Humility and hubris
Why Nigeria has succeeded in eradicating polio, and why Pakistan has not
On the 25th of August, a day when the world saw more than 200,000 new Covid-19 cases and at least 4000 deaths, Africa celebrated a rare and hard-won victory in the fight against infectious disease – the eradication of wild polio. More than 30 years after the campaign began, the disease is not yet eradicated globally, as the wild form of the disease still exists in Afghanistan and Pakistan. It is also possible, although rare, for vaccine-derived strains of polio to cause disease in areas where vaccination rates are low, hence the reference to the eradication of wild polio. Nonetheless, Africa’s victory is worth celebrating, and there are lessons for all of us in how they achieved it.
I have talked previously about polio in my series of articles on childhood mortality and vaccination, but I’ll give a quick recap for those who haven’t read them. Until the development of a vaccine in the 1950s, polio was the most feared childhood disease of the 20th century. When, in 1988, the World Health Organisation set the goal of eradicating polio by the year 2000, the disease was eliminated or in decline in many countries, but there were still at least 350,000 cases per year. Although polio hadn’t been eradicated by 2000, by then there were fewer than 3500 cases a year, and eradication was thought to be on target for 2005.
But, within three years, the eradication programme went badly off track, with a resurgence in northern Nigeria resulting in cases spreading to fourteen countries, re-establishing the virus in six of them. The reason for the resurgence was that anti-vaccine sentiment, which had been simmering in Nigeria since the 1980s, was endorsed by political and religious leaders in three northern states. They openly instructed parents to refuse vaccination, linking it to a plot against Muslims from America and allied countries.
Northern Nigeria has much higher rates of poverty and less well-developed infrastructure than the south, so eradicating polio there was always going to be difficult. But with opposition to vaccines entrenched at such a high level, vaccinating enough children to eradicate polio was going to be nearly impossible. The tactics used against smallpox, which included forcible vaccination in some communities, were no longer acceptable and only likely to make the situation worse. Something quite different would have to be done.
The early steps taken by Nigeria and the World Health Organisation to restore confidence in the polio vaccine are documented in a paper by a Nigerian academic specialising in medical sociology and ethics, Professor Ayodele Jegede. It makes for a fascinating case study in managing anti-vaccine sentiment. On the one hand, the vaccine boycott and attempts to resolve the situation were uniquely Nigerian. At the core of the problem was the divide in the country between the Christian south and Muslim north and the core of the solution came from the involvement of another nation, with a large Muslim population, Indonesia.
On the other hand, the issues and solutions were a textbook example of anti-vaccination sentiment and how to manage it. People fear a vaccine because of misinformation, efforts to correct the misinformation don’t work and the eventual solution comes through building trust.
Nigeria’s religious and political leaders raised a number of concerns about the polio vaccine, but a key claim was that the vaccine was laced with anti-fertility drugs as part of a western campaign against Muslims following the attacks on the World Trade Centre. The Nigerian government set up an advisory committee to investigate the claims. The committee arranged to have the vaccine tested overseas, to determine whether it contained any drugs or other contaminants. When the results were returned, indicating there were no such drugs in the vaccine, the opponents didn’t accept the results, saying that there hadn’t been enough Muslim representation on the committee. The government set up another committee with more Muslims. The vaccine opponents then said that the Muslims on the committee were the wrong Muslims. As polio increased, the vaccine opponents argued that losing a few children to polio was the lesser evil compared with sterilising hundreds of thousands, if not millions, of girls.
Finally, after the debate had gone in circles for nearly a year, the government agreed to send representatives nominated by the concerned states to observe vaccine testing and production in three countries, including Indonesia. It was this action which finally convinced the governor of Kano state, one of the most vocal opponents, that polio vaccination was not a plot against Muslims by western evildoers.
While gaining the support of the Kano governor didn’t solve all the problems faced in eradicating polio, it was a crucial turning point. Soon after, Muslim clerics and traditional chiefs from across the Sahel region were brought together in Kano state to discuss child health in general, and polio in particular. These highly influential leaders became a crucial part of the campaign, encouraging people to get their children vaccinated instead of spreading misinformation, and nominating well-respected women in the community to become “volunteer community mobilisers”.
The female volunteers – 20,000 of them – were the people who actually delivered the vaccines. They went door to door, visiting mothers with young children and giving the oral polio vaccine along with health advice, such as the benefits of hand washing and breastfeeding. They faced more than just concerned parents – nine of them were murdered by Boko Haram while on their mission to vaccinate children. The volunteers are still operating, because vaccination needs to continue for some time when the oral form of the vaccine is used, to protect against the rare vaccine-derived form. But they’ve also become a part of the health infrastructure in rural areas of northern Nigeria, where there are around 22,000 people for every doctor (in New Zealand, there are 77 doctors for the same number of people).
As I read about the Nigerian campaign, particularly the efforts to convince the Kano state governor that the vaccine was safe, I feel a great deal of sympathy for the health officials involved. Since I am strongly in favour of vaccination, I can easily imagine the frustration they felt to have such misinformation and fear spread among parents. And it must have been a thoroughly distasteful concession to send these men, who had no qualification or experience with vaccines or medicine, halfway around the world on a junket to observe vaccines being manufactured and tested.
But it worked. In the end, sending the governor to Indonesia was what convinced him that the polio vaccine wasn’t going to sterilise or otherwise harm Kano’s children. The opponent of vaccination became a supporter, and the polio eradication programme continued, ultimately achieving its goal.
