Learning to Love Modern Day Lepers

“It would be better to die than to suffer this way,” Fathia says, wiping her hands together with finality. She sits across from me at the Caritas Medical Center in Djibouti, crying. I’m trying not to cry. I’m also trying not to back away as she coughs without covering her mouth. She is a single mother, a refugee from Somalia, and all five of her children have tuberculosis, commonly called TB.

According to the World Health Organization, close to 50 people are infected every week in Djibouti—a massive percentage for a small country with a population of less than 1 million. The disease is transmittable by air, a fact that I’m well aware of while we talk. A person of my healthy constitution and plentiful diet is unlikely to develop an active case of tuberculosis. And yet I know American lawyers who have had active TB. Diplomats. Teachers. Students. People just like me. The disease is in New York City, in Minneapolis, in Paris.

Like other infectious diseases that plague the modern world, the cure to TB is complicated. But because of the social stigma and isolation associated with it, medical professionals are increasingly convinced that part of the solution will come from one simple source: trust born of relationships.

A trusting relationship is critical,” says Annie Mikobi, a Congolese doctor working in Djibouti. “Without it, there is no observance of treatment.

“Stigma is a huge barrier, and breaking down stigma requires trust,” says Bob Carter, a family practice doctor with SIM (Serving in Mission) who has worked with TB patients in Kenya and Zambia for over 20 years. “TB patients must trust that I care about them, that I won’t disclose their status to others, and that I have their best interests at heart. When healthcare providers are not trustworthy, those living with infection remain hidden.”

Here in Djibouti, a person with tuberculosis might be kicked out of their home. Family members might refuse to eat with them or to sit in a room with them, and they aren’t welcome at community events or even offices and schools. In other words, Fathia and her children are modern-day lepers.

It’s like we’re dead already, anyway,” Fathia says. “Kids won’t play with my children. They run away from them in the street. People talk about me. They say, ‘Look at that mother. She made all of her children sick. She is a terrible mother.

Although the doctor at Djibouti’s Hol-Hol refugee camp provides free tuberculosis medications, Fathia left the camp and came to the city in order to earn money by begging. She brought only the pills she had at the time, enough for seven days.

Now Fathia gets pills at a center in town but is inconsistent in how she administers them. Sometimes she gives the youngest one all the medicine and sometimes she spread the pills out among the others. No one regulates their care—what doctors call “directly observed therapy”— and they are all getting sicker. They cough through the nights and huddle together under blankets trying to keep warm while their lungs devour themselves. Her youngest, Yusuf, faints on a daily basis.

I have fevers. I’m coughing a lot,” she says. “But I can’t go to the doctor. I can’t leave Yusuf or he will fall into a fire, fall on the stones.” She coughs again, this time into the blue and red cloth of her headscarf.

Until now, Fathia hasn’t understood that by administering the pills so inconsistently, she is possibly giving them multi-drug resistant TB—a death sentence for a refugee in Djibouti. At the very least, she isn’t curing them, and they could be infecting neighbors or friends. Although it might be easy to judge Fathia for failing to follow the doctor’s recommendations, her refugee circumstances bring a unique level of desperation and chaos.

Successfully implementing DOTS [directly observed therapies] in a public health TB program in stable communities is challenging enough,” says Carter. “The difficulties are multiplied many fold in migrant or refugee populations.

With Fathia in front of me, I am reminded of the lepers of Jesus’ day who suffered from the same fear, loneliness, and social marginalization. Jesus touched their disease and in doing so, he restored not just their health but also their place in the community and their sense of dignity. He made them clean and whole.

While I don’t have the healing power of Jesus, I do hope to hear and affirm Fathia’s story without being afraid of what floats between us, without shrinking back. The call of the gospel is to go to the jails and slums and medical clinics and to offer dignity, affection, and humanity. In other words—to establish relationships like this one that build trust and extend Christian love.

Medical professionals, in particular, know the faith community is key to the TB cure. “Our response to tuberculosis and AIDS would not have been and will not be the same as it is today without the faith community, and now there are five critical actions we need to take together,” Eric Goosby, United Nations Secretary-General’s Special Envoy on Tuberculosis, said at a UN interfaith prayer breakfast last September. “Educate, advocate, and fight stigma. Continue to fight for patient-centered care. Give voice to the voiceless, especially the children.”

