefully last a long time, even to the neglect of routine immunization and the wider primary health care system. In this light, one can appreciate the (overly) positive feedback on PEI coverage given by field staff, which may potentially be framed with the intention of sustaining the lucrative door-to-door campaign.

Part of the suspicion surrounding the polio campaign undoubtedly stems from a perfectly understandable failure on the part of local people to understand why such disproportionate resources are being devoted to it. The WHO and UNICEF have been recognized as the forefront players in driving the PEI in Nigeria, in partnership with the Federal Ministry of Health and the NPI. The role of UNICEF as a champion of child health in Nigeria and the role of the WHO as a long-standing partner in the development of Nigeria's health sector have been brought into question by the recent polio eradication campaign. Given that WHO and UNICEF have worked hand-in-hand with Nigerians for many years, many people do not understand why they were adamant to push the polio eradication campaign through a system that clearly lacked the capacity to manage it. Assertions abound that the diversion of resources to the PEI has been detrimental to Nigeria's primary health care system. A number of local and international health professionals in the voluntary sector have commented that the polio eradication campaign in Nigeria has turned into an obsession of GPEI core partners, consuming endless resources and pushing relentlessly in a clearly unreceptive environment. A senior development advisor at DFID-Nigeria provided an overview of the situation, explaining that within the global vision of the polio strategy, the door-to-door campaign was in effect meant to ride alongside a well-functioning basic health care system, thus serving as a mere booster service.⁷⁰ The almost non-existent primary health care system in Nigeria, however, has served to magnify the door-to-door polio campaign and quite logically brought it into question.

Arising from almost all discussions amongst communities in Bauchi, Kaduna and Kano states was great concern as to why polio was receiving so much attention. The Nigerian people are astonished that the federal government, with the support of the international community, is spending huge resources on ‘free’ polio vaccines when basic medicines to treat even minor ailments are beyond the reach of the average person. A neighbourhood security guard commented:

If I go to the hospital, even simple panadol (paracetamol) for a headache, I cannot buy and these people are following us into our houses, forcing us to bring our children for free medicine for polio. What kind of humiliation is this?⁷¹

Popular opinion views those affected by polio as healthy and active members of the community and able to manage their daily chores even if somewhat limited by their physical capabilities. Far more concern goes to those who are unwell and in need of treatment and medicine.

People have become even more resentful due to the neglect of other vaccine-preventable diseases by the NPI. Between February and May 2001, for instance, there was an outbreak of 100,000 cases of measles nationally.⁷² In the face of this, the polio campaign met with even more ridicule as it went from house to house to administer polio vaccines as parents mourned the deaths of their children from measles. What becomes increasingly apparent in these conversations is a lack of trust in the government and the West, portrayed by many as ‘partners in crime’.

Conclusions—ways forward?

Although the vehicles for the promotion and implementation of immunization programmes often view negative responses to their campaigns as ‘ignorance’ and ‘misinformation’, just beneath the surface lie viable and logical reasons as to why so-called anti-vaccination rumours are created.

In 1996, Uganda also experienced a boycott of polio vaccines with fears of contamination with the HIV virus and anti-fertility agents.⁷³ As in Nigeria, polio was not a priority health care issue for the local communities; there was a greater concern for diseases such as malaria and an abundant dissatisfaction with the quality of primary health care.

Like any other country, Nigeria has its unique political and cultural circumstances which have been explored in this article. The boycott of polio vaccines reveals a sense of insecurity in predominantly Muslim parts of northern Nigeria which, to a certain extent, has its roots in past incidents concerning allegations of unethical medical practices by Pfizer, an American drug company, in conducting illegal drug testing as well as suspicion of US-led population control campaigns, both of which have been interpreted as a ploy to reduce Muslim populations worldwide. Nigeria's unique history and political situation have also contributed to the manner in which the boycott was construed and managed.

With deeper consideration it becomes clear that the failure of the PEI in Nigeria is directly linked to the failure of basic primary health care provision, sowing seeds of distrust directed at both the Nigerian government and Western involvement. The cultural definition of polio as a supernatural affliction, which remains alive in the realities of a significant number of Hausa people, has acquired greater significance in the absence of a well-functioning and effective primary health care system. Traditional healers surpass bio-medically trained doctors both in number and social power.

By subduing the PEI, the northern state governments and communities brought into question Western-driven campaigns. It became very clear how decisions concerning international development issues, such as the eradication of polio, are made in environments far removed from the local realities of targeted societies, resulting in an awkward clash between grand global objectives and local priorities, practicalities and peculiarities.

Although Bretton Woods policies have undoubtedly contributed to the collapse of health care systems across the continent, the Nigerian government cannot absolve itself as a key contributor to the challenges of the PEI. Questions put towards Western health agendas and priorities also rebound to question the political will and failure of Nigerian governance to operate an effective health sector with accessible services. Indeed, broader questions ask why some of the poorest Africans come from the fifth largest crude oil-producing country in the world.

Relentlessly, the WHO, in partnership with UNICEF, pushes on with the PEI, maintaining that northern Nigeria remains the epicentre for the virus and costing close to $12 million for each round of vaccinations.⁷⁴ Debate amongst government staff and donor agencies in the country is now starting to focus on possible shifts of approach that would facilitate the achievement of this goal. Strategies used to challenge similar OPV and tetanus vaccination allegations in Uganda, Kenya and Tanzania have emphasized continuous social mobilization, knowledge and awareness creation, based on the premise that information gaps will be filled by false allegations.⁷⁵ Recent commitments to a people-centred approach are promising, but demand significant budget allocations to ensure the success of future campaigns. Unfortunately, this is an area that is often neglected within immunization budgets.

While an education-focused strategy to quell what is seen as ill-founded rumour is important, OPV has acquired broader meanings, becoming an expression for wider issues of distrust and anxiety which must not be swept under the carpet. Beyond its sole objective to prevent poliomyelitis in children through global eradication of the virus, the oral polio vaccine can be said to have taken Nigeria on a controversial yet significant journey of cultural and political dimensions. Beneath the great visions, power struggles and diverse motivations remain the perplexed communities of northern Nigeria who strongly desire a well-functioning and affordable health care system that takes care of malaria, pneumonia, typhoid and polio, even if it is in this order of priority. While respect and sensitivity towards the needs of Nigerians have fallen short of the noble words of global and national health care strategies, the political boycott of the polio vaccines has served to magnify the shortcomings of Nigeria's immunization programme and broader primary health care delivery. The future of polio eradication in Nigeria is thus inseparable from a search for solutions to the problems of routine immunization and primary health care, requiring an unwavering investment in community-centred relationships and programmes by both international partners and the Nigerian government.

This study was funded by the Committee on Social Science Research of the UK Department for International Development (DFID) as part of a broader comparative project on ‘The Cultural and Political Dynamics of Technology Delivery: The case of infant immunisation in Africa’ led by Melissa Leach and James Fairhead. The views and opinions expressed are those of the author alone.

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