EFTA00615196.pdf

Revised and updated version Vienna, 3 June 2014 IPII The Nexus Center for Health and Peace "Peace is a prerequisite for Health" (The Ottawa Charter for health Promotion, 21 November 1986) 1 EFTA00615196  The Nexus Center for Health and Peace The world is changing at an unprecedented speed. Due to demographic shifts, the planet is becoming more crowded. Urbanization is exploding to the point that now more than half of the world's population lives in cities. Demand for food and water is out-stripping supply. Natural disasters are becoming more frequent and more severe. Rapid advances in technology are shrinking time and space. These fast and dramatic changes are creating new challenges as well as new opportunities. Realizing those opportunities requires peace and security arrangements which are essential for health which in turn is a prerequisite for social and economic development, and the well-being of humanity in general. In an inter-connected world, many of these challenges are inter-linked. They re-enforce and exacerbate each other. For example, polio in Pakistan, Nigeria Somalia and Syria and its recent spillover to Iraq, Ethiopia, Cameroon and Equatorial Guinea demonstrate in the starkest terms how zones of instability are vulnerable to disease and its spillover. By better understanding the linkages or nexus between various factors, it is easier to identify areas of risk or vulnerability and, on that basis, to seek more effective remedial solutions. The key is to replace vicious circles with virtuous ones, and to strengthen resilience in order to reduce vulnerability. In the case of polio the security situation is seen as the biggest barrier to the disease's global eradication. New ways to enable mass immunization need to be developed and implemented in remote areas which sometimes are not controlled by the central government. Diplomacy, strategic coordination and advocacy in combination with a broad range of health care services will be the key to access previously inaccessible regions. To better understand the nexus of factors that creates instability and to improve the nexus of knowledge and promote action to resolve these problems, the International Peace Institute (IPI) has decided to establish the Nexus Centre for Health and Peace in Vienna. This Centre of excellence will analyze the factors that contribute to conflict and — working closely with key decision-makers — seek new solutions in order to reduce the threat of instability that can harm health, development, and social harmony. The Centre will take a structured, multi-disciplinary approach to enable health and peace: Primary activities will include (i) analysis of the security and healthcare situation in affected countries, its drivers and interdependencies, (ii) development of strategies in order to improve the security and healthcare situation and (iii) track II diplomacy and strategic coordination to enable the implementation of the strategies. Supporting activities will bring together experts from diverse backgrounds including the private sector, academic institutions, think tanks, civil society, as well as governments and 2 EFTA00615197 multi-lateral organizations. This will strengthen networks among experts from around the world across a wide area of disciplines. The aim is to proactively provide and implement solutions as well as encourage adaptive leadership in order to reduce the potential harm caused by conflict and instability, to enable policy makers to be better prepared to cope with these crises, and to face the challenges of the future — even the unexpected ones. It will be a "do tank" and not just a "think tank". Areas of Focus The focus areas of health and peace can be further broken down into subcategories. There are complex interdependencies among the subcategories; therefore an institutionalized multidisciplinary approach is necessary in order to coordinate the efforts to ultimately improve peace and health. The topics that the Nexus Centre will focus on are: • Health o Enable childhood immunization in conflict zones o Decrease child and maternal deaths in conflict and post conflict states o Increase government's healthcare expenditure o Improve healthcare infrastructure o Support activities to avoid food shortages o Improve disaster prevention and relief • Peace o Promote conflict prevention and resolution o Increase resilience to transnational threats o Enable peacebuilding and statebuilding 3 EFTA00615198 Methodology The Nexus Centre for Health and Peace will map global trends, collect and analyze information on health care and security issues, drawing on IPI's strategic assessments, the Global Observatory, and mapping skills. In a second step IPI will engage with regional and thematic experts in order to develop mitigation strategies. Finally, it will coordinate the implementation of these strategies through facilitation, track II diplomacy and strategic coordination. For each issue area, the Nexus Centre will look at good practices and positive case studies in order to identify factors