Uganda - Rumours by Radio - Combatting Antivaccination Rumours: Lessons Learned from Case Studies in East Africa

Rumours by Radio against OPV

Rumours started in 1996 in the Buganda area around Kampala when NIDs were first implemented. They came from two sources, according to several officials who were interviewed for this report. In 1996 Mulindwa Muwonge, who operated Central Broadcasting Service (CBS) Radio, a private FM station in Kampala, questioned why the polio NIDs were implemented. Why at that particular time? He purportedly said that the OPV contained anti-fertility drugs to end the race. His actions had a big influence in lowering coverage in Mpigi District.

At the same time, Muwonge's message was reinforced by a group called the Bazukulu or “Grandchildren of Buganda,” a radical group of Buganda youths. They said that the polio vaccine was a plot coming from the West to kill off the race. In addition to these stories, the HIV rumour was still circulating. Since some OPV formulations are red, the children were said to be receiving blood contaminated with HIV.

Ugandan health officials responded to Muwonge by meeting with him, briefing him about the polio campaign, and answering his questions. He stopped broadcasting the rumours as a result. The Ministry of Health talked to the Minister of Health for the Buganda Kingdom at that time and asked him to use his influence with the university students. He held meetings to sensitise the students. After 1997 to 1998 there were no further problems with rumours in the Buganda area. Central Broadcasting Service aired interactive programmes with questions and answers.

During the 1990s the Uganda government allowed for private ownership of FM stations under its policy of media liberalisation. Health officials from UNEPI, the Ministry of Health, UNICEF, and the WHO believe that it was during this period that one radio operator who began broadcasting in mid-1999 contributed to declines in routine immunisation and poor coverage for NIDs in the southwestern regions of Uganda.

While officials believe that one owner affected NIDs negatively, coverage results have always been above 90 percent in each year NIDs were held. In addition, all medical personnel interviewed concede that routine immunisation declines began around 1994. This was long before Greater Afrikan Radio FM 98.3 began broadcasting from Mbarara town in western Uganda, covering an area of about 50 miles, inclusive of six districts. The station, according to the proprietor, currently has a listenership of about five million people, covering most of Uganda except for the northern and far eastern districts.

Dr. Mark Grabowsky, a former WHO medical officer now in Washington, DC gave his retrospective on the rumour campaign that was promoted on Uganda FM radio. He says that “rumours happen and that the radio station responded to market forces. People were listening for more.” Dr. Iyorlumun Uhaa, a UNICEF Senior Project Officer, seemed to agree with Dr. Grabowsky: “Radio fills a niche we didn't have. It gives information.”

Several factors reported in the 1996 and 1997 documents on NIDs may have contributed to some of the rumours, such as expired drugs and the attitudes of health workers themselves. Moreover, NIDs and the HIV vaccine campaign kicked off on the same day. Many perceived HIV/AIDS as a Western plot and that the West had originated HIV.

It was in this context of rumours that Nkamuhayo Rwacumika or, as he is popularly known, Kihura Nkuba, began broadcasting in early 1999. He said that he kept his views on immunisation to himself until May 1999, when he went to the village of Bwizibwera in Mbarara District to give a lecture. Here he says he learned from people that many children had died following mass polio immunisations in 1997. According to Kihura Nkuba one of the preachers said, “I buried children and my cassock got old.” According to an uncorroborated account by Kihura Nkuba, one of the parents, who had four children die after OPV, was forced at gunpoint to get her last child immunised,. Many people began hiding, rather than take their children to NIDs. Kihura Nkuba said that people reported that officials went house to house and jailed people who refused to have children immunised.

When Kihura Nkuba heard these accounts from people in Bwizibwera, he began reading about OPV and vaccinations on the Internet and from many books on scientific and alternative medicine subjects. He has by now amassed an extensive library of technical and scientific information on vaccines and vaccinations.

In response to the people's questions, Kihura Nkuba also contacted the CDC and researched vaccines and vaccine safety on the CDC Website. He was particularly concerned about the use of the Sabin polio vaccine, OPV, because it contains the live but weakened poliovirus. In an interview, he said that his main concern was that OPV was being used in the mass polio campaign without regard to the HIV status of recipients. Kihura Nkuba had read the CDC guidelines. These stated that OPV should not be given to individuals with compromised immune systems. Further, he pointed out that the manufacturer's literature accompanying the vaccine vials recommends that OPV not be given to anyone with immunodeficiency, or who has a family history of AIDS.

