Since the end of World War II, global assistance in development and the conquest of disease have been constant elements of U.S. foreign policy. How pivotal health issues have been at any given historical moment has varied, however, based both on a particular administration's priorities and on U.S. perceptions of the threat posed by a given disease and the effectiveness of available means to control it. Today, for example, the United States is working together with many nations in a multi-billion dollar campaign to prevent or mitigate a global pandemic of virulent influenza—an effort the Bush Administration defines as a matter of national security.
Immediately following World War II, the general air of optimism that dominated American thinking was complemented by fundamental breakthroughs in disease control: the development of DDT and other pesticides to control disease-carrying flies and mosquitoes; antibiotic inventions that revolutionized bacterial treatment; and a succession of new vaccines that virtually eradicated measles, diphtheria, typhoid fever, polio, whooping cough and other childhood infectious diseases from the wealthy world. Buoyed by scientific successes, as well as America's post-war global economic position, Congress dedicated funds throughout the 1960s and 1970s specifically for the eradication of diseases worldwide, designating the monies for use both in bilateral and multilateral efforts (mainly through the World Health Organization and its sister agency, the Pan American Health Organization). As the Cold War heated up, the Soviet Union and United States waged a sort of proxy war over health, each side trying to demonstrate the superiority of communist or capitalist approaches to the conquest of disease. The major beneficiary of this competition was the smallpox-plagued Third World, which saw the disease eradicated in 1977 thanks to an unprecedented, highly aggressive global campaign.
By the end of the 1970s many public health leaders thought it possible to eradicate a long list of infectious diseases, including tuberculosis, malaria, measles and polio. But as the 20th century rolled on, the obstacles to eliminating many diseases rose, in part because the expanding HIV pandemic created vast pools of immunologically vulnerable populations in which tuberculosis and malaria thrived. By the end of the 20th century there were actually more people dying of malaria and tuberculosis annually than there were at the beginning of the century.
The one disease that remained a viable candidate for eradication was polio: The prevalence of the virus was unrelated to HIV; pediatric vaccination was highly effective and affordable; the virus did not spread in dangerous forms in animal populations; and by the end of the 1980s three continents—the Americas and Europe—were on the verge of eradicating polio cases, paralysis and deaths. With high hopes, the world community set out to make polio the second great eradication campaign in human history.
But just when victory seemed at hand, and the virus had been eliminated from nearly all human populations, a tragic set of political events in northern Nigeria reversed the momentum, resulting in the horrific spread of polio to children in much of the Islamic world. In the "Cliff's Notes" version of this saga reported in the world media, the potential collapse of the global polio campaign has been described as a confrontation between Nigerian Islamic leaders and the World Health Organization. That simplistic picture fails to capture a highly nuanced reality, however: The actual story is one from which policymakers the world over should learn vital lessons regarding religious tension, the security implications of weak or absent public health infrastructures, the political limitations of UN agencies, the folly of purely bilateral aid efforts, and the volatility of long-term distrust not only of people against their own governments, but against "the West" writ large as well.
Eradication and Revival
The 1988 World Health Assembly in Geneva, Switzerland created the Global Polio Eradication Initiative (GPEI) to eradicate polio by the year 2000. The World Health Organization (WHO) took the lead for the GPEI with support from three other organizations: UNICEF, the U.S. Centers for Disease Control, and Rotary International. The program proceeded very successfully: Though not completely eradicated by 2000, polio was no longer endemic—continuously transmitted in a specific area—anywhere in South America, North America, Australia or Europe. By 2003, polio was at its lowest level since the first known polio epidemics of the early 20th century. In 1988, more than a thousand people a day were infected with polio in 125 countries. By 2003, only 784 people worldwide contracted polio for the entire year, and polio was endemic in only six countries: India, Pakistan, Afghanistan, Egypt, Niger and, alone responsible for nearly half of all new cases, Nigeria.
