Historical Antecedents and Implications of Polio Outbreaks in Northern Nigeria

In September 2016, Nigeria's attempt to wipe out polio suffered a major setback when a new case of wild poliovirus infection was reported in Borno State, northern Nigeria, by the World Health Organization (WHO). This brought the number of cases reported since August 2016 to three.¹ The Nigerian government declared a health emergency for the Lake Chad region in response to the new infections. The seriousness of wild poliovirus outbreaks and other public health threats is particularly poignant for Nigeria's northern region because of the Boko Haram insurgency, which has claimed more than 20,000 lives and created a refugee crisis of 2.3 million displaced persons in six years.² Although Nigeria has come a long way in checking outbreaks of wild polioviruses, as of 2016 the country remained on the list of countries considered by the WHO as an endemic place for the outbreak and transmission of wild polioviruses. (Pakistan, Afghanistan, and India are the other endemic countries.) The three infections of 2016 were the first reported cases in Nigeria since 2014. The two-year absence of fresh infections between 2014 and 2016 is remarkable considering that in 2009 Nigeria was considered the epicenter of a worldwide outbreak of wild polioviruses. The number of wild poliovirus outbreaks jumped from 286 in 2007 to 801 in 2008, making Nigeria the source of 48.4 percent of cases worldwide.

The unacceptably high number of cases from Nigeria had serious consequences for the worldwide effort to wipe out polio, prompting major initiatives on the part of the WHO, the World Bank, the United Nations Childrens Fund (UNICEF), the Gates Foundation, Rotary International, and a number of other major international development agencies collaborating with the Nigerian government in a campaign to eradicate the disease. But the effort to eliminate polio from Nigeria, particularly from its northern region, has not been without major obstacles, such as overcoming local resistance to the distribution of polio vaccines to vulnerable populations and the rejection of campaigns to change attitudes and perceptions about the value of adopting vaccines against preventable childhood diseases. The upsurge of violence in northeast Nigeria resulting from the Boko Haram insurgency since about 2010 is the latest and most deadly of long-standing suspicions, structural barriers, and simmering resistance to polio vaccines. Although vaccine uptake met with some success following the peak outbreak period (2008–2009), things took a deadly turn for the worse when nine female polio workers were killed by armed attackers in Kano in February 2013. Two weeks earlier, two state security officers guarding community organizers for the polio campaign were also killed by armed attackers.³

Deeper Roots of Vaccine Resistance

As mentioned, Nigeria's northern region—particularly the belt stretching from the northeast to the northwest—has long been a bedrock of resistance to vaccine acceptance programs that target pregnant women and mothers of children under five years of age. Much of the recent attention to resisting polio vaccines in the region has been linked to the politics of rejection of Western donor-driven vaccine initiatives because of suspicions that the vaccines are somehow tainted by powerful Western countries bent on limiting the number of births by Islamic women.⁴ One version of this conspiracy theory blames Western countries' war against terrorism in the aftermath of the September 11, 2001 attacks. The suspicion is that the United States and its allies plan to sterilize Muslim women through vaccination. In reality, the suspicion stems from much deeper roots in Nigeria and sub-Saharan Africa. There is substantial evidence to show that long before 9/11 there was widespread skepticism and some resistance against taking disease preventing vaccines, especially those targeted at pregnant women and young children under five (who are most susceptible to childhood killer diseases such as measles, tuberculosis, whooping cough, tetanus, and polio).⁵ In the case of Nigeria, the root of skepticism goes back to the first childhood immunization program to eradicate smallpox in the 1960s and measles in the 1970s. Smallpox was successfully eradicated but measles persisted. To bolster the measles eradication effort, the Nigerian...