Child receives oral polio vaccine (WHO photo)

Nearly three hundred new cases of polio have been reported this year in Nigeria, with most of the suffering taking place in the predominantly Muslim northern states. If vaccinated, children are protected against the virus, which can cause death or paralysis. The World Health Organization was on track to eliminate polio altogether from Africa by this year or the next. But local officials in Nigeria's north stopped their vaccination program in 2003. They cited claims that the vaccine was part of some mysterious Western plot to render Muslims infertile. To prove the rumors wrong, the vaccine was taken to independent laboratories in Muslim countries, where it was shown to be pure and safe. In May, the governor of Kano State, the last Nigerian region holding out, finally agreed to resume vaccinations. But serious damage has already been done. The polio outbreak that began in Nigeria has spread throughout the continent. New cases of polio, all of them traceable to Nigeria, have cropped up in countries that had been free of the disease, including Burkino-Faso, Chad, Benin, Botswana, Ivory Coast, Togo, Cameroon, Ghana, Central African Republic, and most recently, Sudan. Joining us to talk about the polio outbreak are Jennifer Cooke, deputy director of the Africa program at the Center for Strategic and International Studies, and by phone from Switzerland, David Heymann, representative for the World Health Organization's global polio eradication campaign. Welcome, and thanks for joining us today.

David Heymann, are you there by phone?

Heymann: Yes, I am.

Host: How serious is the polio outbreak in Nigeria right now?

Heymann: At present polio in Nigeria represents 79% of all polio in the world. In other words, 79% of all children paralyzed since the beginning of this year by the polio virus are living in Nigeria. In addition, the spillover from Nigeria into the rest of Africa, has made Africa have 88% of all children who are paralyzed [by] polio in the world.

Host: Now of the children who are paralyzed, how many do they represent of the total number of people who are actually infected with the virus?

Heymann: For every child who’s paralyzed, there are about 200 children who are affected with the polio virus, but [who] do not develop paralysis. Therefore, they can spread the virus as what we call healthy carriers.

Host: And so how does that affect then the challenge that now faces the eradication program with what must be thousands of carriers of the disease?

Heymann: The challenge is that the borders in Nigeria, like in most African countries, are quite porous. People go back and forth across the borders on a daily basis in their usual work or their usual commerce. And with those people, many times, goes the polio virus. And therefore, the polio virus has recently gone into Chad and from Chad across into Sudan. So by road and by walking through these countries or travelling on buses, people transfer the polio virus from country to country

Host: If the vaccinations had not been halted, what was your prediction or your expectation of the number of cases that you’d be facing at this point?

Heymann: In January of this year, we called together the ministers of health of the six countries in the world that still have polio: India, Pakistan, Afghanistan, Egypt, Niger, and Nigeria. Those ministers of health studied with us the epidemiology of the disease -- that is, the number of cases present in the world. And they declared that they would be able to interrupt transmission of polio virus in human populations by the end of this year. Again in May these same health ministers met with W-H-O, and again they agreed that they could reach their target. So now what needs to be done is intensive work in Africa especially in Nigeria, to catch Nigeria up with the rest of the world.

Host: Jennifer Cooke, is Nigeria in particular, and the surrounding countries, are they facing an epidemic of polio as it goes into the fall when transmission happens more readily?

Cooke: As I understand it, yes. And Kano is the epicenter of that and we are just at the beginning of the polio season. I think as the rains come the incidents of polio goes up. And I think a number of countries around Nigeria are seeing cases as Doctor Heymann referred to. They’ve been putting a lot of pressure on Kano state to reinstate the vaccine.

Host: Now what were the circumstances of the vaccination program being stopped? What were the specific accusations, and where did they come from?

Cooke: It’s a little unclear whether it was rumor, whether there was some legitimate concern on the part of the leaders, or whether it was something of a political ploy to kind of aggravate the center, the federal government of Nigeria, and kind of show defiance to the West and to the central government. But as I understand it, last year a number of rumors began circulating which you referred to saying that this vaccine was a plot by the West to cause infertility among Muslims and perhaps also to spread HIV/AIDS. And I think it’s important, this isn’t the only place where that kind of rumor, a kind of an anti-Western rumor, and that the West has tried to control population for example has surfaced.

Host: Where else has that surfaced?

Cooke: It’s kind of a generic complaint. I think even among polio vaccines in India, there were some rumors, but the leadership did not take it up and stop the vaccine as was done in Nigeria, in Kano specifically.

Host: David Heymann, how often is that something that you run into in the polio eradication program and other infectious disease eradication programs -- running up against rumors that the vaccination program is somehow meant to hurt rather than help?

Heymann: Rumors about the safety of vaccines are prevalent throughout the world. They’ve certainly plagued the polio eradication program since 1988 when it began, first with the theory that the vaccine was contaminated with the HIV virus, and then later on that it was contaminated with family planning elements. There have also been rumors of vaccine safety in countries such as France where there was a concern about hepatitis B vaccine and recently in the United Kingdom where they was great concern about the vaccine that controls measles and rubella. So these rumors are continuing throughout the world at various times.