that promote resilience. The aim is to carry out evidence-based research and assist policy makers in order to have an impact on policy. It will also look at how technology can be used to reduce health and security threats and enhance resilience. Added Value Short-term independent initiatives are necessary but not sufficient. In order to be sustainable, preventive and remedial measures need to be part of a coordinated, comprehensive and long-term global process that unites all stakeholders and ensures a multi-disciplinary and evidence-based approach. To be effective and sustainable, this process should be centralized and institutionalized. That is the logic behind creating the Centre. Outcomes Working with a wide range of experts from the private sector, academic institutions, think- tanks, civil society, specialized institutions, inter-governmental organizations as well as all levels of government, IPI will develop a series of operational recommendations on how to strengthen health and peace globally and coordinate the implementation of these. In the process, it will help strengthen networks among actors from a cross-section of backgrounds. These connections can enable more effective prevention and a quicker response during times of crisis. 4 EFTA00615199 Health The planet is facing challenges to biological security, including pandemic diseases (like malaria, polio, tuberculosis and HIV/AIDS), resurgent diseases (like SARS), or accidental or deliberately perpetrated outbreaks. Several regions suffer from hunger caused by food insecurity or conflict. Some of the world's most vulnerable people face double jeopardy by falling victim to counterfeit medicines. Areas where there is instability and weak governance are particularly vulnerable. Polio was limited to a few isolated regions of Afghanistan, Nigeria, Pakistan, Somalia and Syria but due to intensifying conflict and low immunization levels the disease was able to spillover to neighboring states Ethiopia, Cameroon, Equatorial Guinea and Iraq. This development shows the link between instability and disease and highlights the need for coordinated action. Therefore, to improve health it is essential to reduce violence and promote peace. As stated in the World Health Organization's Ottawa Charter for Health Promotion (1986), peace is the primary condition for health. Armed conflict, instability, and state fragility claim lives, disrupt livelihoods, and halt delivery of essential services, such as health and education. The relationship among these factors is established, but remains complex. First of all, armed conflict and public health interact in many different ways. Besides the obvious but important fact that people are killed, injured, disabled, abused or traumatized due to armed conflict, it can be said that in most countries indirect and nonviolent deaths far outnumber violent ones. In Darfur, 87 percent of civilian deaths between 2003 and 2008 were nonviolent! Some indirect effects of armed conflict on global health include: • impeding access of health professionals and humanitarian agencies to populations in need (conflict-affected countries have on average less than one health professional per 10,000 people); • "flight" of health professionals from conflict zones for safety issues (health workers are often targeted by government security forces as well); • lack of supplies and basic equipment in hospitals and clinics in conflict zones, as well as uneasy access to health facilities for populations in needs, also due to deterioration of infrastructure and transportation; • decrease in government expenditure on healthcare; • food shortages, even famine, due to damaged agricultural structures, collapse of the economy, aid deliberately withheld, and disruption of the family unit. • three to four times higher under-age five mortality rates in conflict zones than the rest of the world; 1 Olivier Degomme and Debarati Guha-Sapir, "Patterns of Mortality Rates in Darfur Conflict," The Lancet 375, No. 9711 (2010), pp. 294-300. 5 EFTA00615200  • sharp decline in basic childhood immunization in conflict zones (decline of routine immunization level in Syria from 83% in 2010 to 52% in 20122); • highest rates of maternal deaths due to childbirth complications and other debilitating conditions in conflict-ridden or post-conflict states; • increased incidents of sexual violence towards women and children, with greater numbers of sexually transmitted diseases, as well physical and psychological trauma; • increased incidence of infectious diseases (polio, malaria, cholera, measles) during conflict due to malnutrition, unsanitary conditions, lack of clean water, etc. Not only can these diseases travel across borders, but they can also create such a high number of victims in conflict-affected countries that vulnerability to further political and military instability as well as state failure are increased. States characterized as fragile or failed tend to have far worse population health indicators than states at comparable levels of development.3 As of today, for