War, Poverty, Disease and Vaccines in Central Africa: A crisis of health care and human rights

A child in the United States is born in a hospital, glistening in blood and placenta, promptly cleaned and welcomed into the world by smiling parents, gowned and gloved doctors, and a birth certificate. Within fifteen months, this child will go to a pediatrician and receive vaccinations for a variety of illnesses, including tetanus, polio, measles, mumps, rubella, and meningitis, diseases that have been essentially eradicated in the Western world. The fact that this child has been vaccinated will be written in medical records that can be accessed later; the information is secure and accessible. Vaccination is routine, and besides the contingent of the population that now believes vaccines to be dangerous – risking the health of the entire population – enough children in the United States, and other wealthy western countries, are vaccinated against these diseases to prevent reoccurrence of epidemics. Some diseases, like smallpox, have been entirely eradicated by vaccination, a miracle of modern medicine.

A child in the Democratic Republic of the Congo is born on the floor of a haphazardly built shelter in a rural area, glistening in blood and placenta, promptly bathed in dust, and welcomed into the world not by doctors, and perhaps without a birth certificate. Within fifteen months, the child may or may not have received her vaccinations, and if she has received them, they may or may not have been effective. If the child is vaccinated, that fact may or not be written down somewhere, and if it is written down somewhere, that information may be accessible later on, but it may not be; whatever health care facility these records are held in may be destroyed by civil war, or may not have enough funding, supplies, or staff to continue operating.

Suppose this child did not get vaccinated. One night, when she is two years old, she develops a runny nose and a high fever. A harsh, dry cough persists throughout the night. Her mother is worried, but not seriously so. But then, she develops pneumonia secondary to the original infection, as well as diarrhea and a rash. She is leaking electrolytes and nutrients she can’t afford to lose from her severely malnourished body. The closest health care facility is many miles away, and it is unrealistic for her mother to walk the entire way carrying the child in her arms. The mother assumes that if she goes to the health care facility, anyway, she would just be taking her child to the morgue. People go there to die, she thinks, not to receive care and walk away for the better.

This child coughs and sneezes on other children she comes into contact with, young children who are also malnourished and vulnerable. Less than 95% of the population in her community is vaccinated, which is the determined threshold for preventing an outbreak. This child infects eight others who have also not been effectively vaccinated. Eventually, she dies, and her mother buries her, crying over the dead body of this baby that, like too many others, was taken too soon. The virus isn’t buried with its patient zero, however; each of those eight children infects eight others. And so, with what started out looking like an innocent cold, the seeds of an outbreak are sown. The outbreak will spread through the rural community like a choking weed, devastating the population with a disease we now rarely even think or talk about in the United States: measles.

Vaccination, a universal human right we take for granted in the United States, is the most effective public health intervention ever identified. Yet in developed countries, we consider diseases like measles to be mere nuisances, incognizant of the fact that in vulnerable populations throughout West and Central Africa, it can be deadly. Despite that it’s generally non-fatal in the US, “measles is among the world’s most contagious diseases and one of the leading causes of death among children worldwide, especially those who are malnourished, according to World Health Organization and UNICEF” (“Measles Outbreaks”).

Though fictional, the story of this child, and this outbreak in a rural community in the Democratic Republic of the Congo, could be an “everyman” story. The same series of events could have unfolded in Benin, Burkina Faso, Central African Republic, Ivory Coast, Cameroon, Chad, Guinea, Liberia, or Sierra Leone, and it would have been just as consistent with the reality in those places. With the percentage of the population that is vaccinated in these areas consistently coming in below the 95% required to prevent outbreaks, large and sustained outbreaks happen every few years.

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Anne Rimoin, Ph.D., M.P.H, is an associate professor in the epidemiology department at the UCLA School of Public Health. She is the daughter of a very close family friend, the geneticist who diagnosed me with cystic fibrosis when I was three. When I was young, Annie’s work was mysterious to me; she lived half the year in Africa, and half the year in Los Angeles, and that’s all I knew. I came to learn about the work she does in the Democratic Republic of the Congo (DRC) within the last year, and was inspired to talk to her about human rights and public health in Central Africa.

