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PEOPLE AND POLITICS MY MOHAMMED HARUNA NPI, Immunisation and Matters Arising
My column of November 30, “The NPI: Why Dr. Dere Awosika should go”, drew two contrasting response, one very short and the other very long. Because of the issues of vital importance they raised, I thought I should share them with you this morning. Below are their edited versions:- Osagie Ayanru Mohammed Haruna’s write-up on the National Programme on Immunisation (NPI) in the Daily Trust of 30 November 2005 has prompted me to do a kind of premature u-turn on my self-imposed policy not to respond to anything attributed directly to my person, true or false. Rather, my policy has been to allow time, the great independent healer, to respond on my behalf. I am certain Haruna meant no harm, and I am personally unperturbed by his assertion that I was ‘sacked’ as Chairman of the NPI. However, he was dead wrong about the manner of my departure from the immunisation agency. I hereby declare for today and for posterity that I was never sacked as Chairman of the NPI, “unceremoniously” or not, “for all practical purposes” or for no purpose at all. In similar vein, I am emphatic that there was never “bad blood” (whatever that means) between me and anyone else, not least Dr. A. Awosika, National Coordinator and Chief Executive of the NPI. I state further that never will there be such “bad blood” on my side in relation to any person, as I hold that this kind of disposition is a pastime only of small-time, small-minded and professionally inept recognition.
Now to the substance of the write-up. Mohammed Haruna is an extraordinarily competent, objective and courageous media practitioner. He was right and factual, though short on details, in his presentation of events at the NPI that necessitated an inquiry. Consequently, what he dished out to the public is only a tip of the iceberg. The letter from the country Director of the World Bank is something I thought would never happen, even though I saw it coming. The contents of the letter as revealed by Mohammed Haruna were among the several critical points I had raised in several reports to Government, in my professional and administrative capacity as chairman of the NPI. I will use the unique opportunity offered to me by this disclosure to address some of the most important issues that have combined to bring immunisation to the edge of a precipice in this country. I intend to address the issues mostly from a professional standpoint without ignoring the vicissitudes of political intervention in public health policy.
I am sure many will make the mistake of thinking that I might be pleased with the letter from the World Bank’s Nigerian chief, but they could not be more wrong. As a proudly patriotic Nigerian, I am extremely saddened by its contents, although I am delighted that operational agents of international organisations are now willing to ignore or sidetrack diplomacy and be ‘point blank’ (apologies Tony Iredia) on such crucial issues as failure of immunisation that threaten the lives and livelihood of millions of people in poor ‘developing’ countries. The palpable failure of disease control and prevention sequel to poor performance in immunisation, classified by the United Nations as a fundamental right of all people, most particularly women and children, is indefensible and scandalous, because, let truth be told, I know for sure that this Government has funded the immunisation programme on such massive scale that was never done before.
Thus, with particular reference to support for immunisation in Nigeria, I have nothing but respect and admiration for Mr President, who took the trouble to summon me for a meeting one-on-one no less than three times, and promised me adequate funding and personal political commitment to the cause of disease control via immunisation, which he carried through during my tenure as Chairman of the NPI. That is among the most important reasons for my consternation at what had happened to prevent the Board of Management from fulfilling our own part of the bargain. My resolute insistence on thorough, full and unfettered investigation of massive financial mismanagement and the failure to achieve Mr. President’s target of “near 100% coverage” in routine immunisation (RI) was one way of convincing him of the real reasons behind what, to all practical intents and purposes, is the collapse of the immunisation programme. Against this personal commitment and strong support to the NPI, it scandalises the Board and Management of the NPI, that instead of raising RI coverage up from 40% in 1999 towards the set target of 80%, the coverage plummeted down to 13%, despite timely funding in excess of several billions of Naira, and hundreds of millions of US Dollars in direct funding from abroad.
The fraud and very poor RI coverage, both of scandalous proportions, can lead to only one conclusion: the NPI has failed the nation, as well as the President who had exhibited such deep political and financial commitment to immunisation, on a scale never done before in Nigeria.
The problems highlighted by Mohammed Haruna are grave enough, but their sum total is a disaster of unimaginable proportions. Failure to execute immunisation with competence and professionalism has left Nigerians exposed to potentially devastating epidemics of infectious disease. Instead of protecting Nigerians from vaccine preventable diseases, the NPI has brought the programme down on its knees and on the verge of total collapse. The failure has led to severe escalation of the burden of disease in this country, by providing the atmosphere for outbreak of epidemics that result in the avoidable death of millions of Nigerians, particularly our children. While the scale of immunisation failure in Nigeria is a matter for deep national concern, regrettably, all indications are that nobody seems to care. Never has any country recorded such dismal routine immunisation (RI) coverage, despite massive funding from sources at home and abroad. With 12.7% RI coverage, Nigeria may well be on its way to the Guinness Book of Records as the first and only country ever to have compromised the health of its citizens with reckless abandon.
