Academic journal article Africa

The Politics of the 1996 Cerebronspinal Meningitis Epidemic in Nigeria

Academic journal article Africa

The Politics of the 1996 Cerebronspinal Meningitis Epidemic in Nigeria

Article excerpt

The child's eyes, the pupils of which were tiny and showed a tendency to

squint. The pulse raced. Muscular contractions developed, and an incipient

rigidity of the neck. It was cerebro-spinal meningitis ... [T. Mann, Dr

Faustus]

In May 1996 the New York Times (1996b) reported the Saudi Arabian government's decision to ban Nigerian pilgrims from visiting Mecca on account of the cerebrospinal meningitis (CSM) epidemic in northern Nigeria. However, what appears to be a simple story of cause and effect, the CSM epidemic and subsequent pilgrimage ban, is considerably more complex, with political ramifications at the local, national, and international levels. Ibis article documents these different dimensions first by examining local attempts to stem the outbreak, based on participant-observation and epidemiological data collected from northern Kaduna State. The 1996 CSM epidemic is then considered in the national context, with the general deterioration of the health care system associated with economic decline and with a national structural adjustment programme, and with a general crisis in political leadership resulting from the failed transition to civilian rule in 1993, which has contributed to a lack of adequate supervision and accountability in the mobilisation of immunisation implementation. Finally, this discussion of the local and national context of the 1996 CSM epidemic is related to the view held by many Nigerian Muslims that reports of the epidemic's severity reflected international politics, particularly the uneasy relations between the Nigerian, Saudi Arabian, and US governments, The subsequent Saudi ban on Nigerians' pilgrimage to Mecca (Hajj) was thus widely believed to have been a result of political as well as health concerns. An understanding of the connections between the handling of the epidemic at the local and national levels and of how international reactions to the epidemic were interpreted in northern Nigeria is important if the difficult problem of stemming future CSM outbreaks in Nigeria is to be addressed. The article concludes with some recommendations for a national policy and for community health initiatives that take the politics and economics of CSM immunisation into account.

CEREBROSPINAL MENINGITIS IN NORTHERN NIGERIA

Widespread outbreaks of cerebrospinal meningitis (meningococcal meningitis caused by the gram-negative coccus Neisseria meningitidis, serogroup A; Whittle et al., 1975) have regularly occurred in the flat savannah area of West Africa (Parry, 1976: 253), the `meningitis belt', which includes parts of Nigeria, Niger, Chad, Benin, Togo, Burkina Faso, Ghana, Cote d'Ivoire, Mali, Guinea, and Senegal. CSM outbreaks have tended to occur in five- to ten-year cycles.

In northern Nigeria the earliest recorded cases of CSM were reported in 1880, although oral evidence suggests earlier occurrences:

The 1905 epidemic in Northern Nigeria was nothing new in Hausa areas; one

doctor was told it had come from the northeast, `but not in the memory of

living man,' and had caused many deaths at intervals over the last fifty

years. A physician working in the Zungeru area was told that the disease

had occurred in some previous dry seasons, causing many deaths, and one

informant described an epidemic at Kukua (Bornu) about 1875. After the

1920 outbreak, Nigerian medical officials reported oral evidence of an

epidemic or epidemics in the northwest c. 1885-1890; it was called Dan

Kanoma, after the town of Kanoma, or sankarau (`stiff neck'). [Patterson

and Hartwig, 1984: 14]

CSM outbreaks in northern Nigeria have been recorded in 1905 (Patterson and Hartwig, 1984), 1921 (Sokoto; Schram, 1971), 1924 (Adamawa; Schram, 1971), 1937 (Schram, 1971), 1944-45,(1) 1949-51 (Horn, 1951), 1960-62 (Ministry of Health, Kaduna, 1962), 1970, 1977 (Greenwood et al., 1978; Hassan-King et al., 1979; Lapeyssonnie, 1963; Schram, 1971; Whittle and Greenwood, 1976), and 1988 (Moore, 1992: 519). The 1996 epidemic represents another peak in this cycle.

