Terrorism, Malnutrition and the Re-Emergence of Polio

The inability of the health authorities to move polio vaccines to Boko Haram strongholds in the North-east, and the compromised immune system of malnourished children in the region, have been fingered as key reasons for the re-emergence of the wild polio virus, setting the country several years back in the eradication of the dreaded disease. Martins Ifijeh writes

When in January this year, an ambitious new partnership was launched in the Northern part of the country, led by the co-Chair of Bill and Melinda Gates Foundation, Bill Gates, President of Dangote Foundation, Alhaji Aliko Dangote, six Northern governors (from Kaduna, Sokoto, Bauchi, Borno, Yobe and Kano), it was in a bid to sustain the delisting of Nigeria from polio endemic nations for at least the next one and a half years, such that by August 2017, Nigeria would have earned for itself a polio-free status.

In the partnership, which resulted in a Memorandum of Understanding in Kaduna State, all the players were enthusiastic that no new case of the virus will be reported in the North, a region most endemic to the disease in the country. It was a time to lay bare concerns, discussions on areas to strengthen, amount of funds to be needed, as well as how to create further awareness on immunisation, which then led to a unanimous decision that the government at all levels, health workers, traditional and religious rulers, as well as politicians and other well respected citizens must scale up interventions in their respective localities in order to finally defeat the highly infectious disease.

True, many stakeholders led campaigns for a final push against polio. In some instances, the Sultan of Sokoto, Alhaji Muhammadu Sa’ad Abubakar, Alhaji Dangote, respectable Islamic and traditional leaders and a lot of other well-meaning Northern Nigerians spearheaded immunisation campaigns in respective areas where apathy was noticed due to religious, traditional or cultural beliefs.

Some used the media in demystifying the beliefs about polio vaccines. The reason being that, for those community leaders, parents and guardians who believed there was no need to subject their children and wards to immunisation because they do not trust the substances being given to their children, when they see these leaders spearheading campaigns for it, they would most likely listen and open their doors for the immunisation exercises against diseases like the polio virus.

While the various strategies embarked on for a final push against the disease was on course, there were worries. How will areas regarded as Boko Haram strongholds be accessed? Who would agree to spearhead advocacy to these regions, which at that time were still much under the control of the terrorist group.

Specifically, a virologist, Dr. Adeniran Azeez, posed the question while analysing how the last lap of general immunisation programme against polio could be the solution needed to sustain Nigeria’s status as a non-polio endemic nation until the country is finally certified polio-free, leaving behind Afghanistan and Pakistan as the only two countries of the world still battling with the highly infectious disease.

Fast forward six months later, just a day shy-away from marking exactly two years without any case of polio in the country, the most feared happened. Two cases of wild polio virus were reported, and this time, the concerns of every stakeholder, health officials and Nigerians who are familiar with the geography of the North-eastern region of the country were not only awakened, but came with a dawned reality.

The cases were from Borno State, and specifically from regions once occupied by the dreaded terrorist group, which at that time would most likely pose a security risk to any health worker who dared to carry out immunisation programmes in those areas.

THISDAY gathered that the first child suddenly went down with paralysis in the Gwoza camp of the internally displaced persons, which prompted medical experts to isolate other children in the camp who may have had contacts with him for the purpose of immunising them. Also, the second child from Jere Local Government Area was reported to have been previously immunised with three doses of the oral polio vaccine but his presentation of polio now showed that the vaccines used during the immunisation exercise may have been impotent.

Vaccines are said to be impotent if they are not kept under a cold chain at very low temperature. Vaccines die or become impotent if kept under heat condition.

Gwoza and Jere LGAs are territories once under the control of the Boko Haram insurgents, and even while they have been said to be ‘liberated’, sporadic attacks still occur there with killings recorded in large scale.

The terror group has publicly denounced the vaccination campaigns as a Western plot,
killed immunisers and made it difficult for government health officials to access some parts of the North-east, especially during the heat of the insurgent’s reign.

Recall that on June 1, 2016, Senate Leader Mohammed Ndume, who hails from Gwoza LGA called on the IDPs from the local government to return to their homes while claiming that the area had been liberated by the Nigerian Army, but in a swift response, the Emir of Gwoza, Alhaji Muhammadu Idrissa Timta, advised all IDPs, including his family not to return to the local government, adding that Boko Haram still has a strong footing in the area. Same advise had also been given to people from Jere LGA by traditional leaders from the local government. Years ago, the former caretaker chairman of the Jere LGA, Alhaji Mustafa Baale, and hundreds of indigenes were killed by Boko Haram

It is in the light of this that a Programme Manager with Project Africa, a non-governmental organisation, Dr. Ben Nkwoma, while analysing what must have gone wrong in the efforts at sustaining the non endemic polio status of the country, stressed that the new outbreak of wild polio virus was a direct consequence of the ability of Boko Haram to control some parts of the state.

In 2014, Boko Haram announced that it had taken over government in 20 out of the 27 Local Government Areas in Borno State, including Gwoza and Jere LGAs.

