Tuesday, November 25, 2014
Can a Costly Campaign to Eradicate Polio From Nigeria Possibly Succeed?
When Rudyard Kipling visited Chicago in 1889, the black canals and soot-filled air made him wonder if he hadn’t wandered into hell on earth. The crowded slums reminded him of Calcutta; the anarchists and religious fanatics, mobsters and businessman, shouting and spitting everywhere, struck him as so many savages.
A few years after Kipling made these scathing reflections, he nevertheless exhorted Americans to assume “the white man’s burden” in a famous poem of that name, and join the imperial mission to civilize the non-Western world. It’s not known whether 28-year-old lawyer Paul Harris was inspired by the poem, but shortly after it appeared, he set out to civilize the people of Chicago.
Harris came from Vermont, where people helped each other out in a jam and friendship and business went hand in hand. He desperately wanted to introduce some small-town civility into the brutal world he encountered in Chicago. So in 1902, Harris founded the first of what would become a global network of Rotary clubs that have been providing fellowship and respite from the harsher side of modern capitalism to millions of business people and professionals ever since. They donated land for community gardens, sent shoes to European refugees and operated a Fresh Air camp for crippled children.
Then, in the 1980s, Rotary set out on its most ambitious philanthropic mission of all: eradicating polio from the face of the earth. During the 1960s and 1970s, the World Health Organization had led a campaign that permanently stamped out smallpox. Like smallpox, polio is preventable with a cheap vaccine, and the disease had been all but unknown in rich countries since the 1960s. That it still crippled thousands of children each year in the developing world seemed to Rotarians a terrible injustice.
They started with a fundraiser that attracted cataracts of donations from ordinary people; at its height, $1 million a day was pouring in from raffles, wine-tastings, golf-tournaments, chicken-plucking contests and other, mainly neighborly, activities. Most of the money went to the WHO and UNICEF, which set out to immunize every child in every country where the virus was still spreading. In India, where polio crippled or killed thousands of people each year, two million volunteers, including 350,000 Rotarians, set up immunization booths in marketplaces and went door to door in slums and villages, some accessible only by camel or elephant. By 2002, the number of polio cases worldwide had fallen from 350,000 to less than a thousand, all confined to just seven countries. Some 5 million people had been spared paralysis or death.
A thousand cases of any disease may not seem like a big problem, but Rotary was aiming to eradicate polio; otherwise, the disease, which spreads through contaminated food and water, could quickly bounce back. But the last 1,000 cases of polio have turned out to be much more stubborn than the hundreds of thousands that came before, and it’s certainly costing more money to get rid of them. The polio eradication campaign spent slightly more than $2 billion between 1988 and 2002; then Microsoft billionaire philanthropist Bill Gates joined the fight, and today, his foundation, along with the American and British governments and other donors, are pouring roughly $1 billion a year into it.
The last cases are concentrated in countries like Afghanistan, Nigeria and Pakistan, all beset with violent conflicts. Polio cases in these countries have declined steeply as a result of the campaign and program officials are cautiously optimistic that they’ll meet the goal of global eradication by 2018. But even if they do, questions will likely linger about the wisdom of their approach. As I was to discover in Nigeria, the polio campaign has exacerbated political tensions, endangered the lives of health workers and contributed to the perceived neglect of other public health issues. There are signs that the Gates Foundation and its allies appreciate these concerns, and are now working to address other diseases such as malaria and measles. But in the future, public health experts should reflect on whether fighting one disease at a time is always a good idea. Diseases like polio are not rogue criminals to be tracked down and killed at all costs; they are rooted in the same injustices that cause conflict in the first place.
In Nigeria, the trouble started in 2003, in the ancient slave trading city of Zaria. The polio vaccine used in the campaigns is a liquid administered by mouth from pre-packaged plastic dropper vials. Shortly after the United States invaded Afghanistan and then Iraq, Nigeria’s Supreme Council of Sharia announced that scientists at Zaria’s Ahmadu Bello University had tested the liquid and found that it contained contraceptives; the polio campaign was part of a secret plan to reduce Muslim populations so that the infidel West could take over the world, they said, and ordered parents to refuse to allow their children to be vaccinated.
The polio campaign was then uncontroversial in other Muslim countries and so the World Health Organization called on the Arab League, the Organization of Islamic Countries and the African Union to persuade the Nigerian clerics that the vaccine was safe. The campaign resumed a year later, but by then Nigerian polio strains had spread to twenty countries around the world, as far away as Indonesia.
