Inside Nigeria’s Polio War-Room

 

…How Bill Gates, Dangote rallied Northern Leaders

By Mustapha Kabir/Abuja

Dahiru Abdulmuminu has spent much of his 14 years on the floor. Crippled from waist, life has been brutal and harsh.  Few years ago, he got two walking sticks which made life a little bearable for him.

He missed out on education for much of his life and he has come to accept that his lot in life would revolve around begging for alms to survive once he is old enough to be on his own. Many times, he had sought answers to why he suffers the pains of paralysis and he got the same answer.

Everytime.

“They said I sat in the field where the evil spirit swept,” Dahiru said, bluntly like he had practiced the art of giving such answers without emotions.

In his Katanbare community in Adamawa state, northern Nigeria, myths and superstition reign supreme. Whenever an incident occurs which cannot be explained, it was attributed to the work of a djin, an evil spirit or Ciwondaji, a disease of the bush.

The disease that crippled Dahiru and thousands of other Nigerian children for many decades, subjecting them to a life of pain and misery was nothing but the Wild Poliomyelitis Virus.

A piece of cherry news

On the morning of Friday, June 19 2020, the Executive Director/Chief Operating Officer ( ED/CEO) of Nigeria’s primary health care agency, the National  Primary Health Care Development Agency (NPHCDA),  Dr. Faisal Shuaib, was preparing his presentation which would be delivered through zoom teleconferencing to the African Regional Certification Committee (ARCC).

His presentation to the ARCC marked the end of over 10 years of excruciating campaign, labour, sweat and blood to end the Poliomyelitis virus in Nigeria.

It was Nigeria’s second attempt to get the ARCC certification which would confer on the country the status of a polio- free nation.

For Nigeria to be certified polio-free, the country must have completed three unbroken years of no reported case of the Wild Polio Virus (WPV).  Nigeria’s first attempt to get the certification ended in tears  in 2016, when four WPV cases suddenly sprang out in Borno state, northeast Nigeria just months to the polio-free certification. This threw into the wind years of hard work and every stakeholder began work all over again.

The import of the meeting was not lost on Shuaib as he was not charting an unfamiliar terrain. Before he was appointed to head the NPHCDA by President Muhammadu Buhari in 2017, he was a Senior Programme Officer at the Bill & Melinda Gates Foundation (BMGF) in Seattle, USA where he was responsible for developing and implementing strategies on Polio outbreak response in Africa.

Before joining the BMGF, Shuaib had played a key role in ending the Ebola Virus Disease (EVD) outbreak in Nigeria acting as the Incident Manager of the Emergency Operation Centre in 2014.

Later that afternoon, Shuaib sent out a tweet which many around the world had eagerly waited for after 10 years of hard work. “What a remarkable achievement and milestone for Nigeria. The Federal Ministry of Health, NPHCDA and stakeholders today gathered to chronicle our journey towards a polio certification.

“To celebrate this milestone-the acceptance of Nigeria’s claim of Wild Polio Virus free status by the African Regional Certification Committee- the NPHCDA and the partnership is having a zoom party.”

Shuaib’s announcement effectively took Nigeria out of the triad nation including Pakistan and Afghanistan, the three nations on earth yet to eradicate the childhood disease of Polio.

But how did Nigeria, against all odds-which included the murder of nine polio vaccinators in Kano in 2013, distrust and rejection of the vaccines; manage to eradicate the deadly virus?

This is how it happened.

The unending trend

For many years, Nigeria had maintained its unenviable position as one of the three remaining countries where polio is still endemic.  In 1988, the World Health Assembly (WHA) had adopted a resolution calling for the eradication of polio worldwide. It launched the Global Polio Eradication Initiative (GPEI).

The GPEI was championed by the World Health Organisation (WHO), Rotary International, United Nation Children Education Fund (UNICEF) and national governments.  They were later joined by the Bill & Melinda Gates Foundation (BMGF) and Gavi, the Vaccine Alliance.