example, no low-income fragile or conflict-affected country has yet achieved a single Millennium Development Goal (MDGs).4 Poor health indicators are a product of inadequate governance and service development. Moreover, fragile states tend to be affected by humanitarian crises that extend for years. In other words, a context of continuing crises and emergencies, combined with weak or non-existent local and national institutions, can undermine health improvements or nullify health investments and programs in the long-term. While armed conflict and instability undermine health goals, the opposite is also true. Investments in health, conflict resolution and statebuilding can be mutually reinforcing. Conflict resolution and peacebuilding measures can help prevent or lessen the impact of the above negative outcomes of armed conflict on public health. At the same time, the position of medical professionals in society, given their neutrality, credibility, and equality, can be a precious resource during negotiations, as are health-related cease-fires. The fact that health issues are of interest to all warring parties can contribute to this advantage. Moreover, health investment can contribute to the well-being of the state and its population. In the long term, stronger health systems can improve the health of the population, leading to greater productivity, stronger economies, less violence, and state stability. Evidence also indicates that improved health services can increase trust in state institutions, thus contributing to the authority and legitimacy of the government.s In its effort to support the Bill & Melinda Gates Foundation and the Polio Eradication Initiative, IPI follows a proactive approach of strategic analysis, development of operational 2 Unicef & World Health Organization, Middle East Polio Outbreak Response Review, 2014, p. 6 3 Rohini Jonnalagadda Haar and Leonard S. Rubenstein, Health in Postconflict and Fragile States (US Institute of Peace, January 2012), p. 2. World Bank, World Development Report, 2011, p. 2 Margaret Kruk, Lynn Freedman, Grace Anglin, and Ronald Waldman, "Rebuilding Health Systems to Improve Health and Promote Statebuilding in Postconflict Countries: A Theoretical Framework and Research Agenda," Social Science Medicine 70 (2010), pp. 89-97. 6 EFTA00615201 recommendations and track II diplomacy to enable implementation. The strategic analysis includes (i) public opinion surveys on health care and security, (ii) analysis of militant groups opposing the vaccination campaign, (iii) mapping of accessible and inaccessible regions and (vi) socio-political research in order to identify the key barriers to polio eradication. IPI has thereafter developed mitigation strategies for each of the identified barriers and implementation strategies in each of the affected countries. In parallel IPI gained access to key political and religious decision-makers in order to coordinate and enable successful vaccination rounds in previously inaccessible areas. Case studies of IPI's work in Nigeria and Somalia are attached (see Appendix).Short briefing reports on the barriers to polio eradication in Pakistan and Afghanistan are attached as separate files. Confidential information is also available upon request. The Nexus Centre for Conflict Resolution will look at how peace can contribute to health, and health to peace. 7 EFTA00615202 Humanitarian issues Natural disasters like droughts, floods, earthquakes, tsunamis, and forest fires can lead to loss of life, displacement, and situations in which diseases (like polio) can spread quickly. Famine is often the result of complex factors — not only drought. Displacement can also negatively affect health: refugees and internally displaced persons suffer from increased mortality, disability and psychological distress. Therefore the links between health and humanitarian issues need to be better understood. The dimensions, frequency and complexity of natural disasters are increasing. Extreme weather conditions are creating mega-storms that are causing damage on a massive scale. Climate change, as well as environmental degradation and rapid urbanization, make the likelihood of such disasters, and the destructiveness of their impact, even greater. In the 21st century, the world will have to become better prepared to cope with this challenge. This necessitates innovative steps to enhance the ability of the humanitarian community and governments to use all available means -including military assets- as quickly and efficiently as possible to meet the needs of victims. People who have had their lives turned upside- down by disasters, need basic shelter, water, food, and medicine in order to survive. In the aftermath of large-scale natural disasters, quickly deploying military and civil defence assets (MCDA) in support of humanitarian relief efforts can mean the difference between life and death. When disaster strikes, there is an explosion of needs, out of proportion with normal capacity, and often under conditions where the national emergency relief