PUBLIC HEALTH DILEMMAS AND THE SMALLPOX ERADICATION PROGRAMME

The urgency of eradication efforts in northern Nigeria is reminiscent of the situation during the final years of the SEP, from 1973 to 1975, when the forced vaccination of adults and children was carried out, mainly in Bihar State, India, and in Bangladesh. In an often-cited work, Greenough (Reference Greenough1995) discusses the human rights dilemmas faced by US physician-epidemiologists, who had been brought in to oversee local health department efforts. At times, foreign public health officials used their distinctive position as American medical professionals to reinforce their authority to break into houses, hold down recalcitrant individuals, and override local public health officials' concerns. Their policy of containment of infected villages was considered justifiable; as one doctor explained, ‘Known infected villages were revisited – often repeatedly – to check for new cases or left-outs. Almost invariably a chase or forcible vaccination ensued in such circumstances’ (S. Music, cited in Greenough Reference Greenough1995: 636). This same doctor described his unease with forcibly vaccinating for smallpox an elderly Bangladeshi woman dying from tuberculosis in 1973:

Greenough observed that this woman's response – her refusal to receive a smallpox vaccination – was common among the poor who could not see how such a health campaign would benefit them.

Such responses relate to public health discussions of individual versus community rights regarding health. While some public health practitioners consider the vaccination of children as the most equitable and effective approach and one that takes precedence over the wishes of individual parents, others see parental input in public health campaigns as critically important (Bradley Reference Bradley, Bradley and Burls2000). In the case of the GPEI in Nigeria, it was the former strategy that was followed. When the 1988 World Health Assembly in Geneva voted to eradicate polio, the decision was approved by Nigerian government officials; neither local government nor community input into this decision was sought. This disjuncture between African states' acceptance of global public health policies at the federal level compromises the position of local government officials, who may be forced to ‘work off the record’ in order to meet the different demands for healthcare of federal health officials and of their constituents (Leonard Reference Leonard2011). Indeed, many Nigerians expect that their government will provide a modicum of primary healthcare, freely available to its citizens, rather than a focus on a single disease. Thus, like the older woman who refused smallpox vaccination unless she first received food, some Nigerian parents decided not to participate in the GPEI, on the grounds that their government was behaving irresponsibly by neither providing primary healthcare nor addressing their main health concerns – malaria and measles, diseases that continue to kill their children. Indeed, measles outbreaks have continued since the implementation of the GPEI, in part because measles vaccination was not initially part of the campaign and also because of low levels of immunization generally; a recent measles outbreak occurred in March 2013 in Kano State (Adamu and Ahmadu-Suka Reference Adamu and Ahmadu-Suka2013). Similarly, in Nigeria, malaria programmes have not made a significant impact on child or maternal mortality attributed to malaria (Leo Reference Leo2013).

VACCINATION BY PERSUASION AND BY FORCE IN NIGERIA

The GPEI, as implemented in Nigeria, differs in other ways from the earlier SEP. Unlike the widespread participation of expatriate medical personnel in the SEP, the polio campaign has employed mainly Nigerian health workers in its immunization efforts. In northern Nigeria, where the majority of WPV cases have been identified, programme officials have relied on several persuasive methods. These tactics have included community rallies, solicitation of the support of Muslim teachers and religious leaders, and, after 2006, the provision of a range of health incentives – deworming medications, soap, measles vaccination, and insecticide-treated bed nets, as well as the showing of polio education majigi (open-air) films (Nasiru et al. Reference Nasiru, Aliyu, Gasasira, Aliyu, Zubair, Mandawari, Waziri, Nasidi and El-Kamary2012). More recently, in June 2013, the industrialist Aliko Dangote announced a plan to provide cooperating mothers with his products – sugar, salt and macaroni (Danjuma Reference Danjuma2013). In November 2013, one local government chairman in Sokoto State not only agreed to community demands for an improved road but also gave one mother the 10,000 naira (approximately US$60) she demanded before allowing her children to be vaccinated (Muhammad Reference Muhammad2013). However, along with house-to-house Immunization Plus Days, food donations and infrastructure improvements, more coercive measures have been implemented in some communities with low levels of immunization and where parents have continued to resist the polio initiative. For example, in Kano, Kwara, Zamfara, Gombe and Niger States, parents can be arrested for failure to vaccinate their children. In early September 2013, Niger State government officials amended the Healthcare Development Agency law to include jail sentences (of ten years) or fines (100,000 naira) for any ‘cleric found guilty of preaching against the immunization of children in the state’, while parents failing to vaccinate their children would be jailed for six months or fined 10,000 naira (Hamagam Reference Hamagam2013).

