Bill Gates has once again revealed that he does not understand the determinants of low vaccine coverage in northern Nigeria. Though he uses words like federal government and state government, ultimately he is defining a technical problem, not a political problem. (See my previous post on this here.) Here he explains to Ezra Klein why Somalia has higher vaccination coverage than northern Nigeria:
Well, in Somalia they’ve given up using the government. The money goes through the NGOs. Whereas in Nigeria they’ve designed a system where the federal government buys the vaccines, the state government provides the electricity, and the one level down below that provides the salaries. It’s just a bad design. You know, the north of India has very poor vaccination rates, so we picked a state up there with 80 million people and we drove it from 30 percent to 80 percent. But they had a really good chief health minister and the federal government was providing lots of money and lots of good technocrats, so the skills were there, as long as you employed them in the right kind of system.
Last week gunmen killed nine polio vaccinators in Kano.
Then yesterday, on reddit, Bill Gates responded to this question: (h/t to Chris Blattman)
Which world-wide health cause are we perfectly capable of easily solving and on the cusp of achieving but just need to put it over the top with a little more attention or resources to actually solve?
with this answer:
Polio is the first thing to get done since we are close. Within 6 years we will have the last case.
From a medical/technical standpoint, yes, we know how to eradicate polio. From a political standpoint, it is less clear.
As anthropologist Maryam Yahya has written [gated], “there is an underlying logic to public anxieties” of the polio vaccine. What is this logic? Here are some reasons northern Nigerians have to be anxious about the vaccine:
- Many Nigerians think vaccines should be administered by trained health professionals. In the eyes of public health workers, the advantage of the oral polio vaccine is that it does not need to be administered by trained health professionals. The fact that sometimes girls as young as nine are responsible for administering the vaccine can cause skepticism among Nigerians (Yahya 2007).
- Some of the vaccination initiatives involved vaccinators going door-to-door requesting permission to vaccinate children in the household. This is not a common way that parents get medical care, and invoked suspicion. More mobile health care providers are less trusted than more stationary health care providers, as if something goes wrong it might be difficult to track down the mobile health care provider (Abdalla 1997).
- The polio campaign has largely targeted the North of Nigeria, which is predominately Muslim. The South is not predominately Muslim. This has created the perception that the campaign is anti-Muslim (Yahya 2007).
- The 1996 Pfizer Trovan drug trial, which triggered a meningitis outbreak in Nigeria, has resulted in suspicion toward Western-led provision of free medicine.
- There was a vaccine-induced polio outbreak in 2005. At least 100 children were paralyzed because of this.
- The Hausa word for polio is Shan Inna. Shan Inna, which literally means “to drink blood,” is a spirit who consumes limbs. Thus many Hausa conceive of polio as a spiritual problem, not a biomedical disease. This might lead people to question the effectiveness of a biomedical vaccine (Yahya 2007). Today, however, younger Nigerians often do not know that Shan Inna refers to a spirit, and many use the word “polio” instead of “Shan Inna” (Renne 2010). If this truly reflects a conceptual change in understanding of polio, this might be less of a cause for anxiety toward the vaccine than in earlier times.
- The National Programme on Immunisation (NPI) is supposed to delegate certain aspects of the polio immunization campaign to Local Government Areas (LGAs). One of the things they are supposed to delegate is responsibility for administering awareness campaigns, as the idea is that LGAs know the best way to do this in their region. However the NPI has done this itself, often in an ineffective way. For example, they use radio to spread information when radio is a luxury in many rural areas. A “traditional” way of spreading information would be for a campaigner to speak with a traditional leader, who would gather community members together and the information would be articulated in the open. This strategy has not been used (Yahya 2007).
- While I have not encountered evidence of this in Nigeria, there is evidence elsewhere that poorly timed vaccination campaigns can heighten suspicions. In Uganda a 1997 National Immunisations Day campaign took place during the season when malaria is most easily contracted. Residents interpreted the association of immunization and high rates of child deaths (mostly likely as a result of malaria) as a causal relationship between the vaccines and death (United Nations Children’s Fund 2001). One could imagine that similar dynamics have taken place in northern Nigeria.
Abeg O, any pikin wey never pass 15 YEARS wey una see say him hand and leg dey weak jus like dat, make una quik quik go report for the health centre wey dey near una place or for the Health officer for local government.
This is a quote from a barber in Kano in 2005. He let his children be vaccinated for polio at a time when many refused because of suspicion that the West was using the vaccine would cause infertility or HIV among Muslims.
If the White man really wanted to destroy us, there are many other easier ways to do it. They can poison our coca-cola, the biscuits we buy, the sweets and even panadol that you can buy in the kiosks for headaches.
From a great article by Maryam Yahya, “Polio Vaccines – “No Thank You!” Barriers to Polio Eradication in Northern Nigeria” in a 2007 African Affairs issue.