Nigeria is closer than ever before to stopping transmission of the paralyzing childhood disease of polio, but world health experts suggest that the Boko Haram insurgency in the north could jeopardize the eradication effort in one of the last countries where the disease prevails.
Medical anthropologist Elisha Renne, of the University of Michigan, say there's no way to stop the spread of polio without addressing the unrest wrought by Boko Haram, the militant Islamist sect infamous for its kidnapping of more than 200 girls in April.
"The problems are intertwined," said Renne, author of The Politics of Polio in Northern Nigeria. "The solution to one is going to contribute to the solution of the other."
The headquarters of Boko Haram lies in the northern Borno state, the same area where poliovirus transmission continues to frustrate international efforts to wipe out polio.
For the past 26 years, a global campaign has waged war on polio, seeking to make it the second disease in history to be eradicated.
Polio remains endemic in only three countries: Pakistan, Afghanistan and Nigeria. But the World Health Organization recently declared a public health emergency for polio after nearly triple the number of cases appeared in the first few months of this year compared to last.
In Nigeria, however, cases have dropped this year to a tenth of what the country recorded by this time last year.
"Collectively, we are in the best position and situation with respect to finally interrupting all poliovirus transmission in Nigeria than we ever have been in history," said Stephen Cochi, senior adviser on immunization to the director at the U.S. Centers for Disease Control and Prevention.
Boko Haram's heartland: Polio central
To date, three cases of polio have been reported in the West African nation. The same period last year saw 22 cases. Worldwide, the case count this year stands at 82, with the majority in Pakistan.
However, the next few months will be critical. The high season for poliovirus transmission in Nigeria lasts from May until August.
The crippling disease continues to thrive in northern Nigeria, in the heartland of Boko Haram, a group that's plagued the country with violent attacks since 2009.
Boko Haram is believed to be responsible for thousands of deaths in northeastern Nigeria, particularly in the last year or so.
In recent months, the militant group ignited two deadly bombs in the capital of Abuja, killed dozens of security personnel in an attack on a Nigerian military base and massacred dozens of schoolboys.
But it was the kidnapping of more than 200 schoolgirls in the northern Borno town of Chibok that’s riveted the world and spurred several Western nations to send intelligence experts to help Nigeria find them. Earlier this week, the Nigerian military said they had located the girls, but won't attempt a dangerous rescue at this time.
The unrest in Boko Haram's stronghold in the northeast has also made it difficult to reach the children for vaccinations. Renne notes that Boko Haram, which translates to "Western education is forbidden," has also been opposed to Western-sponsored polio vaccination efforts.
In response the vaccination campaign has resorted to so-called "hit-and-runs," sending workers guarded by security officers into insecure areas to quickly administer vaccines. Mobile teams are also stationed at transit points along borders of insecure regions to vaccinate those travelling in and out.
Part of the reason it's hard to vaccinate children in the north — and the reason why Boko Haram has flourished — is the deep and worsening poverty in the largely Muslim region.
Though Nigeria is one of the world's biggest oil producers, more than 60 per cent live in poverty. A high portion live in the north.
Many lack basic necessities like water and electricity. Renne says that leads some communities to question government spending on such things as polio vaccines.
In some instances, campaign organizers have drilled boreholes for communities to access water, a way to convince them to allow vaccinations, Renne says.
The insecurity also makes it hard to confirm the true number of polio cases, though Cochi says locals in some areas still manage to communicate with the polio eradication teams.
Cochi says the government-declared state of emergencies in three northern states — Adamawa, Borno and Yobe — has helped immunization efforts, giving teams access to areas when the military goes in.
In March 2013, there were more than 19,000 settlements in Borno state that were inaccessible, but this March, it was down to about 1,900, a reduction of 85 per cent.
"I think that's been part of the reason why the case count has dropped dramatically even since last year," said Cochi.
But Renne warns that military action to both contain ongoing violence and suppress opposition to the polio eradication campaign could backfire.
In an upcoming paper to be published in the Africa journal later this year, Renne argues that threatening non-compliant parents with arrest and conducting house-to-house sweeps might breed sympathy for Islamic insurgents.
Polio's 'dark years'
The last decade has been difficult for the Nigerian polio eradication effort.
In 2003-2004, several northern states stopped vaccinating over fears about the safety of the polio vaccine. An influential Muslim leader spread fear that the vaccine was sterilizing children as a population control measure and was contaminated with HIV, says Cochi.
"Those were kind of the dark years of the polio eradication story in Nigeria," said Cochi, who sits on Nigeria's expert review committee on polio eradication, and has been visiting the country since 1999.
Cases jumped to a peak of 1,122 in 2006. For a few years, the number of recorded cases ranged from 300-800.
Last February, gunmen killed nine female polio vaccinators at health centres in northern Nigeria's Kano state, causing a temporary stop to vaccinations.
However, Cochi says efforts to eradicate polio in Nigeria have transformed in the last two years, with improved quality and accountability. In 2012, 122 polio cases were reported and last year, it was down to 53.
But the CDC adviser says he's worried about distractions that might derail efforts to control polio in Nigeria. The insurgency in the north is one concern, says Cochi, but he suggests a less-discussed issue may pose an equal risk: Nigeria's upcoming elections.
Nigeria's presidential and legislative elections are expected to take place early next year.
Not only does political attention get diverted during heated and sometimes deadly election campaigns, there are also concerns about polio eradication campaign funds getting diverted into political campaigns.
'Enough is enough'
Oyewale Tomori, chair of Nigeria's expert review committee on polio eradication, says it happens every election.
"We're scared but we've handled it before," he said.
Tomori says that the larger issue remains that the government doesn't seem fully committed to the task of polio eradication.
He points to the monumental achievement by India earlier this year when it attained polio-free status, a result of what Tomori describes as sheer determination.
The second most populous country in the world mobilized massive vaccination teams, used Bollywood and cricket celebrities in its polio eradication campaign and tapped in to community leaders to bolster support and counter fear of vaccines.
By comparison, Tomori laments Nigeria's short attention span. "It's very distracted by so many activities that are going on," he said.
Even if the country attains a year with zero cases, he fears the government would become complacent, thus never reaching the three years necessary to become certified polio-free by the World Health Organization.
"We've had enough of this embarrassment," said Tomori. "We need to make up our mind and say enough is enough."