|Title:||Perspectives on Polio Immunization Campaigns in Ibadan, Nigeria|
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Perspectives on Polio Immunization Campaigns in Ibadan, Nigeria
vol. 17, no. 1, 2008
Issue title: New Directions in Medical Anthropology
Perspectives on Polio Immunization Campaigns in Ibadan, Nigeria
Department of Anthropology, University of Michigan
In the last ten years there have been extensive efforts on the part of the international community to eradicate polio in West Africa—and in developing nations in general(WHO-Nigeria 2006). The last four years have seen an intensification of these efforts in Nigeria, with the use of mass immunization campaigns aimed at eradicating polio and preventing its spread beyond Nigeria and West African nations like Niger. Resistance to these efforts in Northern Nigeria created an international controversy, which garnered much attention in Western and Nigerian medias. For example, Muslim leaders believed that the vaccine contained contraceptive agents and other contaminants with which the Western world hoped to control population growth. In 2003, some states in Northern Nigeria, such as Kano State, ‘suspended’ the immunization process sponsored and organized by the World Health Organization, UNICEF, Rotary International, and the Nigerian government (Global Polio Eradication Initiative 2003), until July 2004 when vaccination activities were resumed.1
Kaduna State did not suspend polio immunizations in 2003. However, it was one of the Northern Nigerian states whose residents and leaders voiced opposition to mass polio immunizations and Western involvement in the Nigerian immunization campaigns. In the summer of 2005, Dr. Elisha Renne visited Zaria, the major city, to explore the social and political context of polio in Nigeria (Renne 2006a, 2006b). I accompanied Dr. Renne on her visit as the student contributor to her project, assisting in the design of questionnaires and the conducting of interviews. While Dr. Renne’s work focused on Kaduna State, a trip to Ibadan (a city in the southwestern part of the country) and contact with the Hausa community in Ibadan led us to consider a supplementary project for Southern Nigeria. We hoped to document local responses to polio immunization campaigns in Ibadan’s Hausa community. While conducting interviews for this supplementary project, and in speaking with the leader of the Hausa community in Ibadan, I realized that, contrary to my initial expectation that all Hausa communities in Nigeria are the same, Hausa communities in Nigeria and their members are diverse. This diversity came through in individuals’ responses to the immunization campaigns and their views about resistance to immunization in Northern Nigeria. This paper seeks to challenge the view that all Hausas rejected polio immunizations and resisted the campaigns by presenting the views of several residents of the Hausa community in Ibadan. This paper does not aim to provide an in-depth analysis of resistance to immunization campaigns in Nigeria. Rather, it presents the views of recipients of immunizations, rarely taken into account during the orchestration of disease-eradication campaigns. Ethnographic research and medical anthropological projects such as this one are not only invaluable in gaining local perspectives that can enhance the effectiveness of immunization campaigns, but are also crucial in determining what individuals’ and communities’ health needs are. Research projects such as this one demonstrate that addressing these health needs must take into account local concerns and cannot be based solely on international concerns.
As my first fieldwork experience, my two-month stay in Nigeria was an opportunity to learn firsthand about ethnographic methods and the process of conducting fieldwork. The first month of my stay was spent in Zaria in Kaduna State, where I became acclimated to Hausa culture. I learned to take off my shoes and say the customary greeting of ‘Salam Walaikum’ before entering houses or private rooms. I learned to recite and respond to the morning greetings, inquiring of neighbors if they had slept well (Ina kwana?), to which one responds ‘Lafiya lau’ (‘fine’), and showing thanks for a night of rainfall over dusty and hot Zaria City by saying ‘Yaya ruwa?’ to which one responds ‘Ruwa ya yi gyara,’ or “the rain has done repair” (Akinbuwade n. d.:8-11). The second month of my stay was spent in the city of Ibadan in Oyo State. There I conducted library and archival research, and visited the Ibadan Hausa community and conducted interviews with several residents and their community leader.
