EFTA01078368.pdf

Confidential Barriers to Polio Eradication in Nigeria A Situation Assessment Prepared for The Bill & Melinda Gates Foundation April 2014 EFTA01078368  Confidcntial — Not for distribution or circulation Barriers to Polio Eradication in Nigeria EXECUTIVE SUMMARY 3 EXISTING BARRIERS AND EMERGING CHALLENGES TO Pouo ERADICATION 3 RECOMMENDATIONS ON OVERCOMING BARRIERS OF POLO ERADICATION 3 INTRODUCTION S METHODOLOGY 7 NORTHERN NIGERIA IN CONTEXT 8 HISTORY 9 GOVERNMENT &ADMINISTRATION 10 RELIGION 10 CCIONIALISIM 11 PRESENT SITUATION 11 BOKO HARM 12 THE POLIO EPIDEMIC IN CONTEXT 17 THE 2003 Boxorr 17 LESSONS AND OUTCOMES FROM THE BOYCOTT 23 FINDINGS FROM THE FIELD: EXISTING BARRIERS, EMERGING CHALLENGES. 25 HEALTH CARE INFRASTRUCTURE 2S NEGATIVE PUBLIC OPINION 2S UNSTABLE POLITICAL AND SECURITY SITUATION 29 OPERATIONAL ISSUES 30 RECOMMENDATIONS 32 HEALTH CARE INFRASTRUCTURE 32 PUBLIC OPIMON 32 SECURITY CONTEXT & SCENARIO ANALYSIS 32 MONITORING & FEEDBACK 33 2 EFTA01078369  Confidential —Not for distribution or circulation Barriers to Polio Eradication in Nigeria 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 EFTA01078370  Confidential — Not for distribution or circulation Barriers to Polio Eradication in Nigeria 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 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 el anomie,. to *venom, battlers to polio tmacticalionIn Miens Snit 34-6.1 kes, taw to erormentrnh rnodmart•Import M16101urn teem stnotoipw 03344ataif6Uly Of onplemmaton om with • 0„,<„,implementatc., ton term .,nn Mn overt "- nrodun impact 0 flatemonemlatIons L Implore Cresell 0 healthcare strige 2. Tatgead healthcare imrect/M/446 Of wacceancm 0 elcasU,clure campagn o emprov•Mett 3 Assamtnent of public Oo 404606 on (Conni‘m4V reel 4 Partmipeory p344, campaigns 5 Improve secvnly avennen m lay ilsugts 6 Contmg•my tanning 16, tow mstcuie OsIrmts 7. mammy aidnowt few Ease M trolenentatca NADA at IGAard Wangle* In the graph above, the various strategies laid out have 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 Haram controlled regions. 4 EFTA01078371  Confidential — Not for distribution or circulation Barriers to Polio Eradication in Nigeria 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 Govemment (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' The persistence of polio in Nigeria has global implications. In 2003, for example, several states in northem 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. 'PolioGlobal Eradication Initiative. http;,'Nvww polmendinhon nig,rauttgPoliothisweek vista = See: Polio Global Eradication lnitimrvc. hito:".'www.polooeradicalion.oruThataandmonitonneroliothisweekaarix It is worth noting that the 51caws in 2013 are ilium ll(101122 in 2012, a 57% drop. !"Violence grinds healthcare to a halt in Nigeria's Homo State.' IRIN, 5 February 2014 irinnews repon.99c9tuoliaxe-grind, -h...ilihrin, to-a.halt•iii.nigeri-s..s.homo-ne 4 "Polio endemic' Li the term used to describe a region or country with naturally cin:ulating polimirus and where polio transminnon has never been interrupted. Nigeria is the only polio endemic country in Africa. 3 ReponaI insecurity fuels polio in Canwrixiir MIN, 26 hian:h 2011 http:/Avww.iiinnews.orgreporiaspx?Repon11)-99141 6 WHO Global Alert and Respome. "Poliomyelitis in Nigeria and West Africa," January 6, 2009. htlen/Avww.who.inricseskin'2009 0l 0RrenIndexhInd. 5 EFTA01078372  Confidcntial — Not for distribution or circulation Barriers to Polio Eradication in Nigeria 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."' 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. 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.' Independent Monitoring Board or the Global Polio Eradication Initiative, "Report. October 2011: httn:/Avaw.polioeradicalion.orOortattflocurnent,AboulusliovemancolNIMAIMBNIeetinntlNIBRenort October2011.pdt I Jennifer Oi. Cooke and Farha Tahir, "Polio Eradication in Nigeria: The Race to Eradication: CMS Global Health Policy Cater. February 2012. Jennifer Oi. Cooke and Farha Tahir. "Polio Eradication in Nigeria: The Race to Eradication:CBES Global Health Policy Cater. February 2012. Also see: Charles Kenny, "The Eradication Cakulation.