I originally intended to talk to her about the 2014 Ebola epidemic. Dominating U.S. media about Africa for months, it incited tremendous fear in the west and devastated populations and economies in affected countries. But speaking with Annie, I realized that my decision to focus on Ebola was representative of the problem inherent in how westerners generally deal with and talk about health care and human rights in Africa; we focus on one hot topic at a time, while it’s emphasized in the media, but then, when a new crisis emerges and transplants the old news, we forget about the previous problem. Hunger, malnutrition, poverty, war, corruption, poor infrastructure, and lack of health care services have been so rampant and so entrenched for so long that to just talk about Ebola – the sensational scare that inflamed our imaginations in 2014, quickly forgotten – is to ignore the region’s long history of human rights violations and the context of how this area developed into the kind of place where such an outbreak could even occur. While Ebola certainly is devastating and timely and relevant and deserving of our care and attention, we shirk our responsibilities as moral citizens if our attention to global issues has the breadth of a laser pointer, the depth of a thumbtack, and the flightiness of a migratory bird. We need to, but don’t, talk about the much more basic issues that have been plaguing the area for decades: lack of access to vaccinations, and infrastructure so utterly destroyed by warfare that no reasonably functional health-care system could take root.

Anne spoke of this issue, lamenting that “war and the long-term health impacts don’t get discussed. It’s not just the short-term impact of terrible violent acts, because there’s no process of rebuilding. [USAID and other organizations] aren’t interested in building infrastructure in DRC anymore because they’ve moved on…So they help out in an area as long as it’s hot in the media, and people know and care about it, but then there’s tons more work to be done and they want to pass the baton to the government there. But the government just has no ability to make it happen.”

Historical Context: racial tension, political instability and war

The health care system in what is now DRC was ravaged by war. After brutal exploitation of natives during the Belgian colonization in the late 1800s to mid 1900s, the country gained independence in 1960. Ephemeral leadership rendered the country politically unstable, with rulers taking power only to be promptly overthrown. General Mobutu, the dictator who ruled for over thirty years when the area was called Zaire, came to power in the “Congo Crisis.” In the First Congo War, Mobutu was overthrown in a coup led by Rwandan rebels, which put Laurent-Desire Kabila in power and established the Democratic Republic of the Congo. Ugandan troops launched a counter-movement, but the new government in Kinshasa, the DRC’s capital, expelled all Rwandan and Ugandan troops from the country, alienating them and ultimately helping spur the Second Congo Civil War (World Atlas) (“Africa’s Great War”).

The racial composition of the area is complicated, but there existed immense tension between two ethnic groups, the Hutus and the Tutsis. It’s impossible to truly understand the conflict without considering the context of the Rwandan genocide and the direct involvement of the nine African states who had a stake in the fate and leadership of the DRC. The Second Congo War was the deadliest conflict since World War II; marked by brutal, shocking, senseless violence, it has been called “The World’s Worst War,” with over five million military and civilian casualties (Gettleman 2012).

After the war, the country could finally begin rebuilding – in theory. In practice, many factors prevented the DRC from being able to restore stability and rebuild infrastructure and a healthcare system. Even after the war, there continued to be substantial ethnic tension, political upheaval, and poorly managed infrastructure. Despite the country’s large size, fertile soils, and wealth of minerals, the economy was ravaged and the population remains destitute. They lack basic technology and infrastructure; many roads were destroyed, and transportation is limited. Since the war, reaching (and communicating with) rural areas has been extraordinarily difficult. Thus, getting vaccines into these remote areas, a seemingly simple intervention to reduce disease burden and childhood mortality, has proven nearly impossible.