services are overwhelmed or massively disrupted — causing chaos, collapse of infrastructure, breakdown of communications, and disruption of public services and security. In major disasters, where the magnitude is enormous and destruction extremely heavy, national capacities are quickly exceeded, while international humanitarian assistance needs time to build up. Military and civil defence assets, prepared for responding to disasters, can fill the gap quickly. These assets (like i.e. airlift, airdrop, water decontamination, communications, logistics, search and rescue, reconnaissance, land and sea transport) which may not be available in the traditional emergency response system, can make an important difference in the immediate aftermath of a disaster. They can enable traditional humanitarian assistance providers to leverage their resources, and provide a surge of the volume of assistance. Indeed, in the past fifteen years, relief operations have increasingly called on military assets. There has also been an increased use satellites — and other technologies — to improve disaster relief. The Nexus Centre for Health and Peace will focus on what steps can be taken to improve disaster prevention and relief in order to reduce the health risks to the population at large, particularly the most vulnerable. It will also look at the factors that contribute to famine, as well as the special needs of displaced persons. 8 EFTA00615203 Conflict Prevention and Resolution IPI has been working to prevent and resolve conflicts for more than forty years. It regards conflict resolution as an essential end in itself, and a prerequisite for improving health, development and governance. The best way of resolving conflicts is to prevent them from erupting in the first place. It is therefore essential to promote a culture of prevention, for example by promoting integration in culturally diverse societies, and to promote inter-religious dialogue. IPI has considerable experience in these fields. More must also be done encourage non-military confidence-building measures (CBMs), including inter-community contacts, joint projects (for example in relation to health and humanitarian assistance), sporting events, dialogue among peer groups (i.e. women, young people, business leaders), as well as economic and environmental CBMs. Conflict prevention includes early warning and preventive diplomacy. Lessons need to be learned from successful preventive tools at international as well as at local levels. Furthermore, mediators should intervene at an early stage in order to prevent disagreements (e.g. in relation to land, language, ethnic issues, water, or governance) from erupting into conflict. There is a wealth of knowledge and expertise within countries that are or have been affected by conflict. However, while local knowledge, research, and analysis exist in conflict-affected regions, they are under-represented in the international policymaking circles. It is time to connect these two levels of analysis and intervention —local and international—and to move local knowledge from the bottom-up. When conflicts have broken out, conflict resolution is essential. Track II diplomacy can play a key role to put new suggestions on the table and to open back channels of communication. IPI has many years of experience in facilitating high-level and discreet meetings on vexed issues, while many of its senior staff have direct mediation expertise. After a conflict situation reconciliation is vital. Transitional justice, dealing with the past, and seeking accommodation to move ahead peacefully can all help to build sustainable peace. The Nexus Centre for Health and Peace will promote conflict prevention and resolution with a particular focus on reducing the impact of conflict on health and development. 9 EFTA00615204 Transnational threats Over the past twenty years, states and international organizations have largely failed to anticipate the evolution of transnational organized crime (TOC) from a localized problem into a strategic threat to governments, societies and economies. The problem manifests itself in a number of ways: trafficking of persons, drugs and weapons, piracy, illegal exploitation of timber and wildlife, cyber-crime, economic crime and money laundering, illegal dumping of hazardous waste, and counterfeiting. As a result of the mismatch between well-funded and adaptive criminal groups on one hand and slow-moving, uncooperative bureaucracies on the other, the detrimental impact of organized crime has grown significantly to the point where cities, states and even entire regions are under threat. Organized crime can have an impact on stability, the rule of law, and development. It can also have an impact on public health. This includes death or injury from those caught in the cross fire. More people die from non-conflict deaths — including criminal violence — than from conflicts. El Salvador ranks higher than Iraq in terms of violent death rates per 100,000 population, and two dozen countries (mostly in Central America and Africa) rank