by Katie Nelson
Polio has not plagued the western world in decades. For most Americans, it seems a vestige of a bygone era. But for those working to eradicate it in the rest of the world, polio is a frustrating reminder of the way in which cultural frameworks can have dangerous health outcomes.
Polio is endemic in only a few countries. In India, repeated vaccination campaigns in the northern provinces have not generated adequate immunity. In Afghanistan and Pakistan, inadequate infrastructure and persistent conflict have impeded vaccination efforts. And then there is Nigeria. The most populous country in Africa—home to one in every seven Africans—Nigeria has recently overcome a spate of dictators and military coups to try to establish its rightful economic place as an oil-rich country. Its healthcare infrastructure is generally poor, and its infant mortality rate is among the highest in the world, at 97.1 deaths per 1000 live births.
Such problems, however, are not unique to Nigeria, as they are similar to those of other post-colonial African countries. But in 2003, mounting religious and cultural tension in Nigeria turned vaccination into a political rallying point. In the beginning, several Muslim clerics in the north of the country began to spread rumors that polio vaccines had been designed by Western powers to sterilize Nigerians. These rumors were given some sort of credibility when the Supreme Council for Shariah in Nigeria, then headed up by a doctor, began to perpetuate them. Subsequently, the governors of the states of Kano, Kaduna and Zamfara suspended immunization programs until the vaccines could be tested and certified as safe.
Due to the particular features of polio, that was all it took. Polio is spread through the fecal-oral route, and contamination by one person in an unsanitary environment can cause infection of many other susceptible people.[i] Soon, polio cases in Nigeria resurged dramatically. Previous increases in polio incidence had been a result of infrastructural inadequacies. Soon, a further jump in incidence could be observed as a result of religious conflict.
The events of 2003 need to be understood in the context of Nigeria’s cultural and historical intricacies. Until British expansion in the 19th century, the region that currently comprises Nigeria was divided into several different kingdoms. In the north, the Muslim influence of the fallen Mali Empire permeated the Hausa kingdoms in the 15th century. These northern trading states were slowly infiltrated by Fulani people from the northeast, who created the powerful Hausa-Fulani caliphate in 1806. The southeastern region of the country became increasingly vulnerable to the coastal slave trade, which spread deeper into the interior of the region. The Ibibo people of Akwa Akpa who controlled part of the trade network primarily sold the Igbo people as slaves. The Igbo themselves lived in a system of republican communities in Igboland in the southeast of the country. The Yoruba in the southwest are ethnically related to the people of Benin, and experienced their own cultural golden age under the Yoruba and Oyo Empires from the 12th through the 18th centuries. These ethnic groups remain in roughly the same geographic position as they did before Colonization.[ii]
In 1807, the British government banned its citizens from engaging in the slave trade, and blockaded the Nigerian coast to prevent any illegal trading. The exigencies of maintaining the blockade led the British to establish a military presence on the Nigerian coast, which gradually expanded throughout the 19th century into a sphere of influence in the south. Christian missionaries were especially active among the Yoruba and Igbo peoples. In 1900, the southern palm-oil producing states were officially named the Southern Nigeria Protectorate. The Northern Nigerian Protectorate was formed the same year largely to prevent incursions by other European powers, but the northern emirates maintained their Muslim identity and a large portion of their autonomy. British officials forbade Christian missionaries from entering the region, and made no attempts to institute Western education that might interfere with the Islamic school system. In 1914, the two British Nigerian colonies were merged despite their enormous cultural and ethnic differences. This was done largely for financial reasons, so that the relatively prosperous south could help the struggling north.
Despite these stark regional differences, an anti-British sense of Nigerian nationalism began to emerge in the 1920s. This nationalism was characterized more by pan-African identification than any specific Nigerian one, and the political parties that emerged were largely based on ethnic divisions. In the course of the 1940s and 1950s, the British government began to devolve power to the Legislative Council of Nigeria, but tensions between the more educated, westernized south and the repressive north continued to heighten up until independence in 1960. The Yoruba in the west developed their own political identity distinct from that of the Igbo in the southeast, and as a result the First Nigerian Republic was a fragmented coalition. The Nigerian civil war in 1966, during which Igbo military leaders assassinated northern and western politicians, culminated in the declaration of independence of Biafra in the southeast further splintered the country. The next thirty years of Nigerian history were marked by a series of coups, assassinations, military rule, and a descent into infrastructural chaos.