In some areas, parental permission is circumvented altogether through the mass immunization of children on public transport vehicles or in public areas where they congregate, using biscuits or sweets as an incentive. As one vaccination team leader in Kaduna State described:

However, this method of enticement backfired in Niger State. When rumours that ‘children could be initiated through petty offerings of sweets and biscuits’ into secret cults (a practice called shafi milera) began to spread, the Niger State Immunization Plus programme stopped using the practice (Leo and Okafor Reference Leo and Okafor2012).

Another means of increasing immunization levels of children under five years of age was by vaccinating those who were attending nursery schools, initially without parental consent; after parental complaints, this policy was later revised to allow parents who did not want their children vaccinated to instruct the school authorities of their wishes by letter (Renne Reference Renne2012).

The principal problem for GPEI officials, however, has been the dysfunctional primary healthcare system, particularly in rural areas in northern Nigeria where private health clinics are not available (Adamu Reference Adamu2011; FBA 2005; Omoniyi Reference Omoniyi2012). In some rural communities, local clinics are closed or lack personnel or provisions. When parents take their children for vaccinations, they may find ‘stock-outs’ and so they are forced to return. Indeed, members of the 12th Expert Review Committee, a committee set up to monitor the progress of polio eradication efforts in Nigeria, noted such ubiquitous stock-outs: ‘However much the improvement in coverage, particularly in northern states, has been a result of the IPDs [Immunization Plus Days] … there is not yet a robust programme for the routine delivery of immunization services in several states. Vaccine stock-outs remain common’ (NPHCDA 2007: 8). During the federal and state elections in 2011, there were frequent stock-outs, while post-election violence in several northern Nigerian states also hampered immunization efforts. Furthermore, the irregular supply of electricity makes it difficult to maintain regular, viable supplies of vaccines. Parents who want basic healthcare available free of charge or for a small fee may object to polio workers coming from house to house to provide polio vaccines without charge if they fail to provide treatments and preventative support – malaria medications and measles vaccines – for more pressing healthcare needs. As one farmer living near Ahmadu Bello University in Zaria explained:

This man's dissatisfaction with the failure of the federal and state governments to provide basic primary healthcare exemplifies an attitude that has contributed to continued resistance to the polio campaign. An incident in Kano State in 2011 further illustrates this discontent:

Elsewhere in northern Nigeria, village heads demanded that health personnel provide boreholes or bridges before polio vaccination teams were allowed to enter the village (MM, personal communication, 2012; Ibrahim Reference Ibrahim2013). Thus, the northern Nigerians' lack of interest in polio as a public health concern compared with other childhood diseases and government officials' inability to reconstitute a working public health system and basic infrastructure have undermined the government's credibility there.

POLIO IMMUNIZATION, POLITICAL INSECURITY AND POVERTY IN NORTHERN NIGERIA

The GPEI was officially begun in Nigeria in 1996 during a period of political turmoil. In the period from 1992 to 1993, Nigeria had three heads of state, along with an annulled election that generated widespread political unrest. Following the government takeover by General Sani Abacha in November 1993, the National Programme on Immunization (NPI) was established in 1995; this enabled federal responsibility for immunization activities, including the polio eradication campaign. The NPI operated as an independent agency, whose director was appointed by and responsible to the Nigerian head of state (FBA 2005). One year after the NPI was launched, it came under the direction of Dr Dere Awosika, who continued in this position under three successive heads of state.