In 2000, the Emir of Kazaure state in northern Nigeria, Alhaji Najib Hussain Adamu, began to notice widespread confusion among the populace regarding the polio vaccine. These people, primarily rural Muslims with minimal access to education, wondered what the fuss over polio was. Why were so many outsiders coming to their houses to place two drops of oral polio vaccine on their children's tongues? Few people they knew had ever come down with polio, whereas measles and malaria were widespread and devastating problems in their communities. Where was the outside help for those diseases?
Emir Adamu, a lawyer by training, began doing research on the Internet. A simple Google search (suggested keywords: polio, vaccine, conspiracy) yielded a variety of materials claiming to reveal the devious ulterior motives behind not only the polio vaccine but a variety of other vaccines supported by the mainstream Western medical establishment. The Emir learned that the oral vaccine used in Nigeria was not the same as the injectable vaccine currently used in the United States and other Western countries. He came across a booklet about the oral vaccine called "Polio and the Polio Vaccine", published by the Think Twice Global Vaccine Institute. In this booklet, various theories surrounding the oral vaccine are "exposed."1 Among these theories was the claim that the oral vaccine, which was created using monkey cells, was contaminated with a host of monkey viruses, including Simian Immunodeficiency Virus (SIV), a close relative to HIV. This theory claims that these simian viruses were in the polio vaccine and spawned the modern AIDS pandemic.2
Theories like this have circulated since the early 1990s, and a small but vocal group of individuals still propounds this theory today, even after numerous academic studies and reviews by the U.S. National Academy of Sciences and the Royal Society of Medicine in the U.K. have refuted it. The explanation widely accepted in the scientific community for the origin of AIDS does center around SIV, but it in no way implicates the polio vaccine: Close human-to-simian contact (via monkey hunting and slaughter) has repeatedly introduced SIV into human populations, and is thought to be the likeliest origin of HIV/AIDS.
Another document, altogether unrelated to the polio vaccine or AIDS, also caught the Emir's attention. In 1974, under then U.S. Secretary of State and National Security Advisor Henry Kissinger, a document entitled National Security Study Memorandum 200 was produced. Declassified in 1989, this memo, while gaining only passing notice in the United States, has attained widespread notoriety in Nigeria. The memo is a realpolitik look at population growth. It suggests that population increases in the developing world can generate significant national security threats to the United States through regional destabilization and the increased demand on global food supply and other scarce resources. The memo singles out 13 countries: India, Bangladesh, Pakistan, Mexico, Indonesia, Brazil, The Philippines, Thailand, Egypt, Turkey, Ethiopia, Colombia and Nigeria.
NSSM-200 advocated family planning, but recognized the diversity within the 13 cases. It noted that "this group of priority countries includes some with virtually no government interest in family planning and others with active government family planning programs which require and would welcome enlarged technical and financial assistance." When bilateral efforts are not politically feasible, the memo suggested indirect channels:
In countries where U.S. assistance is limited either by the nature of political or diplomatic relations with those countries or by lack of strong government desire [sic]. In population reduction programs, external technical and financial assistance (if desired by the countries) would have to come from other donors and/or from private and international organizations, many of which receive contributions from AID. The USG would, however, maintain an interest (e.g. through Embassies) in such countries' population problems and programs (if any) to reduce population growth rates. Moreover, particularly in the case of high priority countries, we should be alert to opportunities for expanding our assistance efforts and for demonstrating to their leaders the consequences of rapid population growth and the benefits of actions to reduce fertility.
These recommendations did not sit well with many Nigerians. Many critics of U.S. policy in Nigeria believe this memo reveals a policy of stealth Nigerian population control still being pursued today.
Armed with these Internet-derived claims and suspicions, Emir Adamu embarked upon a campaign to inform his constituents and challenge relevant authorities, demanding that the vaccine's safety be demonstrated. Then, in 2003, Emir Adamu found an outspoken ally in Dr. Datti Ahmed, President of the Supreme Council for Shari'a in Nigeria. Dr. Ahmed, a trained physician who had a year earlier called for the boycott of the Miss World pageant in Abuja, called for a boycott of the polio vaccine, proclaiming, "We believe that modern-day Hitlers have deliberately adulterated the oral polio vaccines with anti-fertility drugs and contaminated it with certain viruses which are known to cause HIV and AIDS."3 Mistrust spread throughout much of Nigeria as many Muslim religious leaders called for the suspension of the GPEI until answers could be obtained about the vaccine. In October 2003 the program was indeed suspended in Kano, Zamfara and Kaduna states.