The goal was to interrupt and stop polio; estimated with a case load of 350,000 in 125 endemic countries. The GPEI made progress and over the course of 20 years, polio cases dropped by 99 percent and all the regions of the world were certified free save three countries: Pakistan, Afghanistan and Nigeria.

By July 2009, the Nigerian government and the traditional leaders in Nigeria’s 19 northern states decided to declare a polio emergency in the region as the polio infection rate more than doubled the number in the previous year standing at 541 cases. The rising cases especially type 2 vaccine-derived poliovirus (cVDPV2) also spread internationally to the Lake Chad Basin and Niger republic.

In Nigeria, polio remained endemic with cases rising and falling.

In 2005, there were 1143 cases which dropped to 353 two years later. But by 2008, there was an upward surge to 861 cases which later dropped to 541 in 2009.

Nigeria’s polio cases had been restricted to the 19 northern states, with its densely populated grassroots, cultural and religious barriers.  But much as the government tried to gain acceptance among the populace, northern Nigeria presented a formidable opposition for immunisation.

The opposition to polio immunisation was spearheaded by some religious leaders who claimed that the vaccines had been laced with family planning chemicals that would destroy the fertility of women.

“Somebody brought the economic politics into the issue of vaccines,” said Muhammed Bala Ahmad Limanci, the Chief Imam of Bauchi. One of the most outspoken and coordinated religious leaders, he had been an advocate for primary health care strengthening and had made the linkage between polio and sanitation early in the campaign.

“They said the vaccines have been polluted with family planning chemicals that whoever takes the vaccines is destroying his own fertility. That is the beginning of the problem,” Limanci revealed.

Mallam Adamu Maina is a prominent figure in his Sabuwan Kariya community in Bauchi state, he was one of the fiercest opponents of polio vaccination. His anti-vaccination activity was so prominent words got to the Emir of Dass, Alhaji Othman Bilyaminu Othman who invited him and enlightened him on the importance of the vaccinations.

“Since the Emir spoke to me, I had a change of heart and I began to advocate for the polio vaccination for our children. Today, I am one of the most important advocates and there is hardly any child who is not vaccinated here,” he said.

But not all opponents had a change of heart like Maina, the opposition grew in the local masjid and community houses, the ‘evils’ of vaccines also spread from one household to another and at the sight of the polio vaccinators, mothers would drag their children indoors and shut the door.

The call of the traditional rulers

The Bill & Melinda Gates Foundation had made the eradication of polio worldwide one of its core mandates.

“Polio eradication is one of our top priorities, and as a major supporter of the GPEI, we contribute technical and financial resources to accelerate targeted vaccination campaigns, community mobilisation, and routine immunisations.

“We have a unique ability to contribute by taking big risks and making non-traditional investments. Examples include our investments in vaccine research and our establishment of emergency operations centres in Nigeria, Pakistan and Afghanistan,” the Foundation said in its Polio Strategy Overview document.

In Nigeria, Gates found a willing ally, the richest man in Africa, Aliko Dangote who has also turned his attention to public health through his Aliko Dangote Foundation (ADF). The businessman has a lot of reason to give back to Nigeria, over the decades, he had enjoyed a near monopoly of lucrative imports in Nigeria and has maintained a strangle hold on the manufacture of household items like Sugar and flour.

But the bulk of his money would come from cement manufacturing where he holds the largest share of the Nigerian market and slowly moving into the African market. With the same business philosophy, Aliko and Bill made a decent pair.

In February 2009, the then world’s richest man and co-chair of the BMGF, Mr. Bill Gates visited Nigeria and paid a very important visit to the Sultan of Sokoto, His Eminence Muhammadu Sa’ad Abubakar 111.

His visit to the Sultan was a closely guarded secret and no detail was leaked until he was safely with the head of Nigeria’s Muslims. Gates had gone to solicit the help of the Sultan for the polio eradication efforts. The meeting ended with a firm assurance from the Sultan that the traditional rulers in northern Nigeria will commit to the polio eradication efforts.

