Natalie Fol – Case Study – July 2010
Resistance to polio vaccination:
What can we learn from the “Social Norms” perspective?
A case study based on the 2003/2004 northern Nigeria’s
boycott
Introduction
Since 1988 and the creation of the Global Polio Eradication Initiative1 (GPEI), major results have
been achieved in the fight against polio. Between 1988 and 2000, global cases have declined from
1,000 cases a day to 719 cases.
In 2002, only two of the 46 African countries, Niger and Nigeria, were still polio endemic. Nigeria
registered 56 cases in 2001. In Niger, only 3 polio cases were registered in 2002, with an additional
case registered in the first half of 2003. Niger was expecting to be soon declared “polio free”.
In mid-October 2003, the GPEI launched what was hoped to be the final onslaught against polio,
with a plan to immunize more than 15 million children in West and Central Africa. The GPEI had
particular concerns about the prevalence of polio in Nigeria, which accounted for 80% of cases
reported in the Africa region in 2003. The high prevalence was attributed to poor vaccine coverage
during previous immunization campaigns.
Unfortunately, three states in northern Nigeria (Kano, Zamfara and Kaduna) decided not to
participate in the October campaigns due to doubts on vaccine safety. A boycott was organized in
northern Nigeria which subsequently spread to southern Niger where an increasing number of
families and communities started refusing vaccination.
This led to a significant increase in polio cases in the two countries. In the second half of 2003, 39
polio infection cases were registered in Niger. Most of the new infections were concentrated in the
regions along the border with northern Nigeria. Polio incidence rates in Nigeria rose from 56 in 2001
to 355 in 2003, reaching a high of 1,122 in 2006. Most of the polio free neighboring countries were
also re-infected.
1
Public health initiative led by WHO, Rotary International, the US Centre for Disease, Control and Prevention (CDC) and
UNICEF
1
Natalie Fol – Case Study – July 2010
PART 1 - Social Norms related to vaccination
Vaccination is recognized by the international community as one of the key means to improve
health. Immunization is a critical component in progress towards the achievement of the Millennium
Development Goal aimed at reducing child mortality by two thirds by 2015.
Resistance to vaccination began in several countries after its introduction in the early 1800s and
has continued ever since. According to Robert Wolfe2, “regardless of how the medical establishment
feels about anti-vaccinationists, it is important to understand that they have deeply held beliefs,
often of a spiritual or philosophical nature and these beliefs have remained remarkably constant
over the better part of two centuries. The movement encompasses a wide range of individuals, from
a few who express conspiracy theories, to educated, well informed consumers of health care, who
often have a complex rationale for their beliefs (…).Opponents argue that mandatory vaccinations
violate individual rights or religious principles”. From the onset, strong imagery was used to
demonstrate the opposition to vaccination as shown in the pamphlet photo below.
The Vaccination Monster (London, 1807)
“ A mighty and horrible
monster, with the horns of a
bull, the hind of a horse, the
jaws of a krakin, the teeth
and claws of a tyger, the tail
of a cow, all the evils of
Pandora's box in his belly,
plague, pestilence, leprosy,
purple blotches, foetid
ulcers, and filthy running
sores covering his body,
and an atmosphere of
accumulated disease, pain
and death around him, has
made his appearance in the
world, and devores mankind
—especially poor helpless
infants—not by sores only,
or hundreds, or thousands,
but by hundreds of
thousands (vide Vaccinae
Vindicia: 413, 423). This
monster has been named vaccination; and his progressive havoc among the human race, has been
dreadful and most alarming.”3
2
3
Robert Wolfe, Anti-Vaccination Activists, Past And Present, British Medical Journal August 24, 2002;325:430-432
Wolfe – Op cit
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Natalie Fol – Case Study – July 2010
Compliance or non-compliance to vaccination: a tension between individual and collective
interests
To reach an efficient coverage for a disease, it is required that almost everyone is immunized. The
collective is hence best off if everybody collaborates (i.e. gets immunized). However given the
potential risks (side effects, religious belief, inefficiency, health complication…), if the vast majority
in the community collaborates, an individual is best off to defect (i.e. not get immunized). In this
scenario, the individual benefits from the collective immunity without having to accept the potential
cost of the risk. If nobody complies with immunization, then the collective is worst off since the level
of immunity will be insufficient to provide an adequate coverage to prevent or eradicate the disease.
This tension between individual and collective interest - or social dilemma - can be described in the
graph below:
C
D
S
C
B
C= collaborate = immunize
D= defect= not immunize
S
T
T
D
B
W
W
B = BEST
S = SECOND
T = THIRD
W = WORST
The option where everybody complies with immunization (S/S) is not the best choice for an