General Abacha's death in June 1998 marked the country's move towards democratic rule. This had two important consequences for the GPEI in northern Nigeria: one operational, the other political. When General Olusegun Obasanjo was inaugurated as president in May 1999, he appointed Professor Eyitayo Lambo as the new Minister of Health, and Dr Awosika continued as head of the NPI. The control of healthcare administration by these two southern Nigerians angered northern health professionals who resented their control of programme resources. Later, this north–south tension was exacerbated by the May 2003 presidential election, in which President Obasanjo, seeking re-election, defeated a popular northern Nigerian candidate, General Mohammadu Buhari. It was following this election that underlying parental resistance to house-to-house vaccination was taken up by political and religious leaders in Kano, the largest urban metropolis in northern Nigeria. Their increasing resentment at their political marginalization combined with grass-roots suspicions about the polio eradication initiative and vaccine safety led the head of the Supreme Council for Sharia (Muslim law) to call for a suspension of polio vaccination (Babadoko Reference Babadoko2003).Footnote ¹ The governor of Kano State, Ibrahim Shekarau, subsequently announced that polio vaccination in Kano State would be halted until tests could be conducted to confirm vaccine safety (Obadare Reference Obadare2005). After several months of tests carried out in Nigeria, South Africa and India, the late Alhaji Muhammadu Maccido, the Sultan of Sokoto and head of Muslims in Nigeria, announced in March 2004 that the ‘oral polio vaccine is safe’. This endorsement did not convince some, although the situation was eventually remedied by the importation of polio vaccines from Indonesia in May 2004. The governor later agreed to resume polio vaccinations in Kano on 29 July 2004. The eleven-month Kano boycott had significant consequences for the GPEI: confirmed WPV cases increased in subsequent years, from 355 cases in 2003 to 782 cases in 2004 and 830 cases in 2005 (CDC 2014).

In 2006, after Dr Awosika was forced to resign as a result of donor pressure in December 2005 (Magone Reference Magone, Magone, Neuman and Weissman2011: 132), she was replaced by Dr Edugie Abebe. While serving as acting director of the NPI, Abebe instituted the popular and effective Immunization Plus Days programme in June 2006, which was evidenced in the decline from 1,112 cases in 2006 to 285 cases in 2007 (CDC 2014). However, with the election of a new president, Umaru Yar'adua, in 2007, the NPI was merged within the National Primary Healthcare Development Agency (NPHCDA); this was directed by Mrs Titilola Koleoso-Adelekan, who had been a political appointee of President Obasanjo. Dr Abebe subsequently resigned (Renne Reference Renne2010: 48). However, Koleoso-Adelekan was dismissed in October 2008 and was replaced by Dr Muhammed Ali Pate, who was named the Minister of State for Health in July 2011. His appointment defused, to some extent, the politics reflected in the north–south tensions associated with the polio programme, although his resignation in July 2013 suggests that these tensions continue (Magashi Reference Magashi2013).

Despite the resolution of the Kano boycott and the decline in confirmed cases of polio following the introduction of Immunization Plus Days, many parents in Kano and elsewhere in the north have continued to refuse to allow health workers to immunize their children. This resistance reflects parents' continued suspicions of Western health interventions. Their knowledge of the Trovan® (trovafloxacin, an antibiotic) drug trial, organized by the US pharmaceutical corporation Pfizer, Inc. and carried out by state health officials in Kano during the 1996 cerebrospinal meningitis epidemic (Renne Reference Renne2010: 107–9), in which eleven children died, led many to suspect programmes in which vaccines were provided free of charge (Frishman Reference Frishman2009). While an out-of-court settlement for US$75 million was reached in 2009 (Washington Post 2009), the consequences of this failed drug trial, locally referred to as ‘Pfizer’, have not been forgotten in Kano and have affected polio immunization efforts there (Aliyu Reference Aliyu2008).