Host: And how do you address at the W-H-O those kinds of rumors?

Heymann: W-H-O first of all purchases, rather it doesn’t purchase, it pre-qualifies manufacturers of vaccines so that we know that products bought from those manufacturers are pure and that they undergo rigorous quality control. These vaccines are then purchased by UNICEF which provides those vaccines to childhood immunization programs around the world. And UNICEF has consistently purchased the vaccine that’s been used in polio eradication.

Host: Jennifer Cooke, you mentioned that this might have been in some large part due to internal politics within Nigeria where states in the Muslim North are at odds with the largely Christian government, national government of the South. How does that play out? What is achieved by local politicians by taking something like the polio vaccine and playing politics with it?

Cooke: A couple of things. I mean Kano has been the locus of a lot of volatility, political [2nd] economic marginalization, that has taken on religious overtones and become seen through the prism of Islam versus Christianity, which at base it probably is not. And then compounded further by kind of this anti-Western, anti-American rhetoric. I think a lot of opponents of the President [Olusegun] Obasanjo -- who runs a secular government, but who is himself a born again Christian -- there’s a lot of effort to defy him, to make him seem ineffectual, and Nigerian politics as chaotic. But also to put him in a very delicate political situation where he can’t come out too strongly against the Muslim leadership. And the Muslim leadership in this case can say, you know, “All we’re concerned about is the welfare of our people after all and we want to make sure that this vaccine is safe.” So this puts Obasanjo in a very delicate position, and in a sense kind of rallies a kind of anti-Western kind of radical elements and radical youth within Kano, who already feel, I think, very marginalized within Nigeria’s larger political system.

Host: David Heymann, did the politics within Nigeria make it harder for the W-H-O to address concerns, to demonstrate the safety of the vaccine?

Heymann: The W-H-O works with federal governments, we don’t work with state governments. And our role has been to facilitate what the federal government has done as it’s worked to mediate the situation in northern Nigeria. And we’re quite confident that this is now being mediated. W-H-O, for example, has provided the names of laboratories to the federal government, laboratories that could test the vaccine for safety should the government choose to do so. At the same time we work with Muslim leaders throughout the world, Islamic leaders, who have helped by providing assurance to populations in northern Nigeria that this vaccine is safe and that this vaccine will protect their children. And at the same time other countries around the world have rallied behind the states in northern Nigeria, other Islamic countries at the Islamic conference, and passed a resolution helping to ensure the governor of Kano and the northern states that polio vaccination has been effective in their countries and, if used properly, will eventually eradicate the disease.

Host: David Heymann, the government in Kano has said that it will resume the vaccinations. Have they actually begun that vaccination program yet?

Heymann: Actually, training for this campaign that will begin sometime this month began at the early part of this month. And now we see that there have been some meetings of the national immunization program and the state immunization program, and we understand that activities will begin within the next two weeks. Now, there have been false starts in the past, so we’re hoping that this time it will be a real start, and we believe it will be. The governor is convinced, from his committee, the vaccine is now safe.

Host: Jennifer Cooke, how does this affect neighboring countries and is there any risk of destabilization from, not just polio, but, you know when you have diseases that aren’t addressed, how do they affect the political situation, not only in a given country, but in the region?

Cooke: I think, we would hate for this kind of phenomenon to spread, but I think it does have implications for how we deliver assistance to countries in the future. I think, we should not hammer the governor of Kano for what he’s done. We don’t want to make him more intransigent and turn this into kind of a combative relationship. But I do think we need to think carefully in the future and face the fact that on certain assistance -- whether it’s polio eradication or HIV/AIDS, which is a lot more sensitive in many ways because it deals with prevention and so forth, or with education or economic development -- that we’re dealing with a certain level of mistrust that I think is going to take a lot of dialog, a lot of exchange, a lot of public diplomacy to overcome. I really applaud the W-H-O for really addressing uncertainty with facts rather than with kind of emotion or a combativeness. But I think we’re going to have to do that a lot more in Western Africa just to overcome that gap of mistrust that there is for the United States and its intentions.

Host: David Heymann, how is the spread of polio to other countries in the region affecting the W-H-O’s efforts of polio? Have you had to re-gear to address states where you thought you basically had things under control?

Heymann: Yes, actually the ministers of health of the African Union countries met here in Geneva at the time of what we call the World Health Assembly, the governing body meeting of the World Health Organization. That meeting was in May, and at that meeting there was great concern that because of the continued exportations of polio from Nigeria that there could be a very severe outbreak throughout Western Central Africa. Those health ministers resolved to have what we call synchronized immunization campaigns throughout Western Central Africa beginning in October and then November. These campaigns will be aimed at children five years of age and under, catching them up with their vaccinations so that there’s actually a barrier of protection in all these countries in Western Central Africa, so that new viruses, if they do come in to those countries, won’t implant themselves. This will cost the international partners of polio eradication -- and those partners are Rotary International, UNICEF, World Health Organization, and the Centers for Disease Control and Prevention in Atlanta -- will cause the partners a hundred million dollars U-S additional.

