Health in Action From Intense Rejection to Advocacy: How Muslim Clerics Were Engaged in a Polio Eradication Initiative in Northern Nigeria Sani-Gwarzo Nasir 1 , Gambo Aliyu 2 *, Inuwa Ya’u 3 , Muktar Gadanya 4 , Muktar Mohammad 1 , Mahmud Zubair 3 , Samer S. El-Kamary 5 1 Federal Ministry of Health, Abuja, Nigeria, 2 Health and Human Services, Federal Capital Territory, Abuja, Nigeria, 3 National Primary Health Care Development Agency, Abuja, Nigeria, 4 Aminu Kano Teaching Hospital, Kano, Nigeria, 5 Department of Epidemiology and Public Health, University of Maryland School of Medicine, Baltimore, Maryland, United States of America Background Before the allegations of polio vaccine contamination a decade ago, Nigeria’s polio eradication initiative (PEI) was affect- ed by traditional barriers such as inade- quate funds, poor coverage, poor supervi- sion, broken cold chains, and lack of community mobilization and ownership. However, after the allegations of contam- ination of the vaccine with HIV, carcino- gens, and sterilizing agents, the program was completely halted in some states [1–3], leading to the reversal of gains made in the global PEI. Following this program inter- ruption, infection reemerged in 20 coun- tries in which the polio virus had been previously eradicated [4–6]. Subsequently, religious, safety, and fer- tility concerns became the main barriers to polio vaccination in most of northern Nigeria, one of the few remaining holdouts of the disease worldwide [2,3,7]. Even in areas with better uptake, failure to engage parents and discuss why a fully vaccinated child may develop polio disease, for instance, increased parents’ negative per- ception of the program [8]. Rebuilding community trust, understanding, coopera- tion, and support—all of which were lost to the groundless controversy on the vaccine’s safety—became necessary. In 2008, a community communication and awareness enhancement methodology known as Majigi (a roadside film show) was pilot-tested in Gezawa, Kano State, located in northwestern Nigeria [9]. In this pilot campaign, coordinated by the Na- tional Primary Health Care Development Agency (the agency responsible for devel- oping primary health care programs and policies in Nigeria), the participation of imams (Muslim clerics) was solicited through the traditional rulers to mobilize people at the community level [9]. Active participation of the traditional rulers in PEI in northern Nigeria became a reality after the office of His Royal Highness, the Sultan of Sokoto, supported this program. The sultan is the current Muslim spiritual leader in Nigeria, with a strong influence on the dominant Muslim community of the region. The sultan title is of historical significance and originates from the time when sultans were the leaders of the Islamic caliphate that ruled northern Nigeria in the precolonial period. The sultan’s support was a major milestone, given that his opinion carries tremendous weight with Fulani and Hausa people from northern Nigeria, and was pivotal to the success of the initiative in this region. The encouraging outcomes of the Majigi polio mobilization campaign led to the formal launch of the Northern Traditional Leaders Committee for Primary Health Care and Polio Eradication in 2009 by the sultan, which set the stage for the engage- ment of the imams. This article discusses the involvement and impact of the imams in promoting polio vaccination and the emerg- ing coalition of polio vaccine promoters at the community level in northern Nigeria. Engagement of Imams in the Polio Eradication Initiative In 2010, the National Primary Health Care Development Agency constituted a team of experts, consisting of mainly Muslim scientists, to work with the tradi- tional leaders committee under the leader- ship of the Sultan to reach out to the various Muslim group leaderships. This team was named the National Facilitation Team, and four of the authors were members of this team, headed by the first author. The team engaged, educated, and solicited for the support of imams and their community followers for the PEI. The team began with mapping out the high-risk local government areas (LGAs) within the 12 polio-prevalent states of northern Nigeria, namely, Bauchi, Borno, Gombe, Jigawa, Yobe, Kaduna, Kano, Katsina, Kebbi, Niger, Sokoto, and Zamfara (Figure 1). A total of 85 high-risk LGAs were selected based on the presence of polio cases, low The Health in Action section provides a place where groups or individuals who are not represent- ed regularly in a medical journal have a forum to describe the important issues from their perspec- tive. Authors might include patient advocacy groups, healthcare workers, or non-governmental organizations. Citation: Nasir S-G, Aliyu G, Ya’u I, Gadanya M, Mohammad M, et al. (2014) From Intense Rejection to Advocacy: How Muslim Clerics Were Engaged in a Polio Eradication Initiative in Northern Nigeria. PLoS Med 11(8): e1001687. doi:10.1371/journal.pmed.1001687 Published August 5, 2014 Copyright: ß 2014 Nasir et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Funding: The implementation of this project was supported by the National Primary Health Care Development Agency and the World Health Organization’s office in Abuja, Nigeria. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript. Competing Interests: The authors have declared that no competing interests exist. Abbreviations: AFP, acute flaccid paralysis; cVDPV, circulating vaccine-derived poliovirus; LGA, local government area; PEI, polio eradication initiative; WPV, wild poliovirus. * Email: algambo@yahoo.com Provenance: Not commissioned; externally peer reviewed PLOS Medicine | www.plosmedicine.org 1 August 2014 | Volume 11 | Issue 8 | e1001687