After two months of debate officials in Zamfara and Kaduna, under considerable international and federal pressure, agreed to resume vaccination. But the government of Kano, the state with the largest number of polio cases in Nigeria, refused to call off its boycott and decided to set up its own committee to investigate the safety of the vaccine. Headed by a pharmacologist, Dr. Alhassan Bichi, this committee ultimately created more controversy than it settled.
Dr. Bichi's analysis of the vaccine found trace elements of the female hormone estradiol. Though present at a level believed to be far too low to be harmful to children, the hormone was not listed on the label of the French-made vaccine. Dr. Bichi insists that he did not make any direct claims about the effect of these hormones on fertility, but in December 2003 he remarked publicly, "I believe there is polio, I believe we must vaccinate our children . . . but where polio vaccine is seen to contain something that has not been declared, then I find it unethical to recommend that the vaccine be used." The anti-vaccine movement saw the committee's conclusion as vindication and was reinvigorated in its battle against the assertions of safety from the federal government and the international community. The governor of Kano, Ibrahim Shekarau, explained, "It is a lesser of two evils to sacrifice two, three, four, five, even ten children (to polio) than allow hundreds or thousands or possibly millions of girl-children likely to be rendered infertile."
The results: Within 18 months, polio spread to 16 countries that had been previously free of the disease, starting with neighboring countries in West Africa, Chad and Sudan. From Port Sudan the disease crossed the Red Sea into Yemen and then Saudi Arabia. Making matters worse for those trying to dispel rumors of a conspiracy to create infertile Muslims, polio spread throughout predominantly Muslim countries along traditional employment and pilgrimage routes. An Indonesian Muslim returning home from the Hajj in February 2004 was most likely the source of polio's reintroduction to Indonesia; before 2005, Indonesia had been free of polio for ten years. But Indonesia's overall immunization coverage was weak and left the nation vulnerable to importation. WHO reported 264 new cases of polio in Indonesia in 2005, all genetically traceable back to Nigeria. What Went Wrong Many blamed the collapse of the GPEI in Nigeria on opportunistic religious leaders using polio as a vehicle to stigmatize the United States through the manipulation of an uneducated public. But many circumstances coalesced to cause the 2003 collapse of the GPEI in Nigeria.
Nigeria's performance with all forms of pediatric immunization is poor, and has been so for a long time. Overall national immunization coverage is extremely low and has been steadily declining despite massive amounts of money directed to immunization efforts. Nigeria spends an average of $56 to fully immunize a child (twice as much as Niger, Benin, Togo and the war-ravaged Democratic Republic of Congo). Even so, only 13 percent of its children are immunized against the major vaccine-preventable diseases, including measles, tuberculosis, diphtheria, pertussis, tetanus and polio, and coverage is considerably lower than that in the north. Even delivery of uncontroversial vaccines is weak. Approximately 200,000 children die each year from these preventable diseases—22 percent of all childhood deaths in Nigeria.
The most likely explanation for the mismatch between spending and results lies in corruption exacerbated by ethnic cleavages. Nigeria is made up of many different ethnicities, with the three largest groups—Hausa, Yoruba and Ibo—making up 68 percent of Nigeria's 129 million people. Northern Nigeria is made up of predominantly Muslim Hausas. To limit interethnic strife during the transition to democracy in 1999, political power was decentralized to the state and local levels. While granting more autonomy to the north, decentralization also cut the north off from the majority of Nigeria's oil wealth in the non-Muslim south; and revenue distribution is controlled by the non-Muslim administration of Olesegun Obasanjo. Much federal largess allocated to the north is diverted or stolen before it arrives. As a result, easily accessible and affordable primary health care provision has virtually disappeared from northern Nigeria.