- Foreign Policy, 17 January 2011, 6 EFTA01078373  Confidcntial — Not for distribution or circulation Bafflers to Polio Eradication in Nigeria 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. NYS ILDneweas El COUNTRIES WITH POLIOVIRUS TYPE I R. El DISTRICTS WITH CASES CAUSED EY WILD POLIO VIRUSES Figure 1: Mop of Worldwide Polio Cases (19 August 203-18February 2014)10 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 and national reports, press artides, and six weeks of field work across 10 states in northern Nigeria. These states include Borno, Yobe, Bauchi, Agawa, 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, govemance and security, all of which are crucial to better understanding the socio-political context in which polio eradication efforts succeed and fail. 10 Global Polio Eradication Campaign, with ntedifications by the author: hivissxsw.i>oliocrailicaiion.org,Dataantnonnoring.Pftliothisvccek Pokoinfoicsklisuicis aspx 7 EFTA01078374  Confidential —Not for distribution or circulation Barriers to Polio Eradication in Nigeria 111/0 0 ■ /1101.010ION Vint) FIXIO musts 11 I Figure 2: Number ofPolio Cases in Nigeria,1996-201311 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 approach and the underlying research that supports the papers conclusions should be treated as such. Northern Nigeria in Context Nigeria is a country of paradox, representing the best and worst of how African states are perceived by the broader international community.° It is an economic giant, an intellectual hub, and a regional leader. At dose to 175 million people, it is by far the most populous country in Africa. Its large area holds productive agricultural land and immense deposits of oil and natural gas." With an urbanization rate of dose to 50% and a population whose median age is 17.9 years, Nigeria seems poised for economic " Figure 2 Sources. WHO and GPEI Clarencel Bauch-M. 'The Causes of Instability in Nigeria and Implications for the United Slates?' Strategic Sludier. Whittle. 19 August 2013. 1) Central Intelligence Agency (CIA). The 2012 World Factbook. 2012. Nigeria. lutps:...'www.cia.emlibrarvinublicationsoithe- world.faelbookceesini.html EFTA01078375  Confidconal — Not for cbstnbution or circulabon Barriers to Polio Eradication in Nigeria prosperity." Already the largest oH producer in Africa, Nigeria's economy has been growing at a rate of 6 to 7 percent per year and is well placed to soon overtake South Africa as Africa's largest economy." Nigeria also views itself as the natural leader of the African continent, in part due to these demographic and economic realities. It possess one of Africa's strongest and most capable militaries which regularly plays an attive tule in peace operations abroad. At the international level, Nigeria has been recognized for its leadership in major organizations such as the Organization of the Islamic Conference (OK), the Organization of Petroleum Exporting Countries (OPEC), the African Union (AU) and the Economic Community for West African States." All of these accomplishments come despite endemic corruption, grinding poverty, and sectarian violente that has plagued Nigeria for decades." In tact, the roots of Nigeria's dysfunction, and the fault lines along which Nigeria may be torn apart can be traced to the very process of its formation." As McLoughlin and Bouchat explain: Like most post-colonial African states, Nigeria is both a mosaic of tribes, related or allied ethnic or ideological groups, and nations now linked economically and politically under a common government in a colonially imposed territorial unit. The British colonial government created a unified Nigeria in 1914 to demarcate its area of control from those of its European competitors and because its northern protectorate was too poorty resourced to stand on its own. It was therefore created as a state by extemally imposted fiat, not for any internat, organic reason. Before the British arrived, there was no shared national consciousness, culture, or language in Nigeria, nor was there any sentiment to coalesce