UN mediates polio deadlock in Nigeria

New infections threaten global eradication drive
From Africa Renewal: 
page 5
In the past, polio was a major crippler of children in Africa, but it is now nearing eradication. Photo: WHO/Jean-Marc Giboux

A long and damaging dispute between state and federal authorities in Nigeria over the safety of UN-supplied polio vaccines may be nearing an end. The progress follows the personal intervention of UN Secretary-General Kofi Annan and his Special Adviser on Africa, Under-Secretary-General Ibrahim Gambari.

Meanwhile, the World Health Organization (WHO) calls the spread of new infections a "stark warning" of the danger of not resuming immunizations.

The controversy began in July 2003, after some Islamic religious leaders charged that vaccines supplied by the UN Children's Fund (UNICEF) had been deliberately contaminated with sterilization chemicals as part of the US war on terrorism. In response, four state governments in predominantly Muslim northern Nigeria halted a vital immunization campaign until their safety concerns were met. Now all but one state has agreed to resume vaccinations, and local authorities in the final holdout, Kano, have indicated they will soon follow suit.

Despite efforts by both Nigerian federal government and UN health officials to persuade local authorities to resume vaccinating children against the incurable and crippling disease, state authorities maintained that the vaccines were impure and unsafe. Efforts to allay those concerns by laboratory testing failed to resolve the problem. Federal Nigerian government and independent testers announced last year that no contaminants had been found, but tests by the Kano state government were said to confirm the presence of oestrogen and other foreign substances. With the scientists at odds and relations between the Muslim north and the federal government already strained by communal Christian-Muslim violence and the adoption of Islamic Sharia law by most northern states, the dispute ground into political standstill -- with disastrous results.

Northern Nigeria is one of only six remaining pockets of naturally occurring polio on earth, together with India, Pakistan, Niger, Afghanistan and Egypt. But because Nigeria's immunization programme was interrupted, the strain unique to the region has spread, reinfecting southern Nigeria and at least 10 other African countries -- Ghana, Togo, Benin, Burkina Faso, Chad, Côte d'Ivoire, the Central African Republic, Cameroon, Sudan and distant Botswana, over 4,000 kilometres away.

The outbreak is expected to cost $100 mn for new vaccination drives to contain the disease in these otherwise polio-free areas. Even worse, it is endangering a 16-year, $3 bn international effort to completely eradicate the disease -- an unprecedented international effort that the WHO describes as the world's "best and perhaps last" chance to eliminate polio.

The Secretary-General intervenes

It was against this backdrop that the principal stakeholders in the global eradication campaign, the US government, WHO, UNICEF and the charitable organization Rotary International, approached Mr. Annan for assistance in ending the crisis. Rarely do senior UN officials become involved in relations between the national and state governments of member countries. Yet during his tenure Mr. Annan has gone out of his way to associate both himself and the office of the Secretary-General with urgent global public health issues, including HIV/AIDS and malaria. With the global eradication drive at risk, UN officials say, Mr. Annan readily agreed to help.

That help came in the person of Mr. Gambari, his top Africa troubleshooter -- and a former Nigerian foreign minister -- who was dispatched to Nigeria in early March to deliver a personal message to the parties and help them resolve the problem. Mr. Annan's message, Mr. Gambari told Africa Renewal, was very simple. "First, that eradicating polio from the world is doable and tremendous progress toward that goal has been made. Second, that Nigeria is a source of infection in other, polio-free countries. Third, that resources devoted to the polio issue can best be used for . . . other development priorities. And finally, that the Secretary-General and the entire UN system was ready to support Nigeria's polio programme."

The veteran diplomat said that his principal challenge was to untangle scientific questions about the vaccine from political and religious issues. "The Secretary-General emphasized to all that this is a public health issue. This is about the children. . . . Whatever the political differences, [leaders] . . . have to put political considerations aside to ensure that all the children of Nigeria are immunized and the disease does not return to places where it has already been eradicated."

High-level contacts

The strategy, he continued, was to mobilize Nigeria's most influential political and religious leaders -- particularly northern leaders -- behind the conclusions of a government verification commission that inspected vaccine manufacturing facilities in South Africa, India and Indonesia in February. The 23-member panel, representing all the stakeholders in the dispute, declared the vaccines safe for use.

