Why are polio workers and campaigns so feared and reviled by some?

Twelve people were shot dead this morning in two attacks on health centres in Kano and Hotoro in northern Nigeria. In the first attack, four polio health workers were shot by gunmen on motorcycles. In the second attack, 30 minutes later, women and children waiting outside a health centre were fired upon. As this is written, details are still coming through, and the motives behind the attack are not clear. However, it fits into a wider pattern of attacks on polio workers, often in Muslim-dominated countries or areas.

In December last year a string of attacks left nine Pakistani health workers dead, including the murder of five women in targeted attacks in Karachi and Peshawar, after Taliban targeted those undertaking polio vaccination campaigns. In January of this year, further attacks in northwestern Pakistan, including three in the last week of January alone leaving three people dead (including a police officer escorting health workers), targeted polio vaccination campaigns.

The killings are shocking, a reminder of the dangers faced by health workers as they go about their business. But tragic as they are, opposition, fear, distrust and even violence against health workers engaged in such activity, have long been a hallmark of polio (and other) mass health interventions across many parts of the world.

Indeed, Nigeria is no stranger to opposition to polio vaccination campaigns. A decade ago, several northern Nigerian states refused to participate or cooperate with a WHO-sponsored campaign, undermining its effectiveness and contributing to a resurgence in cases of polio in northern Nigeria.

Rumours and fears are not, of course, confined to Africa, Asia or the global South, as non-participation rates in the triple vaccine campaign against measles, mumps and rubella demonstrated in the UK.

Resistance to polio vaccination campaigns is often portrayed as irrational, feeding as it does on a virulent mistrust of ‘western’ intentions (such interventions being characterised as ‘western’ by those seeking to resist them) towards often Muslim populations. In northern Nigeria, in 2003, it was rumoured that the vaccine had been contaminated by the US in order to sterilise Muslim men. Similar rumours surround polio campaigns in Pakistan. However, there, rumours about the vaccine itself are compounded by the fact that US agents seeking Osama bin Laden did so under the cover of a fake Hepatitis B vaccination campaign, with inevitable results.

Such rumours and resistance to biomedical advice and expertise is not confined to polio. In Mali during the 1980s and 1990s, rumours surfaced that condoms were laced with HIV. Similar rumours occur elsewhere in Africa, with both male and female condoms linked to such fears. Given such fears, it is not surprising that an early joke (albeit a joke founded upon more serious concerns) about AIDS amongst many Africans was that it stood for American Invention for the Discouragement of Sex (or Syndrome Imaginaire pour Décourager les Amereux for the French term SIDA).

Why do such rumours hold such power, moving beyond concern and refusal to participate, to acts of violence and murder? Perhaps because such rumours feed into longer, decades old, concerns and fears over the intentions of western interventions, including health interventions. In Africa, in the 1930s fears of western ‘Vampires’ can be seen across a wide swathe of eastern and central Africa (and probably west and southern too): unsurprising really, given the combination of the memory of a brutal colonial occupation coupled with the taking of blood, for reasons never really fully explained, by health workers. In South Africa, resistance to health advice over HIV and AIDS in the 1980s was fuelled by the knowledge that medicine and medical services were part and parcel of the Apartheid state: mistrust was not only to be expected, it was an entirely rational response. And such fears would not easily dissipate with the ending of Apartheid. In the US, research has suggested that the lingering memories of Tuskagee have contributed to higher rates of belief in ‘conspiracy theories’ about HIV amongst African-Americans. Again, is it entirely irrational to fear the state in such cases, given that historical legacy?

The belief that ‘the West’ is seeking to eliminate Africans through forced or covert sterilisation, whilst not based on actual fact, nonetheless is build upon foundations which are more solid than many care to admit. From the 1960s, population control policies and debates characterised Africa as dangerously out of control, facing a rapidly encroaching Malthusian disaster: western health interventions, those allied to population control at least, were an attempt to reduce the population. Current language on population, couched perhaps in more moderate language, nonetheless contains reminders of these debates.

More recent history over the past decade or so has given additional reason for the Islamic world to trust ‘western’ intentions. Western powers may state that health interventions are not strategic points of entry (a point terribly undermined by the decision to use polio vaccination campaign as a cover) or designed to establish control, but the very real experience of those living in many parts of the world is that western biomedicine has been used as a tool, alongside others, for domination for well over a century.

What has happened in Nigeria today, and in Pakistan over the past couple of months is a very real tragedy. Health workers and those supporting them, trying to eradicate a horrible disease which continues to cast a shadow over the communities in which it thrives, have been murdered. The bravery of those who continue to undertake such work in these conditions is amazing, and deserves to be more widely recognised.

The rumours around the safety of the polio vaccine are unfounded. But the problem is how to get that message across in a way that is accepted. We cannot easily dismiss such attacks as irrational hatred of the west, or ignorant fear of medicine. It is a sad reflection of the long history of use and misuse of health campaigns and services by colonial powers as part of the arsenal of control and domination. Telling people there is no need to fear biomedicine and health campaigns is a difficult task when so many people have very good historical reasons for doing so. That could never justify the attacks, nor the decision by states and others not to participate in such campaigns. But a better knowledge of the historical roots of such fears and violence might help us understand it.