An unidentified health official administers a polio vaccine to a child in Kawo Kano, Nigeria. (AP Photo/Sunday Alamba)
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.
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