Treatments for these outbreaks have varied. Prior to 1969, when vaccines for meningococcus serogroup C and soon after for meningococcus serogroup A (the group commonly found in Africa; Greenwood et al., 1978) were developed, the Nigerian colonial government encouraged measures such as sleeping with open windows or out of doors to counter the disease. Market areas were dampened to keep down dust (Schram, 1971). During the 1960-62 epidemic a large isolation camp was set up in Kano where patients were housed in tents and fed at government expense; the treatment consisted of sulphonamide drugs (sulphadimidine, solumezathine, soluthiazole, and thiazamide) (Ministry of Health, Kaduna, 1962). During the same epidemic, an experiment in the administration of sulphonamide by snuffing was carried out in one district in Katsina Province, with variable results, owing to the dearth of staff needed for widespread treatment by snuffing and to the mobility of the population, especially in market towns. One unfortunate consequence of this experiment and other sulphonamide treatments has been the subsequent resistance of many strains of N. meningitidis to treatment with sulpha drugs.

During the 1977-78 epidemic, Greenwood et al. (1978, 1980) conducted trials of the new meningococcal polysaccharide vaccine to good effect. Since then, a combined group A and group C vaccine has commonly been administered; oily chloramphenicol or penicillin injection is presently the preferred treatment (Parry, 1976: 257).

After a severe outbreak, sufficient herd immunity results--by exposure (Goldschneider et al., 1969a, b) and through immunisation (Greenwood et al., 1980), which confers approximately three years of protection--so that there will be a considerable drop in CSM incidence in the following years. Thereafter, when the number of susceptible individuals in the high-risk age group (5-15 years) begins to increase, and when the dry, dusty conditions which are conducive to the spread of the coccus are present, the incidence of cases again rises. As will be discussed, the relatively short-term immunity after vaccination Or exposure, a growing population with large numbers in the susceptible age group (47 per cent of the population is less than 15 years; Nigeria, 1992: 11), economic constraints on public health care as well as on individuals' nutrition and housing, and political factors, make the eradication of the disease particularly difficult. Thus, even with effective vaccines and prophylaxis available, the 1996 CSM epidemic was severe (Court, 1996).

An examination of the CSM outbreak in northern Nigeria suggests that the main problem was drug and vaccine supplies and the logistics of their distribution and administration. The following discussion is based on data collected from health institution records, interviews, and participant observation, as well as newspaper accounts and reports by international agencies. The findings illustrate the slow response of local health officials to initial reports of the disease and the later failure to monitor statistics and distribute vaccines systematically.

THE 1996 EPIDEMIC

According to general figures based on reports from several northern Nigerian states (WHO, 1996a), Kano State was particularly hard hit. During the peak of the epidemic in March 1996 the Infectious Disease Hospital was reported to have admitted fifty patients per day, and the Minister of Health, Ibechukwu Madubuike, was considering asking for a state of emergency to be declared in Kano (Ojewale, 1996: 21). It was estimated for Kano State that `two-thirds of the cases were in children under 16 years of age' (WHO, 1996b: 90).

Other states affected included Adamawa, Bauchi, Benue, Borno, Cross Rivers, Jigawa, Kaduna, Katsina, Kebbi, Kwara, Niger, Plateau, Sokoto, and Taraba. From the period beginning January 1996 to 14 March 1996, a total of 20,982 cases were reported, with 3,634 deaths from cerebrospinal meningitis in Nigeria (WHO, 1996b: 90). These figures may be low, either because many people failed to come to clinics or hospitals for treatment or because of under-reporting (discussed below). The difficulty of getting accurate data as well as other problems may be more clearly seen from the following example of the course of the outbreak of CSM in one local government area (LGA, an administrative unit comparable to a county) in northern Kaduna State.

In Kaduna State, each LGA has a local department of health, headed by a medical unit health officer. Within each local government area there are several districts, each with a comprehensive or community health centre (CHC), usually located in the district headquarters, headed by a community health supervisor. Villages within each district may have their own health centre or dispensaries, manned by a village health worker and assistant. The following example illustrates the interactions between village, district health centre, and LGA health personnel.

On 18 January 1996 the head of one rural village in the Primary Health Care practice area of the Department of Community Medicine, Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, in the Giwa Local Government Area, in northern Kaduna State, sent word through an ABUTH staff member Working there that assistance was needed in what appeared to be an outbreak of meningitis. Nine cases of cerebrospinal meningitis (Hausa sankarau; see Last, 1976: 131, and Wall, 1988: 190 on the history and etymology of this term) were reported. By the time the nurse and the registrar of the Department of Community Medicine arrived in the village to assess the situation, three days after receipt of the information, four people had died and the other five had been treated and discharged from the local general hospital.