its peoples into a coherent nation under colonial rule." History 53 years into independence, it is no small wonder that Nigeria remains a single state. White the Biafran war of the late 196Os is the most high-profile manifestation of regionalist and sectarian impulses in post- colonial Nigeria, it is by no means the only one. Even today, the Federal Government continues to face challenges to its authority from a number of armed groups based on regional, ethnic, ideological and religious identity. These movements include the Movement for the Actualization of the Sovereign State of Biafra (MASSOB) in the south-east, the Movement for the Survival of the Ogoni People (MOSOP) and the Movement for the Emancipation of the Niger Delta (MEND) in the south, and an (slamist insurgency in the north all of which are fighting in different ways to wrest control of tersitory away from the central government in Abuja.l0 " Centra! Intelligente Agency (CIA), Tbc 2012 World Factbook. 3312. Nigeria. IttlsgArw.ciaammlibrarypublicatiorialhe. world.facrhook,eto,ti.html 1° Todd J. Men. "BRICN? When Will Nigeria Pass South Africar Center for Global Deselopment: Views trom tbc Center. S Auguwt 2013. hitmllwww.cedetorarblogibricn.when.will-nisteriarross.south-africa 10 Clarence J !kuch.* 'Tbc Causes of Instability in Nigeria and Implications for the United Slaks." Stralegk Studies Institute. 19 August 2013. "See: Clarence J Bouchat. nhe C'auses of Instability in Nigeria and Implications for tbc United Stales." &rank Studies Institute. 19 August 2013. " Gerald McLoughlin and Clarence 3. !louchst. -Nigerian Unity In The Balance." Strategie Studies Institute. June 2013. ' g Gerald McLoughlin and Clarence J. !louchst. -Nigenan Unity In The Balance." Strategie Studies Institute. June 2013. N JonathanEi. Hill, "Sufhm In Nonhem Nigeria: Force For Counter•Radicalatatam?" Strategie Studies Institute, May 3310. 9 EFTA01078376  Confidential — Not for distribution or circulation Barriers to Polio Eradication in Nigeria Many of the difficulties confronting Nigeria are at least partly of its own making." Governing such a divided state was never going to be an easy undertaking. The roster of military juntas that ran the country into the ground only gave way to democracy in 1999, but Nigeria's current government has done little to inspire confidence." Decades of corruption, abuse, and inept government have alienated large portions of the Nigerian population and left a chasm between the government and the governed." Government & Administration Nigeria's government is designed as a Federal Republic. Executive power resides with the President who is the head of state and head of government. Legislative power is divided among two chambers, a democratically elected House of Representatives and the Senate, which together form the law-making body known as the National Assembly. The Supreme Court of Nigeria acts as the country's highest judiciary." Administratively, Nigeria is divided into 36 states that elect a governor and 1 territory (the capital, Abuja). Each state is further divided into 774 Local Government Areas known as LGAs. In turn, each LGA is divided into wards. Religion Islam was first introduced to northern Nigeria in the 11th century, becoming well established in the major urban centers across the north and gradually spreading south into what today is referred to as the "middle belt" of Nigeria by the 16th century." Today, about half of Nigeria's population is Muslim, the majority of whom live in northern Nigeria. 