Distrust of U.S. foils effort to stop crippling disease

FANISAU, Nigeria - If it were possible to wind back the centuries, HalimaUmar's village would probably look much as it does today. Umar and herneighbors fetch water by lowering a bucket into a hand-dug well, toil infields of millet and guinea corn, and sleep in houses made of mud, leaves andanimal hair, the walls sagging like sandcastles struck by an ocean wave.

In January last year, Nigerian health workers knocked on Umar's door,offering her newborn daughter a free dose of polio vaccine.

Two drops of the oral polio vaccine taken at least three times as a child,the health workers told her, would protect her daughter, Zaliha, from thecrippling virus for life.

But Umar turned the vaccinators away. Most of her neighbors did the same,some hiding children under their beds.

They had heard a rumor circulating through the hot, dusty villages ofnorthern Nigeria that the vaccine had been contaminated with an anti-fertilityagent that would sterilize their children or perhaps infect them with the AIDSvirus, all part of an American plot to depopulate the developing world. Thevillagers believed it.

It didn't matter that the World Health Organization, the Nigeriangovernment and dozens of doctors and scientists dismissed the allegations asbaseless, assuring the public that the vaccine taken by 1 billion childrenworldwide is safe.

"We just didn't like the vaccine," says Umar.

During the following three months, vaccinators returned to Umar'sneighborhood two more times to immunize the children. On both occasions, theshy 22-year-old mother politely but firmly declined their offer.

Then in June, 10-month-old Zaliha developed a fever and diarrhea. Zaliha,who had recently learned to crawl, suddenly could no longer sit up. A few dayslater, paralysis, polio's damning trademark, arrived, leaving her legs limpand lifeless.

Aided by rumor, fear and misinformation, polio is making a comeback inNigeria, reinfecting polio-free regions and moving into West and CentralAfrica, putting 15 million children at risk and threatening the goal of apolio-free world.

The outbreak comes just as polio appeared to be backed into a corner. In1988, when the WHO launched a campaign to eradicate the disease, there weremore than 350,000 known cases in 125 countries. Today there are about 500cases in just seven countries: Nigeria, India, Pakistan, Egypt, Afghanistan,Niger and Somalia.

Six of these countries are on track to eliminate polio by the WHO'sdeadline of the end of 2004. But Nigeria, with nearly half of the cases,threatens to derail the worldwide effort.

Most of the country's 286 cases have occurred in Nigeria's predominantlyMuslim northern states, where anti-Western feelings intensified by theU.S.-led wars in Afghanistan and Iraq make the population suspicious of anyprogram supported by the United States.

Radical Muslim clerics preached the dangers of the vaccine during Fridayprayers. Villagers chased, threatened and assaulted vaccinators. Frustrated,some vaccination teams dumped thousands of doses of the vaccine rather thanface angry villagers, WHO officials say.

In response to the outcry, three northern Nigerian states, including Umar'shome state of Kano, canceled immunization campaigns last year, allowing thevirus to spread and get a foothold in neighboring countries.

Nearly a dozen children were crippled last year in Burkina Faso, Ghana,Niger, Togo and Chad from a poliovirus genetically linked to northern Nigeria.

"Polio is now spreading to areas that have been polio-free for years," saysDavid Heymann, an epidemiologist based in Geneva who is leading the WorldHealth Organization's polio eradication campaign. "All it takes is for someoneto hop on an airplane ... to start reinfecting another part of the world."

Such fears have left WHO and local health officials scrambling to containthe spread of the virus and dispel the rumors so the vaccinations can beginagain.

But if there is one measure of the challenges public health officials facehere, it is Umar's defiance. Standing in her doorway on a recent morning,holding her crippled daughter, she expresses no regret.

Asked if she would accept the vaccine if she could wind the clock back tothat day health workers first knocked on her door, she does not hesitate withher answer.

"No," says Umar, shaking her head. "I would do the same."

