Volunteer community mobilizers (VCMs) hold flip charts used for educating parents about polio and other routine immunizations at a health center in Kano, Nigeria, on July 23.
Volunteer community mobilizers (VCMs) hold flip charts used for educating parents about polio and other routine immunizations at a health center in Kano, Nigeria, on July 23. Andrew Esiebo/Courtesy of the U.N. Foundation

Dispatch

Nigeria Just Won a Complex Victory Over Polio

The country’s vaccinators have overcome distrust, misinformation, and an insurgency to reach this point, but they can’t stop yet.

KANO, Nigeria—Addau Saidu weaved his motorbike between lanes crowded with bright yellow kekes, the three-wheeled cabs that ferry people back and forth across northern Nigeria’s megalopolis. He tracked the road’s centerline on his silver bike, wearing a blue and black striped football jersey, completely unruffled by the afternoon rush. He embraced it: “If a place is not Kano, it’s automatically seen as the bush—that’s what we say here.”

Off the bike, he has to be more deliberate about his movements. When Saidu wants to walk, he places the rubber soles of a flip-flop over each palm and uses his arms. Polio took his legs, which are rail thin and often crossed beneath him when he isn’t driving.

“Because of the bike, I feel I am able because I have movement,” he said in an interview in July. “I thank God for the life I am living, but I am not comfortable.” Saidu is working with UNICEF on Nigeria’s polio eradication campaign. “I want to tell the world that they should immunize their kids­—especially in this area.”

Addau Saidu, a polio survivor who works with UNICEF to support Nigeria’s efforts to eradicate the virus, rides his motorbike through Fagge, a high-traffic neighborhood in Kano, on July 23. Andrew Esiebo/Courtesy of the U.N. Foundation

Kano, known as a hub for traders, scholars, and Islamic tradition on the edges of the Sahel, has also been at the center of a three-decade, multibillion-dollar initiative to eradicate polio—an infectious disease caused by a paralytic virus for which there is no cure. It’s the largest global health intervention ever attempted.

Nigeria is officially one of three countries, alongside Afghanistan and Pakistan, where polio is still a threat—a full 19 years after the first deadline set by the World Health Organization (WHO) to eradicate it elapsed. But now Nigeria is set to be removed from this unenviable list.

It has been a difficult fight. “Kano used to be an epicenter for polio,” said Bashir Abba, a doctor who coordinates WHO’s anti-polio programming in Kano state. “Now, we are days away from 60 months without a wild polio virus,” he added, referring to the virus’s original form rather than modified versions that have been weakened for use in vaccines.

If everything goes to plan for the next few months, Nigeria will be certified polio-free by WHO. As a result of Nigeria reaching this mark, all of Africa will be too.

Nigeria has reached this point thanks to the concerted efforts of a broad array of vaccine advocates, including northern Nigeria’s traditional and religious leaders, a network of 20,000 women who have stepped up to take the oral form of the vaccine door to door, and polio survivors themselves.

Because this broad coalition has been able to act as reliable mediators—closing the trust gap between the ambitious global goals of the powerful international organizations that fund the initiative; the Nigerian government, which is responsible for it; and parents who are concerned with protecting their children—the country marked three years since it reported a new case of polio on Aug. 21.

If everything goes to plan for the next few months, Nigeria will be certified polio-free by WHO. As a result of Nigeria reaching this mark, all of Africa will be too. But plans like this have been derailed before. Abba is quick to point out: “As long as polio exists anywhere in the world, nowhere is safe. No child will be safe.”

If local communities lose their faith in the merits of the project or the people who connect them to it, polio could come back with a vengeance. The edge of eradication isn’t a straightforward or stable place.

In 1988, when the Global Polio Eradication Initiative (GPEI)—a collaboration between WHO, UNICEF, the U.S. Centers for Disease Control and Prevention (CDC), Rotary International, and the Bill & Melinda Gates Foundation—set out to reach its goal of immunizing every child in the world against polio, there were around 350,000 cases of the virus.

By 2000, just 12 years later, the number of cases had dropped to under 1,000 worldwide. “We’ve been dealing with the end of polio for half the time we have been fighting it,” said Gillian SteelFisher, a researcher at the Harvard T.H. Chan School of Public Health who studies how public health interventions are perceived. This year, there have been 65 cases between January and August—all of them in Afghanistan or Pakistan.

Yet the stakes of polio eradication are deceptively high, even if the case numbers are very low. WHO estimates that if all vaccinations against polio were called off, the virus could rebound once again to paralyze more than 200,000 people per year. “The alternative is that we stop and then polio comes roaring back … and that is just an unimaginable tragedy,” SteelFisher said.