12 states in northern Nigeria have had sharia law codified within their legal code since 2000. Though the vast majority are Sunni Muslim, there is a significant Shia minority, and a wide array of brotherhoods and sects who preach various violent and non-violent forms of fundamentalist, conservative and moderate Islam. Northern Nigeria has a long tradition as a center of Islamist thought, including fundamentalist strands of Islam- One of the first and most famous instances of armed Islamist uprisings against the state came in the early 19th century when religious scholar Usman Dan Fodio led a group of Muslims from the Fulani tribe to revolt against the dominant Hausa sultanates and the sultanate of Borno.26 At the heart of Dan Fodio's political and social revolution stood the belief that the rulers of northern Nigeria were corrupt and were not true adherents to sharia because they allowed the practice of Islam to be mixed with traditional beliefs. After leading his followers into exile, Dan Fodio called for jihad and returned to launch a successful attack that would go on to establish the Sokoto Caliphate, stretching across northern Nigeria and its environs. The Caliphate represented an Islamic banner of resistance to colonial conquest, and a rejection of secular government." To this day, the Sultan of Sokoto remains one of the most important and influential religious leaders in northern Nigeria. =1 Jonathan.. Hill, "Sufism In Northern Nigeria: FOCIX For CounteoRadicalinium?" Strategic Studies Institute, hlay 1310. = Carlo Davis, 'Holm Hamm: Africa's homegrown Tenor Network.- World Policy Journal 12 lime 2012. =, Jennifer (I. Cooke and Fa:ha Tahir, "Polio Eradication in Nigeria: The Race to Eradication.- CSIS Global Health Policy Center. February 2012. =4 "Nigeria,- CIA World Factbook. 28 January 2014. hitps:/Aoww.cia.govilibraryPpublications.lhe.w.xlil.factbookJgeournilitml Is Emilie °nodal. "Rao I laram: An (herview.- Norwegian 13eferise Rest-arch Establishment (FF1) 31 May 2013. =6 Emilie °nodal. "Hoke I tram: An (herview.- Norwegian Defense Research Establishment (FF1) 31 May 2013. Abimbola Adesoji, -11ic Itoko Hamm Uprising and Islamic Revivalism in Nigeria; Africa Spectnim 45. no. 2(20I0) 10 EFTA01078377  Confidential — Not for distribution or circulation Barriers to Polio Eradication in Nigeria Colonialism In the early 1900s, the British Empire extended its colonial control northward from the Nigerian coast, eventually gaining control of the Sokoto Caliphate. Initially, the British decided to maintain northern and southern Nigeria as two separate protectorates due to their cultural differences. Economic calculations persuaded the British to merge the two in 1914. But even after unifying northern and southern Nigeria, Britain pursued a colonial system of indirect rule in the north, choosing to govern the area through hand-picked indigenous rulers. This policy institutionalized existing north-south divisions, the effects of which are prevalent to this day. Present Situation Nigeria's economic decline since independence has hit the north particularly hard. Per capita public expenditure on health in the north was less than half that in the country's south as recently as 2003.}8 Development indicators remain lower than in the south where there is far more public and private investment, infrastructure and health services. Nigeria's transition to democracy in 1999 saw the election of Olusegun Obasanjo, making him the first Christian and southerner to lead the federal government since his own tenure as a military ruler from 1976 to 1979. This shift in political power from northem political elites to southern political elites, combined with widening economic disparities between north and south, fueled a sense of political marginalization throughout much of northern Nigeria." With little faith left in government and politicians, hundreds of thousands, perhaps millions, of Nigerians have found themselves drawn to individuals and groups who advocate a radical alternative to the status quo, often expressed in religious or moral terms. Within Christian communities, which are predominantly but not exclusively based in southern Nigeria and constitute roughly 40% of the population, disillusionment with government has tracked with the rise of evangelical Christian movements advocating faith as an alternative means to health and economic prosperity. Among Nigerian Muslims, who make up approximately SO% of the population, there has been a surge in support for sharia law as an alternative to a corrupt and ineffectual secular judiciary.)' Researcher Peter Chalk identifies three main streams of Islamic thought in contemporary Nigeria: conservatism, modernism and fundamentalism. Fundamentalism in the Nigerian context, according