Eradication program

Few people in the developed world think about poliomyelitis, but during thefirst half of the 20th century, it was one of the most feared diseases.

The highly infectious virus can strike anyone at any age, although childrenyounger than 5 are most vulnerable. Thriving in unsanitary conditions, thevirus enters the body through the mouth and multiplies in the intestine. If itinvades the nervous system, it can lead to paralysis within five days.

With no known cure, polio left victims crippled for life, rolling inwheelchairs, hobbling on crutches or spending their lives in coffin-like "ironlungs," huge cylinders that helped the most severely stricken victims breathe.

In 1955 Dr. Jonas Salk discovered a polio vaccine. But it was Dr. AlbertSabin's development in 1961 of a live polio vaccine taken orally that mademass immunizations and the dream of a polio-free world possible. Simple toadminister and costing pennies a dose, the oral polio vaccine could bedistributed widely and inexpensively by volunteers with minimal training.

Led by the WHO, Rotary International, the U.S. Centers for Disease Controland Prevention and the United Nations Children's Fund, the anti-polio effortbegan in 1988 and has grown into one of the world's largest public health careinitiatives, costing more than $2 billion so far.

More than 5 billion doses of the vaccine have been distributed door to doorby 20 million volunteers and health workers traveling by train, helicopter,horseback, motorcycle, boat and on foot to deliver the doses to every childyounger than 5.

Vaccinators persuaded soldiers battling in civil wars in Angola, Congo andSudan to lay down their weapons for several days so that thousands of childrencould be protected from the disease. In parts of India, trains have not beenallowed to leave their stations until all children under 5 were immunized.

Five million people who would otherwise be paralyzed are walking becausethey received the vaccine, according to the WHO.

But the campaign has dragged on longer than expected, missing its originaldeadline of 2000.

If there are further delays, health officials fear, the campaign could beundermined by donor fatigue and frustration.

If the campaign is successful, polio would be only the second disease everto be eradicated. The first was smallpox in 1979.

Conspiracy theory

No one quite knows how the rumors about the vaccine's safety began, butlocal officials point to the northern state of Kano, which has the highestnumber of polio cases in Nigeria, as the likely source.

The state capital, Kano, developed as a center for camel caravans crossingthe Sahara to trade slaves, ivory and kola nuts for salt, glass beads, weaponsand cowrie shells.

Enveloped in a gray, exhaust-filled haze much of the day, the city of 1million is dominated by the emir of its walled palace and the central mosque,where as many as 50,000 worshipers gather for Friday prayers.

The dominant tribe is the Hausa, whose culture is defined by Islamic faith.Boys study the Quran in outdoor schools under trees by the side of the road.Women are rarely seen outside the mud walls of their homes. Peace and orderare maintained by the state's Sharia court system.

As in much of the Muslim world, anti-American passions run high amongKano's residents. In such a climate, rumors of plots involving the poliovaccine found a receptive audience.

"What is happening in the Middle East has aggravated the situation," saysAli Guda Takai, a WHO doctor who investigates all polio cases in Kano state."If America is fighting people in the Middle East, the conclusion is that theyare fighting Muslims."

It's no coincidence, officials say, that the number of polio cases hasincreased sharply since the wars in Afghanistan and Iraq. There were ninepolio cases in 2001, but 54 in 2002 and 74 in the first 11 months of 2003.

What makes rumors so difficult to dispel in Nigeria is that they aresupported by prominent members of the community, including doctors, Muslimclerics, political leaders and college professors.

"These are highly respected people who hardly tell lies. People believewhat they say," said Takai, a Nigerian who was raised in Kano.

Perhaps the most vocal critic is Ibrahim Datti Ahmed, a Kano physician andpresident of Nigeria's Supreme Council for Sharia Law.

Ahmed, 68, was once a strong supporter of the polio vaccine, immunizing allfive of his children himself. Initially, he was skeptical about the rumors, hesays, but then he searched the Internet and discovered articles questioningthe vaccine's safety.