The failure in routine immunisation has other grave implications for Nigeria. Apart from endangering the health of Nigerians, the low coverage means that Nigerians have no ‘herd’ immunity. One effect of this is that the country will not qualify as a place where trials of new vaccines or drugs can be safely and successfully undertaken. No one in their right senses would contemplate the trial of a new vaccine in a country without herd immunity, and where all the indications point to professional incompetence, infrastructural poverty, executive incapacity, poor logistic support, insecurity of life and property, weak health systems, very poor health services, pervasive poverty, inequity and inequality, low staff morale and disdain for ethical responsibility.
This last point is a sore one that is inflicting pain and disappointment on me personally. Only last week, a meeting was held on “Challenges in the African Meningitis Belt, and I tried to use the opportunity to advocate the cause of Nigeria in relation to the development and trial of a new, more effective and cheaper meningitis vaccine for Africa. The joint WHO/PATH project was made possible by a donation from the Bill and Melinda Gates Foundation. This donation was made largely on account of work done in Nigeria by several researchers over some 30 years, and with particular reference to the largest epidemic of the disease in history, which devastated the country in 1996. Yet no one in the “Meningitis Vaccine Project” or its “Scientific Project Advisory Group” on which I serve wanted to have anything to do with getting Nigeria involved in clinical trials of the vaccine which has already been successfully developed and is being tried.
Still on the 1996 epidemic, it is common knowledge in Nigeria and abroad that a drug trial was conducted in Kano on children with CSM by a multinational drug company, the most glaring evidence of disdain for ethical norms and global responsibility in Africa. It is not generally known, but this misconduct had played a major role in the resistance to immunisation in some states of northern Nigeria. All efforts to stop the trial failed and desperately sick children were used practically as “guinea pigs” by the trial team, who, after concluding their work, disappeared as swiftly and unceremoniously as they came. No arrangements were made for follow up of the trial children to detect and treat any possible side effects, short-term or long-term, permanent or temporary. Despite the fact that an inquiry was held on the orders of Government as a result of the embarrassment generated by publication of this unethical trial by The Washington Post, nothing seems to have been done with the report of the panel of investigation.
Meanwhile, Nigeria continues to be ridiculed by the international community on this trial. Some three weeks ago, I watched a live interview on SKY News in which the newscaster asked someone from Geneva to comment on the trial. Apparently, a movie had been made in Hollywood on instances of misdemeanour by multinational drug companies in Africa, and the newscaster specifically gave the example of the trial of this investigational drug in Kano during the epidemic of CSM, and asked the respondent how this action could possibly be defended. The man was imperial in his response, claiming that (1) the trial was approved by the Nigerian Government, and (2) informed consent was obtained from the patients or their parents. He then instantly took off at a tangent and spent 90% of his response time dishing out information on how the drug company in question had promoted many causes aimed at reducing the global burden of disease, from which poor “Africans have benefited”, as though he was the public relations consultant for the company.
These claims about government approval and informed consent for this macabre action are absolutely false and unfair to the Government and people of Nigeria. I have been waiting to see if anyone would respond to the same questions in defence of Nigeria, but to date, there is no evidence that this has happened, and it is as if nobody in government cares. For anyone to seek to justify this cynical breach of ethical responsibility by advancing “good causes” by the drug company in question is preposterous and an insult to Nigeria. Meanwhile, the negative international portrayal of the country on this matter continues.
I cite these examples so as to show how they have contributed in no small measure to the setback suffered by immunisation in the North, particularly in Kano, with the people understandably suspicious about any campaigns because they associate them with motives similar to those of the drug trial. This is however not the biggest impediment to the conduct of immunisation in the country. The major problems arise largely from incompetence, fraud, deliberate misinformation and similarly obnoxious conduct that lie squarely at the heart of the NPI.
Consider the polio eradication initiative (PEI) for example. This project is most vigorously pursued by the WHO, UNICEF and Rotary Polio Plus, apparently on behalf of the only remaining superpower. The timely attainment of success in interrupting polio transmission has been prevented solely by incompetence on the part of Nigeria’s NPI, where professional ineptitude and fraud have led to the failure to achieve the desired effect, despite the billions of US dollars expended on the campaign. Contrary to the propaganda, this failure has little or nothing to do with the oft-described “semi-literate Muslims of northern Nigeria”. Rather, it is all to do with professional failure, managerial lethargy and the relentless pursuit of self-interest against programme objectives.
The people of the northern states have been led to believe that the polio vaccine contains contaminants some of which transmit HIV or promote family planning. The purported cassette tape recording, allegedly by “The Freemasons” is nothing but a deliberate ploy to scare northerners away from immunisation activities, and blame them for failure of such high profile but relatively insignificant projects as the polio eradication initiative. Although the propaganda has led to a sharp decline in routine as well as polio immunisation, its major objective has been, and remains, to divert attention from mind-boggling financial impropriety. It seems to have succeeded in large measure, and that is what is disastrous to the children of the northern states.