above Afghanistan.6 Crime-related violence can also affect mental health, particularly among victims of crime. Furthermore, drug trafficking enables drug use which is a major cause of suffering and death for millions of drug dependent people worldwide. Organized crime threatens health in other ways. The unregulated dumping of hazardous waste causes ecological damage (like poisoned ground water). One of the most callous crimes is the counterfeiting of medicine. Many of those in most need of medication — particularly retroviral drugs — are sold fake medicine. This not only make the most vulnerable even sicker or even kills them, it can contribute to the generation of drug-resistant strains of the most deadly pathogens. Organized crime can also lead to devastation of the environment, for example through illegal logging or fishing. Other transnational threats include the ones posed by biological and toxin weapons, as well as radiological incidents. Greater attention is needed to ensure that the positive advances of biotechnology can be shared by mankind, while safeguarding against misuse and unintended negative implications. Furthermore, the peaceful uses of nuclear energy should be encouraged while reducing the risk of nuclear accidents and the smuggling of radiological materials. The Nexus Centre for Health and Peace will look at what steps can be taken to reduce the threat posed to public health and human security by organized crime as well as biological and toxin weapons and radiological incidents. 6 Global Burden of Armed Violence 2011, p. 53. 10 EFTA00615205 Peacebuilding and Statebuilding In the areas of peacebuilding and statebuilding, IPI has a long-standing reputation for enhancing knowledge and policy development. More recently, IPI has provided direct support to UN officials and Member States on the challenges facing the UN peacebuilding architecture. These new institutions are a step forward in coordinating the various actors and activities in peacebuilding, but major gaps, both at strategic level and operational, still persist. These gaps include: 1) insufficient attention to the political dynamics of post-conflict situations; 2) lack of coordination among diverging actors' viewpoints, interests, and objectives that hamper the development and implementation of coherent peacebuilding strategies; and 3) failed support toward reestablishing national capacities for governance and service delivery. All of these gaps point to the fact that each post-conflict situation is unique, defying general theories and blueprints for action. Through strategic partnerships, IPI has provided policy analysis to enhance understanding of state fragility and to support bilateral and multilateral donor efforts to promote aid effectiveness and sustainable development in conflict-affected and fragile states. This is a particularly important area to focus global efforts, since, as mentioned above, no low- income fragile or conflict-affected country has yet achieved a single MDG and poverty rates are, on average, more than 20 percent higher in countries where violence is protracted than in other countries.? IPI also recently examined how international actors analyze the local context and dynamics in the countries where they work and asked whether and how this analysis feeds into decision-making and strategic planning. This study stressed, in particular, the need to "promote a culture of analysis" and "cultivate multiple sources of information and analysis locally and internationally."8 The Nexus Centre for Peace and Health will look at what factors can strengthen resilience in post-conflict settings, and promote new thinking on how to build peace and statehood in countries in transition. ' World Bank, Ibid. s Jenna Slotin, Vanessa Wyeth, and Paul Romita, Power, Politics, and Change: How International Actors Assess Local Context (New York: International Peace Institute, 2010), p.19. 11 EFTA00615206 Appendix 12 EFTA00615207 Barriers to Polio Eradication in Nigeria A Situation Assessment Prepared for The Bill & Melinda Gates Foundation April 2014 13 EFTA00615208 EXECUTIVE SUMMARY 15 EXISTING BARRIERS AND EMERGING CHALLENGES TO POLIO ERADICATION is RECOMMENDATIONS ON OVERCOMING BARRIERS OF POUO ERADICATION 1S INTRODUCTION 17 METHODOLOGY 19 NORTHERN NIGERIA IN CONTEXT 20 HISTORY 21 GOVERNMENT & ADMINISTRATION 22 RELIGION 22 COLONIALISM 23 PRESENT SITUATION 23 BOKO HARAM 23 THE POLIO EPIDEMIC IN CONTEXT 28 THE 2003 BOYCOTT 29 LESSONS AND OUTCOMES FROM THE BOYCOTT 34 FINDINGS FROM THE FIELD: EXISTING BARRIERS, EMERGING CHALLENGES 36 HEALTH CARE INFRASTRUCTURE 36 NEGATIVE PUBLIC OPINION 36 UNSTABLE POLITICAL AND SECURIn SITUATION 40 OPERATIONAL ISSUES 41 RECOMMENDATIONS 43 HEALTH CARE INFRASTRUCTURE 43 PUBLIC OPINION 43 SECURITY CONTEXT & SCENARIO ANALYSIS 43 MONITORING & FEEDBACK 44 14 EFTA00615209 Executive Summary Existing Barriers and emerging Challenges to Polio Eradication A) Healthcare Infrastructure Nigeria's governance structures are highly decentralized making health service delivery a multi layered process