Regular readers will know that one of my interests is junk science in other times and places, largely because I think we can learn a lot from other cultures when it comes to dealing with quacks. Well, in the wake of continuing debate over vaccination, here's an interesting case of anti-vax mentality from Nigeria, as described in the PLoS Medicine paper "What Led to the Nigerian Boycott of the Polio Vaccination Campaign?", by Ayodele Samuel Jegede [1].

Polio has been a problem in Africa for many years, and in 1988 the W.H.O. launched a campaign to mass-vaccinate African children. This ramped up in 1996 with the campaign to "Kick Polio out of Africa", launched by Nelson Mandela, and supported by the African Football Confederation. This initiative combined vaccinations with health-worker training and door-to-door awareness campaigns. It was ambitious, aiming to vaccinate 50,000,000 children in 1996 alone. Jegede tells us that "in mid-October 2003, the GPEI launched what was hoped to be the final onslaught against polio, with a plan to immunize more than 15 million children in west and central Africa. The GPEI had particular concerns about the high prevalence of polio in Nigeria, which accounted for 45% of polio cases worldwide and 80% of cases reported from the African region in 2003 [2]."

But Polio survives in Nigeria to this day, because the officials of three Nigerian states refused point-blank to allow the vaccine to be administered. The map below shows the 5 Nigerian states that accounted for more than half of all the world's Polio cases in 2006. Of these, Kano and Kaduna blocked the vaccine, along with Zamfara (not shown). Why?

Jegede points to a variety of causes. Vaccination campaigns need to reach virtually 100% of a population to prevent pockets of resistance from emerging, and so they rely on public trust, since they require healthy people to allow themselves to be treated with preventative medicine. If trust is eroded, rumours begin to spread, creating a cancerous meme that disrupts all efforts to continue. Under this conditions, a mass-vaccination strategy becomes impossible.

"[The leaders of the three rogue states] argued that the vaccine could be contaminated with anti-fertility agents (estradiol hormone), HIV, and cancerous agents. Datti Ahmed, a Kano-based physician who heads a prominent Muslim group, the Supreme Council for Sharia in Nigeria (SCSN), is quoted as saying that polio vaccines were 'corrupted and tainted by evildoers from America and their Western allies.' Ahmed went on to say: 'We believe that modern-day Hitlers have deliberately adulterated the oral polio vaccines with anti-fertility drugs and?viruses which are known to cause HIV and AIDS'."

This story is depressingly familiar for the U.N. and W.H.O. The resurgence of certain diseases is an unintended consequence of America's War on Terror, as Muslim populations have grown to distrust anything produced by the west. A similar situation occurred in Pakistan last year. As The Guardian reported, "The parents of 24,000 children in northern Pakistan refused to allow health workers to administer polio vaccinations last month, mostly due to rumours that the harmless vaccine was an American plot to sterilise innocent Muslim children".

The key agents behind this were extremist Muslim clerics, apparently more interested in making their points than in protecting their society's children. Indeed, we hear that "Ali Guda Takai, a WHO doctor investigating polio cases in Kano, told the Baltimore Sun, 'What is happening in the Middle East has aggravated the situation. If America is fighting people in the Middle East, the conclusion is that they are fighting Muslims' [3]."

It would be simplistic to blame this entirely on the War on Terror though. Nigeria has a huge population, over 140,000,000 by Christmas 2006, an increase of some 63% since 1991. During the 1980s, this growth led to government interventions to control the population, most notoriously President Babangida's policy of allowing only four children per woman. This has directly contributed to a mistrust of government health plans.

Jegede relates that: "Some people connected this population control campaign with immunization, believing that vaccination was one way the government might be reducing the population [5]. This belief was not restricted to northern Nigeria—similar opinions were also expressed in some communities in southern Nigeria. For example, in an anthropological study carried out in Nigeria [6], an adult male participant stated that 'people do carry rumour that immunization is a secret way of controlling population.' A young female participant said 'some people say that immunization is part of the methods used to check the number of children a woman can bear.'" Incidentally, there's a fascinating link here between Nigerian fears, and the paranoia exhibited by our own Western anti-vaccination groups that may be worthy of further study.

A third major reason is one that probably wouldn't occur to many of us. "In his report for the Baltimore Sun, John Murphy wrote: 'The aggressive door-to-door mass immunizations that have slashed polio infections around the world also raise suspicions. From a Nigerian's perspective, to be offered free medicine is about as unusual as a stranger's going door to door in America and handing over $100 bills. It does not make any sense in a country where people struggle to obtain the most basic medicines and treatment at local clinics'". Would you trust a stranger knocking on your door offering you free medicine?

As a result, total eradication failed, and Polio remained endemic in northern Nigeria. In 2006, the region accounted for more than 80% of global Polio cases. Nigeria has also become an exporter of Polio to other nations as far afield as Yemen, Saudi Arabia, and Indonesia - a reminder of just how closely related the health of Africans is to our own health [7].

How can we prevent these boycotts in future? There are no clear answers. "One lesson from the Kano boycott is that research is needed to investigate why people have concerns and fears about vaccination, and what steps should be taken to avoid boycotts in the future." In particular, public awareness needs to improve, and international organizations need to realize that dealing with local authorities and religious organizations may be at least as important as dealing with national governments.

Western anti-vaccination extremists live in something of a fantasy world, insisting that vaccination strategies are ineffective, and harmful. Largely, this view is driven by their own ignorance, living a Western lifestyle where disease is less of a threat. In countries like Nigeria and Pakistan, the consequences of failing to vaccination children are fatal, and until every child is vaccinated, Polio will continue to thrive in pockets, leaving an ever-present risk that it will surge forth once again. On the other hand, if we can educate the population, and get the last few thousand children vaccinated, mankind will have eradicated the second disease in its history. What a wonderful legacy to leave the next generation.

[1] Jegede , A.S. (2007). What Led to the Nigerian Boycott of the Polio Vaccination Campaign?. PLoS Medicine, 4(3), 417-422.

[2] Renne E (2006) Perspectives on polio and immunization in northern Nigeria. Soc Sci Med E-pub 8 June 2006.

[3] Murphy J (2004 January 4) Distrust of US foils effort to stop crippling disease. Baltimore Sun.

[4] Nigeria's Population Tops 140m (BBC).

[5] Odumosu O, Robert FN, Jegede AS, (1996) Regional differential and implementation of the national policy on population: Pilot study of Borno and Oyo states of Nigeria. In Phillips AO, Ajakaiye DO, editors Population–environment interactions in Nigeria: NISER studies in sustainable development in Nigeria Ibadan (Nigeria): Nigerian Institute of Social and Economic Research. pp. 7–42.

[6] Jegede AS (2005) The cultural and political dynamics of technology delivery: The case of infant immunisation in south western Nigeria. West African Social Science and Immunisation Network. Available: http://www.ids.ac.uk/IDS/KNOTS/PDFs/VaccJegedeNigeria.pdf#search=%22Regi.....

[7] World Health Organization, Regional Committee for Africa (2006) Polio eradication in the African region: Progress report. Available: http://www.afro.who.int/rc56/documents/afr_rc56_inf_doc_1_polio_erudicat....