In the following week, village heads from three other villages in the area came to Yakawada (District) Comprehensive Health Centre to report outbreaks of CSM in their villages. One village head reported four cases and one death, another, five cases and one death, and the third reported eleven cases and no deaths. Recognising the onset of a CSM epidemic (identified primarily by the symptom of neck stiffness and secondarily by severe headache, fever, back pain, and convulsions), health centre personnel were told to go to local government officials and to warn them about the outbreak. Together, they could plan a strategy for addressing the epidemic.

The last week of January 1996, the LGA medical unit head was briefed about the rising number of cases of the disease being reported in the local government area. He was informed of the need for the adequate provision of CSM vaccines and of the relevant drugs and other materials required by Department of Community Medicine staff to contain the outbreak. The man responded by saying that the local government had neither vaccines nor drugs. Instead he advised them to go and give the villagers water injections in place of vaccines for `psychological satisfaction'.

By 7 February 1996, when residents of the Department of Community Medicine went back to assess the situation, they were informed by the LGA health personnel that they had received reports indicating that the disease had spread to many villages throughout the local government area. By this time, nineteen villages reported cases. Still with no drugs or vaccines forthcoming from the local government, one village head approached the staff of the Yakawada Comprehensive Health Centre, offering to purchase drugs and vaccines to treat cases in his village. Initially the medical officer in charge of the centre refused, saying that he did not want to get involved in local politics (i.e. go over the authority of the LGA medical unit head). Furthermore, he thought that the vaccines purchased on the open market might be of questionable potency. When one of the authors (Ejembi, as head of the Department of Community Medicine, ABU) heard about the offer, she told the officer to purchase the vaccines and to give them to the Yakawada CHC staff to administer. This was subsequently done. Five vials of CSM vaccine (each containing fifty doses) were purchased by community health personnel at a cost of 2,500 naira, paid for by the village head. It was also around this time that CSM specimens were taken from a few individuals exhibiting symptoms, to confirm the diagnosis; the microbiology test showed gram-negative diplococci and the culture grew N. meningitidis.

The intervention of the LGA chairman and LGA health counsellor was sought to expedite action to procure vaccines and drugs for treatment to address the epidemic. The first supplies of 10,000 doses of the vaccine were said to have been received on 12 February 1996 and a subsequent final supply of 7,000 doses came in early March 1996. Both shipments of vaccines were supplied by the Kaduna State Ministry of Health. While the local government did not buy any vaccines, it did buy a limited amount of chloramphenicol tablets, crystalline penicillin, and ten bags of 500ml intravenous fluids.(2)

When the drugs and vaccines came, Department of Community Medicine staff were given a limited number of doses of the vaccine (1,500 doses) to administer. They were also given 500 tablets of chloramphenicol and fifty vials of crystalline penicillin, enough to treat only sixteen patients. It appeared that the LGA health unit personnel wanted to marginalise the Department of Community Medicine staff's participation, in part to maintain their control over the situation.

How much the local government budgeted for these materials and how much was actually spent on them is unknown. For example, the LGA Expanded Programme on Immunisation records for the period show a total of 51,401 doses of CSM vaccines beginning in January 1996 (Table 1). However, the Department of Community Medicine staff member who participated in the management of the outbreak confirmed that, in this local government area, he was aware of only 17,000 doses of CSM vaccines being used for the entire vaccination exercise, which in any event did not begin until mid-February 1996. It is likely that the records were doctored, possibly because officials did not want to appear to have been unresponsive to the epidemic and possibly because of the diversion of vaccines for sale elsewhere. This latter surmise is supported by the fact that whereas the LGA comprehensive health centres ran out of vaccines which were administered free of charge, vaccines became widely available in patent medicine stores and pharmacies in the local government area, where they were administered by shop-owners, selling for 100-200 naira per dose. (Since many of the shops lack electricity and refrigeration facilities, the CSM vaccines obtained by villagers from such sources were of questionable viability.) While it is extremely difficult to prove, it is probable that some people made money out of the transaction (cf. van der Geest, 1982).