Obasanjo's born-again Christian religious affiliation, the inequitable distribution of federal resources and Abuja's allegiance to the United States clearly fueled alienation and mistrust in the north. As a result, many Muslim Nigerians sought political alternatives at the state and local levels. Since 1999, 12 states in northern Nigeria have seen Muslim leaders rise to political power through a platform of strict adherence to shari'a for all Muslims. These 12 states all receive guidance from the aforementioned Supreme Council for Shari'a in Nigeria (SCSN).
Clearly, the SCSN's Dr. Ahmed was much empowered by these developments, and he consistently and effectively sought to undermine claims by the federal government that the polio vaccine was safe. "We are partially happy the government has accepted the need to test and investigate the vaccines", he said, "but we're worried the people they're asking to do the tests are interested parties like UNICEF, who have been bringing the vaccine into Nigeria." Thanks to such pronouncements, religious leaders in the north quickly rejected assurances from Abuja that the vaccine was safe. (The legacy of a previous administration's population control efforts further dampened the trust of northern Nigerians in their federal government. In 1988, Nigerian President Ibrahim Babangida had instituted an unpopular national population policy that attempted to limit families to four children.)
Working in an environment of widespread mistrust and health system shortfalls, the polio eradication program in Nigeria suffered from day one. Lacking basic health care infrastructure, electricity, potable water or faith in the federal government, many northern Nigerians were suspicious when strangers in shiny UN vehicles appeared, traveling house-to-house to deliver multiple doses of a vaccine for a mysterious disease. Emir Adamu, in a meeting with WHO and the National Programme on Immunization in 2003, summed up his overall displeasure with these efforts in the November 8, 2003 Weekly Trust (spelling and other errors in original):
In the whole of this country, you are talking of 109 cases of polio, and in the entire world, just 300 or 400 or 500 cases in a population of over 6 billion, but there are diseases which are far, far more devastating to world population and especially Nigeria than polismyelitis take measles for example, your document here (waiving a copy of WHO pamphlet says measles kills about 2 million children annually). You have no right to go direct to our Ward Heads without our knowledge and that I think really confirms the apprehensions we have about this programme of immunization, because when you go to someones house, you have to knock on the door before you are allowed in. By this singular act of going behind our back to meet our Ward Heads without coming through us confirms to us that WHO Rotary International/Rock feller foundation and so on, really desperate to eradicate 109 cases of polio in Nigeria by going into people's territories and houses without their knowledge. I don't think this is the correct African way of doing things. In every society, there are hierarchy of doing things. You don't start from bottom up, if you really want to do thing correctly, you have to follow the correct norms. You have to seek permission for doing things, that is by the way.
Meanwhile, the outrage sparked by the disclosure of NSSM-200 was exacerbated by the wars in Afghanistan and Iraq, which were seen by many Nigerian Muslims as wars on Islam. Nigerian imams frequently voiced antiwar sentiments to support arguments aimed at the United States and the United Nations. Meanwhile, Dr. Ahmed frequently referred to a 1992 incident involving contaminated tetanus vaccines in the Philippines and Mexico distributed through WHO and UNICEF. Some of these vaccines allegedly contained trace amounts of B-hCG (beta human chorionic gonadotrophin) hormone, which can potentially prevent a woman from sustaining a pregnancy.
Another incident, too, formed the backdrop to the events of 2003. In 1996, the American pharmaceutical corporation Pfizer tested its drug, Trovan, during a bacterial meningitis outbreak in Nigeria. Low doses of a tested meningitis treatment (ceftriaxone) were administered to Kano-area children as a control. A suit filed on behalf of these children in August 2001 at the Federal District Court in Manhattan alleged that parents were not informed that Trovan was experimental; that they could have refused it if they chose; and that another organization was offering an internationally-approved treatment for free at the same site. The suit also alleged that the decision to offer a low dosage of ceftriaxone was made to improve the relative effectiveness of Trovan; that the ceftriaxone was responsible for injuries and death; and that Trovan was, among other things, the cause of brain damage, loss of motor skills and death to some of the participants of the study. (The District Court dismissed the case in 2002, but in 2003 the Second Circuit Court of Appeals vacated the dismissal.)
