By Ben Rossiter
Health care workers are mediums for the spread of deadly illnesses, infertility and espionage, or so say Taliban militants, but is there any basis for these claims? And how has a mistrust of health care workers impacted the delivery of global health initiatives?
Historical experience suggests that health workers will often become targets in civil wars and insurgencies as they did in Nicaragua and Mozambique in the 1980s, Chechnya in the 1990s, and in Somalia in the 2000s. But the February shooting of ten polio immunisation workers in northern Nigeria together with the on-going anti-vaccination campaign by militants in Pakistan has once again pushed the safety of health care workers into the spotlight.
Nigeria is one of the only countries on Earth where polio is still endemic. While three or four doses of polio vaccine administered to a young infant are enough to provide protection in most parts of the world, in Nigeria, with so much polio virus circulating, children under five years must be immunised up to eight or more times.
One of the main reasons campaigns have been unsuccessful here is the ingrained opposition to any initiative stemming from Western sources. This means that health care workers are mistrusted, beaten up, and in some cases kidnapped or killed.
In May, the International Committee of the Red Cross (ICRC) released an interim report on violent incidents affecting health care during armed conflicts in the 22 countries the ICRC services. In 2012, there were 921 incidents where health care was affected. These incidents included threats, denying passage, and arrest as well as more violent attacks. But why all this opposition? Why would a community deny the efforts of international aid workers?
It turns out Nigeria has a history of mistrust when it comes to foreign (Western) aid. Several campaigns to vaccinate the population have failed or achieved poor vaccine coverage in the last 25 years, denied completion by religious and political leaders in the northern states. Some of the mistrust is due to actual, real exploitation of the people there by institutions based in the United States. Other times, mistrust is due to political tensions between the historically Muslim-founded north and the British-founded south. Nigeria has also undergone a transition between a northern-led military regime to a southern-led democracy. The political tensions arising from this change can manifest with friction between state leaders in the north and federal agendas such as health care policies.
Mistrust of vaccinations in particular may have stemmed from federal initiatives to regulate population and fertility in the 1980s. Some people connected this population control campaign with immunisation, believing that vaccination was one way the government might be reducing the population.
The wars in Iraq and Iran have lead much of the Muslim world to think that the US hates them. In an article reported by News24.com, a South African online news Web site, Sule Ya’u Sule, speaking for the governor of Kano, is quoted as saying: “Since September 11, the Muslim world is beginning to be suspicious of any move from the Western world” In the same article, Datti Ahmed, a Kano-based physician who heads a prominent Muslim group, the Supreme Council for Sharia in Nigeria, is quoted as saying that polio vaccines were “corrupted and tainted by evildoers from America and their Western allies…We believe that modern-day Hitlers have deliberately adulterated the oral polio vaccines with anti-fertility drugs and…viruses which are known to cause HIV and AIDS”
Because of these political issues, foreign aid workers are continually trying to legitimise their presence in places of crisis. But public trust has been eroded in Nigeria on several occasions. In 1996, the US pharmaceutical giant Pfizer conducted a drug trial on children during a meningococcal epidemic in Kano, a northern state of Nigeria. During the drug trial, Pfizer tested their new product trovafloxin against one third of the standard treatment of ceftriaxone. Allegedly, they did this without obtaining consent, and without telling participants that Medicine Sans Frontiers were giving away standard treatment in the same hospital. What followed was an extended lawsuit by the government of Nigeria and Pfizer, which was eventually settled out of court.
Another well-publicised occasion that has eroded trust is the CIA’s use of health workers to infiltrate the home of Osama bin Laden in Pakistan. The CIA hired a local doctor and staged a fake Hep B immunisation drive in an attempt to get DNA from bin Laden’s family. The distrust sowed by the sham campaign in Pakistan could conceivably postpone polio eradication for 20 years, leading to 100,000 more cases that might otherwise not have occurred, says Leslie F. Roberts of Columbia University’s Mailman School of Public Health. “Forevermore, people would say this disease, this crippled child is because the U.S. was so crazy to get Osama bin Laden,” he argues.
The political and religious leaders that have boycotted vaccination campaigns in places like Nigeria were acting – with good intentions but mistakenly- in the best interest of their communities. If future health care campaigns are to be successful, then organisations must work with these traditional leaders to gain public trust.
The problem of public trust is not disappearing, either. Mistrust of vaccines and health workers has lead WHO and UINCEF to label Ukraine at risk of polio outbreaks, a report that comes as vaccination coverage is at a 20 year low. Only around 50% of children in the Ukraine are fully immunised against polio, measles, rubella, and other diseases. Dorit Nitzan, head of WHO’s Ukrainian branch, tells The Lancet:
“Many health care workers are not actively promoting vaccinations. They are afraid that… if they vaccinate someone and they get sick then they will get the blame for it.”
Public trust plays an important role in compliance with public health interventions, especially compliance with vaccination programs, which target mainly healthy people. Where trust is eroded, rumours can spread and this can lead to rejection of health interventions. Health care workers take the brunt of this mistrust through violence and fear. It is up to them, but also the organisations that are initiating these campaigns, to actively convince communities of their legitimacy.
References:
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
WHO, UNICEF, ICRC
Image: ‘Eradicating polio one case at a time’ by Gates Foundation available at http://www.flickr.com/photos/gatesfoundation/4774363781/ under a Creative Commons Attribution 2.0. Full terms at http://creativecommons.org/licenses/by-nc-sa/2.0/