In addition, parents' distrust of the federal government was underscored by their dislike of President Obasanjo, who was held responsible for the deteriorating health and economic conditions in northern Nigeria (Obadare Reference Obadare2005: 280). The popular northern Nigerian musician Haruna Aliyu Ninji captured their displeasure in a song, describing Obasanjo as going ‘all over the world to get people to invest in Nigeria. But the people didn't come and the economy of the country became disabled [gurgu – the Hausa word also used for the polio-disabled]. He only gathered the money for himself and left the country for poverty.’ In the north, such moral assessments of political leaders (be they Nigerian heads of state or traditional rulers) often have a religious cast. Indeed, in northern Nigeria, Islamic belief and practice have, to a great extent, affected more general attitudes towards the West and to Western ideas and things. It should not be surprising, then, that suspicions about the danger of polio vaccines were voiced by some malamai (Islamiyya teachers) whose schools are instrumental in the continuation of a particular social order in northern Nigerian communities in which Islamic faith and practice are paramount (Last Reference Last2008). The distrust felt by these men (and others) was voiced in terms of contaminated oral polio vaccine, a fear that raised concerns among a wide range of northern Nigerian Muslims, from villagers to university professors to politicians, suggesting the ways in which religious concerns are intertwined with political interests. The Kano polio vaccine boycott was one example of this dynamic (Ghinai et al. Reference Ghinai, Willott, Dadari and Larson2013).

THE POLITICAL CONTEXT OF BOKO HARAM VIOLENCE

The fact that the 2003 Kano boycott was begun at the instigation of the head of the Supreme Council for Sharia relates to increasing calls for the implementation of Sharia law. While there had been earlier demands for Sharia law during the short-lived democratic Second Republic (1978–83), such demands had been quelled during the periods of military rule that followed. With the establishment of democratic rule in 1999, in the following two years governors of twelve northern Nigerian states argued that Sharia penal code law be incorporated into the criminal laws in their states (Lubeck Reference Lubeck and Hefner2011). Federal officials acceded to this demand, with the caveat that state residents who were not Muslims had access to state and federal courts. The implementation of Sharia criminal law was also supported by some Islamic reform group leaders as a way of addressing what they saw as the moral decline of Nigeria. Such calls for Islamic reform have a long history in northern Nigeria and often come to the fore during times of perceived political, economic and social disorder. For many unemployed young men in early twenty-first-century northern Nigeria, ‘the failure of Western-imposed institutions to meet their material and spiritual needs confirmed that they should recommit themselves to tajdid [reform] in order to implement shari‘a as an alternative path to realizing Muslim self-determination’ (Lubeck Reference Lubeck and Hefner2011: 253).

The Islamic movement Jama‘atu Ahlis-Sunnah Lidda‘awati wal-Jihad (Boko Haram), is one such example of these reformist aspirations. By 2003, its leader, the Islamic scholar Mohammad Yusuf, had attracted a large following in Maiduguri in north-eastern Nigeria (Anonymous 2012). His support for Sharia law and an Islamic state as well as his anti-government sermons appealed to many. As part of his Salafi teachings, he sought to return to the Qur’ān and Hadīth as the main sources of knowledge, which is reflected in his assessment of Western vaccines:

Yusuf's teachings appear to have affected the acceptance of polio vaccination by his followers in Borno State, and are reflected in the low levels of child immunization there. In March 2006, for example, 44 per cent of children in the state had not received any polio vaccinations (NPHCDA 2006). At a meeting held in October 2006, the chairman of Borno State Committee on the NPI observed that: ‘Traditional rulers and parents in Borno State have rejected the vaccination of their children and wards against the deadly polio-virus, claiming that the administration of such vaccines was a “deliberate attempt by the World Health Organization (WHO) to sterilise women [girls] of the state”.’ The director urged the NPI committee to ‘go back to the drawing board to evolve ways to mobilise the people, particularly parents, traditional and religious leaders on the vaccination of their children’ (Musa Reference Musa2006). Nonetheless, confirmed cases of polio have continued to be reported there and, in May 2007, the NPHCDA Expert Review Committee report noted the export of poliovirus from Borno to neighbouring countries, particularly to Cameroon and Chad (NPHCDA 2007). However, it was in 2009, with the escalation of political violence associated with Boko Haram, that the polio campaign, particularly in Borno State, was affected more directly. On 30 July 2009, the state government arrested Yusuf and police officials announced that he had been ‘killed in [a] shootout between the members of his sect and the police’ (Umar et al. Reference Umar, Ibrahim, Bashir, Idris and Mac-Leva2009); others described his death later that day as an extrajudicial killing.Footnote ³ After the arrest and death of Yusuf in Maiduguri, police and military officers have been targeted by Boko Haram members, who have carried out a form of guerrilla warfare in retaliation for the death of their leader and the imprisonment of their members. While some believe that politicians are involved in some of these attacks (Mac-Leva Reference Mac-Leva2011), this violence has led to the deaths of those caught in the crossfire. These events have affected polio immunization efforts in Borno in several ways. Immunization team members fear going house to house to administer polio vaccines in these circumstances. In addition, on 1 June 2011, five men, presumed to be Boko Haram members, set the Ministry of Health drug depot in Maiduguri on fire, destroying 40 million nairas' worth of polio, measles and meningitis vaccines (Idris and Ibrahim Reference Idris and Ibrahim2011). Consequently, confirmed cases of polio continue to be reported in the region. In May 2013, Borno and neighbouring Yobe State accounted ‘for 69% [of] wild polio cases in Nigeria … In Borno, over 335,000 children (32% of the target population) were missed during the April 2013 campaign’ (WHO 2013a).Footnote ⁴

The violence perpetuated by Boko Haram has been exacerbated by the retaliatory violence of the government's JTF. In 2012, Amnesty International (2012) published a report that provides an example of this circular violence:

Under such circumstances, it is difficult for parents to know whom they can trust. For example, in Zaria City, a section of the larger town of Zaria in Kaduna State, some families continue to refuse to have their children vaccinated during house-to-house Immunization Plus Days. However, their fear of polio vaccine is paralleled by the fears of residents who have been subjected to house-to-house police searches for those suspected of being Boko Haram members associated with recent bombings in the city (Sa'idu Reference Sa'idu2012a; Reference Sa'idu2012b). One Zaria City woman, who had heard of the killing of polio workers in Kano in February 2013, noted that while women polio workers were afraid to go house to house in her neighbourhood, the families there were also afraid:

The fact that polio workers, following the Kano killings, are escorted by policemen compounds residents' anxiety and resentment (Isuwa Reference Isuwa2013).

POLIO AND POLITICS IN KANO STATE

Kano State has been at the epicentre of WPV since the beginning of the GPEI. While the number of cases in Kano State has declined significantly since the 2003–04 boycott, continued low levels of immunization have contributed to Kano's position as having the highest level of confirmed cases of polio in the country in 2012 (although this number has been surpassed by Borno and Yobe States in 2013). The situation in Kano State reflects the persistent problem of parental refusal, which has put pressure on health team workers as well as supervisors who feel that they must meet monthly immunization goals. This situation has contributed to vaccine dumping, the illicit sales of vaccine and faked finger markings (Adamu Reference Adamu2011),Footnote ⁶ which help to explain the continued transmission of WPV in the area. Subsequently, in October 2012, Kano State Governor Rabiu Kwankwaso announced that:

This muted resistance on the part of parents, health workers and programme officers in Kano State became openly violent on 18 February 2013 when nine women and one man, who were preparing to go out for polio vaccination rounds in and near the metropolis of Kano, were shot and killed. Many northern Nigerians were shocked by this violence. No group has claimed responsibility for this attack, although some have speculated that Boko Haram members or sympathizers carried it out in reference to the killings of Pakistani polio women health workers two months earlier, in December 2012 (McNeil Reference McNeil2013).Footnote ⁷ Yet in Nigeria, government officials attributed the Kano killings to another event, namely the airing of a programme critical of the polio campaign on Wazobia, a popular radio station. The two radio journalists, along with the station owner, were arraigned and appeared in court in February 2013:

Following the trial, the broadcasting licence of the station was suspended and the station was shut down (Sunday Trust 2013a).