individual since there is a potential risk associated. However, since non compliance of individuals
put at risk the collective level of immunity and increase the risk of outbreaks and number of deaths
of preventable diseases, social norms have to be developed to support immunization. These are
often based on the assumption that there is an overall trust in the medical research and in the public
health system as well as an awareness of scientific evidence that vaccinations save lives and
prevent disease. The social norms related to immunization commonly followed by the majority of
people are based on the following rationale:
Empirical expectation: “I believe that the vast majority of people comply with immunization.”
Normative expectation: “I believe that others expect me to comply with immunization.”
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Natalie Fol – Case Study – July 2010
The sanction for not complying with vaccination can either be legal (compulsory vaccinations such
as yellow fever in most African countries or vaccine against tuberculosis and school attendance in
France) or social (shame, ostracism - not only do you put your children at risk but you also put
others at risk since you contribute to reduce the level of collective immunity to the disease).
The boycott organized in northern Nigeria in 2003 demonstrated that a change in assumptions on
which a norm is based impact on individual expectations within a group. In the Nigeria case,
normative and empirical expectations as well as sanctions attached to social norms relating to polio
vaccination reversed. As a result, a behaviour based on non compliance with polio vaccination
became the normative expectation (“I do not immunize my child because this is what I think I am
requested to do”), hence impacting on the empirical expectation (“the vast majority of my reference
group do not get their children immunized against polio”). Rejecting the scientific-based acceptance
of immunization, the religious and political leaders in northern Nigeria created another social norm
against polio immunization based on political, cultural and religious values.
It is commonly agreed that change in empirical expectations takes time. However, in the Nigeria
case, the process was fast. This must be reviewed in the light of a favourable context enabling
change. This paper reviews the various factors that explain the shift.
PART II - The political context
The northern Nigeria boycott did not happen in a vacuum but can be linked to other public
controversies around polio vaccination that emerged in the 1990s in numerous countries4. These
controversies have been largely amplified by media for several years, hence feeding a reservoir of
fear and mistrust.
Specifically to Nigeria, additional internal factors contributed to the development of resistance.
Politically, Nigeria is divided into 36 states and one territory; the north of the country is
predominantly Muslim and the south is predominantly Christian. In the early 2000, Nigeria was
experiencing a political transition between from a military regime to a democracy. “Until 1999, the
north had ruled the country for more than 30 of the 46 years of independence. Since the beginning
of the new democratic system of government in 1999, power shifted to the south (...). These
changes have resulted in political tensions between the south and north.”5
4
Combatting Antivaccination Rumours: Lessons Learned From Case Studies In East Africa - UNICEF 2002
5
Jegede AS (2007) - What Led to the Nigerian Boycott of the Polio Vaccination Campaign? PLoS Med 4(3): e73.
doi:10.1371/journal.pmed.0040073
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Natalie Fol – Case Study – July 2010
The southern-led leadership probably contributed to an expectation in northern Nigeria of a lack of
attention from the central government, especially in regards to the widespread poverty and low
access to basic services. People living in these areas were often extremely poor, with very poor
indicators for child health and access to education, nutrition, and sanitation.
The Hausa factor
The vast majority of people in northern States of Nigeria belong to the Hausa ethnic group. “The
impact of Hausa culture in Nigeria is paramount, as the Hausa-Fulani amalgamation has controlled
Nigerian politics for much of its independent history. They remain one of the largest and most
historically grounded civilizations in West Africa”6. The vast majority of Hausa live in northern
Nigeria and south-eastern Niger. They share the same culture, same language and same religion.
Given the historical power of the Hausa culture, resistance to « external threats” is obviously a
strong component in the group identity. As underlined by Antanas Mockus, the former Mayor of
Bogota, “Civil resistance movements tend to appear in the midst of communities or societies that
throughout their history have built a very strong identity. In most cases, their identity has to do
precisely with their resistance to invaders or illegitimate governments”.7 In the Nigeria case, the civil
resistance organized through the boycott by the Hausa influential leaders also demonstrated their
capacity to resist to what was perceived as outside potential threats (central government, western
values).
PART III - What factors influenced the boycott?
The Nigerian resistance was influenced by a complex interplay of factors. It was first and foremost