The memory of the Trovan incident still haunts many Kano residents. Islamic scholar Muhammad bin Uthman told a French news agency in 2002, "The Pfizer drug test in 1996 is still on our minds. To a large extent, it shaped and strengthened my view on polio and other immunization campaigns." He went on to add that the UN was in cahoots with the United States: "They claim that the polio campaign is conceived out of love for our children. . . . If they really love our children, why did they watch Bosnian children killed and 500,000 Iraqi children die of starvation and disease under an economic embargo?"
In an environment where even the most rudimentary health services are generally unavailable, and where the germ theory of disease is still virtually unknown three centuries after Leeuwenhoek, traditional healers often fill the void. A recent WHO estimate stated that 85 percent of Nigerians receive some or all of their health care and health education from traditional healers. The Hausa word for polio, Shan-inna, means "a powerful female spirit that consumes the limbs of human beings." Maryam Yayha, in her polio vaccine case study funded by the Committee on Social Science Research at the UK Department for International Development, remarked that "for those who believe strongly in the spiritual manifestation of certain diseases, it is inconceivable that a few drops of liquid in a child's mouth (whose limbs are in good working condition) could appease or ward off the female spirit, Shan-inna." Even so, a well functioning health system that people trust can make campaigns like the GPEI much more successful. John Leigh, working in Nigeria with the UK Department for International Development remarked, "When there is a viable alternative that is seen to work, people switch very quickly. If there is a government health facility that is working and healing people . . . people switch away from traditional healers overnight."
With polio still spreading throughout Africa and Asia, threatening to reverse decades of work and billions of dollars of investment, the World Health Organization has redoubled its efforts to address the source of the problem in Nigeria. A second vaccine review committee was established in March 2004, this time with medical doctors on the board. Public statements in support of the polio campaign were issued by leaders of the G-8 and the African Union. Tests on the oral polio vaccine were conducted in South Africa, India and Indonesia. Fatwas from Saudi Arabia and Egypt urging Muslim countries to do all they could to eradicate polio were promulgated as well. The Sultan of Sokoto, the highest-ranking Muslim in Nigeria, has also supported the resumption of the vaccination campaign. The Organization of the Islamic Conference (OIC), an umbrella organization representing 57 Islamic countries, passed a resolution urging an all-out effort to eradicate polio from the countries of the OIC still afflicted by it.
Rhetorical support from Saudi Arabia and the OIC has not translated into financial support, however. WHO has embarked on a fund-raising effort to procure $250 million to contain new polio outbreaks while strengthening coverage in the remaining endemic areas. To date, the Persian Gulf countries have donated less than $3 million of the requested $250 million. Nonetheless, things are looking up in Nigeria. In July 2004, Kano, the only Nigerian state that had maintained its boycott, finally reversed its decision. Convinced by the second committee of vaccine review and armed with rhetorical support from Islamic countries and scholars around the world, the governor of Kano publicly vaccinated his own children. A massive public information and immunization campaign supported at the local, federal and international level followed, and by September 2004, 57 percent of children in Kano state had been immunized.
But polio continues to erupt in countries like Somalia and Indonesia. Lingering mistrust persists and Dr. Ahmed's SCSN continues its denunciation of the GPEI. In July 2004, SCSN secretary general Nafiu Baba Ahmed criticized the governor of Kano for caving in: "We believe that the Kano State government was forced into submission due to pressure and propaganda from the West." Reports from the area reveal continued resistance among some parents regarding not just the polio vaccine, but childhood immunization as a whole. WHO recently reported that polio cases have dropped 20 percent since the resumption of vaccination in Kano but that Nigeria "has 13 times as many cases as the endemic country with the next most cases, India (489 cases compared with 37 cases as of October 11, 2005)."
