Professionalism/Resistance to Polio Vaccination in Northern Nigeria

Polio in the United States
Poliomyelitis, commonly known as polio, is a childhood disease caused by a highly infectious virus that attacks the nervous system. Approximately 1% of infected persons will suffer paralysis and 10% of paralytic cases end with fatal paralysis of the respiratory muscles. In 1921, Franklin D. Roosevelt contracted the disease. He used his political influence to start and raise money for the National Foundation for Infantile Paralysis. This organization would go on to fund research by Dr. Jonas Salk and Dr. Albert Sabin.

Dr. Salk and Dr. Sabin developed polio vaccines in 1952 and 1957, respectively. These vaccines, coupled with public health policies, were able to eradicate the disease from the United States by 1979. Polio is one of few diseases that can be eradicated because infection or the vaccine confers lifelong immunity and there is no environmental or animal host for the virus. Once everyone has the vaccine, the disease cannot exist.

Global Eradication Initiative
The Western development of a vaccine and the eradication of Polio from the United States prompted the World Health Assembly to pursue a global eradication. In the 41st assembly in 1988, members of the World Health Organization (WHO) voted to pass the Global Eradication Initiative. It stated, “Recognizing that the global eradication of poliomyelitis by the year 2000… represents both a fitting challenge to be undertaken… and an appropriate gift… from the twentieth to the twenty-first century.”

The WHO treated this act as both a “challenge” and as a “gift.”. This decision was made and funded largely by the Western world. The United States contributed over $1 billion. The United Kingdom donated over $500 million. Japan, Canada, Germany all gave over $250 million. Other top donors were Norway, Denmark, France, Russia, Italy, Sweden, Australia, Spain, and Ireland.

Initial Success
With millions in funding, oral polio vaccines were distributed throughout the world. By 1991 polio was eradicated from the Americas. In 1996 the number of polio-free countries totaled 150. Also in 1996, Rotary International worked with Nelson Mandela to start the Kick Polio Out of Africa campaign. The Western Pacific was declared polio-free in 1997 and a year later Europe followed suit. By 2003 only six countries were polio-endemic: Egypt, Afghanistan, India, Niger, Pakistan, and Nigeria. In 1988 when the first polio eradication initiative was started by the World Health Assembly, there were 350,000 cases worldwide. In 2003 the number of cases had dropped to 700. Enormous strides were made to eradicate the disease and 2003 represented the closest we had come to total polio eradication. However, at the end of 2003 a polio boycott erupted across Nigeria; they had the highest number of cases anywhere in the world. Many factors led to this backlash including past injuries brought on by the Western world, religious infighting within Nigeria, and sects vying for political power.

Historical Reasons
In Nigeria, there are many deep seeded roots for the reasons for the Polio Boycott. In the 1980's, President Babangida adopted a population policy which limited the maximum of four children for each woman. Many people connected this population control campaign with immunization. They believed that the vaccination was one way the government was reducing the population or at least checking the number of children a woman can bear.

Also, there was a general distrust of aggressive, mass immunization programs especially in a country where access to basic health care is not easily available. John Murphy of the Baltimore Sun 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."

Trovan Trial
One experience in particular left northern Nigerians suspicious and mistrustful of western healthcare and “free medicine”. During the summer of 1996 in Kano, Nigeria, there was a devastating meningococcal meningitis epidemic. The American drug giant Pfizer Inc. had just developed a new antibiotic, trovafloxacin (Trovan), they hoped could treat bacterial meningitis. Animal studies with Trovan were promising so Pfizer wanted to move forward with human trials. Pfizer saw the meningitis outbreak in Kano as a perfect opportunity to test the efficacy of Trovan in humans.

At the height of the outbreak, Pfizer conducted an open label drug trial of Trovan against the “gold standard” meningitis medicine ceftriaxone. Two hundred children were enrolled in the trial; half were given Trovan and the other half given ceftriaxone. Out of the two hundred, five children died given Trovan and six died given ceftriaxone. In total, 15,000 Nigerians lost their lives during the meningitis outbreak.