“While everyone was waiting patiently for next year until the country is certified polio-free by the World Health Organisation (WHO), I was one of those who believed it wasn’t time yet to celebrate, because for obvious reasons, we all know the immunisation that was done about three, four, five or six years ago, would most likely not have covered everywhere, especially in areas where Boko Haram was controlling. So it was just a matter of time before cases would be reported in those areas. There is no two ways about it, immunisation didn’t reach those areas. Obviously, no health worker went to these flash points during the heat of those periods when the terrorist group was seizing territories,” Nkwoma added.

Collaborating his claim, some members of Journalist Against Polio (JAP) who reside in Borno confided that truly no much immunisation took place in Gwoza and other towns overran by the terrorist group.

JAP has been a key campaign group that actively raised awareness on the benefits of vaccination and the need for families and communities to immunise their children. But like the health workers, their media campaign later stopped in Borno due to insecurity.

Also, the Governor of Borno State, Kashim Shettima, fingered the activities of Boko Haram as the causal factor for the recent outbreak of the disease, describing the development as an embarrassment to the state and the nation. “The Boko Haram activities made some communities in the state inaccessible for polio vaccination between December 2013 and the end of 2015; as well as the earliest part of 2016.”

Shettima said further, “back in November, 2013, the Bill and Melinda Gates Foundation even awarded Borno State for being the most committed to fighting polio in the North-east despite our insurgency. It is however unfortunate that last week, fresh cases of polio were identified in Borno. While this is officially painful and personally embarrassing to me, as an award winner in polio eradication, the basis of the recent outbreak of polio is largely due to the unimaginable condition we found ourselves.

“I have seen one commentator saying Borno was dragging the country backwards on polio eradication. From December 2013 to the end of 2015, we had hundreds of communities in 20 local government areas seized by Boko Haram; many roads were practically under their command; citizens including young children wandered for months around the deserts and forests, scampering for safety in the wake of attacks by Boko Haram on their communities; thousands of citizens were trapped in communities around the Sambisa forest, around the shores of the Lake Chad and around territories being administered by Boko Haram; thousands, including pregnant women and children, were held captive by Boko Haram while hundreds of children were even born in captivity,” the governor noted.

While expressing optimism that the problem was only a temporary setback that would be surmounted, he said the new cases were because some citizens, especially children, who were held captive had now been freed.

He said it was impossible for the Government to have sustained its wide reach in polio immunisation under such an atmosphere where some territories were being controlled by the terrorist organisation, adding, he said the new diagnosis was made because most communities were now free, hence easier to identify persons with medical challenges.

“We all know that a problem identified is a problem half solved. Our communities are mostly free and this makes room for a critical round of aggressive polio eradication campaign in Borno. Unlike before, we don’t envisage the killing of health workers administering polio and other preventive vaccines in most of our communities which they couldn’t access since 2014. The tide has now changed. In the past, our people were those running but today, it is Boko Haram that is on the run,” he stressed.

Meanwhile, the United Nations Children’s Emergency Fund (UNICEF), while x-raying what must have gone wrong, said malnutrition, in addition to the displacement caused by the terrorist group was already a handful of discomfort for the children leaving in the North-east, urging the government to find an immediate solution to all three issues; terrorism, malnutrition and polio re-emergence.

Role of malnutrition in the re-emergence of polio
While the causal factor for the re-emergence of the disease largely tilts towards the lack of accessibility by health workers to provide vaccination in Boko Haram strongholds, Nkwoma, believed the role of malnutrition must not be wished away, adding that, a malnourished child who has been vaccinated may not get the full potential in the vaccines.

“Studies have shown that polio vaccination is about four per cent lower in malnourished children than the healthy ones. And we all know that due to the unrest in the North-east, several children are malnourished. What this therefore means is that a malnourished and vaccinated child may still end up being infected with polio because of the lowered immunity,” he noted.

Way forward
As part of efforts to tackle the new challenge head on, the federal government, through the Minister of Health, Prof. Isaac Adewale, has announced an emergency mass polio vaccination campaign in the North-east, which will be done under military presence.

Though termed a late response by experts, it is believed that if all the children in the affected areas and neighboring states are accurately vaccinated during the renewed exercise, there were likelihood that the federal government would have ended up securing a guarantee in areas once inaccessible by health workers.

“The priority is to boost immunity and ensure that no more children are affected by this terrible disease. Also, we are currently investigating the situation to find out where the virus has spread,” Adewale said.

Meanwhile, Nkwoma said while the government, UNICEF and WHO are on top of the game to find a quick response to the outbreak, the malnutrition issues in affected areas must not be taken for granted. “As vaccines are being carried to these places, food as well should accompany it. There should be plans as well to flood those areas with food because if you visit these areas yourself, you will discover that virtually every child there is suffering from malnourishment. How can the immunity of the children respond positively to vaccines,” he added.

While it’s a known fact now that some vaccines used in some areas in Borno State were impotent because they were not preserved in the right temperature, it is imperative that all measures are put in place to provide potent vaccines this time.