Mallam Saleh, the local religious leader in Fagge, teaches a workshop for caregivers on routine immunization in Kano on July 23. Andrew Esiebo/Courtesy of the U.N. Foundation

“We are on the finish line,” said Nefiu Abubakar, a 23-year-old polio survivor who now draws on his experiences to counsel parents about the vaccine. “The real problem of polio is about noncompliance,” he said, “and there is hardly any here now.” Almost all of the people in Kano are now accepting the vaccine, he added.

Abubakar is now routinely involved in the kinds of trust-building conversations with parents that have gotten Kano to this point—no small thing when it involves talking about protecting others from the virus that attacked the nerves to your own legs.

For Abubakar, one particular conversation stands out: “There was a man I visited. He said, ‘You usually come with this vaccine, but what is the impact?’ I showed him my legs. … I told him he should understand the risk. … I came back the next day, and his children got vaccinated. We are good friends now, actually. We text.”

Conversations like this haven’t always been possible in Kano. In 2003, the governor of the state at the time, Ibrahim Shekarau, banned the polio vaccine campaign and brought immunizations in his state to a halt for a year.

Rumors in northern Nigeria around the polio vaccine tracked familiar fault lines of distrust.

At that time, northern Nigeria was awash in misinformation. There were widespread rumors that oral polio vaccine campaigns were being used as a front that would allow Western powers to sterilize Muslim communities so they could decrease the size of their populations. Levels of parental conviction and rumors of how exactly the vaccine was supposed to be tampered with varied. Two staples of the genre involved the oral polio vaccine being combined with contraceptives or HIV.

Rumors in northern Nigeria around the polio vaccine tracked familiar fault lines of distrust. Local Muslim leaders across the board, from politicians to religious officials, were concerned about the motivations and legitimacy of both the Nigerian federal government and the international actors that formed the GPEI.

That the GPEI was funded largely by organizations based in the United States was not lost on northern Nigerians, who had become increasingly wary of the country since the initiation of wars in Afghanistan and Iraq. Neither was the detail that Olusegun Obasanjo, a Christian from the South, had beaten out Muhammadu Buhari, a Muslim army general from the north and Nigeria’s current president, in the 2003 election. The resulting trust vacuum gave polio a disastrous amount of room to spread.

Ado and Hajara Musa hold their daughter Faiza outside their house after a visit from VCMs in Kano on July 23. They have five children, and all of them have been vaccinated against polio. “I have five children, I accepted the vaccine, and now there are not any problems that polio has given me,” said Ado Musa, who works for the police force in Kano. “We see it in our children’s bodies. … They are healthy.” Andrew Esiebo/Courtesy of the U.N. Foundation

With Kano’s ban in effect, new outbreaks of the virus swept beyond the state, driving a national outbreak. Lagos now had to contend with polio again, as did countries in the region that had already been declared free of it, including Burkina Faso, Ghana, and Mali.

With the state bearing responsibility for 80 percent of global polio cases at the time, Kano’s widespread anti-vaccine sentiment became one of the biggest threats to the global eradication of the disease. By the time the ban was lifted in August 2004, people in 21 countries that the WHO had previously declared polio-free had already been paralyzed by outbreaks of the virus, which could be traced back to Kano. And the knock-on effects would be felt for a long time—including within the state itself. In 2009, a full five years after the ban, Nigeria reported 384 cases of polio—and 84 percent were concentrated in the north.

Kano’s widespread anti-vaccine sentiment became one of the biggest threats to the global eradication of the disease.

At that point, the GPEI donors went in search of the kind of collaboration that could reverse the area’s status as an originator of outbreaks and approach the kinds of levels that could see it wipe out polio. They found it: Traditional leaders from each of northern Nigeria’s 19 states, including Kano’s own emir, Muhammadu Sanusi II, signed on to form a Northern Traditional Leaders Council focused on tackling the virus. In 2016, Sanusi reportedly downed an oral polio vaccine in front of a crowd.

Traditional and religious leaders are deeply influential in the region. As a demographic that once included a formidable and vocal group opposed to vaccinations, they now include some of the biggest advocates of childhood immunization efforts to be found anywhere.

Mallam Mujjitaba Adam Saleh, a local religious leader, has been involved in Nigeria’s polio eradication efforts since 2013 and runs workshops where he encourages caregivers to immunize their children. “We have been working hard to eradicate this disease and misunderstandings between us and the people,” Saleh said in the booming voice of someone that talks to people for a living. “We have achieved a lot.”

For Saleh, “Kano state is a place where 99 percent of people are Muslim, so whenever you want to send a message, you have to use us.”


