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Polio: A fight in a lawless land

Targeted by warlords but armed with a new vaccine, teams fan out across Somalia to wipe out the disease

Dr. Elias Durry, who is in charge of the World Health Organization's efforts to eradicate polio in Somalia, listens to Habiba Nour, whose son, Abdi, 6, contracted polio in 2002.
Dr. Elias Durry, who is in charge of the World Health Organization's efforts to eradicate polio in Somalia, listens to Habiba Nour, whose son, Abdi, 6, contracted polio in 2002. (Globe staff photo/John Donnelly)

MERCA, Somalia -- The local polio eradication coordinators shared their troubles in a meeting in this southern Somali coastal town. Mukhtar Qassim -- in charge of vaccinating children against the crippling disease in a village called Wanleweyn, about 40 miles northwest of the capital, Mogadishu -- clearly had the worst.

In his district, population 200,000, nine clans are at war. Each clan has a warlord. Each warlord has rifles and at least one anti-aircraft gun mounted on the back of a truck.

When Qassim, 42, started the polio campaign last year, one warlord's men twice riddled his house with bullets; Qassim and his family narrowly escaped. The issue: He hadn't hired members of that clan for the $5-a-day jobs to vaccinate children.

''They could shoot up my house again -- easily," said Qassim. ''The elders in the village can't manage the militiamen. Everyone wants a job, and they'll do anything to get it."

In the global push to wipe out polio, the leaders of the effort see two particular looming trouble spots: Nigeria, because it's difficult to persuade parents the vaccine is safe after religious leaders long spread false rumors that the immunizations were a Western plot to sterilize Muslim children; and Somalia, because after 15 years of no central government and frequent skirmishes across the central and southern parts of the country, no one can assure the safety of polio vaccinators.

In 1988, when global health leaders set a goal of eradicating polio from the globe, the virus crippled roughly 1,000 children a day. Last year, just under 2,000 children contracted polio in 16 countries, and more than 90 percent of the cases were either in or imported from Nigeria.

The heads of the World Health Organization, UNICEF, the US Centers for Disease Control and Prevention, and Rotary International hope they can finish the job this year largely because of a stronger vaccine. They have just started using a vaccine that specifically targets polio types one and three; type two hasn't been found since 1999. Until last year, the polio vaccine covered all three types of polio, but by focusing on the two remaining types, organizers say the vaccine will be stronger.

Dr. Elias Durry, 49, from the World Health Organization, recently took over the coordination of the Somalia campaign. He has worked in the virus's strongholds past and present -- Nigeria, Yemen, India, Djibouti, Sudan, and Somalia -- once before.

In 2002, the Ethiopian native oversaw campaigns that ended polio transmission in Somalia. But last year, a major outbreak from imported cases out of Nigeria swept through the country. Somalia registered 184 cases last year and five so far this year.

Durry is optimistic despite the challenges. ''We did it once. We can do it again," he repeated over and over to his staff during meetings in Merca.

He supervised a nationwide vaccination campaign last week. This week he will watch a smaller effort -- in Wanleweyn. Local coordinator Qassim said he will work hard to keep the nine clans from getting in the way.

''I've committed myself to eradicate polio from my community," Qassim said. ''I don't mind if they kill me. It is very important that I try to do this job."

Durry's countrywide strategy is to go door to door and hut to hut at the same time in every village, town, and city in Somalia. And then he plans to repeat the process multiple times this year. To do that, his workers need to hire vaccinators, train them, assign each an area, and win the support of the communities.

But in Somalia, winning support is never simple, and so Durry has developed strategies for trouble.

If clans demand jobs, as they did in Wanleweyn, Durry has told his teams to shut down the polio campaign. Then he has informed the warlord that WHO also would cancel its vehicle contract, worth $60 per day per vehicle.

''That usually works," Durry said. ''They don't want to lose the vehicle rentals." (He learned long ago never to bring vehicles into Somalia: ''The warlords would just take them away," he said.)

If many parents refuse the vaccine, he has told his teams to ask elders and religious leaders for help.

And if there's a report of a case of a child crippled from polio, his teams are to get the word out far and wide. Durry wanted to see recent cases, personally, so his local coordinators brought him to the village of Shalombot, about 15 miles south of Merca. Here, after two children came down with polio, no parents refused the vaccine in the next polio campaign.

''People were running out of their homes, bringing their children to us," Hawa Hassan Ali, a local immunization coordinator in Shalombot, told Durry.

Durry asked to see the two crippled children. A neighbor brought out 2-year-old Fartun Abdullahi Alasow, and Durry wiggled the boy's legs; they were limp. The neighbor, Amina Bulle, 24, then lifted the boy's shirt to show burn marks seared across his back.

''Oh, geez," Durry said, knowing right away what it meant; he had seen this before. The boy's parents wrongly believed they could kill the virus by burning it out. They had used embers from a fire on the boy's back.

''Tell everyone here that this doesn't get rid of polio," Durry told the neighbor, pointing to the wounds. ''The only way to protect yourself is with the vaccine."

Bulle, a mother of four, nodded. ''We thought the vaccine was useless, but now we realize it is necessary," she said.

But many were unconvinced. In a neighborhood in Merca, a vaccinator had written on one house gate ''0/4," meaning that none of the four children under the age of 5 had been vaccinated.

''What happened here?" Durry asked during a visit to the area.

''I've met with the father many times," said Ali Mao' Mo'allim, one of Durry's most valuable local polio coordinators. ''He said if my child is sick, I will read my Koran and pray for him."

In 1979, Mo'allim was the last person in the world to come down with wild smallpox virus, which is the only disease affecting humans ever eradicated; polio would be the second.

At the time he was a cook at Merca Hospital, and when smallpox vaccinators administered the vaccine to the hospital staff, Mo'allim held his right shoulder and pretended he had received the shot.

''I was scared of being vaccinated then. It looked like the shot hurt," said Mo'allim, 48, who was sick for 50 days with smallpox but recovered completely. ''Now when I meet parents who refuse to give their children the polio vaccine, I tell them my story. I tell them how important these vaccines are. I tell them not to do something foolish like me."

Mo'allim, like Durry, believes the campaign will work. ''I want to be able to see the last person with polio," he said. ''That's why I'm doing this."

John Donnelly can be reached at donnelly@globe.com.

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