Current Drug Safety
, 2006,
1,
117-119
117
1574-8863/06 $50.00+.00
© 2006 Bentham Science Publishers Ltd.
How Vaccine Safety can Become Political – The Example of Polio in
Nigeria
Christopher J. Clements
*,1
, Paul Greenough
2
and Diana Shull
3
1
Centre for International Health, The Macfarlane Burnet Institute for Medical Research and Public Health Ltd.,
Melbourne, Australia
2
Departments of History and Community and Behavioral Health, University of Iowa, Iowa City, Iowa, USA
3
History Department, University of Colorado at Boulder, Boulder, Colorado 80309, USA
Abstract:
Vaccine safety is increasingly a major aspect of immunization programmes. Parents are becoming more aware
of safety issues relating to vaccines their babies might receive. As a consequence, public health initiatives have had to take
note of pressures brought to bear by individual parents and groups. Now we document a new phase in vaccine safety
where it has been used to achieve political objectives. In 1988, the World Health Assembly declared its intention to
eradicate poliomyelitis from the globe by the year 2000. This goal had to be postponed to 2005 for a number of reasons.
Although the progress has been spectacular in achieving eradication in almost all nations and areas, the goal has been
tantalizingly elusive.
But arguably the most difficult country from which to eradicate the virus has been Nigeria. Over the past two years,
tension has arisen in the north against immunizing against polio using the oral polio vaccine (OPV). Although this vaccine
has been used in every other country in the world including other Muslim states, some religious leaders in the north found
reason in August 2003 to advise their followers not to have their children vaccinated with OPV. Subsequent to this
boycott, which the Kano governor had endorsed for a year and then ended in July 2004, cases of polio occurred in African
nations previously free of the virus, and the DNA finger-print of the virus indicated it had come from Nigeria. In other
words, Nigeria became a net exporter of polio virus to its African neighbours and beyond. Now the disease has spread to a
dozen formerly polio-free countries, including Sudan and Indonesia. We show that, while the outward manifestations of
the northern Nigerian intransigence were that of distrust of vaccine, the underlying problem was actually part of a
longstanding dispute about political and religious power
vis a vis
Abuja. It is unlikely that polio transmission will be
interrupted by 2005 if this dispute is allowed to run its course.
INTRODUCTION
In 1988, the World Health Assembly declared its
intention to eradicate poliomyelitis from the globe by the
year 2000 [1]. This goal was postponed to 2005 for a number
of reasons. Although the progress has been spectacular in
achieving eradication in almost all nations and areas, the
goal has been tantalizingly elusive. The number of countries
where polio is endemic declined from 125 in 1988 to six by
the end of 2003. Further progress in 2004 toward
interruption of transmission has continued in the three Asian
countries where polio is endemic (Afghanistan, India, and
Pakistan). However, in 2003, two countries in Africa
experienced a resurgence of polio cases; the resurgence
continued to spread in 2004 from the Nigeria-Niger endemic
reservoir to involve a total of 14 countries that had not
reported polio for over a year. Local transmission of wild
poliovirus has been reestablished in six of these 14 countries,
including Sudan, where a major outbreak occurred [2].
Arguably the most difficult country from which to
eradicate the virus has been Nigeria. Being not only a
*Address correspondence to this author at the Centre for International
Health, The Macfarlane Burnet Institute for Medical Research and Public
Health Ltd., GPO Box 2284, Commercial Road Melbourne, VIC 3004,
Australia; Tel: +613.9282.2199; Fax: +613.9282.2144; E-mail:
john@clem.com.au
densely populated country, it has a number of other factors
that have made success especially hard. The country is
divided into 36 states and one territory that have
considerable autonomy, but are controlled in certain aspects
of administration from President Olusgun Obasanjo’s central
government in Abuja. There is a north/south divide that can
be seen geographically as desert/savanna to the north and a
lush tropical climate in the south. It also divides the country
into predominantly Muslim in the north and predominantly
Christian in the south. Over the past two years, tension has
arisen in the north against immunizing against polio using
the oral polio vaccine (OPV). Although this vaccine has been
used in every other country in the world including other
Muslim states, some religious leaders in the north found
reason in August 2003 to advise their followers not to have
their children vaccinated with OPV.
