The Anti-vaccination Movement: A Regression in Modern Medicine

Monitoring Editor: Alexander Muacevic and John R Adler

1
Azhar Hussain, Syed Ali,2 Madiha Ahmed,3 and Sheharyar Hussain4

Author information Article notes Copyright and License information Disclaimer

Abstract

Introduction and background

Vaccines are one of the most important measures of preventative medicine to protect the
population from diseases and infections. They have contributed to decreasing rates of common
childhood diseases and, in some cases, have even wiped out some diseases that were common in
years past, such as smallpox, rinderpest, and have nearly eradicated malaria and polio [1]. In fact,
according to the World Health Organization’s Polio Global Eradication Initiative, the inactivated
polio vaccine (IPV) will be used as a backbone for eradicating poliovirus in the next decade.
However, there has been a recent rise in anti-vaccination sentiments surrounding beliefs that
vaccines cause more harm than benefits to the health of the children who receive them. The
premise of the anti-vaccination movement can also be contributed to the demonization of
vaccinations by news and entertainment outlets. Voices such as Jenny McCarthy’s have proven
to be influential, sweeping fear and distrust into parents’ minds by parading as “autism experts”.
Social media and television talk show hosts, such as Oprah Winfrey, played a big role in this
miseducation by giving credence to the campaign. This has caused vaccination rates to sustain a
surprising drop in some Western countries [2]. The decrease in vaccinations has led to recent
outbreaks of diseases that were thought to be “eliminated”, such as measles. Still, other reasons
for the anti-vaccination movement can be due to personal reasons, such as religious or secular
views. A drop in immunizations poses a threat to the herd immunity the medical world has
worked hard to achieve. Global communities are now more connected than ever, which translates
to a higher probability of the transmission of pathogens. The only thing that can protect
populations against a rapidly spreading disease is the disease's resistance created by herd
immunity when the majority are immune after vaccinations. Given the highly contagious nature
of diseases like measles, vaccination rates of 96% to 99% are necessary to preserve herd
immunity and prevent future outbreaks [3].
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Review
Origins of the anti-vaccination movement
Fear of vaccines and myths against them are not a new phenomenon. Opposition to vaccines
goes as far back as the 18th century when, for example, Reverend Edmund Massey in England
called the vaccines “diabolical operations” in his 1772 sermon, “The Dangerous and Sinful
Practice of Inoculation” [4]. He decried these vaccines as an attempt to oppose God’s
punishments upon man for his sins [5]. Similar religious opposition was seen in the “New
World” even earlier, such as in the writings of Reverend John Williams in Massachusetts, who
also cited similar reasons for his opposition to vaccines claiming that they were the devil’s work
[6]. However, opposition against vaccines was not only manifested in theological arguments;
many also objected to them for political and legal reasons. After the passage of laws in Britain in
the mid-19th century making it mandatory for parents to vaccinate their children, anti-vaccine
activists formed the Anti-Vaccination League in London. The league emphasized that its mission
was to protect the liberties of the people which were being “invaded” by Parliament and its
compulsory vaccination laws [7]. Eventually, the pressure exerted by the league and its
supporters compelled the British Parliament to pass an act in 1898, which removed penalties for
not abiding by vaccination laws and allowed parents who did not believe vaccination was
beneficial or safe to not have their children vaccinated [8]. Since the rise and spread of the use of
vaccines, opposition to vaccines has never completely gone away, vocalized intermittently in
different parts of the world due to arguments based in theology, skepticism, and legal obstacles
[9].
Anti-vaccination propaganda
While pushback against the measles vaccine due to fears of its connection to autism is the most
recent example that comes to mind, there have been other instances of outbreaks of previously
“extinct” diseases in modern times. One example is the refusal of some British parents to
vaccinate their children in the 1970s and 1980s against pertussis in response to the publication of
a report in 1974 that credited 36 negative neurological reactions to the whole-cell pertussis
vaccine [10]. This caused a decrease in the pertussis vaccine uptake in the United Kingdom (UK)
from 81% in 1974 to 31% in 1980, eventually resulting in a pertussis outbreak in the UK, putting
severe strain and pressure on the National Health System [11-12]. Vaccine uptake levels were
elevated to normal levels after the publication of a national reassessment of vaccine efficacy that
reaffirmed the vaccine’s benefits, as well as financial incentives for general practitioners who
achieved the target of vaccine coverage [13]. Disease incidence declined dramatically as a result.
The anti-vaccination movement was most strongly rejuvenated in recent years by the publication
of a paper in The Lancet by a former British doctor and researcher, Andrew Wakefield, which
suggested credence to the debunked-claim of a connection between the measles, mumps, and
rubella (MMR) vaccine and development of autism in young children [14]. Several studies
published later disproved a causal association between the MMR vaccine and autism [15-18].
Wakefield drew severe criticism for his flawed and unethical research methods, which he used to
draw his data and conclusions [19]. A journalistic investigation also revealed that there was a
conflict of interest with regard to Wakefield’s publication because he had received funding from
litigants against vaccine manufacturers, which he obviously did not disclose to either his co-
workers nor medical authorities [20]. For all of the aforementioned reasons, The Lancet retracted
the study, and its editor declared it “utterly false” [21]. As a result, three months later, he was
also struck off the UK Medical Registry, barring him from practicing medicine in the UK. The
verdict declared that he had "abused his position of trust" and "brought the medical profession
into disrepute" in the studies he carried out [22].
Repercussions of declining vaccination rates
The damage, however, was already done and the myth was spread to many different parts of the
world, especially Western Europe and North America. In the UK, for example, the MMR
vaccination rate dropped from 92% in 1996 to 84% in 2002. In 2003, the rate was as low as 61%
in some parts of London, far below the rate needed to avoid an epidemic of measles [23]. In
Ireland, in 1999-2000, the national immunization level had fallen below 80%, and in part of
North Dublin, the level was around 60% [24]. In the US, the controversy following the
publication of the study led to a decline of about 2% in terms of parents obtaining the MMR