He continues to be concerned that health workers giving OPV have never taken into account the health status of the children. Kihura Nkuba also stated in his interview that callers to his radio station told him that some of the OPV vials were expired.

Kihura Nkuba says that he does not tell people not to go for vaccinations. He does not speak against vaccinations. And he doesn't say, “Don't get your children vaccinated, or they will die.” He tells his audience that they should have the right to choose for their children. His goal is to give them enough information to make informed choices and to ask questions. He said that when people questioned officials about adverse reactions or events, the attitude of the Ministry of Health was that people are too simple and uneducated to understand what they are told. To date he says he has only talked about OPV and that he has never discussed other vaccines or routine immunisations on his programme.

Kihura Nkuba and others interviewed in the villages also questioned: why polio? People in the villages have never seen a case of polio. Everyone interviewed pointed out that malaria is what kills people in Uganda. Why have “they” prioritised polio over the disease that kills us?

Since 1999, when Kihura Nkuba began raising public doubts about OPV, the Ministry of Health has resisted his broadcasts. Kihura Nkuba says that the people had a quarrel with the Ministry of Health before he started talking. The Ministry of Health says people were enthusiastic about NIDs until Kihura Nkuba started broadcasting. According to the figures for national coverage, Kihura Nkuba has had no effect on the NIDs. Dr. Grabowsky also thought the impact of the rumour campaign was possibly overrated.

Regardless, officials would like nothing better than to shut down the station or for Kihura Nkuba to simply go away. In reaction to his broadcast in 1999, the Ministry of Health brought doctors to debate with him. They met over lunch and thought that the result of the meeting would be for Kihura Nkuba to desist, but three days later, he started up again. The government also attempted to refute his positions on the air with debates, but this effort was unsuccessful because the moderator, Kihura Nkuba, had a better command of the facts than government officials had. According to Dr. Grabowsky's account, the government also attempted to "buy off" Kihura Nkuba by placing pro-NIDs advertisements on the air, but these were undermined by the station's commentaries.

At a Bushenyi District officials' meeting in September 2001, officials were still at a loss as to how to silence Kihura Nkuba. They conceded that trying to convince him to be quiet is a waste of time, and that the “problem” of Kihura Nkuba must be dealt with on a national level. The government is planning to take action through legislation. According to the Ministry of Health, a law requiring immunisation is in effect, but the punishment for not following the law is weak. The Hon. Mike Mikula, Minister of State for Health, expressed the following view, in a closed-door session prior to an open hearing for the district: "If parents cannot be arrested for not complying, then they should be taken to court and punished."

At that meeting the Ministry of Health proposed to launch a protracted campaign. The Ministry of Health said that the Ministry had failed to explain “negative” (adverse events) to the people. He said that leaders would use the same medium – radio – and that the Ministry of Health and Kihura Nkuba would issue a joint statement answering questions. The Ministry of Health would help with advertising to counter rumours. In addition, the Ministry of Health would go to the grass roots and address their questions. They would involve the churches and schools. The churches are “100 percent behind us.” In schools parents would be met and addressed through the PTAs. Mr. Mikula also noted that the Ministry of Health believes that Kihura Nkuba has used them for a scapegoat. “If he does not bend, then we shall legislate.”

Later that day Bushenyi District held a public meeting attended by over 100 people. Following reports from officials, the chairman took comments from the floor about why that district had the lowest coverage in the first round of SNIDs in 2001. (This district is one targeted for SNIDs for the border districts.) Here is a summary of reasons or opinions people gave for low coverage:

• Inadequate financing – not enough funds for social mobilisation to move around the district.
• Inability to explain to people why Kihura Nkuba is wrong because he brings research; Ministry of Health is not responding with opposing views.
• Local leaders are not adequately supporting immunisation.
• People who did not take their children were not punished.
• Leaders did not take their own children.
• Rumours that OPV contained HIV.
• Rumours that OPV contain anti-fertility drugs.
• People say they are tired of the exercise (NIDs).
• People are suspicious. Why NIDs again?
• Sensitisation is poor – radio is sending negative messages but no one explains that radio is wrong.
• Adverse events in 1998.
• Messages given during social mobilisation are not consistent. Speakers say different things.
• Too much freedom for people – they can refuse. Biggest response was in remote areas of the country where the government came out strongly and forced people.
• Non-standardised data – incorrect projection figures for number to be immunised.
• Superstitions and suspicions – no one had seen a case of polio.
• Rumour that the government is using the vaccine against those that don't agree.
• Questions about why supplemental (booster) immunisations for polio only?
• Before NIDs mothers took children for routine immunisation. Why is this (NIDs) necessary?
• Doctors are not punished for not immunising their children.
• Government is making it political.
• People giving OPV are not trained, and parents question their skills.