Subsequent to this boycott, which the Kano governor had
endorsed for a year and then ended in July 2004, cases of
polio occurred in a dozen formerly polio-free neighbours of
Nigeria. Ethiopia had been polio-free for a year when cases
reoccurred. Genetic tests showed that the virus was the same
one that originated in northern Nigeria. Now Sudan, Ethiopia
and Yemen are all experiencing outbreaks that can be traced
back to Nigeria. Dr. David L. Heymann, director of polio
eradication for the WHO, says Ethiopia is now trying to raise
$15 million to stop the spread of the disease throughout the
country, which is one of the most populous African nations
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, 2006,
Vol. 1, No. 1
Clements et al.
[3]. Nigeria had become a net exporter of polio virus to its
African neighbours.
NOT UNIQUE
The rejection of vaccines has, of course, not been limited
to Northern Nigeria. Rumours from a number of countries in
Africa relating to presumed adverse events from various
vaccines have been well documented by UNICEF [4]. A fall
in vaccine acceptance has generally followed such rumours.
Nor is such rejection limited to Islamic societies. For
instance the vaccine preservative thiomersal that contains
small amounts of mercury has generated widespread hostility
against certain vaccines in many Western countries [5].
ESCAPE FROM AFRICA
A case of polio was detected in April 2005 in Indonesia,
indicating that the outbreak had spread from northern
Nigeria and had crossed the Indian Ocean. The World Health
Organization reported that Indonesia's last case was in 1995,
and was the 16th country to be re-infected by a strain of the
virus that broke out in northern Nigeria [6].
NOW MEASLES
According to IRIN
a
, the Nigerian Red Cross and the
World Health Organization, Nigeria reported over 20,000
measles cases and nearly 600 deaths from the disease from
the start of the year until March 2005. More than 90 percent
of the measles cases reported by this time had occurred in
Nigeria’s northern states, as had the overwhelming majority
of deaths. People in the northern region were reported to be
wary of vaccinations for religious reasons [7,8].
INFLUENZA IN THE COLONY
Without the hindsight of history, the world might think
the behaviour of the northern Muslim clerics as extreme and
time-bound. This may not be the truth. For instance, in 1918
the world was freeing itself from the clutches of the Great
War. But it was caught up in the death throes of a great
influenza pandemic called “Spanish Flu”. Millions of people
throughout the world succumbed to this scourge, including
many in Nigeria. Influenza spread throughout the northern
part of the country by December of 1918 through the
colonial trade and communication networks of roads,
railways, and rivers. The Muslim population generally
ignored what British colonial medical assistance there was
during the epidemic. In the north, they attempted different
treatments from either Europeans or other local groups.
While Europeans inhaled eucalyptus vapors, Muslims drank
water that contained slips of paper inscribed with prayers
and extracts from the Koran. The Muslim population of the
Northern states also did not go to the colonial hospitals in as
large numbers as other ethnic groups. The Muslim villagers
mainly kept to their houses and did not interact with British
medical officers as they passed through their districts. The
population’s tendency to ignore British advice on the
epidemic surfaced throughout the reports of British medical
officials both in the Northern and Southern provinces [9].
In reporting on the epidemic, the British sanitary officers
noted the increasing levels of tension and unrest they
a
IRIN - Integrated Regional Information Networks, part of the UN Office
for the Coordination of Humanitarian Affairs.
experienced throughout Nigeria, including the Northern
provinces. In addition to the economic unrest created by the
flu, the British also indicated marked anti-colonial and anti-
British sentiment throughout the country. Throughout
Nigeria there were attempts to rid themselves of the British
whom they explicitly blamed for the epidemic and the
resulting crises. One report described attempts to drive the
white man into the sea. There was also a plan to prepare
medicines that would make the land “too hot” for white men
[10,11]. The influenza epidemic in Nigeria constituted more
than a medical crisis. It highlighted the tensions already
present between Nigerians and the British colonial regime as
well as creating new points of conflict between Nigerians
and the British. The Muslims’ responses to the epidemic
emphasized their lack of faith in the supposedly superior
British medical knowledge.