TABLE 1. Doses of vaccines administered in one LGA in northern Kaduna State during the 1996 CSM epidemic

                Doses of CSM administered

                                                Reported by Dept of
                Reported by LGA health          Community Medicine
Month           dept                            residents

January          7,400                          nil
February        21,250                          10,000
March           13,121                           7,000
April            5,350                          nil
May              4,280                          nil
June            n.a.                            nil
Total           51,401                          17,000

Note The population of the LGA is estimated at 210,000.

By the end of February 1996 the pace of vaccination and treatment slowed due to the beginning of Muslim observance of `Id-al-Fitr. By March, local attention had shifted to local government elections and the subsequent assumption of office by the new chairman, bringing the local government's response to the epidemic essentially to a standstill. Nonetheless, people continued to present themselves to the local comprehensive health centres and the main general hospital (Table 2). The actual number of CSM cases and subsequent deaths in Giwa LGA or in the neighbouring Makarfi LGA is unknown, since hospital and clinic statistics represent only the tip of the iceberg; many patients were treated locally or died at home. For example, the Community Health Officer in charge in Hunkuyi, a village in Makarfi LGA, estimated that of the 116 deaths reported from meningitis alone in the local comprehensive health centre for the period from December 1995 through June 1996, twice that number died at home without access to health facilities (Table 3).(3)

TABLE 2. Cases of CSM seen in Giwa General Hospital, Giwa LGA, Kaduna State, during the 1996 epidemic

                                                Case
                                                fatality
Month           Cases           Deaths          rate (%)

January           38               3               7.9
February          65               7              10.8
March            138              15              10.9
April            167              13               7.8
May               20               2              10.0
June               7             --               --

Source Giwa General Hospital records.

TABLE 3. Reports of CSM from Hunkuyi Comprehensive Health Centre, Makarfi LGA, Kaduna State, October 1995-July 1996

                                                Case
                                                fatality
Month           Cases           Deaths          rate (%)

October            0             --             --
November           0             --             --
December          91              14             15.4
January          161              42             26.1
February          87              11             12.6
March            103              24             23.3
April            102              20             19.6
May               44               5             11.4
June               1             --             --
July               0             --             --

Total            589             116             19.6

Even after the epidemic had peaked in late March and early April 1996, patients continued to come to local health centres. As late as 26 June 1996 the resident doctor reported having just discharged a CSM patient, although there was a considerable drop in cases with the beginning of the rainy season in June 1996.

There was some variation in the responses of LGA officials to the outbreak. While some officials contacted the state epidemiological unit, which responded immediately with considerable effectiveness, the majority were slow in responding and sometimes took inappropriate action. The responses reflected in these examples from local government areas in northern Kaduna State were apparently repeated in other parts of the country. In one local government area (also in Kaduna State), for example, even though the LGA health department had recorded 207 cases and 101 deaths by mid-January 1996, drugs and vaccines were not made available until March 1996. Furthermore, the drugs that were purchased were grossly inadequate to meet local needs. Government health workers failed to realise the severity of the problem, for reasons which are discussed in the following section.

THE DETERIORATION OF THE PUBLIC HEALTH CARE SYSTEM

The initial slowness of the response to the CSM epidemic in northern Nigeria may be attributed to several factors--infrastructural, economic, administrative, and political.

The decline in federal spending on the health care sector and its effect on public health in Africa have been widely documented (Cornia et al., 1992; Erinosho, 1989; Ogbu and Gallagher, 1992). Spending cuts have led to infrastructural decline, evidenced by the lack of basic drugs (Foster, 1991), equipment, and sometimes water and electricity. Further, the ending of subsidised public health care has made it necessary to charge for declining services, leading people who can afford it to attend private clinics and those who cannot to forgo treatment altogether.

The devaluation of the national currency, the naira, prescribed as part of the structural adjustment programme instituted in 1986 has further exacerbated public health problems by making imported medicines prohibitively expensive (Lancet, 1990). Furthermore, reductions in the salaries of medical staff have led many to leave public clinics and hospitals for private practice or for overseas employment, resulting in low morale among staff who remain (Ejembi and Bandipo, 1989). While the breakdown in the health care system (Popoola, 1993) is not solely the result of the implementation of a structural adjustment programme, the programme has been widely criticised both within and outside Nigeria for treating health and welfare as simply a matter of economics (Cornia et al., 1992).