Ethical Concerns
On the surface the Trovan trial seemed like a success, Trovan was just as effective as the gold standard ceftriaxone. Controversial ethics on the part of Pfizer, however, drastically tainted the results and caused a severe anti-Western sentiment to spread throughout the region. According to the British Medical Journal, “at least one child was not taken off the experimental drug [Trovan] and given the standard drug [ceftriaxone] when it was clear that her condition was not improving.” This raises obvious ethical concerns as it is viewed as putting the results of a drug trial ahead of the health and well-being of a human child. The child should have immediately been given ceftriaxone as her condition deteriorated to try and prevent further damage.

Secondly, Pfizer never warned the Nigerians about the health risks associated with Trovan. Previous animal trials had shown that drugs like Trovan were linked to joint and cartilage damage. By not providing the parents with all the facts, Pfizer could not legally receive proper consent from the Nigerians. In subsequent Trovan trials in the United States, patients were properly informed of Trovan’s risks. So it begs to question why the information was withheld from the Nigerians?

Lastly, according to reports, Pfizer never had the correct ethical approval from the Nigerian government to even run the drug trial in Kano. Pfizer is accused of falsifying and backdating the letter of ethical approval from the Nigerian government to fit the correct timeline of the trial. The doctor who oversaw the trial has said it was possible that the letter could have been drafted up to a year after the trial was conducted.

Backlash
These ethical concerns outraged the northern Nigerian population. A member of the press wrote, “The government has the duty to tell us whether out children were used as guinea pigs and, if so, who committed such criminality” Such obvious feelings of betrayal and indignation resonated throughout the Kano community. So when the polio vaccine began to be circulated in Nigeria in 2003, people remembered the Trovan trial and were hesitant to again trust a foreign medicine.

Political Reasons
In Nigeria, the states have administrative control over health affairs at the primary level. The Kano state government was able to issue a directive to halt the immunization exercise planned by the federal government. In northern Nigeria in 2003, the political and religious leaders of Kano, Zamfara, and Kaduna states brought the immunization campaign to a halt by calling on parents not to allow their children to be immunized. These leaders argued that the vaccine could be contaminated with anti-fertility agents (estradiol hormone), HIV, and cancerous agents.

Also, there has been tension between the northern-led military regime and the southern led democracy. The north was colonized by the Islamic Jihadists and the south was colonized by the British. Since the beginning of the new democratic system of government in 1999, power shifted to the south. These changes have resulted in political tensions between the south and north. These tensions might explain why the religious leaders in northern states who boycotted the polio immunization campaign believed that the southern-led federal government was acting in the interests of Western powers. The northern states have mistrust of the western world. Sule Ya'u Sule, speaking for the governor of Kano, says "Since September 11, the Muslim world is beginning to be suspicious of any move from the Western world…Our people have become really concerned about polio vaccine."

Current Situation
Nigeria still had the highest number of polio cases, over 700, in 2008. However, increased communication and cooperation with both religious and political leaders in the region have led to increased confidence in the vaccines. Moreover, fewer rumors are being circulated and more vaccines are being administered. This certainly has been a driving factor in the decreased case counts. The number of cases dropped to 388 in 2009 and most recent CDC reports indicate only three cases in the first half of 2010. It is evident that the Western "challenge" and "gift" was improperly implemented in the beginning. Little communication with leaders and no public education tools doomed the project from the beginning. Initial success was apparent, however prior history with engaging outsiders left a wariness with the people of Nigeria. The Trovan trial, in addition to political leveraging, caused mistrust in the vaccines and Western gifts. This case exemplifies the importance of education and communication. It is considered unethical to force a solution on a group of people if they are unwilling to accept it; the best implementation therefore is to educate a group about the benefits of the solution before it is given to them. Technology and innovations are only as useful as their application in the society they are used.