While the country’s politics have become more stable since the reestablishment of civilian government in 1999, interreligious violence has increasingly plagued Nigeria, and ethnic divisions run deep. Citizens’ faith in the government has been eroded by years of corruption, and most people rely more on the governance of their regional leaders rather than that of the Nigerian state.
Polio in Nigeria can be thought of as a product of these problems. The north, whose leaders have been long afraid that modernization would threaten Islamic authority, has resisted many infrastructural and social programs, and remains backwards compared to the south. Already resistant to western health programs, northern Nigerian leaders were further alienated by the expansion of worldwide polio vaccination programs in the 1980s. Matters came to a head in 2003, when a Southern Christian, Olusegun Obasanjo, was elected president, defeating the incumbent, a Muslim.
Fears about the vaccine began as rumors in village councils, but spread rapidly through the northern region. An easy scapegoat for the specter of western imperialism, the vaccine was condemned as a plot by the West to limit the Muslim population of Africa. Most damning of all, the rallying cry was taken up by Dr. Datti Ahmed, a doctor and leader of the National Council for Shariah. Ahmed claimed that “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.”[iii] Because of this statement, the governors of three of the most populous northern states had no choice but to ban vaccination efforts.
The reaction of the public health community compounded the problem. Not believing that mere rumors could defeat the vaccination effort, they initially made no comment and waited for the furor to die down. When it did not, they were forced to announce testing of vaccines by independent parties to ensure safety.
The World Health Organizations’s top-down approach to vaccination programs was equally problematic. While the Nigerian federal government was included in the program-planning process, religious and community leaders were not, a decision rife with consequences for the fragmented Nigerian state. If local leaders were not invested or even involved in the process of the campaign, they could not vouch for the vaccine’s benefits to their community. After nearly a year of independent testing by laboratories in Muslim countries, the governors lifted their bans. But it was too late; the disease had escaped Nigeria. Polio can spread extremely quickly in an unprotected community, and it only takes one sick person shedding the virus to perpetuate the disease. Within months of the vaccination ban, Nigerian states that had been previously polio-free reported cases, and the disease spread into Niger, Burkina Faso, Togo, Ghana and Chad. To date, Nigeria has spread wild polio back into 25 countries.
Despite the slow diminution of rumors, and reinstatement of the anti-polio program in all states, Nigerian vaccination rates continue to be low. Six states in the north have rates of missed vaccination (which includes refusals) of greater than 10%, and many of the refusals stem from inadequate information about the benefits of the vaccine. Infrastructural problems are the main cause, but refusals remain higher than in most African countries, due to religious and ethnic issues addressed above. The reelection of President Goodluck Jonathan, a southern Christian, may be problematic, since he lacks a northern ethnic or religious base of support.[iv]
However, some positive signs can be discerned. Refusal rates, while still high, have diminished by 12 percent since 2007. Much of the credit goes to the work of community health engagement programs, which seek on-the-ground support for vaccination programs. While Nigeria works hard to overcome the setbacks of 2003, it serves as an important case study for the global medical community about the importance of trust and communication for polio eradication efforts.
[i] Poliovirus has an R0 of 5-7, which means that each infected person will probably get 5-7 more people sick. This geometric increase (each of those 5-7 will infect another 5-7 each, and so on) means that the higher the R0, the more difficult the disease is to control. Given that eradication programs have been ongoing for over three decades, polio has been extremely difficult.
[ii] Nigeria encompasses more than 250 ethnic groups and 400 languages, by some counts; the geographic and cultural distinctions mentioned in this paper are an unnuanced, general look at the tensions between the three most important and populous groups.
[iii] Another frightening step towards religious tension occurred in 2002-3, when Sharia law was officially extended to cover criminal as well as civil matters in twelve northern states.
[iv] In 2007, in an election considered to be extremely unfair, Umaru Musa Yar’Adua, a former governor of Katsina in the north and member of a Fulani royal family, was elected president, with Goodluck Jonathan, a southerner, as his vice presidential running mate. In 2009, Yar’Adua disappeared, apparently to seek medical treatment, and was never seen in public again. This danger power vacuum created by his disappearance could only ever be partially filled by a Christian southerner like Jonathan.