to Chalk, focuses on "anti-system movements that articulate vehement opposition to the existing political (secular) status quo, the federal govemment, established (and perceived ineffectual) religious elites, modern-oriented Muslim identity, and foreign -- mainly Westem — influences."" In other words, the fundamentalist strand of Islamist thinking in the north of the country says that the continued failures of the Nigerian government are evidence of inherent flaws with secular government. In recent years, a re Jennifer (1. Cooke and Fasha Tahir. "Polio Eradication in Nigeria: The Race to Eradication. OSIS Global I lealth Policy Center. February 2012. "I Jennifer G. Cooke and halm Tahir. "Polio Eradication in Nigeria: The Race to Eradication. CSIS Global Health Policy Center. &bras 2012. f4 JonathanU. Hill. "Sufism In Northern Nigeria: Force For Counteeltadkalizabon?" Strategic Studies Institute, May 31110. )1 Peter Chalk, - Islam in West Africa: The Case of Nigeria." in The Muslim World after 9111. ed. Angel M. Rabasa et al. (Santa Monica. CA: RAND. 20001. II EFTA01078378  Confidcntial — Not for distribution or circulation Barriers to Polio Eradication in Nigeria group called Boko Haram has emerged as the most salient and destructive manifestation of this philosophy. Boko Haram Boko Haram is an Islamist sect in northern Nigeria. Initially established as a religious movement in the late 199Os or early 2000s that sought to purify northern Nigeria from the corrupting influences of Western culture, Boko Haram has since transformed into an armed insurgency determined to transform Nigeria into an Islamic state. Though the group had been carrying out violent attacks for the better part of a decade, Boko Haram burst onto the international scene in 2010 and 2011 when it carried out a string of deadly attacks against the Nigerian govemment and detonated a car bomb after crashing into a United Nations building in Abuja, killing 23 people in the process. Nigerian President Goodluck Jonathan has sought to crush Boko Haram through the enlistment of civilian vigilante groups and the deployment of some 8,000 soldiers supported by fighter jets and helicopter gunships to northern Nigeria. Due to a virtual media blackout northeast Nigeria, where a state of emergency has been in place since May 2013, very little information can be independently verified. Consequently, it is difficult to assess the effectiveness of the Nigerians government's heavy- handed tactics, and the effects of fighting between the government and Boko Haram on the civilian population. As a result of the upsurge in violence, Nigerian citizens are openly wondering if their country is on the brink of a civil war. Amid checkpoints and constant security wamings, an air of apprehension pervades daily life throughout much of northern Nigeria, with social and economic activities in some northern states grinding to a halt and and bringing previously peaceful communities to the verge of fracture.° The relative strength of Boko Haram is unclear. While Boko Haram appears to be growing more lethal -- the group is thought to have killed thousands since 2009 and carried out several audacious large scale attacks on heavily fortified military targets in the last few months — precious little is known about its leadership, organizational structure, funding streams, and membership. At any given time, a patchwork of armed groups or individuals in northern Nigeria may be carrying out attacks under the banner of Boko Haram. Even its name, "Boko Haram" -- a phrase borrowed from the Hausa language native to northern Nigeria - - is an unofficial moniker ascribed from the outside that the group's core members do not use, preferring its official Arabic name of alarna'a AN al-sunnah li-da'wa wa al-jihad" instead. Despite its Hausa name, the majority of its initial membership is believed to be ethnic Kanuri, from northeastern Nigeria. But over the course of the last decade, the group has metastasized, spreading throughout northern Nigeria and inserting itself within longstanding conflicts in the "middle-belt." LI Michael (Morena &Alpo. 