However, the escalating attacks on police stations in Borno and Yobe States contributed to President Jonathan's decision to declare a state of emergency in May 2013 in three north-eastern Nigerian states – Borno, Yobe and Adamawa – which was renewed for another six months in November 2013 (Krishi and Sule Reference Krishi and Sule2013). Borders have been closed and mobile phone services discontinued, with over 8,000 troops and jet fighters initially involved (Wakili et al. Reference Wakili, Hassan and Idris2013). As of December 2013, it was unclear how this situation had affected polio immunization efforts, as communications and news reports were limited, although in late July 2013, the Borno State governor received an award for his work as the north-east's best performing governor in polio eradication for 2012 (Daily Trust 2013). Additionally, children from Yobe and Borno States whose parents crossed the border to Niger to escape the state of emergency occupation received doses of polio vaccine and bed nets there (Audu Reference Audu2013). Four confirmed cases of polio reported in neighbouring Cameroon, associated with Borno State refugees, suggest that WPV continues in north-eastern Nigeria.

The difficulty in ending poliovirus transmission in the north-east reflects the continuing violence and counter-violence there. First, on 2 December 2013, there was an attack on the 79 Composite Group of the Nigerian Army, the 333 Artillery Brigade, and the divisional police headquarters in Bulumkutu, just outside Maiduguri (BBC World News 2013a). Second, on 20 December 2013, there was an attack on the 202 Tank Battalion in Bama (a town about 78 kilometres from Maiduguri; BBC World News 2013b). One may ask, as did Will Ross, the BBC correspondent in Nigeria, ‘How is it that significant numbers of well-armed Boko Haram militants are still driving around Borno State causing havoc?’ (BBC World News 2013a). Indeed, this situation suggests that this military intervention and state of emergency rule may not be able to provide the security needed to stop polio transmission in north-eastern Nigeria.

PARALLEL DILEMMAS, PARALLEL SOLUTIONS

The similarities in the means used by the Nigerian government to contain the transmission of WPV and the political violence associated with Boko Haram relate to questions about the ethics of coercion raised in Greenough's analysis of the concluding phase of the SEP in South Asia. In northern Nigeria, the use of intimidation – of parents, of those involved in public media, of those questioning vaccine safety – by government health officials suggests the sort of public health double standards discussed by Greenough (Reference Greenough1995: 643): ‘It would be an ethical error to hold that consent to immunization is less important in villages of Bihar and Bangladesh than it is in Birmingham or Buffalo – unless one accepts the ethical partition of the world.’ In the US and European context, closing down radio stations for questioning vaccine safety, arresting parents concerned about autism and vaccines – however misguided their beliefs – or distributing sweets to very young children in public places without parental permission would not be acceptable.Footnote ⁸ Yet such intimidating actions are seen as acceptable and necessary by Nigerian health officials (and, indirectly, by their international counterparts), as evidenced by statements from the Minister of Health Onyebuchi Chukwu (Leo and Okafor Reference Leo and Okafor2013). Moreover, some Nigerians support both the closing down of radio stations and publishing houses and the silencing of individuals opposed to the polio campaign, particularly when their actions are seen as contributing to the deaths of polio health workers.

Similarly, some Nigerians support the Nigerian government's military tactics in addressing the Boko Haram insurgency, which include the 2013 declaration of a state of emergency. For them, government efforts to end the political violence associated with Boko Haram, which they equate with war, are justified. Unfortunately, the reprisals against civilian populations – the house-to-house searches, the warrantless arrests, and, at times, scorched earth tactics, as were witnessed in Baga in Borno State in April 2013, where 200 people were killed by the JTF (Nossiter Reference Nossiter2013a) – not only have tragic consequences for individuals but also terrify local populations and encourage anti-government sentiments. Reports in June 2013 from Nigerian refugees who had fled to Niger following the initial state of emergency decree in the north-east described a chaotic situation (Nossiter Reference Nossiter2013c).