Not surprisingly, economic and infrastructural problems are compounded by administrative ones. Political in-fighting over authority and access to funds has led to delays and mismanagement of public health care initiatives. In Plateau State, for example, CSM vaccines could not be administered until the new agency in charge of immunisation there had met Ministry of Health officials to decide on a strategy, leading to a two-week delay. Further, the national immunisation programme was transferred from the Ministry of Health to the Family Support Programme, which was neither technically nor logistically equipped to handle emergency immunisation, resulting in an insufficient quantity of vaccine being available at the time of the outbreak.

The proliferation of organisations and health initiatives has also affected the quality of the statistics collected and made the co-ordination of their analysis extremely difficult. Because there is no clear-cut chain of authority and responsibility, statistics are haphazardly collected, record books lost, and figures altered when necessary. For example, the difference in the statistics collected regarding CSM cases for the same period in one local government area in Kaduna State is striking. Data made available to the LGA chairman collected at the time of the epidemic reported 207 cases and 101 deaths in mid-January 1996. By the time one of the authors visited the LGA health department in July 1996, she was given statistics that recorded only five cases and no deaths in the same period.

In a period of economic constraints, the difficulty of purchasing expensive imported vaccines and drugs was exacerbated by people, themselves strapped for funds, exploiting the situation for personal profit (cf. van der Geest, 1982). On paper, there is a system of notification and response. In practice it is unwieldy, and there is no well defined national hierarchy of responsibility and authority for handling epidemics such as CSM. Thus it is difficult not only to co-ordinate efforts at various levels but also to maintain oversight of existing efforts. This situation also undermines efforts at accountability, so that timely responses and judicious use of resources are particularly problematic.

Furthermore, corruption in the health care system and uncertainty in the political programme have supported various types of patronage, in this case in the form of contracts for the purchase of medical supplies.(4) There was a widespread belief that `a lot of people have became millionaires over the epidemic' (Nwosu et al., 1996). In one local government in northern Kaduna State, several people saw a connection between LGA funding to combat the CSM epidemic, the unavailability of vaccines, and the new car purchased by the head of the LGA medical unit at the end of February 1996.(5) The need to cover up financial discrepancies and to avoid blame was complicated by a desire to downplay the poor handling of the epidemic, particularly as Nigerian political leaders were already hypersensitive to US criticism regarding their human rights record and the annulment of the 1993 elections (New York Times, 1996a). Thus the disaster-style reporting of the 1996 CSM epidemic broadcast in Nigeria on 8 March 1996 (provided by Reuter's) was taken as further evidence of Western attempts to portray Nigeria in a bad light.

This particular brew of local, national, and international affairs contributed to many people's attempting to avoid responsibility for the severity of the epidemic, which would likely have been tempered had it been effectively managed (Democrat, 1996a). It also contributed to a tendency to lay the blame for the subsequent Hajj ban on political factors rather than simply on the CSM epidemic. This view--which differs considerably from the stories reported in the New York Times (1996b) in April and May (French, 1996)(6)--warrants some explanation.

INTERPRETATIONS OF THE CSM EPIDEMIC AND INTERNATIONAL POLITICS

From the previous discussion it is clear that a severe outbreak of CSM took place in northern Nigeria, as well as in Benin, Burkina Faso, Mali, and Niger, during the period from December 1995 to June 1996 (WHO, 1996b: 89), although it was handled somewhat differently in different places. In Niger, for example, Medecins Sans Frontieres personnel reported that `the national authorities appeared to have the meningitis [outbreak] in hand' (MSF, 1996: 42).