with complicated and unclear division of responsibilities. Funding flows are unclear and unpredictable, while accountability is almost non-existent. In northern states people are highly dissatisfied with health care facilities and access to them. B) Negative public Opinion Refusal of polio vaccination based on a negative perception of "Western" and "American" aid, particularly vaccinations from Western pharmaceutical companies, as well as the government siphoning funds from foreign organizations. Few people see polio as the biggest health threat and therefore do not understand the overemphasis on polio compared to malaria, typhoid and diarrhea. C) Unstable political and Security Situation In northern states, such as Borno and Yobe, the security situation is the primary concern of families and poses a key challenge to vaccination teams. Attacks by Boko Haram on polio workers and vaccination facilities as well as lack of information and feedback about the development of the situation add to the difficulty for polio teams to plan vaccinations. The situation has deteriorated in the first quarter of 2014. Elections in 2015 are expected to slow down polio eradication efforts. D) Operational Issues Lack of monitoring and coverage of vaccination campaigns have resulted in the same children and households being consistently missed in immunization rounds. In addition, lack of financial oversight and overabundance of cash has distorted the public health market. Some organizations might purposely fail to monitor their work so eradication campaigns and funding will continue. Recommendations on overcoming Barriers of Polio Eradication Based on the initial assessment of the situation, the following mitigation strategies are suggested in order to address the issues associated with polio eradication: A) Improvement of overall healthcare infrastructure and services 1) Improvement of overall healthcare services: Polio vaccination campaigns should be part of a broader push for better governance and better delivery of health services. This would strengthen the credibility of polio and health workers and potentially reduce "polio fatigue" and vaccine rejections. 2) Targeted healthcare infrastructure improvements: Development and maintenance work of facilities could be undertaken as well as improvement of medical equipment and supply of medication in affected regions. These measures would improve the health care infrastructure in particularly distrustful communities. B) Changing public opinion and maintaining stakeholder involvement 3) Assessment of public opinion on community level: Determining the public opinion on community level will be necessary in order to review and reassess current communication strategies and campaigns for different regions. 4) Participatory polio campaigns: Immunization programs should involve state and local governments, community leaders and traditional rulers such as emirs, political and religious leaders. The merits of polio vaccines should continue to be broadcast through formal and 15 EFTA00615210  informal networks, such as community radio television, pamphlets, religious ceremonies and cultural events. C) Raising awareness of the security context & performing scenario analysis 5) Improve security awareness in key districts: Setting up a network to gather information about the security situation on LGA and ward level would help mitigate the risk of attacks on future vaccination campaigns. 6) Contingency planning for insecure districts: GPEI should develop contingency plans for each LGA on how to operate in a crisis environment. In addition, public health professionals need to be educated about political and security issues in the areas in which they work. D) Mitigating operational inefficiencies 7) Monitoring and training for vaccination staff: Staff should be trained in order to perform more robust monitoring at the LGA and ward level to facilitate efficient use of funds and resources. Assessment of measures to overcome barriers to polio eradication in Nigeria High Short term strategies: Medium term strategies: Long term strategies: Easy to implement with Moderate difficulty of 0 Difficult implementation moderate impact implementation with with high impact medium impact CO Recommendations 1. Improve overall healthcare service Impact/reachof vaccination campaign O O 2. Targeted healthcare infrastructure improvements 3. Assessment of public opinion on community O level 4. Participatory pobo campaigns 5. Improve security awareness in key districts 6. Contingency planning for Low insecure districts 7. Mortitonng and training Easy Ease of implementation Difficult at LGA and ward level In the graph above, the various strategies laid out hove been clustered according to their likely impact on the polio eradication campaign, as well as on their ease of implementation. Ease of implementation was assessed along three criteria: cost, time and risk. In particular, the issue of risk is pertinent for those interventions seeking to have impact in Boko Horam controlled regions. 