vaccine for their children in 1999 and 2000. Even after later studies explicitly and thoroughly
debunked the alleged MMR-autism link, the drop in vaccination rates persisted [25].
As a result, multiple breakouts of measles have occurred throughout different parts of the
Western world, infecting dozens of patients and even causing deaths. In the UK in 1998, 56
people contracted measles; in 2006, this number increased to 449 in the first five months of the
year, with the first death since 1992 [26]. In 2008, measles was declared endemic in the UK for
the first time in 14 years [27]. In Ireland, an outbreak occurred in 2000 and 1,500 cases and three
deaths were reported. The outbreak was reported to have occurred as a direct result of a drop in
vaccination rates following the MMR controversy [28]. In France, more than 22,000 cases of
measles were reported from 2008 - 2011 [29]. The United States has not been an exception, with
outbreaks occurring most recently in 2008, 2011, and 2013 [30-32].
Perhaps the most infamous example of a measles outbreak in the United States occurred in 2014-
2015. The outbreak was believed to originate from the Disneyland Resort in Anaheim, California
and resulted in an estimated 125 people contracting the disease [33]. It was estimated that MMR
vaccination rates among the exposed population in which secondary cases have occurred might
be as low as 50% and likely no higher than 86% [34]. Physicians in the region were criticized for
deviating from the CDC's (Center for Disease Control and Prevention) recommended vaccination
schedule and/or discouraging vaccination. As a result, California passed Senate Bill 277, a
mandatory vaccination law in June 2015, banning personal and religious exemptions to abstain
from vaccinations [35].
Technology and its effects on anti-vaccination movement
Access to medical information online has dramatically changed the dynamics of the healthcare
industry and patient-physician interactions. Medical knowledge that was previously bound to
textbooks and journals, or held primarily by medical professionals, is now accessible to the
layman, which has shifted the power from doctors as exclusive managers of a patient's care to the
patients themselves [36]. This has led to the recent establishment of shared decision-making
between patients and healthcare physicians [37]. While this is beneficial in some ways, the
dissemination of false and misleading information found on the internet can also lead to negative
consequences, such as parents not giving consent to having their children vaccinated. When it
comes to vaccines, the false information is plentiful and easy to find. An analysis of YouTube
videos about immunization found that 32% opposed vaccination and that these had higher ratings
and more views than pro-vaccine videos [38]. An analysis of MySpace blogs about HPV
immunization found that 43% portrayed the immunization in a negative light; these blogs
referenced vaccine-critical organizations and cited inaccurate data [39]. A similar study of
Canadian internet users tracked the sharing of influenza vaccine information on social media
networks, such as Facebook, Twitter, YouTube, and Digg. Of the top search results during the
study period, 60% promoted anti-vaccination sentiments [40]. A study that examined the content
of the first 100 anti-vaccination sites found after searching for “vaccination” and “immunization”
on Google concluded that 43% of websites were anti-vaccination (including all of the first 10)
[41].
Online anti-vaccination authors use numerous tactics to further their agendas. These tactics
include, but are not limited to, skewing science, shifting hypotheses, censoring opposition,
attacking critics, claiming to be “pro-safe vaccines”, and not “anti-vaccine”, claiming that
vaccines are toxic or unnatural, and more [42]. Not only are these tactics deceitful and dishonest,
they are also effective on many parents. A study that evaluated how effectively users assessed
the accuracy of medical information about vaccines online concluded that 59% of student
participants thought retrieved sites were entirely accurate; however, out of the 40 sites they were
given, only 18 were actually accurate, while 22 were inaccurate. These sites were not evidence-
based and argued vaccines were inherently dangerous without any merit-based argument. More
than half of participants (53%) left the exercise with significant misconceptions about vaccines
[43]. Research has also shown that viewing an anti-vaccine website for merely 5 - 10 minutes
increased perceptions of vaccination risks and decreased perceptions of the risks of vaccine
omission, compared to visiting a control site [44]. The study also found that the anti-vaccine
sentiments obtained from viewing the websites still persisted five months later, causing the
children of these parents to obtain fewer vaccinations than recommended [45]. The role of the
online access to false anti-vaccination information just cannot be understated in examining the
rise and spread of the anti-vaccination movement.
Ethical and legal issues regarding vaccination
Opposition to the MMR vaccine among parents leads to an ethical dilemma that can be analyzed
using both medical ethics and moral principles. Medical ethics call for health professionals to
abide by a code of bioethics upholding autonomy, non-maleficence, beneficence, and justice.
The most relevant in mandating vaccinations are autonomy and non-maleficence [46]. Patients
are entitled to the right to refuse vaccination using “our children, our choice” based on their
autonomy, while health care providers are morally obligated to treat everyone with non-
maleficence and avoiding harm to society at all costs.
At the individual level, religion is a common reason to refuse vaccination. The MMR vaccine
specifically has been the cause of instigating debate among the Hindu, Protestant, Orthodox
Jewish, and Jehovah’s Witness communities. Specific religious views on vaccines in general,
however, are not normally the cause for debate but instead the components of the MMR vaccine
[47]. The MMR vaccine, combined with the rubella vaccine, was originally derived from the
cells of aborted fetal tissue. Hindu, Protestant, Muslim, and Jewish communities are generally
opposed to abortion for moral reasons based on religious teachings; thus, individuals from these
beliefs may cite religious reasons for filing vaccine exemptions. Further, the MMR vaccine
contains porcine gelatin as a stabilizer, a means for ensuring effective storage. The porcine
ingredients are unlike gelatins used for oral consumption and purified down to small peptides,
commonly used in medicine capsules as well [48]. As there is a wide range of practice
preferences in every religion, some individuals belonging to religions, such as Judaism, Islam,
and Hinduism (to name a few), may be opposed to injecting a porcine product into their body
along with the vaccine [47]. Further, other religious views, such as the ones held by Dutch-
Protestant Christian congregations, consider vaccinations “inappropriate meddling in the work of
God”. These groups, therefore, believe that we should not change the predestined fate of
someone who becomes ill [49].