In northern Nigeria, for various reasons, the epidemic was poorly managed. It is clear that the spread and extent of the disease could have been reduced if prompt action had been taken when early reports became known to local health officials (Democrat, 1996a). Yet, despite the severity of the 1996 CSM outbreak, the sense that their government had failed to address the problem in a prompt and appropriate manner, the knowledge of the highly contagious nature of the disease, and the Qur'anic injunction against movements of people during epidemics, many people in northern Nigeria did not believe that the Saudi Arabian government's decision to ban Nigerian pilgrims from performing Hajj was a simple matter of disease control (Adekilekun, 1996: 24). Rather it was seen as due to a combination of political, religious, and medical factors. That this belief may impinge on attempts to stem future outbreaks of the disease and other epidemics makes it important to understand the reasoning behind the belief.(7)

The sequence of events

When the Saudi government abruptly announced in early April 1996 that on health grounds Nigerian pilgrims would not be allowed to visit Mecca, over 1,000 pilgrims from Kano and Jigawa states had already arrived in Jeddah (Majigi et al., 1996: 1). The Saudis based their decision on a WHO report which documented the severity of the 1996 CSM epidemic, 9,000 deaths and 74,000 cases being attributed to the disease in Nigeria, Niger, Mali, and Burkina Faso (Ugbolue and Funtua, 1996). While there was initial hope that the ban would be suspended and Hajj flights resumed (Democrat, 1996b), by the middle of the month it had become clear that only 3,000 Nigerian pilgrims (10 per cent of the total) aged 35-50, from southern parts of the country not affected by the epidemic, would be permitted to visit Mecca (Funtua and Anuku, 1996).

The seriousness of this situation should not be underestimated. Once a Muslim has made the vow to perform the pilgrimage (one of the five tenets of Islam), and assuming that the route is safe, nothing should stand in the way. There had already been criticism of the government's handling of Hajj preparations, particularly the high cost for pilgrims (up from 40,000-60,000 naira in 1995 to 120,000 naira in 1996), Not surprisingly, immediately after the ban there were anti-government and anti-Saudi demonstrations in Zaria (by the local Shiite Muslim group) as people expressed their displeasure with their government's inability to remedy the situation. Yet the government was able to defuse the tension as certain inconsistencies regarding the Saudi decision became known. Among them were the following.

1. While many people believed (incorrectly) that the epidemic had already peaked by April and hence did not pose a health threat, they were indeed correct in their assessment that the risk of Nigerian pilgrims spreading CSM would have been reduced by vaccinations (Yousuf and Nadeem, 1995: 321) and prophylactic doses of rifampicin being administered to pilgrims before they boarded the plane to Jeddah. (Concurrent treatment would have been necessary, as there is a ten-day serum conversion period after immunisation.) Indeed, the Saudi government has dealt with outbreaks of CSM in conjunction with the Hajj in the past. For example, an outbreak of CSM took place during the 1987 Hajj (Moore et al., 1989). In Medina, ninety-nine pilgrims (mainly from South East Asia) were hospitalised and treated for cerebrospinal meningitis (N. meningitidis, group A); there were twelve deaths (Barlas et al., 1993: 237). As a result of pilgrim exposure to this particular strain of CSM (clone III-1; Moore, 1992: 519), cases of CSM appeared in the Gulf states (Novelli et al., 1987), in the United States (Moore et al., 1988; CDC, 1987: 559), in England (Jones and Sutcliffe, 1990), and in several countries in the `meningitis belt', including the Sudan and Chad (Moore, 1992: 520) as well as Niger and Cameroon (Riou et al., 1996). Consequently, all pilgrims travelling to Jeddah (the main entry point to the holy places in Saudi Arabia) must have certificates showing vaccination for CSM within the last three years (WHO, 1994). A study of a CSM outbreak in 1992 in Jeddah and Mecca found that vaccination was effective in preventing its spread (El Bushra et al., 1995: 717).

2. There was some inconsistency in WHO reports, particularly as a WHO official in Nigeria in early April 1996 Oust before the ban) was reported in the local press as saying that the epidemic was under control:

According to the World Health Organisation representative in Nigeria, Dr

B. K. Njelesani during a courtesy call on the military administrator,

Colonel Muhammed Abdullahi Wase, stated that in addition to training

health personnel the organisation has also purchased a large consignment

of vaccines and equipment for use in Kano and some Northern States for

effective assault on the scourge of cerebre [sic] spinal meningitis and

other killer diseases....

Dr Njelesani commended the Kano State Government for launching an

effective attack towards containing the spread of killer diseases that

ravaged the state last month, but frowned on foreign media reports about

the epidemic in Kano, saying `the reports are full of exaggerations and

biased statements'. [Funtua, 1996]

Dr Njelesani, when contacted, said that the last part of this report (beginning with the phrase `but frowned on foreign media') was incorrect (Njelesani, personal communication). As reported, however, these comments would appear to readers as differing from the WHO report issued to the Saudi government later in April 1996.