Today, the campaign is running, but it’s not for the fainthearted. When I visited northern Nigeria earlier this year, polio vaccinators, most of them women who visit hundreds of households each month, told me they have been stoned, cursed, doused with hot oil and had guns pulled on them. In some areas, they hide their UNICEF thermos bags under their hijabs. In early 2013, assassins shot dead nine vaccinators in the city of Kano. The western aid workers who manage the project from Atlanta, Seattle and Abuja, the faraway Nigerian capital, dart into these areas for a day or two at a time in bullet-proof vehicles driven by guards armed with Uzis.
Everyone, from the campaign managers to the vaccinators, risks his or her life daily, and their heroism is astonishing. I interviewed one young man who had previously worked on polio eradication in Pakistan, where dozens of polio workers have been killed by Taliban fighters angered about drone strikes and the CIA’s use of a door-to-door vaccinator to help track down Osama bin Laden. One morning, as he was walking on the street in Karachi, a boy of about 12 approached him and asked if he was American. “No,” said the polio worker, who asked that his name not be printed. “I’m African,” and he pointed to his T-shirt, which had a map of Africa on it. Later that day, gunmen on motorcycles opened fire on his vehicle and a bullet flew through the side door and lodged in his hip. After months of rehabilitation, he can walk again and is now working to eradicate polio in Nigeria. “I am so committed to polio eradication,” he told me when I asked him why he took such risks. “I want to see the last case in the world. Nothing will stop me.”
Why are so many Nigerians hostile to the polio campaign? Just as in Pakistan, the campaign in Nigeria has become a symbolic front in a battle between the nation’s leaders, widely seen as corrupted by the West and failing their own people, and the radical extremist reaction against those leaders. Ordinary Nigerians told me that what angered them most about the polio campaign was that the government wasn’t doing anything else for them. Nigeria has the largest economy in Africa, and yet its people are among the poorest in the world. Although roughly $52 billion from oil sales is earmarked annually for poverty reduction, more than 70 percent of the population lives on less than a dollar a day. Meanwhile, elite politically connected Nigerians rake in millions in a parallel universe of shell companies, bribery, ghost pension schemes, fake subsidies and other charades.
The poverty alleviation money is supposed to go to Nigeria’s state governors and local government councilors, who are like mayors. They are supposed to use it to run basic services such as schools and medical clinics and maintain supplies of electricity and clean water. And yet half of the children in Northern Nigeria are malnourished; fewer than 25 percent have received all their vaccinations for diseases such as measles and tetanus; and fewer than 15 percent of adults in some states can read. A health clinic I visited one day was doubling as a dress shop. When I asked the nurses about various medicines, half were out of stock, and the nurse in charge was on her way to a pharmacy because she thought she had malaria.
Because of the intricate and dangerous nature of Nigerian corruption, trying to find the missing money is a fool’s errand. In 2011, British development officials reported that the majority of clinics in one state kept no budgetary records at all, and most of those that did spent far less than state officials claimed they were.
Meanwhile, polio has been getting all the attention. Ten times each year, polio vaccinators visit millions of households in northern Nigeria offering polio drops to everyone under 5 years of age. The cost of this program, almost entirely paid for by Western donors like the World Bank, the Bill and Melinda Gates Foundation and the American and British governments, is equivalent to roughly one-sixth of Nigeria’s entire (official) health budget.
While trying to figure out why so many people are angry about the polio campaign, I came across the writings of Murray Last, a brilliant anthropologist who has been studying northern Nigeria for over fifty years. He explains how the disproportionate emphasis on polio has fed into suspicions about Western medicine traceable to precolonial times.
In the nineteenth century, northern Nigeria was under the control of a small number of vast caliphates headed by powerful sultans. Life was organized locally by the sultans’ emirs, who lived in big houses, had elaborate spy networks and knew what everyone was doing. If there was a dispute, the emir would arbitrate; if people were hungry, the emir would put food out for them. There were no public entities in this feudal world: no courts, no police, no hospitals, not even public water fountains. After the British took over in 1903, they tried to set up bureaucracies to carry out sanitary inspections, adjudicate disputes and collect taxes, but these came to be seen, according to Last, as “synonymous with extortion.”
Modern medicine was seen as part of this conspiracy to undermine the caliphates. During sleeping sickness epidemics in the 1950s, health inspectors rounded up people with swollen glands and took them away for compulsory treatment. When beautiful girls were caught in the dragnet of this highly coercive program, many locals saw it as a form of kidnapping, and bribed the inspectors to go away.