VCMs go door to door visiting parents during a polio immunization campaign in Kano on July 23. Andrew Esiebo/Courtesy of the U.N. Foundation

When it comes to public health interventions of this scale, getting the messaging right is a major achievement but is only part of the battle.

“What we are trying to do is to get to 90 percent coverage everywhere we go, but it’s a massive country,” said Omotayo Bolu, the director of immunization for the CDC’s Nigeria office. “One state could mean vaccinating 5 million children.”

This level of coverage depends on an extensive network of around 20,000 women—the volunteer community mobilizers, or VCMs—who have joined the country’s polio eradication campaign to go door to door, talking to parents about the benefits of the oral polio vaccine and pipetting drops into children’s mouths.

Last month, in a small courtyard bordered by earth-toned walls, Kadijah Abdulrahman shed some light on another one of the reasons why this works.

In her neighborhood, like in much of northern Nigeria, male health care workers would routinely be shut out of homes until a husband or brother or father were home to approve their visit. “It is not proper for men to just walk into the house, but a woman who is a VCM can easily walk in,” Abdulrahman said. With this kind of access and 4,000 women in the state taking on the role, Kano hasn’t had a case of wild-type polio since 2014.

A team of women who work as VCMs visit Ado Musa and his daughter Faiza at their house in Kano on July 23. Andrew Esiebo/Courtesy of the U.N. Foundation

“They are people that the community members can trust with their lives and with their children,” said Ngozi Nwosu, a physician who leads the Nigerian government’s program to redistribute anti-polio assets after the virus has been dealt with. “Because of the VCMs, in every street, there may be someone who parents trust, who can speak to them about the importance of vaccines.”

Parents in Kano and other northern states have often coordinated to refuse vaccines not because they don’t value them but because they have other urgent needs that the government hasn’t responded to.

It is no small thing to convince parents in Nigeria to allow their children to receive five doses of oral vaccine a year for a virus they are seeing less and less of in their communities when other diseases, such as measles and malaria, are more consistent threats and other priorities like connecting to electricity, securing sources of clean water, and finding employment are going unmet.

Against this backdrop, parents in Kano and other northern states have often coordinated to refuse vaccines not because they don’t value them but because they have other urgent needs that the government hasn’t responded to.

Kadijah Abdulrahman sits in her courtyard with her daughter Aisha on her lap while VCMs discuss the oral polio vaccine in Kano on July 23. Andrew Esiebo/Courtesy of the U.N. Foundation

In neighboring Kaduna state, parents refused multiple rounds of vaccination until they were finally connected to electricity. In the city itself, one community put up signs that read: “[T]he government does not care about the conditions that we are in, they are only interested in polio.”

In this context, the volunteer community mobilizers are not only offering oral polio vaccines; they are often serving as connectors between parents and other health services. Beyond that, they are acting as sounding boards for what northern Nigerians want and are not getting.

“No one wants a child to have polio—it’s terrible. But there’s a million things that are terrible,” SteelFisher said. “So we have to build systems that are real and trustworthy, responsive and connected—and that is really hard.”


A man makes a roadside call as traffic passes in Kano on July 23. Andrew Esiebo/Courtesy of the U.N. Foundation

Women who work as vaccinators have also had to maneuver around outright violence. In 2013, Boko Haram insurgents shot two teams of health workers in Kano while they were making their rounds, killing nine women.

Outside a clinic in Kano’s Nasarawa district, Zainab Mustapha, who works as a VCM, spoke of how she was directly impacted by the insurgency. “My relative, Jemilah Yusuf, was shot by Boko Haram immediately after she finished school for nursing. She was about to start working for the government,” she said. “I used to get scared when I’d go out to work.”

In Pakistan, where vaccinators continue to be shot and public health workers were involved in U.S. efforts to track and kill Osama bin Laden, and in Afghanistan, where the Taliban recently banned door-to-door vaccination efforts, global ambitions for eradicating polio are still faltering because of the very same threats. And Nigeria still has its fair share of them as well.

“I used to get scared when I’d go out to work.”

In Borno—the northern state where Boko Haram emerged and where it maintains its last tiny pocket of territory—the insurgency continues to be an unwelcome obstacle for Nigeria’s polio eradication efforts.

Nigeria had hoped to wipe out wild-type polio in 2015, but then four children from the state who had been paralyzed by the virus came to the attention of authorities a year later.

“There is this group of 60,000-plus children who are trapped in Borno that may have never received any vaccines,” noted Bolu, the CDC immunization director. “You want to celebrate because it’s been a long road, but at the same time we know that there is a risk.”

