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  3. Friday, 02 April 2004
POST 00656E : COMBATING RUMOURS Follow-up on Post 00619E, 00643E and 00647E 2 April 2004 _______________________________________ This posting contains three contributions. The first is from Alasdair Wylie (mailto:[email protected]) independent consultant from the UK, and the second from Hans Everts (mailto:[email protected]) from WHO/HQ. The third is from Anthony Battersby (mailto:[email protected]) also an independent consultant who shares his experience from having worked in Nigeria on this very issue. After Hande Harmanci's comment in the previous posting ("It may have been us, the health team.....) that intrigued me much, Anthony is also throwing a particular light on the problem. I have also been involved in the Nigeria case although on a different plane and not in the country. So I am risking some comments. _______________________________________ Regarding the WHO statement on safety and quality of OPV supplied to Nigeria (which it appears was not shared with Technet when it came out?), the important question is: how has this information been used in Kano and other northern states as part of an advocacy/Behaviour Change Communication effort to address the problem, and with what results? Regards Alasdair Wylie ______________________________________________ There are a lot of reactions going on in terms of advocacy, high level visits, support of the Organization of Islamic Conference and other high rated Islamic authorities to mention a few, but the problem is political and largely internal. Nigerian virus has now been found in Niger, Ghana, Burkina, Benin, Togo, Ivory Coast, Chad and CAR. There were some signs of mounting resistance in the southern provinces of Niger, bordering Nigeria, but these were very limited (1 case of resistance on 1500 children immunized nationwide and 1/200 in the most affected regions) and hardly clustered. Following the president's launch of the NID in February and his strong speech in Hausa, the problem seems to have vanished for the February 2004 round. It is important to add that rumors about resistance sometimes incline to become more persistent than the resistance itself. If resistance is not properly quantified and mapped there is always the risk of overstating the problem. Another key issue in relation to resistance is that it becomes an easy dump yard and excuse for failing to immunize children. We found in several countries that the vast majority of so-called resistance cases had much more to do with the quality of service delivery, vaccinator's attitude, proper planning, etc., than with conscientious refusal. On the almost 2000 cases of 'refusal' in December 2003 in Niger, 85% could be converted by a usually short visit of the committee that deals with refusals. In my personal experience most refusals can be resolved by simply taking a few minutes to explain the importance of vaccination to the parents. This is not to under estimate the problem in countries like India and Nigeria, but it has to be put in the right context and the vigilance should be directed at the resistance as much as at the rumors. Hans Everts WHO Geneva Technical officer EPI ______________________________ I was working in Nigeria before Christmas on this precise issue. The answer to why the situation has arisen in Nigeria is that WE DO NOT KNOW ACCURATELY. It appears to be the result of a conjunction of a number of issues. For example: - Over focusing on one disease, e.g. polio a disease which is not considered important by many Nigerian parents because they do not see it. - Lack of attention to the diseases which they do see e.g. measles, TB, malaria. - Use of people in the NIDs who are manifestly not health workers and are unable to answer parents questions. - Insensitivity to cultural aspects e.g. male vaccinators entering women's quarters. - Insensitivity to social mores, e.g. young women wearing short skirts. - Lack of routine services both preventive and curative. - Lack of continuity, I was told about 80% of vaccinators only do one NID because they find they do not get paid. - Using vaccinators from cultural groups different from the recipients. Add to these: - Wider concerns such as one can find on web sites such as http://www.thinktwice.org , which give international credibility to local arguments e.g. why not use IPV like some developed countries. - National politico/cultural issues e.g. The perception in the North that the South wants to be dominant. - International political issues e.g. the invasion of Iraq (described in one paper as a Judeo-Christian plot to dominate Islam). and the scene is set for trouble. So what can be done? The first task is to understand in DETAIL what the parents and caretakers actually think. We have been far too unsophisticated over the years in our attempts to understand why children are not immunised, for years I have advocated recording the actual reasons given to the interviewer rather than checking precoded answers. Unless we understand the real constraints it is not possible to find solutions. For example "mother too busy" does not get you anywhere. " I am not free during the day when the team comes because I am away at work, I can only be available in the