16 EFTA00615211 Introduction At the start of the campaign in 1988, there were an estimated 350,000 cases of polio worldwide, with 125 countries classified as polio-endemic. By the start of 2012, only 222 cases were reported worldwide and the number of polio-endemic countries had been reduced to three: Afghanistan, Nigeria and Pakistan. In total, polio has disappeared by 99.9%, but the remaining .1% of eradication has proven to be the most difficult, the most expensive — and the most important.' Nigeria rests on the front lines of the global fight to eradicate poliovirus. In 2013, 53 new cases of polio were detected" while the first weeks of 2014 saw dozens of clinics close and hundreds of doctors flee amid continuing attacks by Islamist sect Boko Harm in the country's north." Nigeria remains the only polio-endemic country in Africa, and one of the few countries in the world where children are still at risk of paralysis or death from polio." These grim realities come despite a coordinated push by the Nigerian Federal Government (FG), state and local governments, and the international community to eradicate polio in northern Nigeria. As one of the last polio-endemic countries in the world, Nigeria represents not only one of the last pieces of the global polio eradication puzzle, but a puzzle in its own right. Regional insecurity recently lead to a spillover of polio to Cameroon. In March 2014 three new cases of polio have been reported with a total of 7 since 2013, making it the first outbreak since 2009. The World Health Organization stated that the virus is at high risk of crossing borders. The same strain as in Cameroon has just been confirmed in Equatorial Guinea, making it the first case since 1999.13 The persistence of polio in Nigeria has global implications. In 2003, for example, several states in northern Nigeria banned federally sponsored polio immunization campaigns amid the "discovery" that the vaccine was contaminated with drugs intended to sterilize young Muslim girls. This decision led to a global outbreak accounting for the spread of polio into 20 countries across Africa, the Middle East, and Asia, causing 80 percent of the worlds' cases of paralytic poliomyelitis. In addition to effectively ending any hopes of eradicating polio by the revised goal of 2010, the vaccine boycott eventually led to an estimated $500 million in costs to control the outbreak." Within its own borders, polio eradication in Nigeria represents much more than a public health issue. It sits at the center of a complex web of incentives which are shaped by cultural concerns, structural constraints, and political calculations amid an environment of insecurity. In its own self-assessments, the GPEI Independent Monitoring Board has expressed concern as recently as 2011 that polio will not be "eradicated on the current trajectory" asserting that "important changes in style, commitment and accountability are essential."" 9 Polio Global Eradication Initiative htto://www.00lioeradication.ora/Dataandmonitorino/Poliothisweek.aspx 10 See: Polio Global Eradication Initiative, httpiAvww.polioeradication.orp/Dataandmonitorinp/Poliothisweek.aspx It is worth noting that the 53 cases in 2013 are down from 122 in 2012, a 57% drop. II "Violence grinds healthcare to a halt in Nigeria's Bomo State; IRIN, 5 February 2014 hitp://www.irinnews.orgireport/99595/violence-grinds-healthcare-to-a-halt-in-nigeria-s-borno-state "Polio endemic" is the term used to describe a region or country with naturally circulating poliovirus and where volio transmission has never been interrupted. Nigeria is the only polio endemic country in Africa. 3 Regional insecurity fuels polio in Cameroon" IRIN, 26 March 2014 http://www.irinnews.orgireportaspx?ReportID.99841 " WHO Global Alert and Response, "Poliomyelitis in Nigeria and West Africa," January 6, 2009, http://www.who.inticsadon/2009 01 06/entindex.html. 1 Independent Monitoring Board of the Global Polio Eradication Initiative, "Report, October 2011," http://www.polioeradication.ordPortals/0/DocumentiAboutus/Govemance/IMB/4IMBMeetinp/IMBReport October2011.pdf. 17 EFTA00615212  NIGER WA LAGOS % 1 year-oicls with all CROSS basic vaccinations RIVER AKWA ■ 40+ BAYELSA IBOM CAMEROON ▪ 30 - 39 Port Harcourt • 20 - 29 RIVERS O 10 - 19 10-9 Source: Nigeria Demographic and Health Survey 2008 Figure 1: Percent ofI year-old with all basic vaccinations16 These warnings are still applicable today. Divisive national elections that are all but guaranteed to exacerbate existing political, ethnic, and religious tensions at the national and local levels are scheduled for February 2015. Meanwhile, the Federal Government finds itself bogged down in an intractable war against an Islamist insurgency that is escalating by the day, leaving the lives of hundreds of thousand, if not millions of northern Nigerians hanging in the balance. While elections and ongoing security concerns in the north are sure to divert critical attention and resources away from vaccination efforts, they also increase the risk of further politicizing, or even militarizing