My trip was much more than a first fieldwork experience. It was also a chance for me to return to Africa, an opportunity I cherished immensely. I grew up in Cameroon and welcomed wholeheartedly the chance to visit and learn about Nigeria, Cameroon’s neighbor to the west. Several Nigerians, in both Zaria and Ibadan, asked me if I was originally from Nigeria. One man, in a busy market in Ibadan, called out to me, as I walked by his shop: “Are you a child of Nigeria?” Some of the research participants saw me as more ‘African’ than foreign. This no doubt made it easier to establish trust with participants and conduct interviews, especially considering that I did not reside within the Hausa community, but was lodged in a nearby upper-class residential area. Most of the respondents I interviewed appeared to be comfortable with me and would sometimes ask me questions about my background or solicit my comparisons of Cameroon and Nigeria.
I set out to learn from these participants whether there were any differences in perspective regarding the polio immunization campaign between Hausa communities in the North and those in the South. If there were any differences, I also wished to gain perspective on why these differences existed. The time constraints of conducting this month-long preliminary project did not allow for as many interviews as needed to provide a more comprehensive picture of the perspectives from Sabo (i.e., the Hausa community in Ibadan, or other communities of Hausa settlers within predominantly non-Hausa towns in Nigeria). To make up for the small sample size, I asked my interviewees to speak about their fellow Hausas’ levels of resistance to the polio immunization campaigns and general views in their community.
Dr. Renne and I predicted that participants would report a lower level of resistance in Ibadan to the polio campaign than was reported in Northern Nigeria. We expected people to have felt less apprehension about the immunizations for several reasons. First, we speculated that because the Hausas in Southern Nigeria are a minority population, they would feel more pressure to conform to national, state, and local policies and accept immunization. Second, Hausas’ residence in Southern Nigeria meant that they would perhaps be more integrated into state and national policies with regards to the campaign. Third, their residence in a state in the South meant that they were less directly connected, at least geographically, to Hausas and Hausa leaders in the North. We anticipated that, for Hausas in the South, this geographical and political separation from the North would reduce the influence of Northern Hausa political leaders who spoke out against the campaign.
Only some of our predictions held. The residents whom I interviewed acknowledged a strong and indelible connection between Hausas in the North and the South, even though some agreed that religious and cultural practices by Hausas in the two regions differed. Our prediction that there would be less resistance in Ibadan was accurate, but two residents attributed this to reasons other than those we proposed. They agreed that, as a minority group in Ibadan, it was important that Hausas not develop a reputation for being uncooperative when it came to national campaigns, health or other. Hausas in Ibadan were like “guests,” one said, and as guests, it was natural for Hausas to behave in ways similar to the non-Hausa residents of Ibadan. However, they saw other factors as more central to creating the positive response to immunization in Sabo. They credited the work of vaccinators and local guides in ‘convincing’ Sabo residents to accept the vaccine.
Doing research in Ibadan
From July 23 to August 22, I lived in an area of Ibadan named Bodija, which is a short drive away from Sabo, the Hausa community in Ibadan. I lived with one of Dr. Renne’s contacts and visited Sabo several days each week. The help of a research assistant familiar with the city of Ibadan was invaluable to me. My research assistant helped me with getting around Ibadan, one of the largest cities in West Africa. Traditionally a Yoruba city, it is now home to a diverse population, playing host to people of various Nigerian ethnicities, people from other West African nations, and people from beyond Africa. During the British colonial era, it was an important seat of the colonial government. The British were influential in the various ethnic communities of Ibadan and often played a key role in the Hausa community by installing some of its leaders (Shehu 2005). Sabo is only one small area of this vast urban center.
Hausa immigrants began arriving in Ibadan during the 1840s; however, the settlement of Sabo was only formally established in 1916 (Cohen 1969:30; Shehu 2005). Most settlers came as traders and established Hausa settlements in many other towns in Southern Nigeria. The community is home not only to Hausas, but also to other Northern ethnic groups like the Fulani and Kanuri (Shehu 2005). During my interviews, I was told that through intermarriage, individuals who are Yoruba or hail from other southern ethnic groups have become part of the community. Many Sabo residents engage in business activities. Sabo is especially known for its male moneychangers. Whenever I went to Sabo, many men approached me, asking if I had dollars to change. However, I had already changed my dollars into Naira2 in Kaduna State, so had to decline their offers.
Businesses line the streets through Sabo. Beggars who were blind or disabled sat near Mokola Junction, a roundabout that provides access to the main street into Sabo. Children also hovered around this junction and did not hesitate to ask for money or a treat from passers-by. Begging, while certainly stigmatized, is a valid economic activity in many Hausa communities and according to Abner Cohen, “is a highly organized institution” in the Ibadan community (1969:44). Beggars often form associations that assist those who are disabled and also assign them sites for begging (Cohen 1969:44-45). Common sites for begging include busy intersections like Mokola Junction because of large numbers of people who pass through or make stops at the junction.