motivated by an attempt by the local leaders to protect what they consider as “their” people from
perceived risks. These risks were based on the analysis of various past events.
1. The factors embedded in negative past references (categorization)
In 1996, a US pharmaceutical company sent a team to Kano during an epidemic of meningitis. The
team conducted a trial to test the efficacy of its new antibiotic. Lawsuits were undertaken against the
company, alleging that the drug trial was illegal and that it had killed children included in the trial. In
northern Nigeria and especially in Kano this event was still on people’s minds and had contributed
to shape a negative bias against western pharmaceutical companies and immunization campaigns.
According to Hussaini Abdu, Coordinator of the Centre for Development, Research and Advocacy,
“the Pfizer problem is a good example of how people have lost trust in government. When it
6
7
Hausa People – Wikipedia, the free encyclopedia
Antanas Mockus – Citizen-Building (vision of society)
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Natalie Fol – Case Study – July 2010
occurred, the government did not provide any strategic protection or any information as to what
actually happened. It took two years before people even got to learn about it and to also discover
that the government actually collaborated with the American company (Pfizer) to conduct drug tests
for meningitis.” 8
According to Jegede9, another historical factor related to population and fertility regulation should be
taken into consideration to understand the boycott. “In the 1980s, (…) a population policy was
adopted that set a limit of four children per woman. Some people connected this population control
campaign with immunization, believing that vaccination was one way the government might be
reducing the population. This belief was not restricted to northern Nigeria—similar opinions were
also expressed in some communities in southern Nigeria”.
2. The dissonances between two reference systems
Fear and mistrust in the western world
The events around September 11 attack as well as the US foreign policy in the Middle East
contributed to create a gap of fear and mistrust between the western world and the Muslim
communities. Based on a religious rationale, if the Western world was engaged in wars against Iraq
or Afghanistan, it led to the conclusion that it was a war against all Muslims. The amalgam between
politics and religious values shifted the debate around immunization from the scientific field to a
moral field.
In an interview with Agence France Presse dated 18 November 2003, Muhammad Nasir, the imam
of Waje Central Mosque, the second largest in Kano, clearly stated his trust in the iniquity of the
vaccine. However, according to him "the major factor behind the revulsion against the vaccine is the
deep-rooted anti-American sentiment, because we see America as an enemy (,,,), As a Muslim it
would be foolish to expect somebody who is busy killing my brothers' children in Iraq, bombarding
them and destroying their homes to come here and save my children from disease."10
Mistrust was reinforced by the delivery mode of the polio vaccine itself. The concept of the door-todoor campaigns is used only for polio immunization. In a context of widespread poverty, with low
access to basic care, the free delivery of polio vaccine in every household was perceived with great
suspicion.
Hussaini Abdu, Interview, Kaduna, 4 July 2005 – Cited in : Maryam Yahya - Polio Vaccines – Difficult to Swallow : The
Story of a Controversy in Northern Nigeria - March 2006, IDS Working Paper 261 – Interview, Kaduna
9
Jegede, Op Cit
10
Agence France Presse - November 18, 2003
8
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Natalie Fol – Case Study – July 2010
During fieldwork, Yayha noted that “arising from almost all discussions amongst communities in
Bauchi, Kaduna and Kano states, was great concern as to why polio was receiving so much
attention. The Nigerian people are astonished that the federal government with the support of the
international community is spending huge resources on free polio vaccines, when basic medicines
to treat even minor ailments are beyond the reach of the average person (…) Popular opinion views
those affected by polio as healthy and active members of the community, able to manage their daily
chores even if somewhat limited by their physical capabilities. (…)There are clearly strong
sentiments and concerns about health care priorities in terms of who decides what they should be
and why. People became even more resentful due to the neglect of other vaccine preventable
diseases by the National Programme on Immunization. Between February and May 2001 for
instance, there was an outbreak of 100,000 cases of measles nationally (FBA 2005). In the face of
this, the polio campaign met with even more ridicule as it went from house to house to administer
polio vaccines as parents mourned the deaths of their children from measles”.11
In this context of suspicion, mistrust also involved international organizations and development
partners. In response to the WHO representative who had warned on the serious repercussion the
failure of the immunization exercise in Nigeria would have on the image of the country in the