the already controversial issue of polio eradication. The stalemate in the battle against polio in Nigeria also comes at a time when public health experts, as researchers Jennifer G. Cooke and Farha Tahir have noted, "are beginning to express concern about the opportunity costs of continuing a campaign with a price tag of $1 billion annually to eradicate a disease that, however, devastating, is not among the top 20 killers in the developing world.."" Put another way, the poliovirus and efforts to eradicate it do not exist in a vacuum. The considerable progress that has been made over the last decade in eradicating polio in Nigeria remains as reversible as ever, due in large part to dynamics such as "polio fatigue," continued gaps and failures in governance, and an increasingly precarious security situation in the country's north. 16 88C, "Nigeria's National Conference start in Abuja", 17 March 2014 http://www.bbc.cominews/world•africa.26613962 f7 Jennifer G. Cooke and Farha Tahir, "Polio Eradication in Nigeria: The Race to Eradication: CSIS Global Health Policy Center, February 2012. 18 EFTA00615213 Polio eradication is a political issue, and comprehending the socio-political context in which these vaccination campaigns must operate is critical not only to identifying barriers to polio eradication, but to understanding why consolidating gains to date has proved so challenging. This report investigates the nature of these barriers to polio eradication in northern Nigeria by placing them within their proper socio-political context. It identifies several types of barriers and emerging challenges to polio eradication, and aims to offer a nuanced analysis of the way in which various dynamics work against consolidating the gains of polio eradication in a symbiotic, cyclical and often self-sustaining manner. Polio eradication efforts have made considerable strides over the last decade in northern Nigeria, and the global public health community has shown an admirable commitment to self-evaluation. The challenge of polio, however, is that unless transmission is interrupted entirely, dramatic reversals remain a strong possibility.° While incorporating the lessons of past shortcomings into future activities is a critical component of effective programming, GPEI efforts could be further enhanced by improving its ability to think "strategically" about polio eradication within Nigeria's shifting socio-political and security contexts. A better understanding of "human terrain" might allow GPEI to anticipate problems before they occur and to better mitigate the negative impact of events that are outside of its control. O COUNTRIES WITH POLIOVIRUS TYPE I Loon Go . DISTRICTS WITH CASES CAUSED BY WILD POLIO VIRUSES Figure 2: Map of Worldwide Polio Cases (19 August 203-18 February 2014)" Methodology In order to gain a more strategic understanding of the barriers to polio vaccination within northern Nigeria's current political and security environment, the authors of this paper conducted a rapid- assessment consisting of a comprehensive review of pertinent works of scholarship, international I9 Jennifer G. Cooke and Farha Tahir, "Polio Eradication in Nigeria: The Race to Eradication," CSIS Global Health Policy Center, February 2012. Also see: Charles Kenny, 'The Eradication Calculation, Foreign Policy, 17 January 2011 http://wwwloreignpolicy.com/articles/2012/01/17fthe eradication calculation 39 Global Polio Eradication Campaign, with modifications by the author: http://www.polioeradication.orp./Dataandmonitoring/Poliothisweek/Polioinfecteddistricts.aspx 19 EFTA00615214 and national reports, press articles, and six weeks of field work across 10 states in northern Nigeria. These states include Borno, Yobe, Bauchi, Jigawa, Kano, Katsina, Kaduna, Zamfara, Sokoto and Kebbi. The field work for this report was carried out by local journalists and interlocutors who could safely and responsibly navigate the risks involved in arranging and conducting interviews in northern Nigeria given its current security environment. Due to the sensitive nature of the subject at hand, interviewers relied on long, semi-structured interviews in order to approach the subject of polio discretely. This interview format also provided ample space for wider discussions about development, health services, governance and security, all of which are crucial to better understanding the socio-political context in which polio eradication efforts succeed and fail. Figure 3: Number ofPolio Cases in Nigeria, 199640132° In an effort to consult a broad and diverse set of perspectives on these issues, over sixty interviews were carried out with men and women from a range of backgrounds. The authors sought opinions from local government officials, doctors, healthcare providers, religious leaders, traditional leaders, school teachers, business people, community organizers and much more. Though the authors are confident that this methodology is the most appropriate for the questions this paper seeks to engage, it is worth emphasizing that this is a qualitative ap