POST 00656E : COMBATING RUMOURS
Follow-up on Post 00619E, 00643E and 00647E
2 April 2004
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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.
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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
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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
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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
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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.
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