Along with these concerns, the radio station and Kihura Nkuba were mentioned many times by the people in attendance. Officials put forth a plan of action to counter rumours and educate people about immunisation, starting at the community level. They would develop scientific, focused messages and disseminate information through all channels available to them, including radio. They would develop radio programmes and begin using film vans again with the goal to make Bushenyi a model district in polio eradication.

The Ministry of Health said it wanted Kihura Nkuba to meet and discuss areas of disagreement so that the Ministry of Health and Kihura Nkuba could develop a team approach. At this district-wide meeting the Ministry of Health noted in response to Kihura Nkuba's broadcasts that it was Ministry of Health policy not to immunise those known to be HIV-infected. According to Kihura Nkuba in a later interview, this was the first time the Ministry of Health stated this policy publicly. Nkuba seemed to feel this was a small vindication of what he had already been saying on the radio.

Near the close of this meeting, Kihura Nkuba was invited to come and speak. He said that he was happy that “the Ministry of Health and I are engaged in a dialogue for the betterment of our people's health.” The Ministry of Health agreed that a post-vaccination survey would be conducted in the region to determine whether there was credence to the belief that many people expressed: health of children goes downhill after OPV. The Ministry of Health and Kihura Nkuba declared a “cease-fire.”

In an interview several days later when asked what he wanted to see happen, Kihura Nkuba said that he would like these questions addressed:

• Why spend all those resources on polio when it kills few or no people?
• If IPV is a safer vaccine, why use OPV?
• Malaria is the number one killer of children. Most people cannot afford treatment, so why devote limited resources to polio?
• If global organisations and governments want to help Uganda, why not have them put resources into diseases that kill? Wouldn't paralysis be preferable to death?
• If polio vaccination is so good, why do you have to force us?
• If polio is actually caused from faeces, if I improve sanitation/hygiene, how could I come into contact with polio?
• If OPV is safe and we know its ingredients, why don't we manufacture OPV in this country?
• If we made the vaccine in Uganda, would we force people in other countries to take it and put them in jail if they didn't?
• Before we started vaccinations, we didn't see a lot of polio and we had our own methods (herbs) to vaccinate. Why can't we emphasise this method?
• When we vaccinate, the children die. We do not see you. You come to vaccinate and leave. We remain with the children.

Kihura Nkuba's questions and concerns, which he says are the questions and concerns of mothers and fathers, are confirmed by the mothers and fathers interviewed. Letters that the listening audience sent to Kihura Nkuba during that period of time and until the present continue to raise the same questions. Parents are especially concerned about the safety of OPV and why it is being given to their children in Africa when it is banned in America? And why are their children dying?

In addition to answers to these questions, Kihura Nkuba said that the Ministry of Health needs to do the following:

• Change from OPV to IPV.
• Allow children some time between birth and when they receive vaccination.
• Conduct a study to see what is killing children. (Ministry of Health has already agreed to this.)
• Make exceptions to vaccinations: e.g. do not vaccinate in cases of HIV, malaria, infections, vomiting, and fever.
• Concede ground to give parents full information and the right to choose. He stated here that force will cause campaigns to collapse. Parents need information about reactions and post-vaccination support. Officials defeat their own purpose: if a child dies, the entire village will not go. Fully informed parents have an incentive to go.
• Improve radio advertising through thoughtful concepts and by giving information. Promote immunisation all year – not just in July. The Ministry of Health does not have a public relations or research department. Ministry of Health could reduce its budget by giving information. Kihura Nkuba would be willing to help design health messages.
• Implement an independent consumer protection and advocacy organisation (similar to the U.S. Food and Drug Administration) that can be trusted by the people.

