The Rotary team stands in the baking sun outside the front door of a house; inside, the family is refusing to allow a child to be immunized against polio. Saliu Ahmed and his fellow Rotarians are eating peanuts, waiting for the head of the household to emerge. Ahmed blows a handful of nut husk out of his hand. The flaky ocher skin catches the sunlight as it flutters down and lands in the open sewer that runs in front of the row of houses. The sewer is filled with a thick, brown, stagnant scum.

Some people here in Kaduna State, and in the rest of northern Nigeria, are still reluctant to immunize their children. But for four days in November, Rotarians, local government health workers, and staff from the World Health Organization and UNICEF put on a massive effort to immunize millions of children and move a step closer to eradicating the crippling disease.

This house has three chalk “Rx” symbols above the door, indicating that this family has repeatedly refused the vaccine. Ahmed, 2007-08 governor of District 9120 (Nigeria), and Rabiatu Musa, a local community health worker, try to persuade them to change their minds.

Musa brings the mother out – men are not permitted to enter if the husband is not at home. Earlier, the nurses leading the house-to-house immunization team were turned away with a firm “ba yara” – Hausa for “no children.” Now a crowd of kids gathers around the entrance. The woman who comes to the door has a baby strapped to her back.

“Is that not your boy on your back?” As Ahmed speaks, his tone is polite but firm. “Come now, let’s talk. We are your friends. Good morning. How old is your baby?”

“Two years and eight months.”

“What is his name?”

“Abdul Rahman.”

“Oh, beautiful; my youngest child is also called Abdul Rahman. Why have you not allowed your child to be immunized?”

“I used to go and collect immunization. But according to our belief, we have stopped.”

In 2003, a yearlong boycott of polio immunizations by Muslim clerics and traditional leaders resulted in a huge increase in the numbers of new wild-poliovirus infections, and disease spread to 20 previously polio-free countries. Rotarians, led by 2003-04 RI President Jonathan Majiyagbe, of Nigeria, helped persuade Nigerians to resume immunization. But fears linger in some communities.

“But what belief is that, madam?” says Ahmed. He has already begun to head her off by letting her know that his child is called Abdul Rahman and that he too is Muslim.

She shifts her ground to another reason for refusing: “It is our belief that when you go to the hospital, they cannot even give you a registration card if your child is unconscious. They will not even help you with anything. But now they come house to house with this polio. We may not know [what it is] because we are not educated. Most of us you see are villagers.”

Distrust of government and health services is widespread in Nigeria. The team must try to overcome this suspicion on the doorstep.

Ahmed says, “We are providing vaccines for tuberculosis, measles, and tetanus, and the more we provide things, the more people say, ‘What is this?’ ”

“No, it’s not like that,” says the mother, waving away the words as if she is keen not to be a burden.

“Thank God you do not have a child who is infected with polio,” Ahmed says. “Do you know of a child who is infected?”

“Yes, there are many in this area,” says the mother. Two children in the family who live opposite were crippled because of it, she says.

Ahmed points to the sewer: “What you have here in front of your house is so dirty, it could infect your children, but there is one way to prevent that. Submit your child to be immunized. Bring Abdul Rahman forward.”

There is one more hurdle that prevents her from offering her child to receive the two drops of vaccine. She smiles in the way people do when they know they are wrong but can’t back down. She looks away from the people at her door.

She says: “I will talk to his father. I know he is my son, but I know I belong to someone as well. I will talk to him and encourage him.” Abdul Rahman will not be immunized today.

As the team walks away, Musa, a mother of eight, says she’s worked at the local hospital for four years and has never seen the woman. “Mostly it is the men that say they cannot have the vaccine, and they cannot even give reasons for that. They say it is their religious belief that prevents them. But that is not so.”

This scene is repeated on every street in every village in northern Nigeria during the immunization drive. At another door a man blocks the immunization team’s entrance with his motorbike and steadfastly refuses to admit that there are any children in his house, even when Musa says she can see them peeping out the door.