While exercising autonomy and refusing vaccination is valid for sensitive personal issues, it will
cause more harm than good if a certain percentage of the population does not get vaccines
causing the immunization rate to fall below the herd immunity threshold. This threshold varies in
every disease. The development of vaccines is considered one of the greatest strides made in
medicine due to the enormous benefits to an entire population. From an ethics perspective,
achieving herd immunity and minimizing the amount of “freeloaders” is in the best interest of
society as a whole [48-49].
Further, studies liken the decision to object to vaccinations to military service drafts. For the
conscientious objectors, military duty and receiving a vaccine hold the same costs: liberty,
personal risk, and utility in terms of time [41]. Naturally, the costs of military duty are more
taxing and demand more from an individual than receiving a vaccine. In terms of herd immunity
and depending on the severity of impending diseases, these costs are ones that they should incur
for the benefit of themselves as well as society.
At the forefront of the legal complications lies the state-regulated vaccinations for all children
attending school. Anti-vaccination proponents argue that this is an infringement upon autonomy;
however, public health policymakers justify their actions using rule utilitarianism. Rule
utilitarianism is the ideology that a rule for society should be established that has the best
outcome for the greatest amount of people in the society. In addition to this, John Stuart Mill’s
essay, “On Liberty”, explains the Harm Principle that is often used to justify mandated infectious
disease control methods, including vaccines [50]. The Harm Principle justifies interfering with
autonomy and individual liberties, against their will, if it is done so as to prevent harm to others.
An example of this was seen in California in 2014-2015 after an outbreak of measles led to the
passing of Senate Bill 277 calling for state-mandated vaccinations for everyone - no personal
exemptions. The root of the problem, however, was most likely to be contributed to Wakefield’s
fraudulent findings striking the fear of a vaccination-autism link in parents, which led to an all-
time low rate of people receiving the MMR vaccine. The hoax has been called the most
damaging medical hoax in 100 years after bringing about outbreaks of diseases otherwise
eradicated [8-9, 11].
In the times that we have achieved herd immunity, there remain two questions then. Can legal
exemptions still be justified? And should these exemptions be limited to religious reasons or
should they include secular reasoning as well [21, 25]? Most scientists and medical experts
suggest that exemptions should only even be considered if society is well within the limits for
herd immunity. As for the religious versus secular debate, it is difficult to ignore secular
objections as most of them are rooted in spiritual or holistic personal views [6, 47]. Since herd
immunity is cumulative, the ability to waive immunizations is concluded to be difficult but not
impossible. If the waivers are given to a small number of individuals who sincerely need them
rather than ones who are inconvenienced by them, waivers may be ethically and legally sound.
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Conclusions
The rise of anti-vaccination movements in parts of the Western world poses a dire threat to
people’s health and the collective herd immunity. People of all ages have fallen victim to recent
outbreaks of measles, one of the most notable “eliminated” diseases that made a comeback as a
direct consequence of not reaching the immunization threshold for MMR vaccines. These
outbreaks not only put a strain on national healthcare systems but also cause fatal casualties.
Therefore, it is of the utmost importance that all stakeholders in the medical world - physicians,
researchers, educators, and governments - unite to curb the influence of the anti-vaccination
movement targeting parents. Research has shown that even parents favorable to vaccination can
be confused by the ongoing debate, leading them to question their choices. Many parents lack
basic knowledge of how vaccines work, as well as access to accurate information explaining the
importance of the process. Furthermore, those with the greatest need for knowledge about
vaccination seem most vulnerable to this information. Further, we must effectively combat the
wrongful demonization of vaccinations through social media and news media platforms. A
qualitative study that explored how parents respond to competing media messages about vaccine
safety concluded that personal experiences, value systems, and level of trust in health
professionals are essential to parental decision making about immunization. Therefore, to combat
the anti-vaccination movement, there must be a strong emphasis on helping parents develop trust
in health professionals and relevant authorities, educating them on the facts and figures,
debunking the myths peddled by the anti-vaccination movements, and even introducing
legislation that promotes vaccination, if not mandating it.
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Acknowledgments
We would like to thank Dr. Alice Anne Brunn, Ph.D., Associate Professor of Psychiatry and
Ethics, and Chairman of Behavioral Sciences and Ethics Department, as well as Dr. Xenia
Sotiriou, Ph.D., Assistant Professor of Behavior Science and Ethics at St. Matthew’s University
School of Medicine.
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Notes
The content published in Cureus is the result of clinical experience and/or research by
independent individuals or organizations. Cureus is not responsible for the scientific accuracy or
reliability of data or conclusions published herein. All content published within Cureus is
intended only for educational, research and reference purposes. Additionally, articles published
within Cureus should not be deemed a suitable substitute for the advice of a qualified health care
professional. Do not disregard or avoid professional medical advice due to content published
within Cureus.
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Footnotes
The authors have declared that no competing interests exist.
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Children -- United States, 1990-1998. [Jun;2018
];http://www.cdc.gov/mmwr/preview/mmwrhtml/00056803.htm U.S. National Library of
Medicine; April 02. 1999 /:48–12.
2. Another media scare about MMR vaccine hits Britain . Anderson
P. BMJ. 1999;318:1578. [PMC free article][PubMed]
3. Evaluation of the establishment of herd immunity in the population by means of serological
surveys and vaccination coverage. Plans-Rubió P. Hum Vaccin Immunother. 2012;8:184–
188. [PubMed]
4. Sermon against the dangerous and sinful practice of inoculation. Preach'd at St. Andrew's
Holborn, on Sunday, July the 8th, 1722. / By Edmund Massey, M.A. Lecturer of St. Alban
Woodstreet. [Jun;2018 ];Massey E. http://name.umdl.umich.edu/N02782.0001.001 Gale Ecco,
Print Editions. 2010
What Led to the Nigerian Boycott of the Polio Vaccination
Campaign?
Ayodele Samuel Jegede

