Solving the problem - Fighting measles in South Sudan

Our plane lifted roughly from the airstrip in Chuil and deposited us 25 minutes later safely at our home-base in Lankien.

Our plane lifted roughly from the airstrip in Chuil and deposited us 25 minutes later safely at our home-base in Lankien. While my immediate interest was using a proper shower, a toilet that did not involve squatting and washing my clothes, within the hour we were planning out the details of a mass measles vaccination campaign that involved vaccinating nearly 10,000 children in Thol ‘Payam’ (district).

I had never given a measles vaccine in my life, was brazenly unfamiliar with our surroundings outside of the market and compound, and until a few weeks ago had never treated nor diagnosed a patient with measles. To me, the planning felt like a fight against an enemy from the past; like trying to eradicate small pox. While I recognize that there is a considerable amount of controversy in the US and Europe regarding vaccine preventable diseases, here in Lankien, measles is second only to Kala Azar as a cause for serious paediatric admissions.

Measles hits children under five particularly hard; even with timely diagnosis and care, many don’t make it. The typical presentation starts with a fine, elevated rash on the forehead that progresses down the body, an eye infection and runny nose. Those that develop pneumonia are admitted for IV antibiotics and nutritional support. It is important to isolate these patients as soon as possible. We have a ‘measles tent’ for this purpose, but many are isolated well after they have infected other children in the ward and/or their siblings.

The Thol Payam measles campaign that took place six months prior had been effective at reducing admissions immediately following, but shifting populations from ongoing security concerns and cattle grazing had brought new, unvaccinated children to the district. Even if you have a competent immune system and were vaccinated, it is less than 90 percent effective, should be followed by a booster dose, and the child must be at least six months old to receive it.

Herd immunity (the protection of those who are susceptible to an illness by those around them who are immune) with measles is a vital step in controlling outbreaks. An effective campaign would ensure that this trend was reversed, and additionally, we would take the opportunity to de-worm and vaccinate for polio.

MSF mobile clinic team is vaccinating children in a remote area of northern Bahr el Ghazal, South Sudan, October 2014 ©Mathieu Fortoul/MSF

MSF mobile clinic team is vaccinating children in a remote area of northern Bahr el Ghazal, South Sudan, October 2014 © Mathieu Fortoul/MSF

With a few days to hire, train, and supervise 48 health staff at 15 sites, the pressure was on. Our Lankien outreach staff of five, whose names I had barely learned, would be key in ensuring success. Tyson and I would be going flat out for a week, covering many miles of rough dirt terrain in two cars filled with supplies. At times, crashing through trees and shrubs while avoiding dogs, goats, and cattle would be the only way to deliver the necessary medicine and supplies. Each morning, Tyson and I would gather all our equipment (needles, tables, chairs, documentation, cotton etc.), pharmacy would prepare our cold chain and vaccines and before 8 am we would set out.

I hadn’t predicted how difficult it would be to vaccinate in remote villages. While mobile vaccinations to control measles is important work, the other needs in the communities were overwhelming. Repeatedly, Tyson and I felt inadequate in our efforts when people, some without shelter, approached us begging for food, wound care for leg ulcers and treatment for a whole range of other illnesses and injuries. With no diagnostics, no scans, no lab work and little more than my stethoscope and hands, it was amazing how quickly my ICU skills adapted to auscultation, palpation and signs and symptoms to triage and treat patients.

The critically ill patients we drove back to Lankien at the end of the day, but to prevent too many passengers, all others had to foot their way to the hospital. Footing is no small task when you are sick and hungry and the temperature is well over 35 degrees Celsius.

All the time in the car made for endless conversation opportunities. When one of our staff was asking me what I missed from home, I awkwardly attempted to explain the idea of an air conditioner, living alone, a grocery store and what a burrito is; all funny, unfamiliar and slightly guilt inducing conversations. They taught me about sour milk, popped sorghum, harvest season and roasted lalope seeds; I listened to recordings of famous speeches from past political leaders of South Sudan (and Obama interestingly enough) and learned new Nuer words for describing cow patterns. Many conversations in South Sudan are centred on cattle: their color, their value, grazing, illnesses and cattle raids. Cattle are a huge source of pride, trade and culture.

Our colleagues also took this time to grill Tyson and I on our marriage status and eagerly suggested that Tyson marries me to solve this ‘problem’. One colleague was kind enough to offer up a cattle of his own to encourage the process along. How kind… and very uncomfortable for us both?! While Nuer marriage customs may seem very different on the surface from the Western world, their exchange of cattle for a wife and the common practice of polygamy, underneath the surface there are many similarities. Family acceptance and coming from a respectable clan are very important. Men and women look for compatible personalities and friendship as well as their interests in maintaining cleanliness and order in the house. And yes, health and looks do play a part, as they do anywhere.

There were obviously many hurdles to overcome executing a measles campaign, both logistically and emotionally. The short-term employment and management of our vaccination teams was complicated. Our vaccinators, who largely ranged in age from 18-25, predominantly male, and without previous work experience, like in any country, were challenging to manage. With the added language barrier and limited opportunity for direct supervision (we were splitting our time between many vaccination sites) there were continuous frustrations; for them, and for Tyson and I. Even with a day of training, needles were in the glass waste and tally forms were sometimes questionable.

On the flip side, teams organized the screaming children with little more than ropes tied to trees and plastic tables, rounded up the community, referred malnourished people for treatment at the Lankien ambulatory therapeutic feeding center (ATFC) and maintained their momentum throughout the constant location changes, schedule changes and repeated packing and unpacking while footing between sites.

Remarkably, things went really well. Our target number of children was met and measles admissions declined drastically in the weeks following. It was also a good learning experience for me. I walked away with new HR, security, radio operation, cold-chain, inventory, assessment, documentation and epidemiology skills. I feel much more comfortable with my outreach colleagues, and them with me. Luckily our drivers were beyond amazing, most importantly for their interest in keeping us safe by making strategic driving decisions but also because of their knowledge of working bore holes, footing times, assistance with packing and unpacking all the equipment and their genuine, funny and honest conversations… mostly about cattle.

Ultimately, once Tyson and I had some time to unwind, as we were counting more inventory from the campaign in the rub hall (luckily this time without bats) we felt confident the community benefited from everyone’s hard work and lives were unarguably saved.