Sagab Sani Ahmed, vice chair of the Nigeria PolioPlus Committee, says the only way to eradicate polio is to change the minds of all the people who refuse. They do so because they’re misinformed, he says, and the strategy of going house to house is gradually working. Now, only small pockets of noncompliance remain.

“We are now identifying the reluctant people and can focus on them accordingly,” says Busuyi Onabolu, a member of the African Regional PolioPlus Committee and chair of the Nigeria committee. “We are including a community dialogue, with traditional leaders going along with the teams, whatever it takes – going at night if necessary.”

At the epicenter

A girl chases her breathless friend around a corner and up a mound. The kids have run toward a dead end, and they stop suddenly, the chase over. They grab each other and burst out laughing. They’re standing on the brink of a giant pit, 50 yards across, at the center of Sharada, a slum in Kano City. Around it are huge piles of rubbish. Household trash and sewage are poured into this hole. At the bottom is thick green water.

Kano State is the crucible of polio in Africa. In Sharada, as in every other slum, dirty brown rivers of human and animal waste run between the buildings. Polio is spread when children come into contact with these sewers. Chickens and goats walk in and out of the rivers and into people’s houses. The sewers overflow. In the rainy season they flood, running into the houses.

The people of Sharada take their water from a deep well only yards from the rubbish pit. The water is brown, murky, and unclean.

In the village head’s office, rough, hand-drawn maps of the slum have been posted on the wall for the immunization teams. Yusuf Musa Ishaq is dressed in his finest flowing robes, blue with rainbow embroidery. The sounds of children playing outside mixes with the call of peacocks that wander through his garden.

He says: “There has to be more awareness and education. Before, a lot of people really didn’t know what polio was. We are really now aware of the disease [and] we are ready to cooperate.”

Ishaq was one of the traditional leaders who called for the immunizations to stop. Now he says: “The world is based on rights, and you can’t force people to take medicine if they don’t understand what it’s for. If you force him, then he may believe it’s something harmful.”

In 2003, with Rotary’s help, the traditional leaders and clerics were brought together in a massive education program, and since their inclusion, the number of new cases has dropped from its peak. In 2006, there were 998 cases by November. By the same time last year, there were only 225. The rate of infection has not yet dropped as low as it was before the boycott, but government leaders in Nigeria are optimistic that polio will be eradicated very soon. On Nigeria’s long road to ending polio, the country has faced a thicket of challenges – poverty, illiteracy, unsanitary conditions. “We need help to have water treatment,” Ishaq says. “It is part of my responsibility to lead and fix our problems.”

Onabolu adds: “Rotary’s support for primary health – sanitation and clean water – is also a big part of eradicating polio.”

Reaching the last child

At the launch of the National Immunization Plus Days in Barnawa, Kaduna State, hundreds of mothers, dressed in their colorful wrappers and holding their babies, wait under canopies for the politicians’ speeches to end. Every speaker lists the names of every other esteemed guest before beginning his or her address. Virtually none of the women are listening. They are calming their children or chatting in Hausa.

Before Amina Namadi Sambo, the governor’s wife, speaks, a group of praise singers chants, “Kaduna State government are the ones who kicked polio out of our land, this year and last year and forever. Amina Namadi Sambo is taking good care of her people in Kaduna State.”

In her speech, a government health official talks confidently about the government’s promise to eradicate polio. She finishes and walks over to start giving the children drops of vaccine.

After the day is over, she says: “I think our own health promotional methods need to be revised. These mothers are very young, and we need to bring in their husbands and maybe their grandmothers too. Those are the people really making the decisions in the household.”

As long as one family refuses to immunize its children, the struggle at the doorstep will have to be repeated, time and time again. As Onabolu, the Nigeria PolioPlus Committee chair, puts it: “We cannot afford one person to be left out.”