Vaccines must be kept cold, but to reach remote areas, health care workers must travel long distances. There are often no vehicles, so people must walk hundreds of miles carrying vaccines that last only a few days and need to be refrigerated. Compounding the problem, many of these remote communities don’t want to be accessed; the historical context of war and violence has led some to fear outsiders as dangerous. And when vaccines are given, there is no proper documentation of what vaccines people have received. Thus, collecting data on population immunity is difficult, an issue worsened by the fact that asking people which vaccinations their children have received leads to inaccurate data. Personal medical history accounts do not match up to actual data, as oftentimes parents don’t understand the difference between various diseases and vaccines or don’t remember which vaccines their children have received.

War and Public Health: the long-term impacts

Anne started work in the Congo in 2002, doing epidemiology research there with PhD students through the UCLA-DRC program she established. “To be able to make a difference you have to understand the perspective of the local population and what they’ve been through,” she says. “Human rights are continuing to be violated even after the war. There’s a long-term legacy of disruption of trade, fear, isolation, and lack of access to health care services. The health system in DRC is broken because Rwandans came in, raped all the women, and they were like a band of locusts, taking everything – they’d rip metal roofs off huts, go into a convent and steal wires of the generator, every vehicle, motorcycle, refrigerator, every radio.”

The DRC will take a step forward, but then infrastructure gets decimated. “Rwanda says they ‘liberated’ the area,” she says, “but this is what actually happened.”

During her time in Yambuku, the village in northern DRC where Ebola originally emerged in 1976, she witnessed the incredible difficulty of simply reporting disease incidence accurately in these areas. In the farthest outpost of Yambuku, nurses have to walk 260 kilometers just to report a disease. Once they get to the center of the village to tell a doctor, the doctor has to get on his motorcycle to get to the closest radio to send the message to the provincial capital. The provincial capital can then call Kinshasa, the official capital. The process is unreasonably arduous. But this is one of the issues government and NGOs must address first to start to move the needle, because without proper roads, there cannot be accurate disease surveillance. And without accurate disease surveillance, it’s difficult to determine how to allocate limited resources. Where are vaccinations in the shortest supply? Where are the most children dying? Where do people need the most help?

Anne is working on a study assessing population immunity to vaccine-preventable diseases. Funded by the Bill and Melinda Gates Foundation, this research will help the Congolese government determine how best to allocate their resources to close immunity gaps. Many pockets of adults who have grown up in these insecure areas never got vaccinated, so she is attempting to figure out which adults to vaccinate and how – and without good medical records, the only way to do that is by looking for antibodies in blood samples.

In areas where people have to walk hundreds of kilometers to deliver vaccines, it’s hard to tease out whether people are dying because of failure to vaccinate, or vaccination failure from the vaccine going bad. Another problem to consider is that even when people receive the right vaccinations at the right time, issues with host immunity often render them ineffective. When a child is riddled with co-morbidities like malaria, malnutrition, or anemia, that child won’t form antibodies to the vaccine, which is critical to its efficacy. The body has limited resources, and if it’s tasked with fighting nutritional deficiencies and infections, those resources may be redirected away from antibody creation and toward fighting the more immediate, pressing concerns of starvation and infection. This situation breeds distrust and resentment, as “people stop believing in the health care system when they get vaccinated and still get the disease.”

In the U.S., we’ve entered a new era. We no longer die from infectious diseases, instead succumbing to chronic diseases like heart disease and diabetes; ironically, we could call it a privilege that we live long enough to die of chronic disease. But in developing nations, infectious diseases still kill an unacceptable proportion of infants and children and mothers, preventing societies from progressing forward. While we have a lot of work to do within the United States to alleviate health care disparities and improve outcomes for those in poverty, we are drastically luckier than our counterparts in the global South. We must do the work, and we must not take for granted the fact that infectious diseases no longer kill the majority of us; failing to vaccinate our own children is an irresponsible show of ignorance of the devastation preventable infectious diseases can cause, of how far we’ve come in the U.S. in terms of eradicating these diseases, and of how far places like the DRC still have to go. The global North is careening forward into a world of biomedical advances and technological innovation. Meanwhile, it’s as if the global South exists in the past, lacking the basics we’ve long taken for granted: roads, radios, phones, cars.