I’m not a medical professional and I have no control over cures, but I can direct Fathia to the pulmonary care nurses at the social service center where we sit. We can talk about inexpensive, healthy meals for her family. I can urge her to be consistent with the pills and to allow a medical caregiver to supervise her family.

As Fathia coughs, I think about Jesus touching lepers and place my hand on her shoulder. I pray she will trust me enough to take my advice. That’s the closest I can get to a miracle.

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Statewide, Minnesota has a healthy measles vaccination rate. But in some school districts, the rate is much lower

The share of Minnesota kindergarteners who are up-to-date on the vaccines that ward off measles, mumps and rubella has seen a small decline in recent years, dropping from 93.7 percent to 92.5 percent between 2014 and 2017, according to data from the Minnesota Department of Health. (Nationally, the rate is around 91 percent.)

That’s not great, but it’s probably not a huge cause for alarm. Despite a rash of anti-vaccine sentiment pumped up by debunked theories linking the MMR vaccine to autism, experts say a vaccination rate in the 90 percent to 95 percent range, is typically enough to prevent outbreaks.

But that high statewide average hides much lower vaccination levels in some corners of the state. In some school districts, the vaccination rate is less than half the state average, leaving kids vulnerable to illnesses public health officials say can be deadly and should be preventable.

Outbreak

An outbreak of a vaccine-preventable disease isn’t a theoretical fear. This year, 15 stateshave seen cases of measles, a highly contagious and sometimes deadly childhood disease that had been all but eradicated in the U.S. until recently.

In the spring and summer of 2017, Minneapolis saw a major outbreak of measles. The disease took hold in the city’s Somali community, susceptible due to decreased rates of childhood immunization.

Between 2004 and 2014, the rates of MMR immunization at two years of age in Hennepin County’s Somali community had declined, from more than 90 percent to about 40 percent.  A Centers for Disease Control report attributed the decline to “concerns about autism, the perceived increased rates of autism in the Somali-American community, and the misunderstanding that autism was related to MMR.” In recent years, prominent members of the anti-vaccine movement have visited Minneapolis, drawing ties between the MMR vaccine and autism, a claim with no scientific basis.

Mariam Osman, of Rochester, holds her four-month-old son, Mohamed Abdi-son, while listening during the community forum about measles hosted by the Somali Health Advisory Committee on Monday, May 22, 2017, at Olmsted County Public Health Services in Rochester. PHOTO: Andrew Link / alink@postbulletin.com

The outbreak was costly. All told, there were 65 patients, and the outbreak cost Hennepin County and the Minnesota Department of Health $1 million, said Kris Ehresmann, director of the infectious disease division at MDH.

Vaccination rates shouldn’t get that low. Under Minnesota law, kids are required to be vaccinated against a battery of illnesses in order to attend school or licensed childcare facilities.

Unless, that is, their doctor believes they have a medical condition, such as an immune system that can’t handle a vaccine, or an allergy to a vaccine’s components, or have a notarized “conscientiously held belief” statement that declares an objection to vaccines.

The state has allowed non-medical exemption to vaccines in one form or another since 1967. The “conscientiously held beliefs” language was added to statute in 1978, according to MDH.

Whether to vaccinate kids or not is sometimes framed as a personal choice, but it has major implications for public health. The state requires vaccines because of a concept called herd immunity: If 97 percent of a population is vaccinated against a given disease, the 3 percent who are not — say, for medical reasons — run a much lower risk of bumping into someone with the disease than they would in an unvaccinated community. If 50 percent of the people in a community are unvaccinated, someone with a compromised immune system is at a much higher risk of contracting a preventable, and potentially life-threatening, disease.

You want to have a threshold level — above 90 percent or more — to make sure that you have enough people vaccinated so if disease is introduced, it really can’t get a foothold,” Ehresmann said.

Varied rates

Statewide, Minnesota kindergartners meet that threshold for widespread protection, at a 92 percent vaccination rate for chickenpox; a 93 percent vaccination rate for diphtheria, tetanus, and whooping cough (DTaP), polio, and MMR; and a 95 percent vaccination rate for hepatitis B.