The few hospitals were run by evangelical Christians. The colonial administration, worried about antagonizing the emirs and imams, tried to discourage them from building their hospitals in the heavily Muslim north, but medical care was desperately needed and the evangelicals defied the authorities and set up hospitals anyway. As expected, the hospitals came to be seen locally as part of a wider conspiracy to undermine the caliphates. Preachers read Bible verses to people waiting to see the white doctors who were rumored to steal body parts for witchcraft, cast spells with their X-rays and suck blood with stethoscopes. Some people, Last says, suspected whites might not be entirely human: they were always washing; the dye on their clothes didn’t run; you never saw their feet, which were always hidden in shoes; they didn’t like walking; they built big lakes and dams and sometimes dove under the water. People whispered about what they were doing under there. Perhaps they were some kind of fish.
It didn’t help that the British arrival in the early twentieth century coincided with famine and epidemics of meningitis and Spanish Flu. People believed whites were yet another scourge sent by Allah to punish blacks for being insufficiently devout. As a result, Last writes, there were a series of Muslim revivals around this time, as people sought spiritual protection from the terrifying power of these besieging outsiders.
Suspicion about what whites are up to remains prevalent, even now, along with a craving for order through intensive religious purification. Since the 1970s, and especially since the end of military rule in 1999, numerous charismatic Islamist movements have emerged to try to cleanse Nigeria of what many northerners see as the corrupt, unruly ways of the more Westernized tribes of the south, who now dominate the nation’s politics. Some of these movements have called for Sharia law; others want Nigeria to become an Islamic state like Saudi Arabia; and others, like Boko Haram, seek to revive the ancient caliphates that colonialism broke apart and replaced with what they see as a corrupt system overseen by Western-backed figureheads. What all these groups share is a yearning for bygone order and a suspicion of Wwestern-style modernity. Over the years, one group or another has declared that not only polio vaccines but also watches, radios, books other than the Koran, cars and even dried bouillon cubes are haram—forbidden.
Bill Gates, the Microsoft founder and megaphilanthropist, waded into this maelstrom in 2009. By then, he’d already spent $657 million on polio eradication, but he’d never visited the operation in Nigeria before. According to a 2013 Rolling Stone article by journalist Jeff Goodell, Gates cares more about polio eradication than anything else because it provides a crucial test of his philosophy of philanthropy as problem solving. For Gates, writes Goodell, “The world is a giant operating system that just needs to be debugged”; he thinks there’s an app for everything, from ending global poverty, to improving education, to fighting disease and climate change. He has no patience with anyone who says any problem is too complicated.
Gates brought technical rigor to Rotary’s polio campaign, with new vaccines, disease modeling programs, satellite maps and GPS tracking methods to find unvaccinated children. But after the Nigerian clerics revolted against the campaign in 2003, he came to understand that the problems weren’t just technical; they were also political. So, in 2009, he visited Nigeria and met with Predident Yar’Adua and the governors of all of Nigeria’s thirty-six states. Eventually, they unveiled a new plan to encourage clerics and other celebrities to say positive things about polio vaccination in their sermons and on the radio and to sponsor public events to promote polio. Some were paid to do this. In 2011, Gates launched a competition: state governors who best performed a set of promotional polio campaign activities would be awarded $500,000, which they could use to support other healthcare projects.
But the program was no match for Nigeria’s legendary corruption. When I was there, I heard a new story every day: shortly before I arrived, some of the vaccinators were caught throwing out their vaccines, and then reporting preposterously high success rates to their bosses; then local government officials were caught reselling toys and biscuits intended as gifts for vaccinated children; then I heard that officials from one of the international agencies were going around with sacks of cash, for who knows what purpose. Finally, just as I was leaving, a group of young men took over a clinic where polio vaccines were being stored and refused to release them. They said they were angry that a local politician who promised electricity for their neighborhood still hadn’t delivered three years later. When the police turned up, hundreds of women and children formed a barricade, chanting, “If you want the vaccine, you’ll have to kill us first!”
To date no one has been able to identify who killed the nine polio workers in Kano in 2013. Boko Haram, which usually celebrates its atrocities, didn’t lay claim to this one. The shootings occurred at two separate clinics, at around the same time. Security guards had been hired to protect the vaccinators but, according to local sources, both groups of guards left to get a drink at the same time, just before the killers arrived. There are speculations that some people want to sabotage the program so that the epidemic, and the millions of dollars it brings in, will continue.
