This is the second in a five-part series on global polio eradication, based on interviews in Washington, in Atlanta at the Centers for Disease Control and Prevention, and at National Immunization Days in northern Nigeria.
In 1988, four international aid groups - the World Health Organization, UNICEF, Rotary International and the Centers for Disease Control and Prevention - launched a global campaign to rid the world of polio. They hope to reach that goal by 2005.
Conditions are ripe for polio in Nigeria. It has the largest population in Africa - 120 million people. Public sanitation is a serious problem, and the national rate of immunization is low. A 2001 UNICEF study said only 54 percent of children between 1 and 2 years of age are routinely immunized. That figure drops to 4 percent in the northwest, where polio is most problematic.
Even so, in 2001, the number of new polio cases reported in Nigeria fell from 2,000 in the previous year to to just 57 cases. Experts credit this positive trend to Nigeria's National Program on Immunization.
In the late 1990s, Dr. A. Awosika was brought into Nigeria's newly-elected democratic government to develop the program. She said the administration then and now places a high priority on public health services, especially for children. "To me, it's a success and an encouraging one. It started from nowhere and with nothing in late 1998. We had no data to work with," she said, "and now we have a strong database in Nigeria, and immunization can build on that. We have brought the child into focus in Nigeria because we have placed so much premium on what it means to give the child its rights."
Since 1999, the National Program on Immunization in Nigeria has mobilized 200,000 people for National Immunization Days, held two or three times a year for house-to-house campaigns. The focus is on polio, although recently, vaccinators have also begun to administer doses of Vitamin A, which helps promote healthy bone growth, bolster the immune system, and prevent blindness.
The massive exercise includes a strong support staff of international aid workers from dozens of international agencies. But most of the vaccinators, field guides, surveillance officers, team supervisors, trainers and managers are Nigerian.
Two-person teams - a vaccinator and a town guide - are assigned to knock on every door in the country.
In the weeks before National Immunization Days, training sessions take place in community centers, clinics, hospitals and schools across the country. Housewives, health workers, civil servants and unemployed citizens are hired for the campaign. The women work as vaccinators, the men as local guides. They practice their parts, take tests on polio facts and are coached by the trainer to "leave no child behind."
"You are not going have problems," the trainer reassures them. "If you explain very well, no one is going to refuse you. Everyone is moving together. Your ward head knows every corner of the village and he is leading to show you the children below five years. Just exercise patience and try to explain and they will accept you. Thank you."
The entire country is mapped - every district, every local government, every ward, every settlement, every house, every footpath, every landmark.
We turned off the main highway on to a dirt road into Kibiya, a district with dozens of small settlements where goats and sheep roam freely. We stopped along a street of crumbling concrete houses and watched as a crowd gathered around a town crier who shouted, "The District Head is calling on members of the community to cooperate [with] immunization teams who are making house to house visits. This is to immunize children under the age of five against poliomyelitis."
In Kibiya, Colonel Anna Odey - a squat and lively 63-year-old retired army nurse and grandmother - was clearly in command of the immunization operation. She imposed stern, but kind, military discipline on her 54 two-person teams. Wearing green aprons and carrying Styrofoam boxes with vaccines and ice packs over their shoulders, the teams must reach every child in 129 settlements.
Having worked on polio campaigns over the last several years, Colonel Odey said what has changed is that the Islamic religious leaders now endorse the initiative. They are father figures, she explained, that men and women in Northern Nigeria look to for spiritual guidance. She said this is a result of a concerted effort by the National Program on Immunization to get their help in combating rumors and misconceptions that connect the vaccine with AIDS or infertility.
"And we have ward heads and village leaders who uphold the traditional institution and authority. And, with them backing us, we get the inhabitants to accept this immunization for their wards without problem," said Colonel Odey. Asked how they are sure no child is missed in such a remote area, she replied, "That is the work of using the villagers themselves, who know the nooks and corners of each settlement, and the village and ward heads [who] know all of their inhabitants, that even if I should go back to one of them and say, 'In a house in this corner or this corner the man refused,' without even telling him, [the ward head] might even know the person, and he would call and ask, 'why have you rejected [the immunization.]' That is, if there is a rejection."
Asked if she felt confident polio could be eradicated, Colonel Odey said, "By the grace of God and the tempo we are going, we will wipe polio out of Nigeria."
Nigerian health officials say that based on the success of the door-to-door campaign, they are confident they can stop polio transmission by year's end. The World Health Organization will certify Nigeria as polio-free after three years with no new cases.
In part 3, we look at the importance of surveillance in halting the spread of the crippling poliovirus.
Photos for this series provided by Rosanne Skirble