international world, the governor of Kano “pointed out that under a democratic government the
people have the right to chose what they want their government to do for them, and that hence they
don't want polio they cannot be forced by any threat from any donor organization”.12
In Nigeria, authority over health issues is divided between the federal and the state levels. While the
federal state sets national health policies, immunization falls under the authority of states. This
division of accountabilities must also be taken into consideration to understand the boycott. It
allowed to “legally” establishing local norms for immunization in northern states in total conflict with
national norms.
The cultural divergence to understand polio disease
In her anthropological analysis of the polio controversy in Nigeria, Mariam Yayha underlines “an
almost irreconcilable difference between Hausa and biomedical definitions of polio. These
differences have led to clashes of perspective which have significantly contributed to worries about
the polio vaccines. In biomedical terms, polio is caused by a virus and is preventable through
scientific methods of immunization. In Hausa culture, Shan-inna (the name for polio) is an ailment of
Maryam Yayha – Polio Vaccines – Difficult to Swallow : The Story of a Controversy in Northern Nigeria - March 2006,
IDS Working Paper 261
12 Vanguard (Lagos) November 18, 2003 - Tina Anthony
11
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the spirit world. Amongst Hausa communities, it remains a strong belief that Shan-Inna is a powerful
female spirit that consumes the limbs of human beings”13.
Traditional healers are often the first ones consulted for treatment in Nigeria, especially in rural
communities. According to WHO, it is estimated that 80–85 per cent of Nigerians and Africans as a
whole rely on traditional healers for health education and health care.14 “Traditional healers are
greatly respected in the Hausa community (…). Their thorough understanding of the local culture
and their role in issues of governance, family and health issues, places them in variable positions of
influence. It is not surprising to find therefore that notions around Shan-inna/polio are defined and
sustained by traditional healers, particularly in remote communities where other forms of health care
are unavailable”15
3– Inadequate provision and delivery of health services
Primary Health care across Africa is generally weak and it has difficulties responding to people’s
basic needs. Accessibility to basic health services and the availability of vaccines remain a concern
in most countries and has a direct impact on immunization rates. In 2003, according to Yayha,
“immunization services have been inaccessible to a significant proportion of rural communities
where 80 per cent of Nigeria’s population resides”16.
The door-to-door strategy prioritized local female vaccinators to promote cultural acceptance among
communities. However the fact that these vaccinators were sometimes teenagers did not contribute
to build trust in the system. Yayha underlines that during fieldwork, “community members expressed
considerable concern about the age and competence of vaccinators. (...) A number of parents who
opted for the polio vaccine nevertheless discriminated against door-to-door girl-child vaccinators in
favor of immunization services at the local health centers, which they believe to be more
trustworthy”17.
4 - Weak knowledge in the field of immunization
Although information and social mobilization activities are a critical component of vaccination
campaigns, public knowledge on polio immunization was insufficient at parents’ level. The
dissonances perceived between two discourses (the one promoting the polio vaccine and the
13 Maryam Yahya – Op cit
14
WHO Traditional Medicine Strategy 2002–2005, 2002b
Maryam Yayha - Op cit
16 Maryam Yayha - Op cit
17 Maryam Yayha - Op cit
15
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western values and the one protecting the group and religious values) probably contributed to
increase confusion.
Yayha underlines in her research the limited knowledge and understanding of immunization
amongst parents. “Not surprising, therefore, are prevailing notions that one vaccine prevents all
diseases; that vaccines prevent diseases such as malaria, pneumonia and cholera, and that one
dose of a vaccine is quite sufficient for any one disease (…) In relation to the polio campaign it was
therefore not surprising to find a number of parents complaining that their child has already been
vaccinated for polio once, questioning how many times vaccinators wish to administer the same
vaccine? (…) Many were told by door-to-door vaccinators that there is no limit to the number of
doses a baby can receive. A number of parents, however, spoke of their resentment of such
medical advice coming from an 11-year old vaccinator”. 18
PART IV - How did the rumors spread?
The fears related to the vaccines were not shared by the prominent international Islamic bodies.
Hence, the diffusion of rumors and resistance seems to be linked more to the Hausa identity,
combined with strong Islamic religious values.
The network analysis shows that various powerful channels were involved in the spread of the
rumors. They benefit from a considerable level of credibility among the Hausa people. The networks
that conveyed the rumors include:

The political and religious leaders in Kano, Zamfara, Kaduna, Bauchi and Niger States.
These leaders argued that the vaccine could be contaminated with anti-fertility, HIV and
cancerous agents. They called on parents not to allow their children to be immunized.

The chairman of the Supreme Council for Sharia in Nigeria (SCSN) 19 who is a medical
doctor.

Numerous national and international media. « Radio and television broadcasting in Hausa is
ubiquitous in northern Nigeria and Niger, and international broadcasters such as the BBC,
VOA, Deutsche Welle, Radio Moscow, Radio Beijing, and others have regular Hausa
broadcast”.20
18
Maryam Yayha - Op cit
In late 1990s, Sharia law were reintroduced in late 1990s, in Zamfara State. Eleven other States followed suit: Kano,
Katsina, Niger, Bauchi, Borno, Kaduna, Gombe, Sokoto, Jigawa, Yobe and Kebbi. Sharia law is “an Islamic legal system
which had been used long before the colonial administration in Nigeria.
20 Hausa People – Op Cit
19
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A study21 that analyzed the social factors on which the boycott was embedded included:

Local leadership exerted influence

Local customs were invoked

Local symbols with resonance were mobilized

Local decision-making fora were used

Key local ‘‘facts’’ were spread

Local public debate was promoted

Local neighborhoods were organized to resist

Private local dialogue amongst heads of household was encouraged

Relevant local fears and worries, resonant to overall issues, were stressed

Polio was integrally linked to the broader socio-cultural and socioeconomic issues
The diffusion of the resistance was based on critical factors that allowed it to succeed. It includes;

community discussion at various levels (households, through local media, communities);

involvement of trusted local leaders;

Strengthening of group identity, values and beliefs against external threats;

Public statements of influential leaders largely amplified by Hausa and international media;

Resistance perceived as a moral norm and a religious imperative hence providing a positive
incentive to comply with the new norm.
PART V - Reaching an agreement -The end of the boycott
The response to rumors was organized on the same networks as the one used to create the
widespread resistance. Partnerships with the most influential traditional leaders and community
dialogue were the two main strategies used to overcome resistance.
The role of traditional leaders
In the Hausa culture, traditional and religious leaders are by far the most credible source of
information on beliefs and values. In Niger and Nigeria, a series of meeting were organized with
political and religious leaders. These meetings demonstrated public commitment of influential
traditional leaders in favour of polio vaccination. They also led to a consensus in February 2004 to
test the vaccine independently in a Muslim country. The meetings were also an opportunity to
share knowledge and experiences and generated an advocacy agenda to ensure that the right
messages were delivered to the people.
21
A drop of tension - Journal of Health Communication, 15:3–8, 2010
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In 2004, Kano State and the Supreme Council for Sharia in Nigeria, the two main bodies involved in
the boycott, came under increasing pressure to resume vaccination. Pressure came from:

the central government

development partners

the Organization of the Islamic conference (OIC)22

the Sultan of Sokoto, Alhaji Muhammadu Maccido23, one of the most influential religious
leader, and

