Public Health: Polio's Moving Target

In 2012, Ewen Callaway travelled to Northern Nigeria, one of the three last remaining polio-endemic countries, to learn more about the global polio eradication effort. This article describes his search to find out about one of the virus' last remaining strongholds in remote nomadic communities, such as the Fulani (who "receive little education or health care from the government"), which the vaccines have not been able to reach.

The following vignette sets the scene: "Mohammed Abubakar's home is not on any map - at least not yet. To reach his settlement in a desolate part of northern Nigeria, four health workers creep over deep-rutted roads in an old Peugeot for an hour, then ride motorcycles over narrow dirt trails for another 30 minutes....Finally, they spot a cluster of mud-brick huts, known to the Fulani nomads who live there as a ruga. 'As-salamu alaykum,' - peace be with you - says Ardo Babangida, a traditional leader accompanying the team. Children swarm around the visitors, and Daniel Santong, an easy-going veterinarian and leader of the group, asks to meet Abubakar, the head of the household. Meanwhile, a young colleague whips out a smart phone and uploads the settlement's Global Positioning System coordinates into a database. Abubakar arrives...and Santong tells him that they are trying to eliminate polio in nomadic people. Abubakar clasps his guest's hands in appreciation. He says that he cannot remember the last time that health workers came to vaccinate his children. It is a story that Santong and his colleagues are now accustomed to hearing, even though door-to-door immunization campaigns happen on a near-monthly basis in the region."

Noting that this population is thought to include hundreds of thousands of young children, many of whom have received none or only some of the multiple oral polio vaccine doses required to achieve full protection, in June 2012, the National Stop Transmission of Polio (N-STOP) programme, organised through the Global Polio Eradication Initiative (GPEI) and supported by the Nigerian government, started a census of Fulani nomads and other hard-to-reach populations. N-STOP's census programme was designed to support ongoing vaccination efforts, uncovering areas of need and directing resources and local vaccination teams to them. So as not to interfere with local efforts, N-STOP teams didn't bring vaccine stocks with them until the federal government asked them to. Questions have been raised as to whether the mapping data will be enough to allow health workers to locate nomadic communities; perhaps actually showing teams where settlements are and not just writing it down would be fruitful. And a suggestion is made by one person quoted here that the N-STOP programme needs to coordinate its day-to-day activities with local health authorities.

According to Callaway, refusals to the polio vaccine amongst nomadic populations such as this one are largely driven by disenchantment, not by religious objection. "People want things other than polio vaccination," says David Heymann, chairman of the advisory board for Public Health England and the former head of the polio-eradication efforts for the World Health Organization (WHO). "They can't understand why people are coming once a month to give them vaccination when what they want are treatments for their children with fever or diarrhoea."

The article concludes with a message of optimism: "Other countries with migrant populations have done the job."