MMR Vaccination rate for Minnesota school districts and charters, 2017–18

Note: school districts and charters with kindergarten classes of 5 students or fewer are excluded from the data to protect privacy.

Source: Minnesota Department of Health

Some districts exceed the state average. Schools in the Cass Lake-Bena district, on the Leech Lake Band of Ojibwe reservation in North-Central Minnesota, have a near perfect score when it comes to kindergarten vaccination rates, according to state data.

Melissa Jenson, the district’s nurse, said a community effort that includes the schools, parents and public health, helps ensure kids are vaccinated.

District leadership is committed to following the state’s immunization requirements, she said, barring students who are not vaccinated and don’t have an exemption on file from attending school.

“We ensure all students are up-to-date. If they aren’t, they are excluded until proper documentation has been received, whether it is the immunization records, or documentation of conscientious beliefs or medical exemption,” she said.

Under Minnesota law, enforcing vaccine requirements comes down to school districts — the state doesn’t receive notification when a student hasn’t had their vaccines — but some districts enforce the state law better than others, said Ehresmann, of the Department of Health.

Jenson says the high vaccination rate also comes down to the availability of services and the diligence of Indian Health Service and other health providers in the area.

In her five years in the district, Jenson says she’s only had a handful of parents question the vaccination requirement or decide not to vaccinate their kids.

“They are concerned, they want to protect their children from harmful disease and they really value protecting the health of the community,” she said.

Not every school district has vaccination rates as high as Cass Lake-Bena’s.

In the 2017-18 school year, Hill City, south of Grand Rapids, Minnesota, had a vaccination rate of 47 percent for MMR. Upsala, northwest of St. Cloud, has a 55 percent vaccination rate, according to data from the Minnesota Department of Health.

Some charter schools, classified in state data as districts, had rates as low as 36 percent, as in the case of Best Academy, in North Minneapolis, and Art and Science Academy in Isanti.

There aren’t a lot of clear patterns in who vaccinates their kids and who doesn’t, Ehresmann said. It doesn’t align with a set of political beliefs or socioeconomic status.

The Department of Health looked at data by mothers’ country of origin and found mothers born in Eastern Europe, Western Europe, Canada and Somalia were less likely to vaccinate their kids than U.S.-born moms. But mothers born in African countries other than Somalia, and those born in Central America, South America, the Caribbean and Mexico were more likely to vaccinate their kids than U.S.-born moms.

Money shouldn’t be a barrier, since the federal government provides free vaccines to kids without health insurance through a program called Vaccines for Children. But sometimes transportation can be an issue. And since getting vaccines requires setting up appointments, some parents decide it’s easier to get the conscientious belief exemption form notarized and turned in, Ehresmann said.

In California, some of the schools with the lowest vaccination rates are in wealthy counties north of San Francisco.

Legislative proposal

This legislative session, Rep. Mike Freiberg (DFL-Golden Valley) introduced a bill aimed at reducing disparities in vaccination rates.

HF 1182 would establish a Minnesota Department of Health-administered grant program to help communities at risk of disease outbreak. It would provide money to community health organizations in such areas to raise awareness of vaccines using Centers for Disease Control educational material. The bill was heard in the House’s health and human services policy committee and now awaits a hearing in health and human services finance. Its Senate companion, SF 1629, awaits a hearing in the Senate health and human services finance and policy committee (another bill, SF 152o, would eliminate the conscientiously-held belief exception).

In the past, Freiberg put forth legislation that would tighten up requirements surrounding the conscientiously-held belief exemption to vaccines. While nearly all states have a religious exemption, which generally require parents to prove vaccines violate a tenet of their religion, Minnesota is one of 17 states that has a looser philiosophical belief exemption, according to the National Conference of State Legislatures.

That approach didn’t pass, so this bill focuses on raising awareness and providing science-backed information to communities where vaccine rates are low.

“There’s a lot of misinformation out there when it comes to vaccines,” Freiberg told MinnPost.

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Addressing health needs of women and children in Baidoa

In Somalia, maternal mortality rates are among the highest in the world. One in 12 women is likely to die during pregnancy, childbirth, or the postpartum period because of a lack of access to health services. Infant mortality is exceptionally high with one in seven children not reaching the age of five.