What will 2006 hold for polio? WHO is confident that the GPEI can overcome recent setbacks and complete its mission. One hopeful sign: earlier this year Niger and Egypt were removed from the list of endemic countries. Dr. David Heymann, the GPEI's executive director, is hopeful that the other countries with endemic polio will cease transmission of the disease this year, with Nigeria not far behind. But it would be unwise to assume that victory is at hand: Donations of cash necessary to escalate the war on polio are woefully deficient; resentments continue to simmer in the Islamic world; and WHO has learned yet another sorry lesson regarding the limits of its capacity to act.
Institutionally, WHO cannot enter a nation without an official government invitation, and it is compelled to work with whatever government is in power. When, as is the case in Nigeria, the central government lacks credibility in significant regions of its country, WHO's hands are tied. During the SARS epidemic of 2003 WHO leaders effectively used shame, global disgrace and the media to shed light on Beijing's cover-ups. But without the full cooperation of the Chinese Ministry of Health, WHO could not investigate claims of SARS outbreaks occurring throughout that vast country, or of patients secretly shuffled from hospital to Beijing hospital in the middle of the night to avoid the agency's detection.
In the spring of 2005 the World Health Assembly, the governing international body for WHO, passed new International Health Regulations (IHR) that significantly expand the powers and authority of WHO, particularly in cases of outbreaks and threatened pandemics. Though the new IHR do not officially go into effect until May 2007, current investigations of avian flu outbreaks are already finding governments significantly more transparent and cooperative. Nevertheless, the new IHR do not give the Global Polio Eradication Initiative the authority to unilaterally initiate polio vaccination campaigns or conduct investigations without the approval of local governments.
And even if WHO had such authority, it would not have sufficient manpower and resources to immunize even a small region of a given nation without the assistance of that country's health personnel and/or major international nongovernmental organizations such as Red Cross/Red Crescent. The latter are extremely reluctant to send operatives into hostile areas in light of a spate of kidnappings and assassinations carried out against humanitarian organizations, especially in Islamic countries.
The GPEI has done more than just fight polio. It has achieved some strengthening of national health systems throughout the world. It oversees a network of 150 national laboratories that now maintain unprecedented quality assessment for polio vaccines, lab reagents and disease surveillance. This network is now broadening its efforts to include diseases such as yellow fever, hemorrhaghic fevers and influenza. The GPEI has also been responsible for training more than three thousand surveillance officers, who have recently been called into action in a number of other local health crises: SARS, cholera in northern Nigeria, a Marburg virus outbreak in Angola and, most recently, even the earthquake in Pakistan.
But eradication campaigns may not ultimately be the best use of WHO's expertise and limited resources, especially in countries that lack even the most basic services and where WHO's mandate to work can generate mistrust from communities that have been neglected and discriminated against by their governments. In an environment where existing health care needs are neglected, where a sound understanding of the value of vaccines is limited, and where there is animosity toward the Western deliverers of health campaigns, conflict over all single-disease eradication campaigns is predictable.
What is also predictable is that even with better International Health Regulations, the WHO needs more resources to cope with an integrating and hence more pandemic-prone world. U.S. global health and development goals, laudable as they are, cannot be met without an international institutional partner that is up to the task. Striving to bring that partner into being should be a part of U.S. policy, too.
1The original polio vaccine, invented by Jonas Salk in the United States, was based on whole, killed polio viruses that were injected into the bloodstream to achieve immunization. Albert Sabin soon realized that people who were so immunized still harbored polio viruses in their intestines and passed them via their feces. Therefore, Sabin reasoned, the vaccinated individuals still posed a public health threat even if they could not themselves contract the disease. Sabin invented a live, attenuated form of polio vaccine that, when ingested orally, sterilized the individual's gastrointestinal tract, providing protection not only for the immunized person but for the community as a whole. The oral Sabin form was used until polio was no longer endemic in the Americas.
2The most detailed account of this controversial claim can be found in Edward Hooper, The River: A Journey to the Source of HIV and AIDS (Boston: Little Brown & Co., 1999).
3Sources for all quotations in this essay are available from the editors upon request.