A few days after my arrival in Ibadan, I was able to meet with the local leader of the community, the Sarkin Hausawa, Alhaji Ahmed Zungeru. On the day I met the Sarkin Hausawa, I felt anxious. As leader of the Hausa community in Ibadan, it was important that he give me permission to talk with people in his community.
My research assistant, Josiah Olubowale, a graduate of the University of Ibadan, suggested that we give him a gift of kola nuts. This is a traditional gift in many West African societies and for the Hausa it has been a commodity of trade and consumption (Cohen 1969:131). The trade in kola nuts, along with British colonial rule in Nigeria and its attendant creation of industrial and urban centers like Lagos and Ibadan, brought Hausa migrants to Ibadan (Omolewa 1986:176; Shehu 2005:22). Hausas participated in and eventually monopolized the trade of cattle and kola nuts between Northern and Southern Nigeria (Cohen 1969:15-21). Cattle were purchased from Fulani herders and sold in the South, while kola nuts, grown by Southern farmers, were sent to the North. This trade was essential to the formation of Hausa settlements. Cohen notes that, “a closely knit network of Hausa centers for the sale of cattle, and for the purchase, storing, packing and transporting of the kola to the North, sprang up in the course of the first half of the [19th century] all over Yorubaland” (1969:21).
Thus, it impressed the Sarki when he opened our gift bag of kola nuts. “A foreigner has given us a very traditional gift!” he said, with a smile. Josiah and I talked with him for a while, answering his questions about our educational backgrounds and our research project. His residence is a modest building situated next to the mosque in Sabo and is brightly lit by sunlight filtering through its large windows. It has a veranda in the front where visitors kick off their shoes before going in, the custom upon entering Hausa homes. It has comfortable chairs along the walls and one special chair for the Sarki along the back wall. There is a dining table with a set of chairs off to one corner. We sat on the carpeted floor in the central space encircled by the chairs and talked with the Sarki.
The Sarki emphasized that the community was multi-ethnic and that most of the residents were born in Ibadan. He gave us permission to conduct interviews with residents in his community and put us in contact with one of his Councilors, who arranged several interviews for us. We were able to interview both the Sarki and the Councilor with whom he put us in touch.
The Councilor to the Sarki assists the Local Government in recruiting vaccinators who are Sabo residents familiar with the community and its inhabitants. He refers these recruits for training at the National Program on Immunization (NPI) office, which we were able to visit at the Local Government Secretariat. The NPI works closely with the foreign agencies to orchestrate National Immunization Days (NIDs), during which vaccinators go house–to–house immunizing children. I was equally nervous about meeting the Councilor. He was our next step in finding participants for our research. The excerpt below, drawn and partially reconstructed from my journal entry for that day, shows that I was right to feel nervous about this meeting.
The Sarki directed us to the chairman of the vaccinator recruitment committee. We went through a few back alleys and paths of the Hausa quarter, instead of simply walking down the main street that catered to cars and pedestrians. We were led by one of the Sarki’s retainers. We were taken to the Councilor who had an office along the main street. He asked us many questions about what we were doing. He asked to see the questions we were going to use for our interviews. We gave them to him and waited, as he examined the list. Finally, he allowed us to interview him. [July 26, 2005]
The interview went very well, as did our subsequent meetings with the Councilor. He contacted several vaccinators he had recruited and we were able to interview two of them who were directly involved in the immunization process as vaccinators or local guides. On some occasions, the Councilor allowed us to use his office to conduct interviews. He treated us as his guests, offering us chilled soda and malted drinks. In addition to interviewing the Sarki and this Councilor, we interviewed five other residents of Sabo.
Our sampling method for Sabo was, for the most part, a snowball sampling method. This method allows the researcher to “locate one or more key individuals and ask them to name others who would be likely candidates” for inclusion in a study (Bernard 1988:98). While our sample size was very small and this sampling method does not allow for generalizations, it was the best method for us to use in Sabo, considering our time constraints and lack of connection to the community. This sampling method was also appropriate because the Hausa community is a smaller community within the urban center of Ibadan, with its own community leaders and history of urban migration (Bernard 1988:98; Cohen 1969:29-50). Individuals within the community are more likely to be familiar with each other and the general views of other residents (Bernard 1988:95-98). While I spent some time talking with participants before and after the interviews, waiting in some of their business offices or shops along the main street, and observing their business exchanges, I did not make explicit use of participant-observation for data collection.