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Alternative Language Text S1: Translation of the article into French by E. I. Amenyah
(94 KB DOC).

pmed.0040073.sd001.doc (101K)

Vaccination is a crucial tool for preventing and controlling disease, but its use has been plagued
by controversies worldwide [1–6]. In this article, I look at the controversy surrounding the
immunization program against polio in Nigeria, in which three states in northern Nigeria in 2003
boycotted the polio immunization campaign. I discuss the problems caused by the boycott, its
implications, and how it was resolved. Finally, I make recommendations for the future to prevent
a similar situation from arising.
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Methods
For this article, I consulted relevant books, journals (online and print), Internet materials, and
newspaper articles. In particular, I also searched for documentary materials on the history of
vaccination in northern Nigeria, factors responsible for the boycott, and ethical issues arising
from the boycott.
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The Kick Polio Out of Africa Campaign

Due to the difficulty faced by some national governments in containing polio outbreaks, the
World Health Organization (WHO) in 1988 launched the Global Polio Eradication Initiative
(GPEI) with the goal of eradicating the disease by the year 2000 (see [7]
and http://www.polioeradication.org). In 1989, the World Health Assembly approved a global
plan of action for eradicating polio and the WHO Regional Committee for Africa adopted the
resolution [8].
The WHO Regional Committee for Africa intensified its polio eradication strategies in 1996.
Nelson Mandela launched the “Kick Polio Out of Africa” campaign (Figure 1) [9], which aimed
to vaccinate 50 million children in 1996 alone. Mass immunization campaigns were boosted by
National Immunization Days (Figure 2), acute flaccid paralysis surveillance, training of
community health workers at the local level, and door-to-door campaigns [10,11].

The Kick Polio Out of Africa Campaign

This photo shows Red Cross volunteers, wearing “Kick Polio Out of Africa” T-shirts, waiting for
boat transportation from Kinshasa, the Democratic Republic of the Congo, on a National
Immunization Day. (Photo: Global Polio Eradication Initiative)

A Vaccination Team Crosses a River to Reach a Village During a National Immunization

Day

(Photo: Global Polio Eradication Initiative)

The Kick Polio Out of Africa campaign assured functional cold chain systems and continuing
education of communities about the importance of routine immunization [9]. From 1997, through
an alliance with the African Football Confederation, leading African football players have
participated in public awareness campaigns by distributing posters, conducting radio interviews,
and holding public autograph sessions [8].
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 high prevalence of polio in Nigeria, which accounted for 45% of
polio cases worldwide and 80% of cases reported from the African region in 2003 [12]. This
high prevalence was attributed to poor vaccine coverage during the previous control campaigns.
But the GPEI's hopes were dashed by a boycott of the polio immunization campaign in three
states in northern Nigeria, amidst rumours and public distrust.
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The Boycott in Northern Nigeria