3. While the Saudi ban was first directed at Nigerian pilgrims it was soon after revised to include pilgrims from Niger, Mali, and Burkina Faso. Yet the latter pilgrims had already travelled to Mecca by the time the ban was in place, thus undermining the claim that they posed a health risk. Also the ban on Nigerian pilgrims included all Nigerians, regardless of where they were residing at the time of the epidemic. While logistically this policy may make sense, it was interpreted as an anti-Nigerian strategy. `It was the Nigerian passport that was banned,' as one Yoruba Muslim man put it.

How an epidemic was explained politically

National politics were partly blamed for the ban--in particular, friction between the head of state and the head of Nigerian Muslims, the Sultan of Sokoto. There was a general feeling that the Sultan was involved because of his inability or unwillingness to intervene, despite his closeness with Saudi officials, in Nigerians' favour. The fact that the Sultan was soon after removed from office, an unprecedented event in an independent Nigeria, lent credence to the belief in his involvement.

International politics were also believed to have been involved. There was widespread speculation that the US government was implicated, in the form of pressure put on the Saudi Arabian government to ban Nigerian pilgrims. Relations between the United States and Nigeria have been tense since the dissolution of the 1993 presidential election and with later human rights violations. On the Nigerian side, there was resentment over the continued ban on direct US-Nigerian air flights and over World Bank and IMF loans, which many view as having worsened Nigeria's economic situation. It was widely believed (by both Muslims and Christians) that US government officials put pressure on the Saudis to enforce the ban on Nigerians in order to embarrass and possibly destabilise the regime.

While there is no concrete information to confirm or refute either US involvement or the Sultan of Sokoto's role in the Hajj ban, the point is not so much whether they were involved as the interpretation that they were and what it means in terms of addressing the problem of CSM outbreaks in the future. The belief that they were underlines the need to put clear-cut administrative structures in place for addressing CSM while not closing one's eyes to the possibility that various parties may use the health care needs of populations to support their own political goals and positions.

CONCLUSION

While condoling Kano and other states whose people died and suffered from

the CSM outbreak, The Democrat wishes to emphasise the need to give

priority attention to diseases like CSM and cholera which are poor-people

killers. In view of the collapse of social services in general and health

infrastructure in particular, as well as the prohibitive cost of common

drugs, the plight of the common folk healthwise can only be imagined.

[The Democrat, 1996a]

As this excerpt from an editorial published in one of the major northern Nigerian newspapers, The Democrat, suggests, CSM and cholera outbreaks represent public health problems associated with poverty: overcrowded housing, particularly in densely populated urban areas such as Kano, combined with general economic decline, reflected in malnutrition, the deterioration of health services, and the unavailability of vaccines and drugs. These factors make addressing future CSM outbreaks extremely difficult. Yet, as The Democrat editorial continues:

Necessary action [must be] taken without delay because the disease is sure to

continue killing people unless what needs to be done is done at the right

time. [The Democrat, 1996a]

The following outline of a suggested programme for addressing future CSM epidemics has four components--organisation, monitoring, prevention and treatment--that take economic and political considerations into account. For example, blanket immunisation of the population in susceptible areas might be the optimal answer to CSM control in Nigeria, but under present economic and health infrastructural conditions such an approach is not economically feasible. Even with the new WHO initiative to aid countries in the `meningitis belt' of Africa in containing future CSM outbreaks (Nigerian Tribune, 1996; WHO, 1997), the best use must be made of available resources through the strategic management of materials, selective immunisation, and careful planning based on accurate data collection.

As Parry (1976: 257) has noted, `a major problem [in bringing a CSM epidemic under control] is to organize the supply of drugs and equipment ...'. Therefore a crucial element in addressing a future CSM outbreak would be the development of a disaster preparedness committee in the Federal Ministry of Health, with a clear-cut chain of command and responsibility, that could immediately be activated when early signs of an outbreak occurred. The committee would have responsibility for overseeing control of CSM as well as other epidemics, headed by a director with the political authority to implement an effective course of action and to enforce departmental rules. Indeed, the present Minister of Health, Dr Ihechukwu Madubuike, has recently initiated meetings to develop `a national emergency preparedness body to ensure early containment of epidemics in the country in the future' (Waniyo, 1996: 8).