'Mitigating Radicalism in Northern Nigeria. African Center for Strategic Studies. No. 26. August 2013. 12 EFTA01078379  Confidcntial — Not for distribution or circulation Barriers to Polio Eradication in Nigeria Boko Haram has deployed suicide bombs and coordinated assaults aimed at an array of targets, including markets, schools, hospitals, clinics, banks, churches, mosques, police stations and military installations. And while the scope and intensity of Boko Haram's terror campaign is breathtaking, the movement is not without its antecedents. The previously discussed Sokoto Caliphate was an armed movement against what was perceived at the time to be the illegitimate rule of powerful elites who were misappropriating Islam. In fact, Dan Fodio's legacy of a purifying withdrawal from society in order to wage a righteous jihad against corrupting influences is seen by many northern Nigerian Muslims, including Boko Haram, as a template for a more just, prosperous and equitable northem Nigeria." More recently, there was the Maitatsine movement, which was led by a Cameroonian preacher named Mohammed Marwa who took up the teachings of Dan Fodio after arriving in the northern Nigerian city of Kano in 1945. Marwa's preaching, predicated on the belief that he himself was a prophet, earned him the name Maitatsine, which translates from Hausa to mean "he who curses" or "the one who damns." Much like Dan Fodio, Marwa's movement stood against Nigeria's corrupt secular government and its allies within the "moderate" religious establishment. Marwa was eventually forced into exile by the British colonial government, but returned to Kano shortly after independence. The Maitatsine message resonated with the young, poor and unemployed in the slums of Kano. Throughout the 1970s, the Maitatsine movement gradually tumed violent, leading to clashes with police. Marwa was killed in 1980 during a confrontation with police, but even after his death, riots spread throughout northern Nigeria, claiming the lives of between 4,000 and 5,000 people." The movement never quite recovered, but isolated pockets of extremism remained, and Maitatsine teachings are thought to be a source of ideological inspiration for Boko Haram." The Maitatsine movement introduced many of the tactics that would become common in northern Nigeria's current wave of Islamic radicalization (both violent and non-violent), particularly the mobilization of poor communities against established, urban Muslim elites perceived to be colluding with a corrupt, secular government." David Cook. The Rise or Boko Ilaram in Nigeria". cr.:Sentinel4.1XL 9 (2011). "Abimbola Adesoji. "The Koko IblUM Uprising and Islamic Revivalism in Nigeria- Africa Spectrum 45. no. 2 (WWI ff Abimbola Adesoji. 'The lloko IblUM Uprising and Islamic Revivalism in Nigeria- Africa Spectrum 45. no. 2 (WWI Abimbola Adesoji. "The ❑oko IblUM Uprising and Islamic Revivalism in Nigeria- Africa Spectrum 45. no. 2 (WWI l) EFTA01078380  Confidential — Not for distribution or circulation Bafflers to Polio Eradication in Nigeria Figure 3: Areas where access is limited due to security concerns'' "SO N 0 f R I A <suites. ❑ STATES WHIN( PIO HAUS THREAT PHISISTS STATUS WHERE ROW HARM& THREAT IS HIGH El ▪ tttttt WHERE 5050 HAW& tttttt IS MOST ANTE • sow MARAM "MAUD YlOttlICE The Nigerian government successfully crushed the Maitatsine movement with brute force." The su cess of these heavy handed tactics may have given the Nigerian government a false sense that Boko H ram was merely the latest manifestation of a violent Islamist undercurrent that could be stemmed through similar means. But all accounts, attempts to crush Boko Haram through military might have proved unsuccessful, even counterproductive. Nigerian security forces cracked down on Boko Haram during mass uprisings in 2003-2004 and thought the problem had been dealt with, only to see Boko Haram re-emerge." A 2009 attempt to deliver a decisive blow to Boko Haram in their stronghold of Maiduguri led to the death of at least 700 people. Boko Haram's then leader, Mohammed Vusuf, was captured by police and summarily 3' Figure 3 source, Council on Foreign Relations, with modifications by the author http:""w ww.cfr.org"nigeria"nigeria-sectirity -tracker p294 "Andrew Walker. "Special Report: What is Hoke 'brim?" United Skates Institute of Peace. lune 2012. "Alex 'lumen. "Nigeria: An Ephemeral Pelice." The Revealer. 