“We understood that one of the barriers was that linkage with the community, so at that point we went back to the traditional institution and solicited their help. The Sultan came back to us with the idea of setting up a coordinating platform for all traditional institutions in northern Nigeria, that is what became the Northern Traditional Leaders Committee on Routine Immunisation and Primary Healthcare Strengthening,” Shuaib said in an interview.

The platform that was set up by the Sultan was to be known as the Northern Traditional Leaders Committee (NTLC) comprising of the Emirs and religious leaders in all the northern states of Nigeria. The NTLC was set up in Kaduna and in July 2009, was inaugurated in Abuja.

 According to the first chairman of the NTLC and former Shehu of Bama, late  Alhaji Shehu Kyari Ibn Umar El-Kanemi: “This Committee was to liaise with the primary health care agency and give feedback to the traditional leaders so that each leader would begin the process of sensitization in his domain.”

It was a big gamble and after years of abysmal failure the polio immunisation campaign seemed to be gaining acceptance. The Sultan had bet on the age-long culture of respect and obedience of the people to their Emirs and religious leaders which seemed to have paid off.

According to Engr. Saleh Muhammadu, the Mai of Kaltungo in Gombe state: “In the north, people are much more attached to their traditional rulers. So whatever problem they have the first port of call would be the Emir, or the District head, the village head or the Mai-angua.”

But the Emirs did not immediately jump into the bandwagon without doing the due diligence. In an interview, the Emir of Argungu, Kebbi state and the vice chairman of the NTLC, Alhaji Samaila Muhammad Mera, the NTLC engaged scientists within the north and conducted fact finding missions to countries where the vaccines are produced including Egypt and Indonesia, two Muslim majority countries.

The master plan

The first agenda of the NTLC aside awareness creation was to domesticate the entire immunisation process within the communities. Mera said: “One of the reasons for the rejection of the vaccines was that the people thought those vaccinators are aliens to the culture, society and the environment where the children lived.

“So we decided to domesticate it and told every village head to bring someone within their community to deliver the vaccine and another person to record the activities. With that we created ownership and it became a contest within our diverse traditional leaders, nobody wants to see the disease in his community anymore.”

The NTLC devised a way to also resolve every conflict and non-compliance and anyone found flouting the rules is reported to the next chain of command until it gets to the Emir. “Traditional institutions are very relevant in all activities that affect their community,” Emir of Dass said.

The religious leaders had a more delicate assignment, most of the anti-polio immunisation messages had been delivered by Imams so they had to thread softly. “At the heart of the rejection is the suspicion about European ploy to decimate the population, so we had to use wisdom, we used our mosques and other gatherings like wedding and naming ceremonies,” Chief Imam of Ningi Bauchi state, Dr. Umar Muhammad Liman said.

Perhaps most significant act of the NTLC members was vaccinating their own families publicly and ensuring compliance by their own household. The former Emir of Kano, Alhaji Samusi Lamido Sanusi was reported to have drank a vial of vaccine publicly to prove it is safe for the children.

By 2010, the polio caseload in Nigeria was a mere 21 according to a WHO 2014 case count.

The deadly encounter

Nigeria was making steady progress in its fight to eradicate polio with the support of the NTLC when tragedy struck in February 2013.

It was a bright morning at the primary health care centre in Hotoro, a municipal of Kano state, polio vaccinators were preparing for a long and hard day, of knocking on doors and entreating parents to bring out their under five years children to be administered two drops of the polio vaccine.

Since 2009 when the NTLC became involved in the polio eradication campaign, there have been marked improvement in the reception of the vaccines. More community mobilisers have been employed and Nigeria’s caseload has been on the decline.

No one at Hotoro thought the day would be different, until men suspected to be members of the terrorist group; Boko Haram arrived on a motorbike, opened fire on the health workers and sped off as fast as they arrived.