Ministry of Health staff are attending to a mother in labour in the labour ward of the Bay Regional hospital, Baidoa, Somalia, July 2018.

Since May 2018, Médecins Sans Frontières (MSF) has supported the Bay Regional hospital in Baidoa, in the South West State of Somalia, to address the health needs of women and children. From May to December 2018, over 4,000 women received antenatal or postnatal consultations and over 1,500 women were admitted to the maternity ward. A total of 686 babies were delivered in that eight month period.

Halima’s story

Halima, 18, lives in a village some 100 kilometres south of Baidoa. She is among the first women to have benefited from free maternity services for pregnant women and new-borns at Bay Regional hospital since MSF started our support in May 2018.

“I was planning on giving birth at home but after two days of labour I passed out, so my relatives put me on a donkey cart and got me to a nearby health centre in Qansah-Dhere district,” says Halima. “When I arrived, I was in very bad shape and the medical staff were unable to help. They kept me there for one night but I was still in a coma so they decided to send me to Bay Regional hospital in Baidoa.”

The next day, Halima was still unconscious and loaded onto a bus headed to Baidoa. The journey takes a full day but a few hours into the journey, Halima went into labour.

The baby started coming out; I was still unconscious and nobody knew what to do,” Halima says. “I was told that by the time I reached the hospital I had been in a coma for eight days. I lost my baby but the doctors in the hospital managed to save my life.

It took Halima another two days to come out of the coma and she has since been recovering in the inpatient ward of Bay Regional hospital.

“Since the hospital is the main referral centre in the region, most of the cases we receive are already very complicated ones, whether women have been referred by other health facilities or are self-referred,” says Asma Aweys, MSF’s medical manager at the hospital.

Building up obstetric services

The first phase of our intervention, aimed at establishing a fully functioning, comprehensive obstetric unit, will involve supporting the hospital’s capacity to deliver antenatal and postnatal care, and ensure normal and complicated deliveries. It will expand in coming months to include a neonatal unit and support to paediatric inpatient, outpatient and emergency room services.

“MSF is committed to helping women during childbirth,” says Himedan Mohammed Himedan, MSF´s Head of Programme for Somalia. Ordinarily this is a very difficult period in a woman’s life, but given that the fighting has destroyed many health structures, the challenges of giving birth are even greater.”

We need to get the word out to the whole community, so that expectant mothers know that they can receive quality care from MSF during this period, says Himedan.

MSF humanitarian medical activities supporting Somalis

MSF resumed activities in Somalia in May 2017, after an absence of close to four years due to extreme attacks on our staff and other serious concerns.  Since our return to Somalia, we have been supporting the Bay Regional hospital in Baidoa and the Mudug Regional Hospital in Galkayo. Our teams have also provided humanitarian assistance in the displaced camps of Galcayo, nutritional support in Dollow in Dhusmareeb, and periodic visits to Jubaland to support child healthcare and prepare for outbreaks in Dhobley, Bardhere and Garbaharey.

We have conducted cataract surgery eye camps in collaboration with local agencies in Ergavo, Las Anod, Buhodle, Galcayo, Baidoa and Bardhere.

“Across Somalia, MSF is looking to ensure that people have access to medical care in areas where needs are critical and where the security conditions permit. The need for free quality healthcare is very high in Somalia and our strategy is to steadily increase our support to existing structures to improve the services,” says Gautam Chatterjee, MSF’s country representative for Somalia. 

While the context is certainly challenging, we can rely on dedicated local staff, often medical staff who have already worked with MSF, to build the capacity and ensure improved access to healthcare services in Somalia.

In Somaliland, we are supporting the diagnosis and treatment of patients with drug-resistant tuberculosis at health facilities in Hargeisa, Borama, Burao and Berbera. We are also planning to support other health structures in Las Anod.

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African refugees’ healthier pregnancies likely due to unhealthy U.S. culture

African refugee women experience healthier pregnancies than women born in the United States, despite receiving less prenatal care, a recent UB study found.