For now, Nigeria’s polio eradicators are confident that the state isn’t concealing any more of the virus. They have been able to reach a steady number of residents by training combat-ready military personnel to either accompany vaccine teams or give drops of the oral polio vaccine to children themselves and by offering the drops at exit points out of the most difficult to reach parts of Borno. However, immunizing children in areas made inaccessible by the insurgents isn’t the only last-mile challenge.


Left: A baby is given drops of the oral polio vaccine at a primary health center in Nasarawa, Kano, on July 23. Right: A UNICEF vaccine security and logistics consultant shows the vaccine supply in a storeroom at the Kano Emergency Operation Center on July 23. Andrew Esiebo/Courtesy of the U.N. Foundation

One of the defining features of the campaign is that it has been able to secure a precipitous drop in the number of people who are paralyzed by the virus by getting drops of the oral polio vaccine into the mouths of children under 5—the most susceptible group. This has meant that community health workers who don’t have the training or qualifications to offer an injectable form of the vaccine can take on a central role.

But eradicating wild-type polio won’t entirely sideline paralytic polio, as the weakened form of the live virus used in the oral polio vaccine can mutate back into harmful variants if it circulates long enough in areas where many people have weakened immune systems or where vaccination rates are low.

As a result, the global polio eradication initiative won’t be able to wrap up their efforts right away, even when the wild-type virus is gone. Nigeria, Syria, Somalia, the Democratic Republic of the Congo, and Papua New Guinea have all struggled with cases of vaccine-derived polio in the last few years—51 cases have been reported to WHO between January and August.

Anis Siddique, who leads UNICEF’s polio team in Nigeria, meets with Aliyu M. Wada, a traditional leader and advocate for polio eradication, at Wada’s residence in Kano on July 23. Andrew Esiebo/Courtesy of the U.N. Foundation

“If you ask me from a global polio standpoint, as an eradicator, I’m not really concerned about circulating vaccine-derived polio,” said Anis Siddique, a doctor from Bangladesh who worked to eradicate polio in India, which was declared polio-free in 2012, and who now leads UNICEF’s polio team in Nigeria. “But if you ask me as a caregiver to children, I am very concerned because kids are still getting paralyzed.”

But according to Bolu, the risks are of completely different magnitudes: If around one in every 200 people who are infected with polio become paralyzed after the virus gets into their nerve tissue, the attenuated version of the virus found in the oral vaccine might do the same once every 2.7 million cases. But while paralysis caused by vaccine-derived polio might not harm Nigeria’s plans to be certified polio-free or might not be a public health threat on any comparable scale to the wild-type virus, it does threaten the trust that the VCMs, imams, and others have worked so hard to cultivate with parents who made eradicating wild-type polio possible in the first place.

As many of those responsible for rolling out vaccines in Kabul, Peshawar, Port Moresby, or Brooklyn can attest, the best shot at immunity from polio—a disease with no cure—can easily sit unused in cold storage if the social trust isn’t there to get a parent behind a closed door to say “yes” to immunizing a child.

The best way to hedge against this kind of polio outbreak is to switch entirely to the injectable form of the vaccine used in Europe and the United States, but that form is five times as expensive as the swallowable alternative and necessitates a much stronger health system than Nigeria has.


Children play on a hill above Kano on July 23. Andrew Esiebo/Courtesy of the U.N. Foundation

In a leafy compound in Abuja, the capital Nigeria fashioned for itself at independence, Nwosu prepared for the shift.

If Nigeria is certified as being polio-free, it will be just the beginning of her work; she is tasked with repurposing the resources of the country’s anti-polio efforts to strengthen its health systems. Nwosu said fighting polio had prepared her team for any outbreak—even the very worst. When a passenger arriving from Liberia brought Ebola to Lagos in 2014, what could have been a global health disaster was limited to 19 cases.

“I’m sure we shocked you,” Nwosu said. “Not too many people were expecting Nigeria to be able to deal with Ebola in such a short time.”

“We’ve been on polio for far too long,” she said. “We need to contain measles. We need to contain yellow fever.”

Fortunately, the same coalition of grassroots actors that made Nigeria’s milestone possible isn’t going anywhere. In Kano, Mustapha, the VCM, is clear about her next steps when Nigeria gets its certification from WHO. “If polio is kicked out of the country, people will still get pregnant, and their kids still have to get routine immunizations,” she said. “We will still have a lot to do.”

This reporting was supported by a press fellowship from the U.N. Foundation.

Jefcoate O'Donnell is an editorial fellow at Foreign Policy. Twitter: @brjodonnell