In his book on risk communication, Peter Sandman talks about one of the most difficult barriers to overcome in risk communication – the reluctance of experts and officials to give any ground to those who are concerned about a risk. After all, the experts and officials have been to university and spent their lives working on the risk under discussion – why should they share decision-making with someone promoting baseless conspiracy theories? While Sandman most often worked with chemical companies, the situation with people working on vaccination is, in my experience, often more polarised. Those involved with vaccination have a justified belief that what they are doing is of great benefit to humanity. As a result, it must be all the more difficult to respond with respect, compassion and humility to an opponent – someone who may very well be endangering the lives of children by their refusal to vaccinate.
That’s why I believe that we all need to take a moment to appreciate exactly what Nigeria has achieved. Both sides of the vaccine debate there seem to have cared more about the health of their children than their own egos. Nigerian health officials and the World Health Organisation did whatever was necessary to convince their opponents that the vaccine was safe. In response, the religious and traditional leaders changed their minds when they were presented with evidence by people they trusted. And it took less than a year from when the vaccine boycott began to when it ended. In comparison, Andrew Wakefield’s fraudulent paper linking vaccination and autism was published in 1998, refuted in 1999 (and many more times since), partly retracted in 2004 and fully in 2010, and exposed as part of an insurance fraud in 2011, yet the myth is still prevalent.
By 2010, the vaccination programme in Nigeria was back on track. The World Health Organisation was reporting that fewer than 10% of children had received no doses of the vaccine, compared with 20% the previous year. State governors had met in the capital, Abuja, to sign a commitment to polio eradication. Traditional leaders in the northern states had formed a polio eradication committee to keep a closer eye on the programme at a local level. Case numbers were falling dramatically.
India, which had more polio cases than any other country in 2009, turned its focus to migrants and other mobile populations, and was also seeing a drop in case numbers. The last wild polio case would be seen there in 2011.
The remote areas of Pakistan and Afghanistan, under tribal control and with significant ongoing conflict, were still a cause for concern, with a significant resurgence of the disease in 2007 and 2008. It was difficult to access the remote areas, and, as they had in Nigeria, certain clerics forbade vaccination. However, by 2010, Afghanistan was also seeing a drop in cases.
That left Pakistan, where, in the words of the normally dry annual report for the Global Polio Eradication Initiative, the virus was tightening its grip. Case numbers were rising, and things were about to get worse – much worse – for a reason almost nobody would have anticipated.
In mid-2010, the CIA believed that they had traced America’s most wanted man, Osama bin Laden, to a compound in Abbottabad, Pakistan. To confirm the identification, they developed a plan to obtain DNA from children living at the compound, which they could then test to determine whether the children were related to bin Laden. But few people had been inside the high-walled compound. Among the few visitors were local health workers, who had been allowed inside to vaccinate the children against polio.
As a ruse to gain access to the compound, the CIA set up an elaborate fake vaccination programme for hepatitis B. The programme was publicised with posters around the city and began in one of the poorer suburbs, where children were vaccinated with their first dose of the vaccine, although not, apparently, the subsequent doses required for the vaccine to be effective. The programme then moved to the suburb where bin Laden was suspected to be living, and a nurse entered the compound to vaccinate the children, and presumably obtain blood.
Within a year, the polio programme was suspended in parts of Pakistan near the border with Afghanistan – banned by the Taliban commander of the region, an act he said was in response to American drone strikes. A doctor and driver working for the World Health Organisation were attacked, and then, in December 2012, six polio vaccination workers were killed in a series of attacks in both Sindh and Khyber provinces, leading to a more widespread suspension of the programme.
Further attacks would follow – by the end of 2013, 25 more people had died in attacks on health workers involved in polio vaccination. By the end of 2014, the death toll was 65 and Pakistan recorded its highest number of polio cases in more than a decade. By mid-2016, nearly 80 people had been killed. By February of this year, the death toll exceeded 100.
Pakistan is a country where terrorist attacks are frequent, but the attacks on health workers involved in polio vaccination haven’t followed the general trend for terrorism and violence in the area. The number of terrorist attacks in Pakistan peaked in 2012, while the numbers killed have been steadily decreasing since 2009. However, the killing of health workers only began in 2012 and hasn’t shown a similar decrease.
There is other evidence pointing to the impact of the CIA’s ill-advised scheme. A review of polio case numbers in Pakistan from 2004-2016 showed that, prior to 2012, case numbers correlated with numbers of American drone strikes. However from 2012 onwards, polio cases increased even while drone strikes decreased. The author suggested that drone strikes made it more difficult for health workers to operate in an area, leading to lower vaccination rates, but that after 2011, vaccination rates dropped because of more widespread suspicion of vaccination as a result of the Americans’ fake programme.
While, of course, correlation does not imply causation, it’s hard to imagine that there is no connection between the increased polio cases, the attacks on health workers and the American actions. The beliefs which caused so much trouble in Nigeria – such as the polio vaccine being part of a Western plot to sterilise Muslims – also existed in Pakistan. The CIA validated those beliefs by, quite literally, proving that vaccination was part of a Western plot, at least on that one occasion.
The contrast between what happened in Pakistan and what happened in Nigeria is stark and ugly. In one country, humility and a willingness to work for the common good overcame huge obstacles. In the other, the short-sighted pursuit of self-interest compromised the health of a region’s children and the safety of thousands of health workers. In the years to come, the lessons of Nigeria and Pakistan must not be forgotten. Communities must be able to trust vaccines, or they will simply not accept them. Vaccination programmes, and those who promote and administer them, must be above reproach. For any individual, organisation or country to subvert such a programme for their own ends is indefensible.
For the next few months, I’ll be writing The Turnstone once a fortnight instead of once a week, while I do a course.
Do you know someone who might enjoy The Turnstone? Please forward it to them.
Did you receive The Turnstone from a friend? You can subscribe and receive it directly every week.
Do you want to see more of The Turnstone? All of the stories can be found in the archive, here.
Have you found a factual error or typo? Let me know and I’ll correct it in the archive version.