Host: Jennifer Cooke, how do these efforts affect relations between governments in the region? Is it something that they are cooperating with, as suggested here, or is it a source of some tension?

Cooke: I think, as I said, it is the African states surrounding Nigeria that put a lot of pressure on Nigeria and were in a better position to do so than, I think, the West was. There are a lot of very delicate issues with Nigeria. Many to do with Sharia in the North, many to do with the volatility in their oil resources in the South, so that the U-S has a lot of sensitivities that it needs to step around. So in this instance, I think, the surrounding African states and the organization of Islamic states [were the ones] who really stepped up and said, you know, “This is safe. You need to go with this.” They were in the best position to do so.

Host: David Heymann, you mentioned that there are other countries in which polio is endemic, among them, Egypt, India, Pakistan, Afghanistan. How is the program for eradicating polio in those countries going?

Heymann: If you look at countries outside of Africa, these countries represent 12% of all children paralyzed with polio since the beginning of the year. So actually we have two different situations. We have the African countries where there’s a danger of a massive outbreak of polio in the rainy season which is just beginning now. And there the concern is mobilizing the resources and the people to do high quality immunization campaign so that polio will not become epidemic, or if it does become epidemic, so that the transmission can be interrupted immediately. In the rest of the world the danger is apathy because they have such low numbers of polio cases. For example in India, this year to date there have been 18 children paralyzed by polio. Last year at this same period there were 87 children paralyzed. So we’re seeing a great decrease in polio throughout Asia and in northern Africa and Egypt. And the danger in that is that there will be apathy. Governments will say, “Well, we’ve done a good job, we can now let down our guard.” And when that happens we’d see that polio comes back. It happened in India in 2002, and they went from two-hundred-fifty-some cases in 2001 to over sixteen-hundred cases in 2002. So it’s in a very dangerous equilibrium right now, and these countries that have done such a good job to date this year must continue the effort, and by the end of this year it’s feasible that they will have interrupted transmission of the polio virus.

Host: Now at what point does that interruption of transmission become so large that you can finally say that the virus has been eradicated?

Heymann: As long as the virus is present in any country, it will be a danger to the rest of the world as we see right now in Africa. So the idea will be to interrupt human to human transmission of the virus everywhere. This virus is in no animal, it’s in no plant, it doesn’t exist in nature without living in humans. It’s only present in humans. If you can stop transmission of that virus from person to person, that virus will die out and polio will be eradicated.

Host: Jennifer Cooke, one of the things you mentioned was that the issues that affect polio eradication are also there with the often more sensitive issue of dealing with HIV and AIDS in Africa. What does this case in Nigeria say about where efforts are going to need to go to push towards ameliorating HIV/AIDS in Africa? And where the help is going to come from?

Cooke: I want to say that we haven’t seen this particular kind of phenomenon on HIV/AIDS yet. Perhaps [Thabo] Mbeki and his denial of the link between HIV and AIDS is somewhat similar in a way–

Host: That was in South Africa?

Cooke: In South Africa. But I think it is a signal that we might encounter this kind of problem in other areas than polio. I think part of it is we’ve in a way -- there’s very little U-S presence or Western presence in northern Nigeria -- so there’s not a lot of opportunity for northern Nigerians, whether they’re religious or political leaders or just regular folk, to dialog and understand what the West and what the United States is about. For example, we have no political presence in northern Nigeria, travel and exchange, educational exchange, cultural exchanges. Those are strapped for funds, and because of immigration restrictions, are a lot more limited. It’s that kind of persistent dialog to hear where is this anti-Western sentiment coming from. I think that we need to get at the root at, and it’s not just for health, it’s not just for polio, it’s for a whole range of other things.

Host: How do you address that, the suspicions, and the belief that there’s perhaps too much Western influence, and yet by increasing Western presence, is there a tension there?

Cooke: Perhaps, but I think in the case of northern Nigeria, there’s not enough dialog. I was part of a public diplomacy effort that went out there talking about what are your perceptions of the U-S. People focus tremendously on U-S policies towards Israel and Palestine dating back sixty years. And there’s a lot of knowledge, a lot of anger, a lot of fervor, a lot of desire to really discuss these things and talk –- what is the United States doing, and then in Iraq and so forth.

Host: I'd like to thank my guests: Jennifer Cooke of the Center for Strategic and International Studies, and by phone, David Heymann of the World Health Organization. Before we go, I'd like to invite you to send us your questions and comments. You can e-mail them to ontheline@ibb.gov For On the Line, I'm Eric Felten.