In addition to interviews done in Sabo, Josiah and I interviewed two medical doctors at the University College Hospital (i.e., the medical school of the University of Ibadan). One of the medical doctors is a physiotherapist and works in the Physiotherapy Department; the other works in the Department of Community Medicine. We interviewed a representative of the National Programme on Immunization (NPI), a coach of the training team responsible for preparing vaccinators to administer the polio vaccine to residents of Ibadan. We were able to interview him at the NPI office at the Local Government Secretariat building in Ibadan. He showed us some of the equipment used by the vaccinators and described the process of administering the vaccines to us. He very graciously responded to all our questions and even provided us with posters and a cap used by the program and its vaccinators to advertise the vaccine and the program’s goal of ‘kicking’ polio.
We were able to interview one polio survivor, Abdul, a disabled man of twenty-eight, who, at the time we interviewed him, was begging at the busy Ojoo intersection in Ibadan. We tried to contact him again for a more in-depth interview but we were unable to reach him. He told us he had been begging for two years. As mentioned above, begging is an important source of income for many Hausas (Cohen 1969:41-47). For polio survivors, begging is one way of surviving, especially if survivors lack kin to support them (Renne 2006a). The young man we interviewed told us that before becoming a beggar, he had been involved in transporting goods from Lagos and smuggling them across the border (probably the border with Benin). Disabled individuals can be successful smugglers, my research assistant later explained to me, as they can play on the emotions of the border patrol. The story of the young man we interviewed confirmed the dangers of smuggling. He was shot while en route to make a delivery for a client. As he briefly described the incident, he pointed to a scar near his left eye where a bullet had grazed him. Fortunately, he was not seriously injured. The dangers of smuggling caused him to turn to begging. He had completed primary school in Katsina State in the North but his parents had been unable to pay for his secondary education. He told us he had been involved in selling clothes.
Like many polio survivors that Dr. Renne interviewed in Zaria, Abdul contracted polio as a child and the financial difficulties his family faced caused him to stop his schooling and turn to various economic activities and, eventually, to begging (Renne 2006b:48). From talking to polio survivors in Zaria, Dr. Renne and I found that being disabled did not seem to deter people from pursuing educational goals or various economic activities. Our conversations with polio victims who were university and polytechnic students in Zaria revealed that these young people did not consider their physical disabilities to be obstacles to their success. The polio survivor Josiah and I interviewed in Ibadan voiced a similar view. Below is a part of our interview during which Abdul3 told us about his goals.
Abdul did not see his disability as an insurmountable obstacle to his success. He spoke to us with confidence and self-assurance. He made it clear that if he had the means to start a business of his own, he would give up begging. Thus, it seems that begging is an option for disabled polio survivors, but it is an option that they are compelled to choose when they lack the resources to pursue their educations or to engage in other economic activities, whether in the formal or informal sector.
Newspaper articles Josiah and I found at the Nigerian Institute for Social and Economic Research (NISER) on immunizations and polio confirmed the difficulties faced by polio survivors, as far as employment is concerned. One article told the story of a man in Ibadan named Aliu Julius who successfully completed his higher education and his term for the National Youth Service Corps, a 12-month period of volunteering that Nigerian university graduates are required to serve (Adekunle 1989). However, he was unable to find employment and was asking the readers of the news article to assist him in gaining employment. Several participants in our research said that they made sure to immunize their children in order that they may lead a normal life and not have to face such difficulties.
Talking to people about polio
My research assistant and I conducted a total of ten interviews. I made slight modifications to our questionnaire depending on the person we were interviewing. For the health practitioners, we tried to get their perspectives on treatments offered for polio patients or their views on patients’ willingness to receive vaccinations or treatments. For Sabo residents, we sought to record their perspectives on resistance to the campaign in their families, neighborhoods and community, and if they thought resistance was less prevalent in Sabo than in Hausa communities in the North. We also asked for their opinions on the value and effectiveness of the campaign and if they had recommendations for national and international proponents of the eradication of polio. My assistant participated actively in each interview, sometimes clarifying my questions or asking about things I overlooked. We transcribed the first two interviews together and I transcribed the rest of the interviews. All the interviews were done in English and all the participants spoke English. The following are preliminary conclusions I have drawn from participants’ responses.
