The Excluded Voices from Africa's Sahel: Alternative Meanings of Health in Narratives of Resistance to the Global Polio Eradication Initiative in Northern Nigeria

"Research on...resistance...can recover the excluded voices, generate understanding of local criticisms, and introduce the voices into spaces of knowledge. Greater knowledge of these voices has implications for their inclusion in GPEI decision making and for reforming the GPEI and similar programs in African nations."

Although the Global Polio Eradication Initiative (GPEI) has been largely successful, it encountered several pockets of resistance (mainly from Afghanistan, India, Nigeria, and Pakistan) that forced the eradication deadline to be postponed. Whereas previous inquiry into resistance to the polio vaccines in northern Nigeria has focused on the 2003 revolt, this study draws on a culture-centred approach (CCA) in order to unearth marginalised voices that were excluded from various sites of decision-making over the period 2012 to 2018. It does so by examining northern Nigerian community members' narrative of resistance to the polio vaccines in Nigerian news media and grounding the resultant analysis in health communication theory.

The paper begins with reviews of the literature on polio, the GPEI, and resistance to the polio vaccines in northern Nigeria. In essence, the 2003 vaccination revolt involved 4 stages: (i) Dr. Datti Ahmed, president of the Supreme Council for Sharia in Nigeria (SCSN), held a press conference where he relayed community beliefs that the vaccinations were being used by the West to depopulate Islamic communities; he then called for a suspension of the campaign until the vaccines could be tested. (ii) 3 northern states suspended their campaigns, and 2 other states aired concerns about vaccine safety. (iii) In response to an advocacy campaign by the World Health Organization (WHO) and the government, 3 northern states supported the campaigns. (iv) Multiple teams (e.g., Islamic groups) tested the vaccines in several countries, resulting in a stand-off where some argued the tests revealed foreign substances, while others argued the substances had harmless levels.

Through a 3-stage research methodology that involved, in part, a search for narratives of resistance in both newspapers and online news, the researchers provide a backdrop for these narratives through a chronology of GPEI milestones in northern Nigeria. For example, we learn that papers reported on the 2014 strategy of engaging community leaders in Ebola campaigns, which drew on Nigeria's negative experience of excluding them from polio eradication.

In understanding not only what happened in 2003 but beyond this incident and more contextually, the article draws on the CCA's concept of agency, which highlights the transformative capabilities and actions of what is here called "the subaltern" (a group that is marginalised by the ruling elite and elitist texts). CCA challenges assumptions that these people lack the facilities for inclusion in decision-making and are passive objects to be acted on. One form of agency is resistance, which "includes communicative acts and messages that challenge dominant social structures and seek to transform them....Actors that gain access to the news media can express their voices through narratives."

In probing the ideological struggle between Western biomedicine and alternative meanings of health, the study analysed 168 speech acts of resistance in the Nigerian news media (again from 2012 to 2018), 116 of which were attributed to community members, 39 to immunisation officials, and 13 to religious leaders. This analysis yielded 3 themes:

• Polio vaccines as involuntary "family planning": "Narrators evinced a cultural meaning of the polio vaccines as covertly carrying out a Western family planning agenda, which led to a use of the phrase 'family planning' that made negligible associations with health and well-being".
• Health as access to foods: The community's rejection of the polio vaccines positioned inequitable distribution of food as a greater health problem than polio. For example, a mother of 3 was quoted in one newspaper as insisting that "I was given card but the agency didn't give me (food), so why are they coming now with drug (polio vaccine)".
• Health as religious practice: Narrators pointed to beliefs the vaccines were prohibited by Islam.

The authors discuss how these findings resonate with previous research and make new contributions to the literature and to theory. One implication, for instance, is the need to focus on how subalterns in sub-Saharan Africa (SSA) invert the dominant meanings of Western health campaign terms. For example, "family planning" is often used in health campaign research, yet the lay use of this term in subaltern narratives rarely makes associations with health and well-being. Thus, rather than using such a term, communicators would need to consider "opposing cultural values such as around children and family size, [as well as] oppositional meanings as a response to traumatic historical events perpetuated by the elites such as colonial-era injustices". As outlined here, "The communication theory of language convergence/meaning divergence (LC/MD) lays a useful foundation for considering subaltern transformation of campaign terms."

Practical implications of the findings include:

• The GPEI and other health initiatives may benefit from pursuing an equal partnership with marginalised communities, such as by engaging religious and traditional leaders and fathers/grandfathers (who often influence child vaccination decisions in SSA), in dialogue.
• Dialogue between parties may be enhanced when multiple perspectives on the community's health are included and when parties in the conversation work toward consensus on issues such as meanings of health, community health priorities, and health solutions. Previous CCA research has fostered such dialogue through community advisory boards, community-wide forums, and PhotoVoice exhibits.
• Collaborative planning may consider building the capacity of marginalised communities to lead health initiatives; such participation can help clarify and/or challenge community perceptions of health initiatives being spearheaded by either the federal government or Western nations.

In conclusion, this research could guide "the future inclusion of voices at the margins in decision-making by the GPEI and other global health programs in SSA."