On his first day in Nigeria, therefore, Mr. Gambari met with two former heads of state, General Abdulsalami Abubakar and General Muhammadu Buhari, about the crisis. Over the next week, Mr. Gambari met or spoke with five of the country's six living former heads of state and succeeded in winning their support for the commission's report and the resumption of immunization activities. He also met with President Olusegun Obasanjo, traditional and religious leaders, and senior government health officials.


Global polio cases *

 2003

June 2004
Nigeria

355

 257
India

 225

 12
Pakistan

 103

 14
Niger**

 40

 18
Afghanistan

 8

 3
Egypt

1

 1

* excludes reinfections from Nigeria, estimated to exceed 400

** includes polio reinfections from Nigeria

Source: UN Africa Renewal from World Health Organization data

Such political access by the under-secretary-general was made possible by his long service to successive Nigerian governments, including a decade-long stint as Nigerian ambassador to the UN during the 1990s. Of those six former heads of state, he noted, "I actually served with five, including as foreign minister under [General] Buhari. In Nigeria I am not seen as a partisan politician."

Mr. Gambari also used his ties to Nigeria's influential traditional rulers in his mission. When he sought to enlist the support of two key Islamic traditional leaders, the sultan of Sokoto and the emir of Kano, he said, "I asked my brother, the emir of Illorin, to contact them to prepare the ground, and he did." When President Obasanjo launched the immunization drive in Zamfara state in late March, he was joined by the sultan of Sokoto and other prominent northern leaders.

Mr. Gambari also sought to improve communications between federal and state officials. "When I went to Kano I took federal government officials. I encouraged the [national] ministry of health to be as inclusive as possible on the [verification] committee final report, to remove the religious and political aspects and build bridges between the federal and state governments."

The final hurdle

As of late June, Kano officials indicated that they will permit immunizations to resume. Part of the difficulty in the past, Mr. Gambari observed, was that tests in South Africa did discover minute traces of oestrogen in some vaccine samples, a finding that Kano state government officials viewed as vindication for their caution. In fact, say WHO experts, the impurities were natural, found in the water used during manufacturing and at concentrations far lower than in birth control drugs. "Kano [was] the only state resisting immunizations because they were not satisfied that their views and people had been sufficiently involved in the verification exercise," he said.

To overcome that last obstacle, Mr. Gambari explained, the UN proposed a compromise: "We asked the governor of Kano if there was a country we could import the vaccine from that he would be comfortable with. He said Indonesia. We've encouraged [UNICEF] to ensure that enough vaccine is imported from Indonesia to cover the immunization needs of Kano. . . . All that remains is for the state and federal governments to sit down and work out the process."

Since then, Nigerian Health Minister Eyitayo Lambo has announced that the state and federal governments have resolved all remaining issues and that immunizations in Kano will proceed with vaccines from Indonesia. An early start is vital. To reach all of Kano's children after the long halt in immunizations, local officials will have to blanket the state with no fewer than six immunization campaigns before the end of the year. Should that happen, WHO officials report, a massive, coordinated regional campaign to contain the Nigerian outbreak would follow, involving the re-immunization of 74 million children in the rest of Nigeria and 21 other countries in West and Central Africa early in 2005.

The US war on terrorism and the deaths of 11 children who participated in a 1996 drug test in Kano by the US pharmaceutical company Pfizer have contributed to public suspicion of the polio vaccine. The war is widely interpreted as an attack on Islam by residents of the area, and international pressure on the state to resume polio immunizations is perceived as coming most aggressively from the US.

But in the end, Mr. Gambari noted, it comes down to doing what is right for the children and good for Africa. "We told the leaders that this [crisis] is in no way in their interest. Nigeria is a leader in NEPAD [the continental development blueprint], it is a leader in trying to bring peace and stability and development to West Africa." And until Kano completes its vaccination programme, he concluded, "the situation is still serious. As long as all Nigerian children are not immunized, all the gains that have been made can still unravel."