As we anticipated, my research assistant and I found that residents we interviewed in Sabo reported that their community did not greatly resist polio immunizations. Several residents said that at the start of the campaign there was a low level of resistance but at the present there was no longer any. However, one of the vaccinators we interviewed said there was quite a bit of initial resistance and that some of the population still remained unconvinced about the merits of immunizing their children. In households where parents did not want their children immunized, the vaccinators did not administer the vaccines to the children on NIDs, during which time vaccinators went from house-to-house administering the vaccine and keeping a record of those who received or refused the vaccine. A community drama I attended in Zaria highlighted the negative responses vaccinators might face, as they are scolded and driven away from households. As the excerpt from our interview with one vaccinator and local guide illustrates, the vaccinators play a great role in reassuring people and, indeed, in the overall immunization process.
Vaccinators made return visits to households that initially declined immunization, based on records kept during initial and subsequent visits. The other vaccinator we interviewed confirmed that initial resistance declined and that the vaccinators were key in convincing people to have their children immunized. The vaccinator quoted above said that announcements made from mosques by community leaders and sensitization through posters and radio broadcasts also helped to increase the positive response of Sabo residents to the immunization campaign.
Despite whatever resistance there was in Sabo, the residents interviewed were sure that there was less resistance in their community than there was in the North. They offered several reasons why this difference existed. Though their shared religious and cultural background gave them a strong sense of community with Hausas in the North, the residents felt that they were not as conservative when it came to religious or cultural preferences. Several participants said they saw themselves as more enlightened than Hausas in the North. They felt that they were not very influenced by Muslim Hausa leaders in the North who said the vaccines had been contaminated with hormones that would render vaccinated children infertile. Cohen notes that, “Hausa culture in Sabo is not an extension of Northern Hausa culture” and that, “there is no uniform, homogenous, Hausa culture” (1969:47). Therefore it makes sense that reactions to the campaign would not be uniform. Reactions were not uniform in the North where Dr. Renne met many individuals who supported the campaign (Renne 2006c).
It is important to mention here that the separation between Northern and Southern Nigeria is very much a product of 20th century British colonial rule. Between 1900 and 1914, the British created a Northern and a Southern Protectorate and united both in 1914 (Omolewa 1986:167-167). While this separation is still used to describe the Federal Republic of Nigeria, it is not a clear one. When we interviewed the Sarkin Hausawa, he was quick to point out that geographical separations between the North and the South do not necessarily follow ethnic lines. This applies to religious divisions as well. Not all Hausas are Muslim or reside in the North, and not all Yorubas are Christian or reside in the South.
The medical staff we interviewed, as well as the NPI representative, confirmed that there was little resistance towards the campaign from the Hausa community in Ibadan. One of the vaccinators said that resistance declined with vaccinators’ attempts to convince families that initially refused the vaccine during subsequent visits. All the residents we interviewed in Sabo were in favor of immunization and those who had children said they had their children immunized early in the campaign. They used their children’s immunizations to set an example for other residents.
Some participants offered recommendations for improving the campaign, while some said they believed the campaign was quite effective. Those who gave recommendations said that accessibility to all the areas of the country was not easy and that organizers of the campaign did not take into consideration the obstacles of transportation in some areas of the country.
The use of members of the Hausa community in the vaccination process was hailed by the Councilor, the NPI representative and the vaccinators. They suggested that continuing to recruit Sabo residents to work as vaccinators would help the campaign. Hausa vaccinators could improve communication between NPI officials and Sabo residents since they could speak Hausa to residents. They also knew the community well enough to act as guides to other vaccinators and supervisors who were outsiders unfamiliar with Sabo.
Several participants recommended that basic healthcare and health facilities be made available to people. They emphasized that there were other illnesses such as malaria that Sabo residents worried about and for which better treatment was needed. Some participants explained that residents wondered why adults were excluded from immunizations and suggested making vaccines available to both adults and children.