Public trust is essential in promoting public health [13]. Such trust plays an important role in the
public's compliance with public health interventions, especially compliance with vaccination
programs, which target mainly healthy people. Where public trust is eroded, rumours can spread
and this can lead to rejection of health interventions.
In northern Nigeria in 2003, the political and religious leaders of Kano, Zamfara, and Kaduna
states brought the immunization campaign to a halt by calling on parents not to allow their
children to be immunized. These leaders argued that the vaccine could be contaminated with
anti-fertility agents (estradiol hormone), HIV, and cancerous agents.
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…Our people have become
really concerned about polio vaccine” [14]. In the same article, Datti Ahmed, a Kano-based
physician who heads a prominent Muslim group, the Supreme Council for Sharia in Nigeria
(SCSN), is quoted as saying that polio vaccines were “corrupted and tainted by evildoers from
America and their Western allies.” Ahmed went on to say: “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” [14].
The New York Sun reported that this fear of polio vaccines in northern Nigeria “caught on
because of the war in Iraq” [15]. Ali Guda Takai, a WHO doctor investigating polio cases in
Kano, told the Baltimore Sun, “What is happening in the Middle East has aggravated the
situation. If America is fighting people in the Middle East, the conclusion is that they are fighting
Muslims” [16].
Embarrassed by the political undertone of the boycott, the prominent Islamic scholar Sheikh
Yusuf Al-Qaradawi, President of the International Fiqh Council, said: “In fact, I was completely
astonished about the attitude of our fellow scholars of Kano towards polio vaccine. I disapprove
of their opinion, for the lawfulness of such vaccine in the point of view of Islam is as clear as
sunlight” [17]. Sheikh Qaradawi said that the same polio vaccine has been effective in over 50
Muslim countries, and blamed the SCSN for creating a negative image of Islam: “They distort
the image of Islam and make it appear as if it contradicts science and medical progress” [17].
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Background to the Boycott

The historical context

The polio vaccination boycott should not be considered in isolation, but rather in the context of
the history of orthodox health services in northern Nigeria. Generally, utilization rates of
orthodox health-care services in the region have always been low. For instance, comparative
utilization rates of southern Nigeria versus northern Nigeria were 50% versus 18% in 1990 (i.e.,
half of people in the south used orthodox health services, compared with less than one fifth in the
north), 60% versus 11% in 1999, and 64% versus 8% in 2003 [18–20].
Other historical factors that fed into the polio vaccination boycott include population and fertility
regulation. In the 1980s, President Babangida's administration adopted a population policy 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 [21]. This belief was not restricted to northern Nigeria—similar opinions were
also expressed in some communities in southern Nigeria.
For example, in an anthropological study carried out in Nigeria [22], an adult male participant
stated that “people do carry rumour that immunisation is a secret way of controlling population.”
A young female participant said “some people say that immunisation is part of the methods used
to check the number of children a woman can bear.”
Another important factor that played a role in the polio vaccine boycott was the general distrust
of aggressive, mass immunization programs in a country where access to basic health care is not
easily available [16]. In his report for the Baltimore Sun, John Murphy wrote: “The aggressive
door-to-door mass immunizations that have slashed polio infections around the world also raise
suspicions. From a Nigerian's perspective, to be offered free medicine is about as unusual as a
stranger's going door to door in America and handing over $100 bills. It does not make any sense
in a country where people struggle to obtain the most basic medicines and treatment at local
clinics” [16].

The political context

In Nigeria, states have administrative control over health affairs at the primary and secondary
care levels while the federal government has control at the tertiary care level. Although the
federal government sets health policy for the nation, immunization is under the primary health-
care system controlled by each state government. This was why the Kano state government was
able to issue a directive to halt the immunization exercise planned by the federal government.
Nigeria being a multiparty society, opposition parties exercise their political rights by constantly
challenging the ruling party. After the May 2003 presidential elections the All Nigeria People's
Party (ANPP) led by General Muhammadu Buhari, one-time military dictator and Head of State,
filed a case in Nigeria's Supreme Court challenging the victory of President Olusegun Obasanjo
of the People's Democratic Party (PDP) [23]. Also, Kano as a state under the control of the
ANPP challenged the polio vaccination exercise organized by the PDP-controlled federal
government.
Nigeria is undergoing a political transition from a northern-led military regime to a southern-led
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 (specifically the south-west). These changes have resulted in political
tensions between the south and north. These tensions might explain why the religious leaders in
northern states who boycotted the polio immunization campaign believed that the southern-led
federal government was acting in the interests of Western powers. The northern and southern
parts of the country had different colonial experiences. While the north was colonized by the
Islamic Jihadists, the south was colonized by the British. These colonial experiences are
responsible for political differences between north and south and different attitudes to modern
medicine.