Regarding the state of emergency, in May 2013, John Kerry, the US Secretary of State, condemned ‘Boko Haram's campaign of terror in the strongest terms’, while also urging ‘Nigeria's security forces to apply disciplined use of force in all operations, protect civilians in any security response, and respect human rights and the rule of law’ (Nossiter Reference Nossiter2013b). Six months later, US State Department officials classified Boko Haram and Ansaru as ‘terrorist organizations’ (Schmitt Reference Schmitt2013), although some State Department officials, like some Nigerians, have argued for a negotiated settlement (Mudashir Reference Mudashir2013), which would include political and socio-economic components. In December 2013, the US's UN Ambassador, Samantha Power, called for the Nigerian government to ‘fast-track a Northeast development plan’ (NAN 2013), although the relatively small amount budgeted for north-east development, 2 billion naira, was seen as an insult by some north-eastern Nigerian governors (Idris et al. Reference Idris, Matazu, Anwar, Mohammed, Sule, Saleh and Hassan2013).

Nonetheless, the inadequacy of a military solution, as reflected by the inability of the JTF and the state of emergency implementation to end violence in the north-east, suggests that a combined political and socio-economic solution is precisely what is needed in order to address the parallel dilemmas of political violence and polio eradication in Nigeria. This solution, however, also requires a working primary healthcare system in Nigeria, as Dr Mohammad Ali Pate, the former Minister of State for Health and the chairman of the Presidential Task Force on Polio Eradication, has observed (Leo Reference Leo2011). The benefits of working primary healthcare programmes in communities in Borno and in other northern Nigerian states would be twofold. First, such a system would facilitate the possible ending of WPV transmission and could enable post-eradication efforts. Second, it would take up the IMB's directive to ‘open its ears fully to understand what is top – the unique needs of every community – and respond to these needs’, providing routine immunization and treatments that would address parents’ concerns with measles and malaria. Even with the continued rejection of vaccination by some northern Nigerian parents, by attending to parents’ health concerns and offering appropriate health incentives, this approach could greatly increase vaccination coverage, as was the case when Immunization Plus Days were first introduced in 2006. Moreover, providing functional primary healthcare programmes to communities in northern Nigerian would serve as a way of addressing, in part, the impoverishment of the north. It is the sort of ‘nimbleness’ and attention to local conditions that the May 2013 IMB report suggests is necessary to complete the polio eradication initiative in Nigeria. Such ‘nimbleness’ is reflected in other recent GPEI efforts in northern Nigeria, which include the inclusion of members of FOMWAN (the Federation of Muslim Women's Associations of Nigeria) on polio vaccination teams and the food distribution programme sponsored by Aliko Dangote. Such efforts have helped to keep the number of confirmed cases of polio low in 2013. As of 12 February 2014, there have been fifty-three confirmed cases of the wild poliovirus WPV1 strain, no cases of the wild poliovirus WPV3 strain, and four cases of circulating vaccine-derived poliovirus (from Borno State) in 2013 (CDC 2014a). As of June 2014, there have only been three confirmed cases of the WPV1 strain and seven cases of circulating vaccine-derived poliovirus reported in 2014 (CDC 2014b).

Yet despite these low numbers, the question remains of how political violence and insecurity – and the political-religious anxieties that they reflect – are best addressed, particularly in areas outside the north-east that are unaffected by the state of emergency order. With respect to Jama‘atu Ahlis-Sunnah Lidda‘awati wal-Jihad (Boko Haram), Murray Last (Reference Last2012: 36) has suggested that the government negotiate a resettlement plan to establish rural religious communities and to provide them ‘with craft skills, land and water supplies, even electricity’, and, perhaps, primary healthcare. While some might argue that such efforts are outside the purview of global eradication interventions, the political and economic contexts in which the GPEI has been carried out have affected its implementation in northern Nigeria. As Taylor (Reference Taylor2009: 556) has argued, global health programmes may ultimately fail if they avoid confronting ‘underlying social and political issues’, preferring instead ‘the political safety of educational problems, rather than recognising the wider problems of governance and the distribution of wealth and well-being’.