Exactly how vaccines, drugs, and related equipment should be obtained and paid for should be decided in advance by the committee, which could work with WHO specialists so that there is a well defined system of procurement and payment that is amenable to committee oversight. However, in the face of lack of accountability in the medical system, the question arises of whether a special Ministry of Health committee, even with WHO help, would be able to address adequately the problems of vaccine and drug procurement, administration, and fiscal and political accountability. Along with the work of the disaster preparedness committee and associated state and local health workers, local community leaders should be empowered to become involved in monitoring and reporting cases of CSM directly to disaster preparedness committee personnel, even funding vaccination campaigns when possible, as in the example of the village head in Giwa LGA who responded so swiftly during the 1996 epidemic. It is encouraging to note that funding and donor agencies such as Medecins Sans Frontieres (who were active in vaccination efforts during the 1996 CSM epidemic in West Africa; Labaran, 1996) are strengthening their links with local non-governmental agencies at the community level, enabling such groups to respond to their own health needs.

These practical measures may help to avert future widespread CSM epidemics in Nigeria. However, they do not address the more systemic economic and political issues that make what should be a straightforward epidemiological campaign a complicated challenge. It is very difficult to provide primary health care, to say nothing of epidemic control, with a deteriorating health service. The structural adjustment programme needs to be reorganised to allow reinvestment in the social system, in particular in health and educational facilities. The investment in human resource facilities could be strengthened by increased government commitment to disease prevention through stronger health education programmes, sanitation, and housing.

Furthermore, local and state health personnel need to improve their knowledge and skills in data collection and use and in investigating and managing outbreaks. They should be encouraged to see the importance of their work, perhaps by setting up some sort of feedback system. Also many people working in the medical sector, particularly private practitioners, have medical data which are not utilised. Some mechanism needs to be established to involve these individuals in public health initiatives. Health care should include an adequate health management information system and an epidemiological disease surveillance infrastructure as well as hospitals, vaccines, and medicines. Only when a well organised, practical programme of monitoring, vaccinating, and treating diseases such as cerebrospinal meningitis is in place and when larger health economic and political factors are taken into account will CSM be effectively addressed in Nigeria.

ACKNOWLEDGEMENTS

The authors would like to thank Dr H. B. Pariya, Mr Saminu, and Matron C. Garba, Kaduna State, Nigeria, for logistical support and Mary Ann Belanger and Wayne Appleton, Office of Population Research, Princeton University, for bibliographical and technical assistance. The opinions expressed in this article are the authors' own and do not reflect the views of their respective institutions.

NOTES

(1) A file was compiled by Ministry of Health personnel in 1945 (KADMOH 5/1, files Nos 115/Vol. IV, 115/s. 1, and 115/s. 2) entitled `Cerebro-spinal Meningitis'. However, it was missing from the Nigerian National Archives, Kaduna, as of July 1996.

(2) It is difficult to assess the actual amount of drugs and associated materials made available by the local government. While the LGA chairman authorised the purchase of 500,000 nairas' worth of drugs, one community health resident said the actual quantities of drugs purchased were quite small; altogether they filled only a plastic carrier bag.

(3) By the beginning of March 1996 the Hunkuyi Comprehensive Health Centre had reported 473 cases, with ninety-three deaths representing a case/fatality rate of 20 per cent for this period.

(4) Allegations that one Kaduna State LGA chairman delayed signing a contract for CSM vaccines, presumably because he wanted to give the contract to someone else, were said to have been the reason for his dismissal by the state governor.

(5) The take-home salary of the medical unit head is approximately 3,500 naira a month. A used Toyota Corolla sells for approximately 250,000 naira.

(6) French (1996) reports that a doctor in one Kano hospital told him that the seriousness of the CSM epidemic was played down so as not to alarm the Saudis and jeopardise Nigerians' performance of Hajj. While this is likely to have been the case, the article does not examine the other local view, that the epidemic was exaggerated by those with other interests.

(7) There is evidence to suggest that the current outbreak of cholera in parts of Kaduna State is being played down by health officials for fear of a replay of the bad publicity arising from the CSM epidemic.

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