The Trovan trial

Suspicions about Western health interventions were already circulating in northern Nigeria,
ahead of the polio vaccination boycott, in the wake of Pfizer's 1996 “Trovan trial” [24–26]. The
trial was discussed in detail in a BMJfeature entitled “Pfizer accused of testing new drug without
ethical approval” [24].
In brief, the BMJ reports that in 1996 Pfizer sent a team to Kano during an epidemic of
meningococcal meningitis. To test the efficacy of its new antibiotic trovafloxacin (Trovan), the
team conducted an open-label trial in 200 children—half were given the gold standard treatment
for meningitis, ceftriaxone, and half received trovafloxacin. Five of the children given
trovafloxacin died, together with six who were given ceftriaxone. The BMJ reported: “The
Washington Post has been investigating the trial and alleges that at least one child was not taken
off the experimental drug and given the standard drug when it was clear that her condition was
not improving—which is against ethical guidelines.” The BMJ reported that the Nigerian health
minister appointed a federal investigative panel to determine whether the trial was conducted
legally, and if so, whether it was morally right.
On May 7, 2006, The Washington Post reported that it had been privileged to see a secret report
of the panel's investigation, which alleged that Pfizer undertook an “illegal trial of an
unregistered drug” when the company enrolled children into the Trovan trial [27]. In response to
the leaked report, Pfizer issued a press statement saying: “Pfizer is confident that no one
associated with the Trovan clinical study—conducted in Kano, Nigeria during a meningitis
epidemic in 1996—ever put a patient's health at risk and that the company acted in the best
interests of the children involved in the study, using the best medical knowledge available” [28].
In 2001, 30 Nigerian families sued Pfizer in a federal court in New York [29]. The suit alleged:
“Pfizer chose to select children to participate in a medical experiment of a new, untested and
unproven drug without first obtaining their informed consent.” During the following four years,
Pfi zer argued that the case should not be heard in a United States court at all [30]. In August
2005, Southern District of New York Judge William H. Pauley III agreed, ruling that Nigeria,
not the US, was the proper place to try a lawsuit over Pfizer's conduct in the Trovan trial [31].
According to John Murphy's report for the Baltimore Sun, the Trovan trial may have left some
Nigerians distrustful of Western interventions: “Some of Kano's fears of the vaccine stem from
its experience with the U.S. pharmaceutical giant Pfizer Inc.” [16].
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Federal Response to the Polio Boycott

In response to public outcry about the polio vaccine, the Nigerian federal government set up a
technical committee on October 29, 2003 to assess the safety of the polio vaccine, sending
samples of the vaccine for laboratory tests abroad. The committee's report, however, was rejected
by the SCSN, which alleged that the Muslim community was not properly represented on the
committee.
In response to this allegation, the federal government appointed another technical committee,
which included selected members of the Muslim group Jama'atu Nasril Islam, to further
reconfirm the safety of the vaccine. But the SCSN again rejected the nominees, asking for the
inclusion of its own nominees. Justifying its continued opposition to the polio vaccine despite the
alarming 30% increase in polio prevalence, in January 2004, the Kano State Government argued:
“…a lesser of two evils, to sacrifice two, three, four, five even ten children to polio than allow
hundreds of thousands or possibly millions of girl-children likely to be rendered infertile” [17].
Although the truth of the rumour that the polio vaccine contained HIV and cancerous and anti-
fertility agents was never established, the lack of trust among the general population in northern
Nigeria about the efficacy of Western medicine remained. All efforts by the federal government
to dispel the rumours were rejected. For instance, in April 2004 Datti Ahmed argued that “the
SCSN harbours strong reservations on the safety of our population, not least because of our
recent experience in the Pfizer scandal, when our people were used as guinea pigs with the
approval of the Federal Ministry of Health, and the relevant UN agencies” [17].
This impasse was eventually resolved in July 2004 through dialogue, with religious leaders
playing a significant role in the process. The federal government had invited political and
religious leaders to a series of meetings in order to find a solution to the impasse. The WHO and
UNICEF also played a role in breaking the deadlock. These meetings led to a consensus in
February 2004 to accept the SCSN's demand to test the vaccine independently in a Muslim
country. In February 2004, the Nigerian government sent state and religious representatives to
South Africa, Indonesia, and India to observe testing of the polio vaccine and “bring back proof”
that it was not contaminated with HIV [17].
In defence of the 11-month boycott, the Kano state governor, Ibrahim Shekarau, reaffirmed that
their decision was influenced by unsatisfactory test results by the federal government's teams.
Satisfied by the quality and process of production of the polio vaccine, the Kano state team
returned with a seal of approval from Biopharma, an Indonesian company, which they later
recommended be the new supplier of polio vaccines for the predominantly Muslim states and
perhaps the rest of the country [17]. Indonesia is a Muslim country trusted by Nigeria's Muslim
leaders for testing the polio vaccine.
Two months after Kano state resumed its polio immunization program, about 150 Muslim clerics
and traditional chiefs from Chad, Cameroon, Niger, Togo, Benin, and Burkina Faso met in Kano
on September 22, 2004 to discuss the way forward in respect to the polio immunization
campaign. The meeting was hosted by WHO and UNICEF, and its aim was to “inform religious
and traditional leaders about issues that affect children, with emphasis on polio.” The meeting
also shared knowledge and experiences and generated an advocacy agenda to ensure that the
right messages were delivered to the people [32,33].
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African Communitarianism
The federal government, having lost the public trust of one state—a loss of trust fuelled by
Muslim leaders—became handicapped in providing health services. In many parts of Africa,
communication and authority flow downward from community leaders who are the gate keepers
and decision makers. In the Hausa community of northern Nigeria, traditional rulers have powers
derived from both culture and religion. This gives them the opportunity to perform both political
and religious roles. They rule through the traditional and the Islamic councils, under the
supervision of the local government, having their received staff of office from the state
government.
The modern political system in northern Nigeria relies on this structure to reach out and mobilize
people. This is important in the sense that it shows a type of communitarianism where individual
autonomy cannot be separated from that of the community [34]. The Kano state leaders believed
that they were acting to protect the interest of their people, though unfortunately, they ended up
disrupting national and global health agendas.
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The Future of Immunization Efforts

