Inoculating against Politics

I have heard it said that British politicians wish that all development was like vaccination programmes – easy to measure, little dispute over effectiveness and not beset by the complex politics of longer term interventions. Vaccination programmes are therefore a popular form of development intervention. Whilst they require logistical support, trained staff and of course drugs and medical equipment, they do not necessarily need the kinds of long-term engagement that other programmes demand. Unlike many other kinds of development goods, a vaccine does not need constant maintenance once administered–although some may require booster doses. Their impacts are easy to measure through the number of people vaccinated. It is most frequently children who are vaccinated and thus the deservingness of recipients is seldom questioned, and neither, the majority of the time, is the value of vaccination itself. The title of one DfID report encapsulates these sentiments: One simple jab, millions of lives saved.

But the attraction of development for politicians as for many others is that it is just ‘doing good’.  There is a desire for there to be a purity in international development engagements, or at the very least a semblance of it. For a long time scholars have been pointing out the erroneousness of approaching development as if it was not political, that you can ‘just do good’.  A key figure here is the sadly now late Adrian Leftwich who argued persuasively about the primacy of politics in development. After all, if schooling and healthcare are central electoral issues in the UK, why are they apolitical development issues in Malawi or Bolivia?

Development agencies such as DfID have started to engage more with the political nature of development (even if their engagement in essence tries to make politics more technical). However, politics is often just seen as an obstacle with the difficulty being getting politicians to do ‘the right thing’. Discussions of vaccination politics similarly frequently see the key issues to be getting political leaders in ‘poor countries’ to put in place the right policies. What is missing in such discussions however is that the nature of politics is that what is ‘right’ is always contestable.

In the accompanying description of the photograph above, DfID tells us:

As his four-year-old sister looks on, five-month-old Mohamed Kamara is about to get his second dose of pneumococcal conjugate vaccine.

Although he doesn’t know it, this vaccine will protect him from pneumococcal disease, the leading cause of pneumonia and the major cause of meningitis.

For someone familiar with Nigeria, vaccinations do not however feel simple, apolitical, or uncontested.  In Kano, Northern Nigeria in 1996, eleven children died and others were left severely disabled, when they were given an unregistered antibiotic by Pfizer in an illegal drug trial. Some families received compensation, some 15 years later. But the effects of this were much broader than the tragic losses experienced by those children’s families.

Globally, polio remains endemic only in three countries and Nigeria is one of these. Efforts to eradicate the disabling childhood disease worldwide have been set back by a boycott of polio immunisations in Northern Nigeria. This boycott emerged in the early 2000s for a variety of reasons, including political dissatisfaction with the federal government and anti-colonial distrust of the West. But the memory of the Pfizer trail fed this suspicion and was certainly seen as the culprit by some.

It is easy for westerners to dismiss this distrust as foolishness – certainly many of my students do when we discuss this case. Yet, whilst I would encourage polio vaccination–if for no other reason than having seen the twisted limbs it leaves behind on the beggars in Nigerian markets–some of the scepticism expressed by residents in Northern Nigeria contains crucial insight into the politics of vaccination. As one Kano resident remarked:

How could I be so naive as to allow my children to be given polio drops by people who go door-to-door giving the vaccine free while the government has failed to provide medication for the most urgent diseases affecting us, such as malaria and typhoid?

She is quite right. What are the politics around which diseases get treated and which do not? How is she to know that these decisions are in her and her children’s favour?

The GAVI Alliance is the premiere agency pushing forward immunisation programmes in ‘poor countries’. It is a public-private partnership which incorporates international organisations such as the World Bank and the World Health Organisation (WHO), donor governments, recipient governments and the vaccine industry (drug companies). Médecins Sans Frontières (MSF) has criticised GAVI for its focus on new vaccines such as the relatively expensive pneumococcal vaccine rather than focussing on the distribution of existing basic vaccines. The focus on new vaccines emerges, it is alleged, because these are vaccines which companies such as GlaxoSmithKline and Pfizer have recently developed, and they need to demonstrate that there is a market for them and recoup development costs. These newer vaccines also tend to be expensive and MSF have criticised companies for not meaningfully lowering the cost for poor countries. There are then indeed questions to be asked about the politics of which diseases get treated and which do not.

There are also broader issues about a focus solely on vaccinations rather than a more encompassing engagement with building public health systems and local health care capacities. This absence of deeper engagement is something which GAVI has been criticised for in the past – although in response, it now provides its own Health System Strengthening support. It is these under-staffed and underfunded frontline services that have been attempting to manage the current Ebola outbreak in West Africa. Unfortunately, their limitations are likely to have exacerbated the spread of the virus. Moreover, as our Kano resident pointed out, if you can rely on a system broadly for your medical care, any messages on particular conditions communicated from within this system will likely be seen as trustworthy. Poor health care infrastructure thus exacerbates levels of mistrust. For example, the confidence in the Liberian government’s measures to manage Ebola amongst the local population is currently under strain.

The logic, if not the conclusion, of the Kano resident has insight into the politics of focusing on particular diseases and into the importance of trust. Even still, it is hard not to find the widespread belief in Northern Nigeria that the polio vaccinations were part of an American plot to make their children infertile and thus decrease the Muslim population, as anything but a fanciful conspiracy theory. Then again, it is almost as fanciful as the idea that a vaccination programme would be used to gather children’s DNA in order to try and locate a fugitive terrorist. Although the CIA have recently promised not to use vaccination programmes in this manner again, the fallout from their strategy is particularly worrisome. Pakistan, like Nigeria, is one of the three remaining countries in which polio is still endemic.

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