One resident blamed “poverty” and the mismanagement of funds by Nigerian leaders as being the main causes of peoples’ problems (i.e., poor health). He cited a lack of food and other resources as more of a threat to Nigerians’ well-being than the polio virus. His comments were particularly poignant and I include part of my interview with him here.
Considerations for future research and polio immunization campaigns
There are several shortcomings in a study of such a preliminary nature. Biases in the questionnaires may have favored a certain response from participants, especially on the questions about the effectiveness of the campaign, where our underlying assumption seemed to be that the campaign was not effective. In the future I will have to consider the nature of questions I ask on questionnaires and underlying assumptions of the research. Another improvement on this study would be more in-depth interviews carried out by the researcher. In the course of transcribing interviews, I realized that there was a great deal of background information I did not have about the participants that would have enriched my data.
It is possible that the reports of less resistance to the campaign may not have been accurate since participants may have sought to provide responses that would cast a favorable light on their community. We speculate that this is the case, since the resistance to the campaign by Hausas attracted negative international publicity. Additionally, neither my Yoruba research assistant nor I are Hausa community members or closely affiliated with the Sabo community in a way that would grant us the residents’ trust. The shortness of my stay and the fact that I did not reside in the community could have only compounded this lack of trust.
A future study continuing this preliminary project will need a larger sample size and will also need to include women’s views, since all the Sabo residents interviewed for this study were male. One vaccinator said that he encountered housewives who refused to allow their children to be immunized. Another participant said women demanded that they be vaccinated along with their children. Women would be an important group to interview, as they are most likely to be the parents at home when vaccinators come. This would probably be the case if the women live in purdah, or seclusion. However, if they did not live in purdah, they would still be more likely to be the ones at home during the day, looking after their children, preparing food for their families, preparing food items and crafts for sale. Women who live in purdah also engage in these domestic tasks and may have their children sell foods prepared for sale (Sudarkasa 1981:55). Despite popular Western notions about the restrictive nature of women’s roles in Muslim societies, women play important economic and social roles in Hausa society and are key in establishing the Sabo-Ibadan community as wives, prostitutes, and food caterers (Cohen 1969:51-70; Cooper 1997; Smith 1956).
Ethnographic studies that document the perspectives of members of Hausa communities in Nigeria are key to understanding why individuals would decline a vaccine, hampering polio eradication campaigns that Western and international organizations deem urgent. Medical anthropologists can make important contributions to the dialogue between health organizations and vaccine recipients as well as bringing in the perspectives of polio survivors in Nigeria. Polio survivors are an important group with great contributions to make to their families, communities and, if given the chance, health education programs (Renne 2006a). The difficulties faced by polio survivors in Nigeria highlight that the issue is larger than simply eradicating polio. Better healthcare, including routine immunizations for children and treatment for other life-threatening diseases, and educational and employment opportunities must be made available for Nigerians. Nigerian citizens must feel they can trust their government and trust that political leaders have their interests at heart. The motives of foreign agencies are distrusted, as resistance to the polio immunization campaigns shows. As Kareem, the participant whose views are presented here, would probably agree, having a government that makes its citizens feel protected might alleviate the burden these citizens bear in protecting themselves and their children. While anthropologists can play important roles in this process and can alert foreign agencies to the complexities of the realities and choices confronting Hausas in Nigeria, I think Nigerian citizens and their leaders remain key actors. When one considers the size of Nigeria and the diversity of its large population, it becomes evident that Nigerians must present their perspectives to the world. By refusing polio vaccination, many Hausas do just that.
I would like to thank the Advanced Studies Center of the International Institute at the University of Michigan, Ann Arbor for funding this research. Special thanks to Dr. Renne for including me in this project; to her research assistants and colleagues for their kindness; to Josiah Olubowale for his great assistance and many hours of thought-provoking conversation; and to our hosts in Nigeria—in Zaria, Abuja, Ikole, and Ibadan—for making me feel at home in Nigeria. I am very thankful to the Sarkin Hausawa of Ibadanland and his Councilor and all the research participants. I thank the University College Hospital Library and NISER for giving me access to their journals and archives in Ibadan.
1Personal communication with Dr. Elisha Renne, July 2, 2007 and September 28, 2007.
2 The Nigerian currency, whose exchange rate in the summer of 2005 was roughly 140 Naira to the dollar.
3 All participant names used in this paper have been changed, and I have assigned them pseudonyms to protect their identities.
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