A fresh outbreak of polio was reported in Kano in October 2003. The BBC reported that, due to
this fresh outbreak, a new strain of the polio virus was traced to other parts of the country [35].
Even many years after the boycott, polio outbreaks remain a regular occurrence in Nigeria, and
these show some form of resistance to vaccines. 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 immunized up to
eight or more times [23].
The recent case of an 18-month-old boy in Nasarawa in Kano shows that there is ongoing
suspicion about the polio vaccine in Nigeria. The boy was considered likely to have polio,
having lost the use of one of his legs after being diagnosed with acute flaccid paralysis. His
mother confirmed that he had never been vaccinated because her husband did not allow it [23]. It
is still a major undertaking to have the population understand that the vaccine is safe [36].
The September 2006 report of the WHO Regional Committee for Africa indicated that “there
continues to be very high-intensity wild poliovirus transmission in the remaining endemic
country in the region. The number of confirmed polio cases in northern Nigeria more than
doubled in the first five months of 2006 as compared to the same period in 2005. Nigeria now
accounts for over 80% of the 2006 global polio burden” [37,38].
New cases of polio have recently been reported in several west and central African countries that
were previously free of polio: Benin, Burkina Faso, Cameroon, Central African Republic, Chad,
Côte d'Ivoire, Ghana, and Togo. The Lancet recently reported that “poliovirus serotype 1 caused
a very serious and large scale outbreak during 2004 in western and central Africa (spreading
from Nigeria) where vaccination was refused for political or theological reasons, or fear of
deliberate contamination of the vaccine with HIV or infertility agents” [38].
The report stated further that: “the same virus travelled in 2005 to Yemen, Saudi Arabia, and
Indonesia (probably by Muslim pilgrims returning from the Hajj or migrant workers)” [38]. As a
result, over 1,500 children were paralyzed. These new cases are genetically linked to the polio
virus endemic in northern Nigeria (Figure 3). New cases of polio genetically linked to the wild
polio strain from Nigeria have also been recorded in countries as far as the Sudan and Botswana,
which were also previously free of polio [38].

The Five States in Northern Nigeria That Accounted for 51% of All Polio Cases Worldwide
in 2006

(Illustration: Anthony Flores; data derived

from http://www.polioeradication.org/content/factsheets/Nigeria_12Oct06.pdf).
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How Can the Health Community Prevent Further Boycotts?

The vaccine boycott in Nigeria was influenced by a complex interplay of factors. These factors
included lack of trust in modern medicine, political and religious motives, a history of perceived
betrayal by the federal government, the medical establishment, and big business, and a
conceivably genuine—albeit misplaced and ineffective—attempt by the local leadership to
protect its people.
A recent editorial in The Lancet argued that “few data exist on the best way to stop the spread of
false information” [39]. One lesson from the Kano boycott is that research is needed to
investigate why people have concerns and fears about vaccination, and what steps should be
taken to avoid boycotts in the future. Other lessons are discussed below.

Governments should be sensitive to local politics, especially as they affect health-care delivery
Immunization campaign programs should be a participatory event involving state and local
governments, community leaders, and parents. There are three types of community leaders in
northern Nigeria—traditional rulers, political leaders, and religious leaders. Traditional rulers
acquire their status through succession and their authority is rooted in traditions and customs
[40–42]. Political leaders acquire their status through the political process and religious leaders
do so on a religious basis. Among the three, the traditional ruler is best placed to represent the
interests of children. Community leaders may contribute to the success or failure of health
research and delivery [43,44].

Public awareness campaigns about vaccination are crucial.

These should stress the value of immunization and involve the media. Reaching the community
requires radio, television, and folk media (such as local music, theatre, and festivals).
Immunization messages can be packaged into songs by local musicians and can be
communicated through drama in the language that local people understand.

Research ethics committees should be established in each local government.

These committees would examine and approve or reject health research in its sphere of
influence. Members of these community-based ethics committees should include volunteers who
are ready to undergo basic ethics training relevant to their duties. The committees should be
under the supervision of, and funded by, the local government's councils, and the committees
should work with local medical associations. They should choose their own chairperson and
determine their own agenda in line with the national ethics code. Barriers to the formation of
local ethics committees include inadequate capacity, funding, and communication.
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Supporting Information

Alternative Language Text S1

Translation of the article into French by E. I. Amenyah:

(94 KB DOC).
Click here for additional data file.(101K, doc)
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Acknowledgments
The staff of the Joint Centre for Bioethics at the University of Toronto reviewed the initial draft
of this article. Thanks to Professor Melissa Leach and Mariam Yahaya of the Institute of
Development Studies, University of Sussex for providing information that I used in this article.
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Abbreviations

ANPP All Nigeria People's Party

GPEI Global Polio Eradication Initiative

PDP People's Democratic Party

SCSN Supreme Council for Sharia in Nigeria

WHO World Health Organization

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Footnotes

Ayodele Samuel Jegede is a Senior Lecturer in the Department of Sociology, University of

Ibadan, and a faculty member of the Center for West African Bioethics Training Program,
College of Medicine, University of Ibadan, Ibadan, Oyo State, Nigeria. E-
mail: moc.oohay@edegejyas

Funding: This paper was written when the author was a Fogarty Scholar/Fellow at the
University of Toronto Joint Centre for Bioethics in the 2005–2006 session.