We must move very quickly and decisively to restore sense and performance in immunisation in this country. First, we must put things in proper perspective. Poliomyelitis is an infectious disease that paralyses people, and it also kills sometimes, but very rarely. The eradication of polio is a very good thing to achieve for all the world, rich or poor. It is almost funded from governments and agencies abroad, which provide all vaccines, as well as supplies, logistic support and remuneration for those who take part in the misnomer “National Immunisation Days (NIDs)” and sub-NIDs. The vaccine is delivered and administered house-to-house, preceded by massive media publicity largely funded by foreign partner agencies. The global eradication of poliomyelitis will be good for all and should therefore be welcome.
However, comparatively speaking, poliomyelitis is not a public health problem in Africa. The major public health problems in his country revolve around vaccine preventable infections that occur in large numbers and are lethal: measles, malaria, HIV/AIDS, tetanus, tuberculosis, cerebrospinal meningitis, whooping cough, diphtheria, yellow fever, hepatitis B and C, tetanus and newly emerging or re-emerging infections. Measles alone infects 20 million children every year, killing one million; malaria infects over 50 million children, killing 2 million every year; epidemics of CSM maim or kill thousands at one go; HIV/AIDS has fuelled a new epidemic of tuberculosis hitherto under control, and both of them have been killing millions of people every year; hepatitis B and C virus infections are prevalent in millions, and cause liver cancer that progresses relentlessly downhill eventually killing the patient.
Yet, virtually all immunisation activities and publicity are focused on the polio eradication initiative (PEI), to the detriment of routine immunisation. The PEI is a project that is inflicting severe damage to routine immunisation, and unless we pause, think and retrace our steps, the long-term consequences will be dire. The PEI has become so pervasive that even health professionals are forgetting what is called ‘routine immunisation’ because this strongest pillar of public health, disease prevention and control has been relegated to near anonymity by the vested interests of the powerful. The rural folk have forgotten EPI, the most important WHO recognised means of curtailing vaccine preventable diseases that account for 75% of Africa’s total disease burden. The people erroneously believe that “immunisation” means only polio immunisation. You cannot blame them and the senseless diversion of energy and resources away from routine immunisation must be checked, and the proper balance between RI and PEI restored without further delay. Nobody will do it for Africa, so African leaders must do it for Africa.
Unfortunately, the NPI will not, and cannot restore RI because, as presently constituted, the agency is hopelessly incompetent and drowning in massive financial impropriety. The agency has been mired in controversy, and is best defined by ineptitude, near zero accountability and mass destruction of opportunity. However, they are not the only problems. Political considerations have also been used to effect, and Northern Nigeria is in deep trouble.
Fortunately, I am not in politics, and will not be a politician. Writing recently on the back page of his Leadership newspaper, under the column “LAST WORD”, Sam Nda-Isaiah asked rhetorically: “Where did they get their guts?”, a very good and appropriate question. The answer, however, is simplicity itself. They got their guts from the land, soul and body of Northern Nigeria. Consider the case of Dr Dere Awosika for example: the “vanguards” in the forefront of her defence on the scandal at the NPI were allegedly prominent northern Senators and Members of the House of Representatives of Hausa-Fulani stock, several northern Governors and traditional rulers. They include some who should know better by virtue of their training and the oath they had taken, quite possibly with copies of The Holy Qur’an in their hands.
The kind of problems encountered at the NPI were created and sustained by considerations that had nothing to do with the success of immunisation or disease prevention and treatment. These problems provide a very good example of the deadly alliance between death, disease and politics. Nigeria would have been far better without the NPI, an agency created by excising immunisation from the department of public health of the Federal Ministry of Health and senselessly (mis)transplanted in the office of the First Ladies where it is more likely than not to fail.
It has been a pleasure for me to have been granted this wonderful opportunity to state my case in brief, not that I had any doubt about the fact that literally everyone at home and (embarrassing to me, I must add) also abroad were fully aware of the truth, the latter category of concerned bodies amply exemplified by the letter from the World Bank officer quoted by Mohammed Haruna.
However, this is where my pleasure stops, because what has happened at the NPI is only one example (though a perfect one) of the wider decadence in this once enviable, peaceful and progressive country with limitless potential.
Nigerians must not make the mistake of holding only those currently in power responsible for bringing us where we are today. We must be charitable to politicians and accept greater responsibility for our role in destroying the very fabric of Nigerian society, a country currently mired in unbelievable fairy-tale political, socio-economic and ethical irresponsibility. After all, it said that a people get the government they deserve. We deserve the government we now have, and it remains our responsibility to bring about positive change, by whatever means, if the country is to survive.
Yours faithfully Idris MohammedDan Isan Gombe.
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