What the US could learn about vaccination from Nigeria

To consider that Nigeria, infamous for anti-vaxx campaigns leading to polio outbreaks, has any lessons for Americans may be shocking.

But as measles cases in the U.S. climb to an all-time high after the disease was declared eliminated in 2000, U.S. public health officials have been looking for ways to address the problem.

As a researcher on religious politics and health, I believe that Nigeria’s highly mobilized efforts to eliminate polio can teach America how to reverse the increase in measles cases and shore up its public health infrastructure. Working with international partners, Nigerians have combated misinformation, suspicion of vaccine science, and appeals to religious freedom to go from ground zero for polio on the African continent in 2003 to nearly polio-free in 2019.

Comparing Nigeria and the US

When the Global Polio Eradication Initiative (GPEI) was established in 1988 with the goal of complete eradication by 2000, several countries could not meet the target. The U.S. seemed far ahead.

India needed another 14 years, while Nigeria, Pakistan and Afghanistan faced stiff internal opposition to immunization. GPEI’s big 2003 push came shortly after Nigeria’s northern states implemented Sharia (Islamic law). Some clerics and political leaders encouraged boycotting immunization, citing contaminants that could reduce the Muslim population and mistrust of the government.

The U.S. is facing similar resistance now. Under scrutiny are anti-vaxx Orthodox and Hasidic Jews in New York City and Rockland County, but The New York Times has also uncovered resistance among Muslims, Catholics, Waldorf school parents and other cultural dissenters.

Anti-vaxxers in Clark County, Washington, are not religious opponents but rather Russian-speaking immigrants who, according to a report, harbor “mistrust of government that built up after being exposed to years of propaganda and oppression in the Soviet Union.” A doctor in their community blames tribalism for suspicion of “people coming from outside.”

Tackling tribalism

A mother and her children outside their home in rural Nigeria. Shobana Shankar, CC BY-SA
Nigerians understood that simply ostracizing religious communities would not work. Anti-vaxx politics tapped into mistrust of government and “others” that ran deep in a diverse but divided society, where religious, regional and ethnic loyalties took priority over national unity.

Nigerians know the ravages of tribalism better than most Americans. By conservative estimates, their nation is home to more than 250 ethnolinguistic groups. The civil war, lasting from 1966 to 1970 after anti-Igbo pogroms in the Hausa-majority north, was a terrifying manifestation of the hatred of difference and a total lack of faith in the government.

To foster reconciliation, Nigerians engaged in efforts to break down tribalism. One experiment, started in 1973 and still going, is compulsory service of college graduates in the National Youth Service Corps in “states other than their own and outside their cultural boundaries to learn the ways of life of other Nigerians.” Notwithstanding problems, the program has instilled in Nigerians a sense that education alone is not enough to build a healthy society. Sometimes it is the source of social separation.

Using this logic to combat polio, Nigerian public health officials took themselves to anti-vaxxers, leaving behind their offices in the city to visit villages with reported polio cases. Their mobility built the “polio infrastructure” that “intensified political and managerial support from all levels of the Nigerian government,” according to a Gates Foundation white paper that analyzed global polio eradication. Traditional leaders like the Sultan of Sokoto also invested time and energy into immunization campaigns and social engagement.

Intensive socialization across class, education and other divisions were as important as traditional public health measures such as scale-up of local technical capabilities and independent monitoring.

Nigerian physicians in the field

I accompanied a team to a village outside Kano city in 2011, after years of public health interventions had reduced reported cases of polio to 20 in all of Nigeria for a 13-month period. The doctor leading the team leader had met four chiefs regularly; the eldest was the most supportive, the youngest the least.

The doctor asked the young man to roll up his left sleeve and pointed to a round scar on his upper arm, remarking, “Your parents had you vaccinated against smallpox. This campaign, though for a different disease, is the same. What’s the problem?” The young chief shrugged, ashamed at direct confrontation and unwilling to insult his parents. They bantered for a bit before we left in the Ministry of Health truck, having accomplished seemingly nothing but a social visit.