As the increasing likelihood of outbreaks puts us all in danger, we need to think about places like DRC. We need to think about how we can combat inequality by reducing child mortality from infectious diseases, so that they can catch up to us as we dance into the future. And we need to realize how lucky we are for what we have.

Reflections and Solutions

The realities of life in the developing world are staggering. And the way human rights issues are so entangled, compounding on each other, makes it nearly impossible to figure out where to start. Lack of access to vaccinations, and poor all-around health care in central Africa (and all over the developing world) must be addressed, and soon.

Environmental change will make all of these issues more pressing and more urgent in the years to come; climate change and altered weather patterns, urbanization, natural disasters, globalization, overpopulation and development will make outbreaks all the more likely, and potentially harder to suppress. Novel pathogens will spill over from animal species, and germs will spread faster and farther than ever as the globe becomes increasingly interconnected. We may be thrust into a real-life version of the board game Pandemic, as epidemics go global. What are we going to do about it?

Anne’s answer is to “forget all the sexy new technologies. We need to invest in the most basic infrastructure: roads, transportation, communication. Give them radios and solar panels with a battery bank that powers the radios... That’s the kind of stuff that needs to be done. We need to be able to give them things that are as sustainable as possible. Nutrition, poverty alleviation, and agriculture are important – but access to markets, communication tools, and refrigerators to keep vaccines cold would make the biggest impact. Without a good foundation any intervention will crumble on top of it.”

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It’s critically important in sustainable development work to physically be in the environment we’re trying to help, doing empathy work with the people and listening to the voice of the community. Rather than impose western solutions, we must work with communities and incorporate their wisdom, and the historical and cultural context of the area, to create change. Not everyone can be there, doing that; but those who do are the unsung heroes that will help raise livelihoods in developing countries to the standards we enjoy in the first world. Anne’s work is inspirational because she puts herself in potentially dangerous situations, in communities tarnished and degraded by war and violence, because she believes in the work she’s doing. Someone has to do it, so why not her? It reminds me of a quote that I have posted up on my wall, a quote that keeps me on track when I think it might be easier to just do something else, to care about things that are less emotionally charged and globally significant. It was spoken by Yeb Saño, the Philippines delegate to the Framework Convention on Climate Change that took place in November 2013.

In the same month as that conference on climate change, November of 2013, the Philippines were hit with the strongest typhoon in recorded human history. It was horrifically destructive, killing at least 6,300 people and impacting two-thirds of the country. As global leaders sat in conference rooms quibbling and failing to enact meaningful change, Saño said, “I speak for the countless people who will no longer be able to speak for themselves after perishing…. I also speak for the people now racing against time to save survivors and alleviate the suffering of the people affected by the disaster.

He posed these questions: “If not us, then who? If not now, then when? If not here, where? We can stop this madness… Can humanity rise to the occasion? I still believe we can.”

Being a member of one country does not absolve us of the responsibility to care about the hardship of those in other countries. We can stop this madness, this relentless injustice, but only if enough of us follow the lead of people like Anne, working at the nexus of human rights, public health, environmental issues and international development. No one person can do everything, but all of us can do anything.

#write4good #iam4

References

“Africa’s Great War.” The Economist. The Economist Newspaper, 06 July 2002. Web. 05 Dec. 2014.

“Current Research.” Anne W. Rimoin, Ph.D., M.P.H. UCLA School of Public Health, Department of Epidemiology, n.d. Web. 05 Dec. 2014.

“DEMOCRATIC REPUBLIC OF THE CONGO.” World Atlas. N.p., n.d. Web. 05 Dec. 2014.

Gettleman, Jeffrey. “The World’s Worst War.” The New York Times. The New York Times, 15 Dec. 2012. Web. 05 Dec. 2014.

“Measles Outbreaks Threaten Progress in Child Mortality in West and Central Africa.” UNICEF WCARO. Media Centre, n.d. Web. 4 Dec. 2014.