Compared to U.S.–born black and white women, African refugee women had fewer pre-pregnancy health risks, fewer preterm births and higher rates of vaginal deliveries. Surprisingly, the refugee women were more likely to delay beginning prenatal care until the second trimester.

The disparity, says the researchers, may be tied to various unhealthy behaviors and practices present within U.S. culture. For African refugee women, acculturation may negatively impact health.

“It is often thought that refugees immigrating to the United States from war-torn nations will experience a better quality of life once here,” says Kafuli Agbemenu, assistant professor in the School of Nursing and lead investigator on the study, published in February in the Journal of Women’s Health.

“However, some of the elements of U.S. life, such as eating processed food, an increased reliance on cars or buses for transportation, extended inclement weather, a more individualistic society, and drug and alcohol use, may, in fact, contribute to African refugee women having poorer reproductive health outcomes.”

Reproductive health disparities between U.S.-born white and black women are well documented, says Agbemenu. However, few comparisons have been made between African refugee women and U.S.-born women.

African refugee women are susceptible to numerous health disparities as a result of factors such as socioeconomic status, gender, ethnicity, low levels of education and language. Another risk-factor specific to their population is the high prevalence of past traumatic experiences.

These risks led researchers to believe African refugee women would have poorer reproductive health outcomes than women born in the U.S. The unexpected results reveal that the healthy immigrant effect — a phenomenon where immigrants experience healthier outcomes than native populations — extends to reproductive health.

The researchers examined electronic birth certificate data from hospitals within Erie County, an area of Western New York that resettles a large number of refugees. The data contained clinical, psychosocial, socioeconomic and demographic information, as well as the mother’s country of birth.

Women born in Burundi, Democratic Republic of Congo, Eritrea, Rwanda and Somalia were considered of refugee status for the study, due to the large refugee populations in Western New York resettled from these nations.

The data contained information on nearly 60,000 white, almost 17,500 black and close to 800 African refugee women who gave birth from 2007-16. The information was limited to mothers who used Medicaid to cover medical expenses to control for socioeconomic status.

Researchers discovered that African refugee women had significantly less maternal medical risk factors, such as pre-pregnancy hypertension or diabetes, compared to U.S.-born women. Refugee women experienced more vaginal births, and were less likely to undergo cesarean sections or to be medically induced into labor.

Less than 1 percent of refugee women smoked or took illegal drugs during pregnancy, compared to white women (12 percent smoked, 4.5 percent took illegal drugs) and black women (15 percent smoked, 18 percent took illegal drugs).

Refugee women also had the fewest preterm birth (6 percent) compared with white women (9 percent) and black women (13 percent).

While most of the women from all groups began prenatal care within the first trimester, African refugee women were more likely to delay prenatal care until the second trimester. Refugee women also received higher amounts of inadequate prenatal care (27 percent) compared to white women (12 percent) and black women (24 percent).

These favorable health outcomes for African refugee women also occurred in spite of the group experiencing higher rates of meconium staining, the earliest stool of an infant that when passed in the womb is a sign of fetal distress.

The high rate of inadequate prenatal care for African refugee women is troubling, says Agbemenu, and indicative of the disconnect between refugee populations and the health care community.

These women have reported feeling ostracized and marginalized by the medical community,” says Agbemenu. “They are at times hesitant to seek care, and when they do, it is typically at a time when the problem has escalated.

The development of culturally targeted reproductive health education is urgently needed, she says. Health care professionals also need to understand that refugee women are likely to have histories of trauma and, therefore, need care delivered from a trauma-informed perspective.

Additional investigators on the study include Nadine Shaanta Murshid, assistant professor, School of Social Work; James Shelton, clinical assistant professor of obstetrics and gynecology, Jacobs School of Medicine and Biomedical Sciences at UB; UB nursing doctoral student Samantha Auerbach; and Ndidiamaka Amutah-Onukagha, assistant professor of public health and community medicine, Tufts University School of Medicine.

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Mother jailed in Brisbane for arranging daughters' genital mutilation in Africa

A woman who took her two young daughters to Africa for female genital mutilation has been sentenced to four years in prison, becoming the first person in Queensland to be jailed for the crime.

The guilty woman cannot be identified for legal reasons.