Ahmed concluded that the United States was contaminating the vaccine withanti-fertility hormones to depopulate the developing world, afraid that rapidpopulation growth in countries like Nigeria, with 126 million people, willoverwhelm the United States, where birth rates are lower.

"They are the worst criminals on Earth to sterilize children for life. EvenHitler was not as evil as that," said Ahmed, who has appeared on radio andtelevision promoting his theory.

As far-fetched as his ideas may sound, many believe them.

"If reducing population will enhance the United States' interests, thenAmerica will go for it," says Samaila Buba. 35, a graduate student at BayeroUniversity in Kano. "I cannot allow my child to take [the vaccine]."

Some of Kano's fears of the vaccine stem from its experience with the U.S.pharmaceutical giant Pfizer Inc., which in 1996 administered an experimentalantibiotic to help control a meningitis outbreak. Eleven children died, andothers suffered paralysis, deafness and blindness as a result of the drug, thevictims' families alleged in a lawsuit filed against the company in New York.The case was dismissed, but a U.S. appeals court recently referred it back tocourt for reconsideration.

Pfizer denies any wrongdoing.

Many Nigerians are further bewildered by the WHO campaign's single-mindedfocus on polio when they are threatened daily by a medical textbook's worth ofillnesses: leprosy, AIDS, tuberculosis, measles, diarrhea, malaria and yellowfever. While there were 286 confirmed cases of polio in 2003, as many as300,000 Nigerians died from malaria during the same period.

"There are more killer diseases that need attention in Africa than polio.Like malaria. It's the No. 1 killer," says Bello, who was recovering from about of malaria himself, but received no free treatment.

The aggressive door-to-door mass immunizations that have slashed polioinfections around the world also raise suspicions. From a Nigerian'sperspective, to be offered free medicine is about as unusual as a stranger'sgoing door to door in America and handing over $100 bills. It doesn't make anysense in a country where people struggle to obtain the most basic medicinesand treatment at local clinics.

The WHO acknowledges that eradicating polio may not be a top priority formany developing countries. At the time the campaign began, some critics arguedthat it would be better to offer routine immunizations for a number ofpreventable diseases. But after the success in wiping out smallpox, the WHOand its partners were optimistic that another narrow, targeted campaign wouldwork.

None of these explanations of northern Nigeria's opposition to the vaccinesatisfy public health officials trying to understand what went wrong here.

Why is it that Muslims in other countries support polio immunizationcampaigns? Why has progress been made in other poor, disease-ridden nations?What makes Nigeria different?

The answer, local health officials say, is politics. Although Nigeriaconsists of hundreds of ethnic groups, the main dividing line is north-south.Northern Nigeria is mainly Muslim. The southern part of the country ispredominantly Christian and animist. There lies the source of many of thecountry's religious and political tensions.

The election of President Olusegun Obasanjo, a born-again Christian, in1999 after 16 years of military rule by dictators from the north, has oftenput northern political leaders at odds with the national government. Anyfederal government program run by the Obasanjo administration arousessuspicions.

Opposition parties use any effort they can to embarrass Obasanjo'sgovernment. The polio vaccination program is one.

Safety test rejected

To calm fears, the Nigerian government recently commissioned independenttests to verify the vaccine's safety. At least four series of tests wereperformed by laboratories in Nigeria and South Africa, all concluding therewas no evidence of anti-fertility hormones or the virus that causes AIDS.

In announcing the test results last month, Nigeria's minister of healthcalled on local leaders to join the federal government to drive polio from thecountry by the end of 2004.

It's unclear whether any of these pronouncements will make a difference.Even before the government declaration, Ahmed announced that the vaccine testshad found evidence of anti-fertility hormones. Anyone who said differently waspart of a U.S.-orchestrated cover-up.