Non-Muslim Nigerians also resisted British medical
authorities and Western-style treatments. The British
officials’ main strategy in combating the epidemic in Lagos
was to institute house to house inspections by doctors. If the
inspectors found an infected person in a house, they would
remove him or her to the infectious disease hospital or they
would quarantine and extract a promise from those living in
the house that no one would be allowed to go in or out until
the sickness passed. British officials soon gave up enforced
hospitalization because “prominent and influential natives
and native practitioners were unanimous in stating that the
fear of being sent to hospital was very great, the idea being
that any who went there were sure to die” [12].
COMPULSORY VACCINATION?
Sporadic local resistance based on moral or religious
objections has dogged public health efforts in other key
20th-century immunization campaigns. For example in the
final phase of smallpox eradication in eastern India and
Bangladesh in 1973-74, vaccination teams were sometimes
opposed by tribal patriarchs and peasant figures who
considered vaccination equivalent to impiety. Instead of
negotiating such concerns on a case by case basis, WHO
epidemiologists adopted the view that "to make an omelet,
eggs must be broken," and "containment" teams in both
countries swept the objectors aside [13]. Police force and
military methods were used when necessary, and it was
standard practice to post guards on houses and establish tight
perimeters in villages where smallpox cases were detected;
everyone inside the village was vaccinated, even though
some may have been immunized previously [14]. While
smallpox eradication has been rightly hailed as a great public
health achievement and a blessing on future generations, it
was achieved in parts of South Asia at the price of ignoring
rights that would have been respected in the North, where
conscientious objection guaranteed exemption from
immunization for the last century [15,16].
The Islamic world is not oblivious to the strategic use of
compulsory vaccination. Saudi Arabia states, for instance,
that for intending travelers to the Haj in Mecca “Vaccination
against meningococcal meningitis is compulsory” [17].
Leadership from such a highly respected country within the
Islamic world may offer a way out of the current dilemma
relating to polio vaccine.
How Vaccine Safety can Become Political
Current Drug Safety
, 2006,
Vol. 1, No. 1
119
WHAT TO DO?
By July 2004, following pressure from the World Health
Organization and other African countries, and after receiving
assurances about vaccine safety from laboratories in Muslim
nations, the governor of Kano State agreed to resume polio
mass campaigns [18]. If this promise does not result in
effective action and the world is serious about the task of
completing polio eradication, there is only a limited number
of options available to the international health community.
First the world can look on and encourage the central
government in Nigeria to solve its own internal politics. This
is not going to happen quickly if history is any guide. While
the outward manifestations of the northern intransigence are
that of distrust of vaccine, the underlying problem is a
longstanding dispute about political and religious power
vis
a vis
Abuja. It is unlikely that polio transmission will be
interrupted any time soon if this dispute is allowed to run its
course. In the mean time, Nigeria may continue to export
polio and measles viruses and precipitate neighbouring
countries such as Kenya [19] and Sudan [20] to embark on
aggressive polio mass campaigns to contain the spillover
[21].
The second option would be to request the central
Nigerian government to impose compulsory vaccination.
The initial world reaction to such a suggestion would likely
be one of dismay. However, this was the way the only other
successful eradication campaign - smallpox - was conducted
in certain high-transmission countries. What will the world
do about polio and measles in Nigeria if the north does not
comply? Will it permit the democratic process to be played
out, if that means that the north will be allowed to continue
limited compliance? Or will it decide there is a greater good
to be chosen by insisting on compulsory vaccination? What
has to be weighed is the possible violation of in-country
human rights and the sovereignty of Nigeria against the well-
being of millions of children for generations to come. Not to
mention the three billion dollars already invested by
countries and donors in getting this far. Northern Nigeria
could push the world towards an historic, but uncomfortable
choice.
CONFLICT OF INTEREST STATEMENT
All authors declare that there are no conflicts of interest
to declare. In the spirit of full frankness, Dr. C.J. Clements
declares that he was employed by the World Health
Organization from 1985 to 2002 but believes this does not
constitute any conflict of interest.
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Received: May 1, 2005
Revised: July 5, 2005
Accepted: July 14, 2005