evening" gives the planner the chance to find ways of reaching the mother at the time she is available. Partly because opinion formers have access to the internet, it is easy to give extreme views the cloak of intellectual respectability, especially when they can point to practices which are not accepted in UK and US but are used locally. There is almost certainly a gap between what the vociferous minority trumpets and what ordinary people understand and think is important, but unless we (the planners) fully understand what their fears are and where their priorities lie, unless we do understand, it is not possible to design a response that will allay those fears and raise immunisation in parents priorities. The response must offer parents what they want and need in a way that they find acceptable and reassuring. When those criteria are satisfied then parents will have confidence in the service and may be willing to accept vaccines that are not in their direct perceived interest. WHO took the trouble to test OPV to prove that it would not sterilise women, the choice of messenger to deliver the message is vital. It must be a person in whom the community to be addressed has complete confidence. For example it is no good using a southerner to deliver the message, the reaction for many will be "he would say that wouldn't he". There will be no quick fix for the problem in Nigeria and any attempt to make a quick fix will simply exacerbate what is now a very very delicate situation. We all want to see the back of polio but unless pressure is eased and more ground work is carried out to provide what people do want, the situation will continue to get worse and not better. Anthony ___________________________ Note from the Moderator We are getting beyond purely EPI technical matters here. Many external factors have sometimes a critical influence on operations. One survey participant expressed the wish that "socio-cultural determinants or factors that frame immunization programs" be discussed. Polio eradication in Nigeria is one of the best examples and a complicated one. Hans' contribution partly replies to the question Alasdair was asking. I am convinced that Nigerian authorities did everything they could to solve the problem. Maybe a Nigerian colleague could inform us briefly of what was done. Obviously, the WHO Position Statement didn't help in the circumstances, I'm afraid, and Michel Zaffran admitted when transmitting it. As Alasdair, I wonder though how this was used in the context. I'm afraid it came rather late. I agree with Anthony that the choice of messenger is very critical. Hans is saying that this is more of a political and internal problem in Nigeria. It is true that many other things coming out of Abuja are considered with suspicion in the north of the country. Whatever side of the fence we stand, we must recognize that power struggle is a permanent fixture of human history. To accommodate the ever increasing number of power-hungry people, we found all sorts of mechanisms, call it decentralization, devolution, subsidiarity. I am not the one to judge who is wrong and who is right in this case. But I believe that we have come to a point where formal mediation may be necessary and compromises will have to be made. When a situation affects other countries as Hans has confirmed, it is no more an internal matter and it seeks for international resolution. The Organization of Islamic Conference (http://www.oic-oci.org ) is a political organization and it could certainly play a useful role. However, such political issues are tinted with religious overtones. As in many other parts of the world, Ireland and the Middle East to name just a few, religion is taken as an excuse to divide, isolate and discriminate often among the same people. And in such a case of recuperation for political purposes, it becomes much more difficult than if it is a purely religious matter. In Nigeria, the problem has taken immense proportions, I don't think it is overstated. NIDs were cancelled in a whole region. And children's health and sometimes life is at stake. This is certainly unacceptable in any religion, especially in Islam. Neither is it acceptable to do politics on the back of children. ______________________________________________________________________________ _________________ Visit the TECHNET21 Website at http://www.technet21.org You will find instructions to subscribe, a direct access to archives, links to reference documents and other features. ______________________________________________________________________________ To UNSUBSCRIBE, send a message to : mailto:[email protected] Leave the subject area BLANK In the message body, write unsubscribe TECHNET21E ______________________________________________________________________________ The World Health Organization and UNICEF support TechNet21. The TechNet21 e-Forum is a communication/information tool for generation of ideas on how to improve immunization services. It is moderated by Claude Letarte and is hosted in cooperation with the Centre de coopération internationale en santé et développement, Québec, Canada (http://www.ccisd.org) ______________________________________________________________________________
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