The WHO meanwhile pushed ahead with immunization campaigns in the areas ofNigeria that would allow them. The northern states of Kano, Kaduna andZamfara, with some of the highest infection rates, did not participate.

Distrustful neighbors

In Plateau state, home to a mix of Christians and Muslims, young men andwomen carrying coolers containing hundreds of doses of the vaccine trudged inblistering heat to hundreds of villages and cities.

They met thousands of families willing to accept the vaccine. But therewere pockets of fierce resistance, as the vaccinators discovered in the cityof Wase.

A poor farming community, Wase appears almost feudal. At the highest pointin the city sits the emir's whitewashed palace. Across the street, just a fewfeet higher is the mosque, its dome rising over the banks of the Wase River,where peasants tend rows of maize and yams.

The polio vaccine has been available in the village for a decade or more.But opposition to the vaccine has grown steadily since residents heard aboutthe concern in the northern states.

After two years without a case of polio, Plateau state has two childrenparalyzed by the virus, including one just outside Wase.

Although two cases may seem to be a small number, the risks of infectionare high for residents living nearby. For every polio case resulting inparalysis, an estimated 200 people carry the virus but may show no symptomsother than diarrhea.

Such risks, however, were apparently not the primary concern for residentsof one neighborhood on the outskirts of Wase. When the team of health workersstarted knocking on doors, villagers turned them away.

The vaccinators retreated, but then sought help from Wase's traditionalward leader, who is sympathetic to immunization efforts.

"I remember when Americans brought some medicine here once and people gotcured," said Albhi Sule Rabo, whose family has ruled over Wase for more than200 years. "Because I saw this I believe in the vaccine."

Rabo agreed to accompany the vaccinators to the troublesome neighborhood.When his car came within sight, the streets suddenly emptied.

Clearly annoyed, Rabo sprang from his car, barking for the fathers to comeoutside with their children. He launched into a 10-minute lecture on thebenefits of the vaccine and how he had ordered all of his own children to takeit. He said there was no reason to believe it was not safe. "God createsmedicines," he says.

"Look at this woman," he said, pointing to one of the vaccinators. "Sheleft her husband and children to help us. Do you think she would leave them tocome and harm us. Do you think that is believable?"

He focused much of his outrage on one father, a feeble-looking man whostood with his head hung low like a mischievous schoolboy caught by theprincipal.

"I had heard on the radio that it was dangerous," the man told thevaccination team. After Rabo's speech, he reluctantly agreed to have his childimmunized.

The vaccinators pulled a vial of orange-colored liquid from the cooler box,attached a dropper to the top and called over the boy, who squirmed and wailedin his father's arms. His father and two health workers struggled to pry openhis mouth.

Then two drops of the vaccine fell to his tongue. His thumb was paintedwith a dab of purple ink to indicate he had been immunized. The ordeal over,the boy's sobbing suddenly quieted, and his eyes darted back and forth as ifto say, "Is that all?"

His work apparently done, Rabo waved goodbye, stepped into his car anddrove home.

Their success, however, was short-lived. As soon as Rabo's car disappearedfrom view, the crowd that had gathered disappeared. The team gave doses to twoother children before it encountered a fresh wave of resistance.

One man claimed the vaccine was responsible for the deaths of two of hischildren. An elderly grandfather sat under a tree and refused to give thewhereabouts of his young grandson, who was hiding. A crowd of teen-age boystaunted a group of young women vaccinators.

"What are you going to do? Force us to accept it?" one boy said, laughing.

At the edge of the village the vaccinators approached a man sitting aloneunder a baobab tree. Alarmed at the sight of them, he stood, waving his armsas if he were trying to stop traffic, saying that he was not about to allowhis children to take the vaccine.

"I don't want anything to do with Christians or Americans," he screamed.

Seeing a white American in the party of vaccinators, the man spread hisarms as if being crucified and hollered: "Now the Americans have come to killme. So kill me now!"

Copyright © 2014, Los Angeles Times
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