Key points:

• Judge Leanne Clare said the mother betrayed her position of trust with her daughters
• The court heard the mother told a child safety officer in Australia she would not subject her girls to FGM
• The mother must serve eight months in jail before her sentence can be suspended

The District Court in Brisbane heard the girls — aged 10 and 13 — had no prior warning they would undergo the procedure after travelling to Somalia with their mother in April 2015.

Last month, a jury found the woman — who cannot be named for legal reasons — guilty of two counts of removing a child from the state for female genital mutilation (FGM).

She will have to serve eight months before the four-year prison term is suspended.

In sentencing, Judge Leanne Clare said FGM involved a "particular type of violence — not born of anger or aggression, but a commitment to tradition".

She said the woman took steps to avoid the reach of Queensland law.

"She deliberately took the girls from a country that would protect them," Judge Clare said.

"She made that journey with the intention of the mutilation.

A mother who subjects her daughters to that treatment seriously betrays her position of trust.

The court heard the girls were staying at their grandmother's house in Somalia when "arrangements were made for someone" to perform the procedures on them.

Crown prosecutor Dejana Kovac said it left the girls bleeding for a day and in pain for up to three days.

"[One of the girls said] her mother was present. She wasn't sedated, was fully awake and felt pain," she said.

The maximum penalty for female genital mutilation charges in Queensland is 14 years in jail.

'Psychological consequences' likely for girls

Ms Kovac said in 2008 the woman, who underwent a childhood procedure herself, told a child safety officer she was aware FGM was illegal in Australia and did not plan to send her daughters to Africa to have it carried out.

Medical evidence suggested there was no permanent scarring to the girls, but ongoing "psychological consequences" were likely, Ms Kovac told the court.

Defence barrister Patrick Wilson said his client, who is undergoing chemotherapy, was supported by her children.

"[They] stand by her," he said.

Judge Clare confirmed it would be the first such sentence in Queensland, and said only two other cases had come before Australian courts, both in New South Wales.

According to the World Health Organisation, FGM involves a "partial or total removal of the external female genitalia, or other injury to female genital organs ... for non-medical reasons".

An Australian Institute of Health and Welfare report, released in February, said the United Nations estimated at least 200 million girls and women had undergone the procedure, with 53,000 of them thought to live in Australia.

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Somalia: The ICRC provided some medical supplies to primary health facilities and few hospitals

In 2018, the ICRC continued to respond to the needs of Somali people affected by 35 years of conflict and harsh climatic conditions like droughts and floods, despite reducing and suspending some of its activities following concerns over the security of its staff and overall acceptance in the country.

Protracted conflicts and violence have particularly corroded Somalia's health care system and created fertile ground for disease and malnutrition. 

Less than 15% of the population in rural areas and less than 50% in urban areas have access to health care. The ICRC provided medical supplies to primary health facilities and hospitals and trained medical personnel in trauma care and other life-saving skills. It also supported the Somali Red Crescent Society (SRCS) to train community first aid responders to enable them to respond to emergency situations

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Resilience and resolve are the keywords for women eradicating Polio

Thanks to the unbending resolve and resilience of women health professionals as they go door-to-door across villages and mountains administering vaccine in some of the most marginalized or remote communities, women are truly the backbone of the polio programme at the ground-level. We asked a few of these women about their most daunting and heartening moments in polio, and how they worked through them.

Asha Abdi Dini—District Polio Officer, Banadir, Somalia

A district polio officer with over two decades of experience in Banadir, Somalia, for Asha Abdi Dini, refusals are always heartbreaking. 

My worst moment was seeing a family who had three girls and a son. They vaccinated their daughters but refused to allow the boy to take the vaccine. The boy got the polio and the girls survived.

Women are on the front lines of polio eradication. ©UNICEF Somalia

 But Asha takes pride in the challenges she has been able to overcome since joining the polio programme.

My best moment is seeing the same children I once vaccinated all grown up and bring their own children for vaccinations. It gives me immense hope and happiness, she says.