That might sound far-fetched, but rumors of sabotage for financial or political gain aren’t unheard of in Nigeria. This past summer, analysts began asking why Boko Haram assailants so often turn up in Nigerian military uniforms, carry weapons stolen from Nigerian military armories and frequently attack military installations where the gates have been mysteriously left open. It’s known that soldiers are furious about army corruption and low pay, and some may be hoping that by making the north of the country ungovernable, they can undermine the prospects of President Goodluck Jonathan—a southerner—in the 2015 elections. It’s conceivable that some may be thinking along similar lines about the polio campaign.
Each four-day polio vaccination campaign begins with a “flag-off” ceremony at which the governor or some other dignitary immunizes the first child and gives her a toy. At a flag-off I attended, thousands of people gathered in a giant field, and some even climbed trees to watch. Then the governor and his entourage arrived. A group of musicians launched into a song, the words of which, I was told were, “May the governor rule for another year and another year and another year!” Dancers dressed in costumes printed with pictures of the governor did handsprings all around them, while party officials showered them with Nigerian banknotes. Then an official promised that the ruling party would bring roads and primary schools and water to the people, if re-elected in 2015. A small group of protestors who managed to get near the podium began shouting, “We’ll do better than them!” They were quickly silenced by security men. There was almost no mention of polio at all.
The highlight of my trip was going around with the “mop up” team when local leaders and health officials demonstrate their commitment to fighting polio by revisiting the houses of vaccine refusers. If parents still refuse, their house is surrounded by dozens of crippled polio survivors in bright yellow Rotary vests, who may remain there for hours, until the parents give in. “Look what happened to us!” they say. “Do you want this to happen to your children?”
Polio is a terrible disease, but the answer to this question isn’t quite as simple as you’d think. I interviewed some of the polio victims expecting sad tales of abandonment and discrimination. Instead, I found a group of Nigerians with remarkable integrity, managerial competence and a charismatic leader named Abdul whom they call their king. Abdul contracted polio as a baby and walks on all fours with flip-flops on his hands, but still manages to support three wives and seventeen children, all of whom (except the toddlers) are enrolled in school, unlike most of northern Nigeria’s children.
Islam doesn’t stigmatize disabled people or begging, which is how many polio survivors earn their living. Abdul’s friend Hamid, also severely crippled by polio as a baby, recently ran for mayor. He didn’t win, but after the election, he led a demonstration of blind, crippled and other “peculiar people”—as he calls them—against a corrupt local official and got her fired.
Polio cases are falling steeply in Nigeria, though the disease’s course is hard to predict. In 2010, the year after Gates’s first visit to the country, polio cases fell by 95 percent, to twenty-one cases. But they rose again in 2011 by nearly 200 percent, to sixty-two cases. This year, there have been only six cases so far, although officials are worried that the virus could bounce back in areas made all but inaccessible to vaccinators by the Boko Haram insurgency. In May, the World Health Organization declared polio a worldwide emergency because the virus had spread from Nigeria to Cameroon, Equatorial Guinea and Somalia, and from Pakistan to Afghanistan, and Syria to Iraq. Case numbers are still very low, but the news is worrying.
Some public health experts, including Donald Henderson who led the World Health Organization’s successful smallpox campaign in the 1970s, wonder whether it’s time for the polio campaign to switch course. Perhaps Nigeria should fight polio the way most countries do: by strengthening local health services so that all children receive not only polio vaccines but also vaccines for measles and other diseases and treatment when they become ill. One such program, known as the PRRINN-MNCH (Partnership for Reviving Routine Immunization in Northern Nigeria; Maternal Newborn and Child Health Initiative), was launched in 2006 with help from Columbia University scientists and achieved considerable success in some northern states. But earlier this year the British government redirected its grant to a less comprehensive program more narrowly aimed at immunization.
Somehow, the Nigerians may have to figure things out on their own, just as the people of Chicago were forced to do in the decades after Kipling and Rotary founder Paul Harris witnessed anarchists and religious zealots—the Boko Harams of the day—battling political graft-masters on the streets of their city. If the west is to be involved, we need to find a better way, because even if the polio campaign succeeds, many serious problems—health-related and otherwise—will remain. Nigeria is filled with savvy, honest and hardworking people who understand the needs and concerns of their communities, but the architects of the polio campaign—for all their billions and technical know-how—seldom encounter them, because few are in positions of power. A more promising approach would be to seek out those people and listen to what they have to say.