Some minutes after the attack, a similar scenario played out in Unguwa Uku as gunmen, again riding on motorbikes opened fire on polio vaccinators who were waiting to collect vaccines for the house-to-house immunisation. When the smoke from the gunpowder cleared, nine female vaccinators laid dead.

The incident was a major turning point in Nigeria’s drive towards eradication of the polio virus. According to Shehu Abdullahi who was then Executive Secretary of the state Primary Healthcare Management Board the state ministry of health temporarily suspended the immunisation campaign as fear gripped the vaccinators.

When the exercise resumed later that year, immunisation was done under the cloak of fear and secrecy. Vaccinators hid their boxes under the veils and visited only with disguised armed guards.

The state also got help from the members of Kano State Polio Victims Trust Association (KSPVTA) who were deployed to their own communities to create awareness.

“We assign each member to his neighbourhood, where he knows everybody, and tell them to be wary of any strange faces or movements around them,” said Tudun-Wada the chairman of the Association.

But the greatest challenge to the vaccine campaign was the insecurity in northeast Nigeria. The deadly Boko Haram insurgency in Borno, Adamawa, Yobe states had cut off thousands of children who could be carrying the WPV.

INFACTNG exclusively gathered that stakeholders including the BMGF were worried about not meeting the deadline for polio-free certification if they cannot get the children behind enemy lines.

“We had to work with the military to get behind the conflict lines, it was a very dangerous endeavour and the fear is that of a repeat of what happened in 2016 if we cannot reach all these children,” a source close to the immunisation campaign in Borno said.

It is however not clear if the campaign was able to reach an estimated 200,000 children caught in the Boko Haram conflict.

Charting a course for the future

Inside the offices of the NPHCDA, a little party was ongoing.  After the acceptance of Nigeria’s polio-free claim by the ARCC, Shuaib and other stakeholders had a little zoom party. But for him and his organisation, the work to keep Nigeria polio-free might just have begun.

“We have to maintain this status. This means we have to continue to give our kids the vaccination that they need against the virus, and all the other vaccine preventable diseases. We should not forget that we still have Afghanistan and Pakistan that are endemic for wild polio viruses, which means there is still a potential that this viruses may be imported into Nigeria,” Shuaib said at the meeting.

Stressing further: “We live in a global village, you can see how COVID-19 spread so fast from China, by the same token, we could have wild polio virus spread from these two endemic countries.”

President Muhammadu Buhari was quick to take credit for the polio campaign successes calling it a dividend of his administration even though NTLC was formed during the previous government.

In a statement signed by his Senior Special Assistant on Media and Publicity, Garba  Shehu, the President said: “ This achievement is not only one of the great successes of this generation of Nigerians but also one of the obvious dividends of this administration, which is consistent with our progressive investment in the health of our people since 2015.”

The next stage of the fight according to experts would be to institutionalise Routine Immunisation (RI). The NPHCDA said it has enough stock of vaccines to keep polio at bay. “The country will continue to make sure that we put in place all of the strategies. We will continue to look everywhere to make sure that there is no child anywhere in Nigeria that will be paralysed from the wild polio virus,” Shuaib said.

Nigeria currently is making steady progress in RI coverage and would have to maintain the tempo in order to stay polio-free.

“It’s an amazing opportunity that we have to make sure that we do not see a resurgence of the wild polio virus, an opportunity to make sure we protect all our kids from vaccine preventable diseases.

“With the support we are getting from state governors and traditional institutions, I think we are in a better place than where were a few years ago. There is a steady increase in coverage. In 2015, we had 40 per cent routine immunisation but, in 2018, it increased to 57 per cent, we are at 67 per cent now,” the NPHCDA boss said.

The certification would take place from August 24 to August 28, 2020 when a formal certificate would be presented to the Nigerian president. This will be followed by a nationwide celebration.

But there will be children who will not be part of that celebration, children like Dahiru, who have been destined to spend the rest of their lives, scared by polio.