Julia Kimutai—Community Strategy Coordinator Nairobi, Kenya

A day in the life of Julia Kimutai as a Sub-County Community Strategy Coordinator in Nairobi, Kenya. ©WHO EMRO

For Julia Kimutai, a 38-year-old community strategy coordinator in Kenya, educating the public about the importance of vaccines is a constant project. As a specialist in dense urban areas with high rise buildings, Julia knocks on a lot of doors and is often greeted with refusals.

To convince some mothers is not easy,” she says. “It has never been a smooth ride.

But where some might just see a campaign-time encounter with skeptical parents as a one-off, Julia sees a long-term project.

Where we have difficulties is where we double down our efforts to build relationships. We even go back when there is no polio campaign to try to talk with parents, emphasize why vaccination is important and try to do a lot of health education, she says.

As a woman and as a mother, Julia believes she is uniquely qualified as she can relate, understand and convey the importance of polio vaccines to the numerous apprehensive mothers she meets daily.

“I am a good listener, a good communicator and patient. These tools help me daily as Polio Eradicator and a mother.”

Bibi Sharifa—Health Communication Support Officer, Islamabad, Pakistan

A continent away, for 39-year-old Islamabad district health communication support officer, Bibi Sharifa, a big part of the job is demonstrating how women can do difficult work and stand firm in the face of adversity.

“People often think that women are incapable, but they really couldn’t be more wrong. The women on our programme are extraordinary – they are strong, gentle, dedicated, humble, passionate, disciplined and fierce at the same time,” she says. “They are driven by the love of their children and their community, and despite the challenges they face, people should realize that women are like grass, not like trees: where trees can be uprooted by floods, grass can face the brunt of flood easily.”

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Wajir tackles measles outbreak as rainy season approaches

Two months ago, 35-year-old Nunai Farit developed a fever coupled with a dry cough and a running nose.
Her family thought it was an asthma attack and contacted a community health worker.

Children getting immunised in the ongoing measles, mumps and rubella vaccination in Wajir County. [Jeckonia Otieno/Standard]

Unfortunately, the health worker could not do much and the mother of five died two days later. She was buried at a community cemetery at her rural home in Mau Mau.

Days after her burial, the results of samples sent to the Kenya Medical Research Institute (Kemri) laboratory revealed that Farit did not die of asthma, but of measles.

Her family was stunned.

However, indicators of what Farit was suffering from were there all along. To begin with, her death came at a time when Wajir County was facing a measles outbreak. So far, four people have died.

The problem was, there were no qualified personnel to give a quick and correct diagnosis.

Only the community health worker would come to help, there was not much we could do,” says her father-in-law, Adow Abdi.

Measles is a highly contagious viral disease. In Kenya, children are vaccinated against the disease at nine and 18 months. But in a region where health facilities are far and scattered, many go without the vaccine.

According to the Ministry of Health, only about three in every five children have received full measles immunisation in Wajir County.

This translates to 66 per cent of children under the age of five which is below the national average of 80 per cent and lower than the World Health Organization average of 90 per cent,

As such, whenever a measles outbreak occurs, it spreads like bush fire.

First outbreak

The first outbreak of measles in the county was reported in September last year. So far, 255 people have been diagnosed; among these 132 are children.

This has stirred the county government into action.

On Saturday, March 16, a massive one-week measles vaccination campaign was launched in the county’s 102 health facilities.

The campaign, targeting 94,000 children, has received backing from the Save the Children Fund which has put Sh14 million.

One of the problems we discovered is lack of cold facilities to preserve measles vaccines, said Save the Children’s Gilberto Koki.

The county has put in Sh14 million and opened all its facilities for the campaign.

Speaking during the launch, Wajir Deputy Governor Ahmed Muktar admitted that measles outbreaks in the region have grown more unpredictable, and more lethal.

Initially, the outbreaks would be expected during the months of May and June just after the rain season,now they come when least expected, said Muktar.

The major challenges in countering measles outbreaks, he said, remained poor infrastructure and myths against vaccines.

To counter these, the county has hired hundreds of health workers to scour the vast terrain to explain to villagers why they need to have their children immunised.

Still, the health workers might not do much, as happened in Farit’s case. Muktar conceded that the region urgently needs more trained personnel.

Besides, whenever the county succeeds in controlling measles outbreak, its neighbour next door — Somalia, does not have an effective immunisation programme.