Competing Interests: The author declares that there are no competing interests.
 Go to:

References

1. Lurie P, Bishaw M, Chesney MA, Cooke M, Fernandes ME, et al. Ethical, behavioural,
and social aspects of HIV vaccine trials in developing countries. JAMA. 1994;271:295–
301. [PubMed]
2. Temoshok LR. Behavioral research contributions to planning and conducting HIV
vaccine efficacy studies. AIDS Res Hum Retroviruses. 1994;10((Suppl 2)):S277–
S280. [PubMed]
3. Berkley S. HIV vaccine development for the world: An idea whose time has come? AIDS
Res Hum Retroviruses. 1998;14(Suppl 3):S191–S196. [PubMed]
4. Excler JL, Beyer C. Human immunodeficiency virus vaccine development in developing
countries: Are efficacy trials feasible. J Hum Virol. 2000;3:193–214. [PubMed]
5. Mbidde E. Bioethics and local circumstances. Science. 1998;279:155. [PubMed]

\
What Is the MMR?
MMR, which stands for mumps/measles/rubella, is one of several live viral vaccines
(chicken pox vaccine and the nasal flu vaccine are two others). It is routinely given at 12 to
15 months of age, which is the age when autism is first likely to become evident. Unlike the
flu vaccine and a number of other childhood immunizations, the mumps/measles/rubella
vaccine does not and did not contain thimerosal (a mercury-based preservative).

How Did the MMR Vaccine Become So Controversial?

The concern over MMR began in 1992 when Dr. Andrew Wakefield, at that time an
accredited British gastroenterologist, tested 12 youngsters with and without autism.
According to a report based on that study, the findings uncovered a possible link between
measles virus in the gut and autism. The theory presented was that certain children have a
genetic predisposition to immune issues -- and that a variety of environmental toxins begin to
attack the child's immune system early on, thus causing the appearance of autism.

Researchers at Wakefield's Texas-based foundation called Thoughtful House claimed that

"The child develops a leaky gut, tissue damage gets worse, the immune system grows
weaker, and autoimmune reactions start. Then a lot of children experience a catastrophic
event. Either in the form of a significant illness or a live virus vaccine. The immune system
is overwhelmed and the child rapidly goes downhill. Some parents report a gradual
deterioration, but many children seem to develop autism after a particular event. They go into
the hospital or they get an MMR shot and they’re never the same again. Autism is the end
result of this developing series of reactions."

These claims have not been supported by any other studies including those that attempted
unsuccessfully to replicate his results. Dozens of peer-reviewed epidemiologic studies
showed no link between MMR and autism. In fact, Dr. Wakefield’s original study was
completely discredited. Ten of the 12 authors withdrew their support from the article.

The CDC, the Institutes of Medicine, and other major research institutions looked into the
issue and found that there was an enormous amount of evidence that there is no connection
between the MMR vaccine and autism and that there is no credible evidence that a link did
exist. Some studies have suggested, however, that autistic children do have more
gastrointestinal problems. In addition, some research suggests that some kind of interaction
between genetic predispositions and environmental issues may contribute to autism. These
studies, however, have not shown a causal link between the MMR and autism -- and,
meanwhile, many large international studies have found no link whatever.
In 2010, Wakefield resigned from Thoughtful House, and the organization changed its name
to The Johnson Center for Child Health and Development. This occurred almost immediately
after Wakefield was stripped of his UK medical license for ethical violations.

All of these events, studies, and announcements, however, have not ended the belief that
there is a link between vaccines and autism. Even outbreaks of measles in both the UK and
the US as a result of withholding vaccines has not changed some minds. There have been
suggestions that research conducted by government agencies has been flawed or that
evidence has been withheld from the public. Some MMR opponents claim that researchers
who work for NIH and CDC come from and return to large pharmaceutical firms -- and they
and their firms have a great deal of money at risk.

Continued belief in an autism/MMR connection has been spurred along by various

celebrities--led by Jenny McCarthy--and by organizations built around Wakefield's legacy.
While these organizations are still extant, they are far less active than they were back around
the mid-2000's. Interestingly, however, their cause has been taken up by some well-educated,
well-to-do people and groups for whom a "clean" (chemical free) environment is believed to
be a ticket to good health for themselves and their children.

The Bottom Line:

Despite ongoing research and emerging theories, little is fully understood about the cause or
causes of autism. A combination of environmental factors and genetic predisposition may
indeed play a significant role in the causation of autism. The overwhelming weight of
scientific evidence, however, tells us that vaccines like MMR are not causing autism.

References: https://www.verywellhealth.com/the-mmr-vaccination-autism-controversy-260556