numerous other influential Muslim scholars and leaders.
Once an agreement was reached on the procurement of the vaccine, the Governor of Kano State,
publically reaffirmed the safety of the OPV. This official re-launch in Kano came to symbolize the
end of the polio controversy in the country. The Emir of Kano, speaking on behalf of the Sultan of
Sokoto, declared their commitment for polio eradication with a promise that traditional rulers “would
ensure quality National Immunisation Days so that our children can achieve their dreams”.24
Additionally, the Emir and the Governor of Kano publicly immunized their own children to
demonstrate the safety of the vaccines. This public declaration of the leaders of the resistance,
done on behalf of the one of the most influential Nigeria’s Islamic leaders, allowed shifting back to
the initial script on which normative expectations related to polio vaccination was based prior to the
boycott (I believe that others expect me to comply with immunization.”). To reinforce the power of
their new positioning, they concretely translated their pledge into action and had their own children
publically immunized.
Dialogue at community level
Traditional leaders played a critical role in local committees that were created to manage cases of
refusal. The leaders also were involved in community dialogue that allowed communities to assess
and discuss issues around polio and immunization. These partnerships are still active today and the
scope of dialogue has been widened to issues relating to child protection, nutrition and health.
Use of mass media and of interactive media
Interactive theatre forum sessions were organized in communities where cases of refusals were
registered. In this approach the audience became active/actors. They took part in the play to
22
In November 2003, the OIC adopted a resolution to pressure Islamic countries to make greater efforts to eradicate polio
in their countries. Nigeria is one of 17 OIC member states in Africa.
23
The Sultan of Sokoto is considered by many as Nigeria’s Islamic leader. The Sokoto Caliphate which the sultan heads
is a pre-colonial Islamic empire that represents the core of Islamic culture amongst the Muslim community in Nigeria.
24
Alhaji Ado Bayero, Emir of Kano - 2004 Synchronised National Immunisation Days for West and Central Africa
Flagged Off, www.afro.who.int/country – 10 October 2004
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explore, show, analyze and transform the reality in which they are living. The use of interactive
media also contributed to feed discussions in communities.
PART VI - Way forward
The Institute of Development Studies conducted research on vaccination in the Gambia, Guinea,
Nigeria and Sierra Leone. The research underlines that “rumours that vaccines cause sterility,
violence and paralysis circulate, but have led to mass refusal only when (a) top-down, coercive
campaigns are privileged amidst weak routine services; (b) technological practices intersect with
cultural conceptions so that anxieties 'make sense'; (c) providers' motivations are interpreted within
prevalent political tensions, and (d) influential individuals and media networks operate”25.
Such conditions prevailed in northern Nigeria in 2003-2004. A lot has been achieved since then
resulting in a huge decrease in number of polio cases registered (only 3 cases since the beginning
of the year as of July 2010). However pockets of resistance remain and require us to review the
situation. Are the conditions underlined in IDS research still prevalent today? How can we better
address resistance to polio vaccination through the lens of social norms?
In this context, the following options should be further explored / strengthened:

Increase community participation and knowledge, respect of the local customs and decisionmaking processes. This includes:
o
Involvement of traditional healers in health campaigns to reconcile traditional and
modern values around health.
o
Reinforce the role of communities in the planning and implementation of
immunization to ensure that the interventions are community-owned and communitydriven to allow a better match between international objectives and local priorities.
o
Reinforce socio-anthropological research to understand the values and beliefs
related to immunization and health issues identify potential tensions between
individual and collective interests as well as root causes of resistance.

Reinforce the awareness of human rights principles at community level and support the
community to link these principles with their own values. How do people view their future?
What are their hopes for their children? What changes are required at collective/individual
25
Childhood Vaccination in West Africa - 'The Cultural and Political Dynamics of Technology delivery' – Institute of
development Studies - http://www.ids.ac.uk/go/idsproject/childhood-vaccination-in-west-africa
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levels to concretely translate their hopes into reality? Are they willing to commit to that
change?

Reinforce a common knowledge on polio and immunization issues
o
Strengthen community dialogue to increase awareness, understanding and clarity on
immunization. Dialogue should aim at creating a cultural understanding of
vaccination value and should also provide concrete and useful information on
vaccination calendar.
o
Forster partnerships with credible and trusted source of information to reinforce
empirical and normative expectations around immunization.
o
Identify dissonances and provide information consistent with major beliefs/values.
o
Reinforce the use of edutainment and interactive media to allow participatory
communication.

Reinforce routine immunization as well as primary health care system to ensure effective
vaccine delivery in addition to campaigns.
13