And measles does not respect country borders. To counter this, a cross-border surveillance is on under a programme funded by the World Health Organisation.

This massive anti-measles drive clearly shows one thing: that Farit did not die in vain.

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Somalia: ending the specter of cholera

Dr Lubogo, a cholera expert working with WHO in Somalia, is passionate about the fight against infectious diseases in the country. “Mention an epidemic, and find it in Somalia”, he says. “People face outbreaks of cholera, diphtheria, dengue - and that’s just in the parts of the country which are safe enough to visit, where we know what’s going on. There may be other diseases in inaccessible areas.”

Dr. Mutaawe Lubogo (l) administering the Oral Cholera Vaccine to a health worker during the 2017 campaign (Photo: WHO)

When Dr Mutaawe Lubogo speaks about his work, enthusiasm colors his voice and a sparkle lights his eyes.

In Somalia, Dr Lubogo says, almost two thirds of the population has not had access to modern health services for the past 30 years. The ongoing civil war has severely damaged Somalia’s health services. It destroyed hospitals and health centers, forced medical professionals to flee danger, and broke down supportive infrastructure like roads and communications services. In addition, the majority of the country faces an annual cycle of flooding and severe droughts, which in turn drives food insecurity, famine, and mass migration. Dire conditions which provide a fertile breeding ground for infectious diseases.

Fig. 1: Distribution of cholera cases in Somalia, January 2018 to February 2019 (source).With so many overwhelming challenges to address, where does one begin? For Somalia, fighting cholera has been one of the first priorities. Dr Lubogo: “If you’re looking for a disease that is both very deadly and at the same time easy to cure and prevent technically, cholera is it.” Since the current outbreak started in December 2017, Somalia has reported 6817 cases and 46 deaths. Although the outbreak is dwarfed by that in nearby Yemen, it is nevertheless a pressing cause for concern for WHO and health authorities, given also the vulnerable state of Somalia’s health system and population.

Although the structural and political causes of cholera outbreaks are often complex, on paper treatment and prevention are simple: both rely on access to safe water. Dr Lubogo: “Somalia has 13 million inhabitants, of whom an estimated 6 million are at risk of cholera, and 2 million at high risk. A large part of the high risk group are people living in refugee camps, and because camp locations keep shifting, setting up high quality, permanent water infrastructure with boreholes, protected sources, piped systems, becomes very complicated.”

A woman washes her hands outside the Cholera treatment centre in Banadir hospital in Mogadishu, Somalia. (Photo: Karel Prinsloo/Arete/Gavi)

But there is a plan. A global roadmap to ending cholera, launched last year. In it, WHO and its partners in the Global Taskforce on Cholera Control set the goal of reducing cholera deaths by 90% in the next 11 years, by improving surveillance, early warning, and oral cholera vaccination. As WHO’s Dr Dominique Legros said in a recent interview, “saying we can end cholera isn’t silly at all.”

Fig. 2: Multi-sectoral interventions to control cholera (source).

An important part of that plan is the oral cholera vaccine,(OCV). OCV has more than proven its worth in Somalia: in 2017, 1.2 million Somalis aged 1 year and above received the vaccine, in different hotspot locations where year after year outbreaks of the deadly disease would occur. The result? Cholera cases fell by 75%, and all new cases currently reported are  people that had not received the vaccine. The successful programme is now scaling up, targeting another 650,000 people during end of April of 2019.

Fig. 3: Cholera cases in Somalia, December 2017 to February 2019 (source).

Despite its success, OCV isn’t a panacea. Instead, the vaccine’s three-year protection span provides a breathing space to implement other health programmes, as well as safe water and sanitation (WASH) measures. Somalia can again boast promising results in this regard; in all OCV campaigns, WHO has worked closely together with WASH partners, combining vaccination campaigns with health education and safe water interventions. As a result, 75% of the people in vaccinated areas now also enjoy improved access to safe water.

The next two years will be crucial to end the cholera outbreak in Somalia. Although the road ahead is not without obstacles, the success of the 2017 OCV campaign and the planned scale-up hold the promise of a cholera-free Somalia. If Dr Lubogo has his way, soon this deadly disease will be a specter of the past in all of Somalia.

Source