He says that he is prepared to work with the government, but the Ministry of Health does not come and ask what he is saying. He views Greater Afrikan Radio as a media organisation that researches the material it presents on air. He feels that he has the ear of the people. He said in an interview that “the government expects to speak and people just go and do it…” Nkuba is, in his own lights, a firm believer in empowerment through knowledge and information.

He said that he had discussed the possibility of developing and implementing an alternative information centre through the radio station with Michel Sidibe, the UNICEF country representative. Although Kihura Nkuba wrote a proposal for such a centre in March 2000, as requested, he claims never to have received a response from UNICEF.

Later in the week, following the Bushenyi District meeting, another example of confusing messages appeared in the newspapers. The Ministry of Health generated the confusion.

In a National Coordinating Committee Meeting to Prepare for the Second Round of SNIDs in Kampala on September 11, 2001 (See Annex ), Kihura Nkuba was still the topic of a great deal of discussion when officials met to assess the first round of polio SNIDs. Several participants talked about taking Kihura Nkuba to court and the possibility of closing down the station.

While many thought that Kihura Nkuba's broadcasting is still having a negative effect on SNIDs, a number of participants noted that instead of reacting to Kihura Nkuba, they sensitised people in the district causing coverage to improve last year in the second round. Others noted that they needed to look at the administration of Bushenyi District because leadership is lacking. Leaders show no interest in the exercise of NIDs: i.e. more vaccine was wasted there; they did not have enough health workers; the cold chain technician is not a former health worker; and mobilisation was inadequate.

The WHO Information Officer, in a later interview, agreed that in 2000, Bushenyi had only 54 percent coverage in the first round of NIDs. He agreed, too, that when intense mobilisation was done at the sub county and parish levels, coverage increased to 94 percent in the second round. He said that Kihura Nkuba is not the whole issue. People asked simple, logical questions which they wanted answered. When their questions were answered, they got their children vaccinated.

The Ntungamo District Chairman, Local Council V, Mr. John Karazarwe, said that when the radio rumours came, resistance to vaccinations developed. “When people listen to the radio or television, they think it's the word from the government, even if it's private.” He said that at first everyone believed Kihura Nkuba's messages because they came at the time when many children were dying from malaria and AIDS.

In response to the resistance to polio immunisations, the LC V Chairman said that Ntungamo District formed an anti-malaria task force. They noted that NIDs coincided with the emergence of mosquitoes in August. That was why the mothers and fathers thought children were dying from polio vaccinations. They did not take their children to hospitals or clinics to find out that the illness and death were from malaria. Some said that vaccine looked like blood and their children were getting AIDS in the mouth. Some simply thought that the vaccine was unnecessary. Since there was widespread ignorance about the polio vaccinations, people withdrew. Everyone, including educated people, stopped taking their children. Even the police had to be arrested because they would not take their children.

Chairman Karazarwe said that in the de-centralisation taking place in Uganda, he got substantial funds that he could decide how to use in his district. He said that he chose to ignore the radio broadcasts and began implementing health improvements that have helped to improve coverage in routine immunisation and coverage in SNIDs. Here are some of the steps he took:

• Upgraded health units from nine to 25 (the district does not have a hospital). Encouraged every parish to have a health centre.
• Trained and required health workers to do outreach.
• Began treatment for malaria – sensitised and trained health workers about treatment.
• Used AfriCare and other institutions to assist with improving water sources.
• Improved food security by encouraging development of back yard gardens, teaching about nutrition and its relation to improved immunity to resist diseases.
• Improved communication and access for mothers.

Ntungamo District moved away from confrontation, took the resources that would have been diverted through confronting and arguing with Kihura Nkuba, and put those resources into district services combined with increased education. The LC V Chairman sees this as empowering mothers.

He believes that when you fight Kihura Nkuba that “you show you're afraid.” His strategy has been to remove the grounds for Kihura Nkuba's strength – his influence with the people. “If you go to radio, at the end of the day, you confuse the masses.” You must disarm him by using a different message.

The challenge, says Chairman Karazarwe, is to be careful not to disappoint people. He says he must make sure to give the services people travel long distances to get. As the level of awareness in the district has gone up, people have started coming to the health units. Thus, demands on local government, especially for drugs, have increased. If people become disappointed, they will drop out.

In addition, the Ntungamo Assistant District Director of Health Services said that Kihura Nkuba said mothers did not get information about possible adverse events following vaccination, such as fevers. “But we tell mothers what to do. If fever persists it might be malaria.”