22 lune 2013. 14 EFTA01078381  Confidential — Not for distribution or circulation Barriers to Polio Eradication in Nigeria executed." After that episode, Boko Haram faded from public view for close to a year, only to come back more determined and lethal than before." As part of its operations against Boko Haram since 2009, the Nigerian government has allegedly killed hundreds of suspected militants and sympathizers, and have stood accused of extrajudicial killings as well as using Boko Haram as a cover for attacks on political rivals or as pretext for score-settling." During raids on suspected Boko Haram strongholds, the military has burned homes and summarily executed suspected Boko Haram members in front of their families. Nigerian authorities have cast a wide dragnet, arresting thousands of people across northern Nigeria, holding many of these prisoners incommunicado without charge or trial for months or even years. In some cases, prisoners have been detained in inhuman conditions, tortured or even killed." Amnesty International reported receiving credible evidence that over 950 people have died in military custody in the first six months of 2013 alone." The ongoing violence and abuse by government forces may even be driving new recruits into Boko Haram's arms." In the wake of an escalation of violence, Boko Haram and its followers are all the more driven by a desire for vengeance against politicians, police, and Islamic authorities aligned with the state. Furthermore, Boko Haram has proved itself to be very adaptable, evolving its tactics swiftly and changing its targets at the behest of a charismatic, if opaque leadership." Part of what makes understanding and defining Boko Haram so difficult is the fact that it may very well be several different things at once. As former US ambassador to Nigeria John Campbell told reporter Andrew Walker, Boko Haram is certainly a grassroots movement that taps into anger over poor governance and a lack of development in northern Nigeria, but it is also a core of Mohammed Yusufs followers who have reconvened around Abubakar Shekau to exact revenge on the Nigerian state. At the same time, it can be viewed as a kind of personality cult, an Islamic millenarianist sect inspired by a charismatic preacher." Boko Haram's increased deadliness and the sophistication of its attacks are widely cited as evidence that they are collaborating with foreign groups. Its violent campaign has expanded in scope and capability, and its membership is believed to have diversified, with anecdotal evidence suggesting that foreign fighters from Chad, Mauritania, Niger, Somalia and Sudan may be in Boko Haram's ranks." In recent years, northern Nigeria has also seen the formation of splinter groups emerging from Boko Haram, the most prominent being a group commonly referred to as Ansaru, though its hill Arabic name at Rom Bhandari."Boko tioram Infiltrates Government.'" Think Africa Press, 10 January 2012. a Alex Thurston. "Nigeria: An Ephemera Peace: The Ren-dler. 22 June 2013. 4: Andrew Walker. "Special Report: What is Bokollarde United States Institute of Peace, lime 2012. a I luman Rights Watch, "Nigeria: Massve Destruction. Deaths Fran Military Raid," I May 2013. "Amnesty International. "Nigena: Deaths ofhundreds of Boko I laram supsets in custody requires inmatigation.- IS October 2013. "Alex Thurston. 'Nigeria: An Ephemeral Peate." The Ren-dler. 22 June 2013. Andrew Walker. ''Special Report, What is Bokollaramr United States Institute of Peace. June 20)2. See John Campbell's quotes in Andrew Walker. "Special Report: What is Boko Baran?' United States Institute of Peace. June 2012. Abimbola Ademni, 'The Haw 'Loam Uprising and Islamic Revivalbm in Nigeria: Africa Spectrum 45, no. 2 (2010) IS EFTA01078382  Confidential — Not for distribution or circulation Barriers to Polio Eradication in Nigeria Juma'atu Ansarul Muslimina Fi Biladis Sudan, tr