Voices from the Field: Vaccinating against measles in Tajikistan
They came to the vaccination centers by horse, by sled, and by foot.
In fact, when a recent measles outbreak threatened the mountain communities of Tajikistan, parents even brought their children by car, a rare commodity in the remote, impoverished villages of the country. And when people could not travel to the clinics, Doctors Without Borders/Médecins Sans Frontières (MSF) volunteer Mary Jo Frawley brought the clinic to them.
"MSF field teams had been communicating the need for a measles intervention to the Tajikistan Ministry of Health since fall," said Frawley. "With winter here, the urgency of protecting the children against a possible measles infection was critical. One shudders to think what would have happened to these children without a mass-vaccination campaign, as the snow and cold made many areas inaccessible except by foot and horseback."
Starting in November 2002, Mary Jo Frawley and a team of 15 battled an outbreak that had first appeared as a disturbing blip on MSF's epidemiological radar screens, but had developed quickly into a full-blown epidemic. By late January, the MSF campaign eventually achieved an impressive 97 percent coverage rate (83,196 children vaccinated) in snowy, remote regions of the country that would euphemistically be called "inaccessible" in the dead of winter.
For Frawley, a veteran of six MSF field missions, as well as a previous emergency measles intervention in Nigeria, receiving the call for an emergency measles treatment and vaccination project in Tajikistan in December came as "kind of a surprise."
Measles, a highly communicable and potentially deadly viral disease, is usually spread quickly among high-density populations of children.
"You don't think of measles in the winter," said Frawley. "Measles vaccinations are a summer thing. To be going to that place in this time of year... I don't know. I'm somebody who grew up in Vermont and left for California because my feet were freezing - I haven't had a winter in twenty-five years, and I don't usually miss it. Then I got curious. I started thinking, 'how do they do that in the winter? How does the logistics of that work?'"
Frawley was soon on an airplane to Dushanbe, the capital of Tajikistan and the "base-camp" for the emergency intervention, where the bite in the air as she stepped out of the plane was enough to suggest that some things would be very different from her previous experiences combating measles with MSF in Africa. For starters, the climate would make it much harder to access the remote villages at risk for the disease. The team would need snow tires and chains for the fleet of 4WD vehicles to negotiate mountain passes where the snow was drifted up to ten feet high on the sides of the road.
In other respects, however, Frawley soon learned, a measles vaccination campaign can be paradoxically aided by wintry weather.
"In a place like Nigeria, when you're doing a measles vaccination, you always run the risk of 'cooking' your vaccines by exposing them to hot air," Frawley explained.
The "cold chain" - a way of transporting frozen vaccines using refrigerated containers, coolers and ice packs - keeps this from happening. In Tajikistan, the concept of a cold chain was redefined, the reach of MSF's campaign extended, by the omnipresent snow, ice and cold air. Refreshing cold packs and coolers with snow to maintain the necessary temperature, the project's national staff was able to carry vaccines by hand up into tiny communities far off the beaten path.
These differences aside, Frawley soon learned that the primary components of a successful winter measles intervention are - like many MSF missions - a motivated and capable national staff and meticulous planning.
"The first week, we mapped out the whole region in terms of target population - kids up to fifteen years old," Frawley explained. "Lots of these places don't have maps, so we would get local people to help us lay out the area and tell us where the villages were and how many people were there. We combined government population figures with what people told us, and figured in the average size of a family in the area to get an estimate of the number of children in each town."
After the planning stage, Frawley's team began an arduous daily routine, with predictable power outages and changeable driving conditions setting the tempo for their work. Breakfast came at 6 am, when the fickle electrical grid could usually be expected to give them about two hours of electricity. When the power usually cut out again, by 8 am, the team was already on the road for a long drive to the first village of the day, where they set up a temporary clinic in a mosque or a school.
Then came another drive to a second village and possibly a third - a continuum of work broken only by tea breaks with the leaders of each community, cementing ties that would be invaluable should MSF need to return.
While vaccinating as many children as possible, the team had to simultaneously treat the people they found in each town who had already fallen victim to infection.
"There was one family, with six children - four of them lying on mats on the floor too sick to move, all with temperatures of over 102 degrees, rashes, coughs and runny noses," said Frawley. "The other two children were in the initial stage of the disease, with temperatures of 101. We treated them on the spot, but with children in different stages, communicating the disease process to the parents and the community was critical so that they could continue to get the care they needed."
So it went, until dropping temperatures and approaching darkness forced the team to turn toward home. After dinner, two more somewhat reliable hours of electric lamplight, from 6 pm to 8 pm, allowed the team to huddle over their homemade population maps and plan the next day's route through the mountains. Building on their initial planning, these nightly sessions permitted Frawley and her team to gauge their success and adjust their strategy to vaccinate as many children as possible.
"If we hit the first village of the day at ten o'clock, and by eleven we'd only seen 15 or 20 kids in the mosque, when the night before we'd decided we should find about 680 in the village, then we knew it was time to hit the street and start knocking on doors," Frawley said.
In the daunting task of locating and gathering families for vaccination in new villages several times a day, an enthusiastic group of Tajik staff members - the second ingredient, Frawley learned, of a successful winter vaccination campaign - proved invaluable. The "mobilizers" as Frawley took to calling her teammates, visited each town before the vaccination team, recruiting priests, teachers, and other community leaders to help them get families to the temporary clinic when the medical team arrived.
Frequently this proved difficult, as religious concerns and general skepticism about the value of the vaccines made some Tajik parents reluctant to allow their children to be vaccinated. But the "mobilizers" and other local MSF staff members worked tirelessly.
"The team on the ground, doing the prep work for our vaccinations... they were amazing," said Frawley. "They were always willing to drive an extra mile and walk to the next town - these guys were committed."
Many of the national staff members, employees of the Tajik Ministry of Health when not working for MSF, continued to put in night shifts at the city hospital in Dushanbe, while working on the vaccination campaign during the day.
"I'm not sure when they slept," Frawley said. "Some of them wore scrubs, staying up all night working on long surgical procedures, and then there they'd be, ready to go at eight in the morning. All we had to do was keep them fresh and provide a little motivation."
On January 16, MSF concluded the intervention, confident that the outbreak had been averted to the extent of MSF's ability.
In just over a month, 80 percent of the target population had been reached in 5 different districts - all told, 1064 cases of measles had been treated and potentially lifesaving vaccines had been delivered to over 83,000 children. The remaining 20 percent, rendered inaccessible by the snow, will be covered by MSF as soon as weather allows.
For Frawley, now back in California, nursing a pair of frostbitten earlobes, this stands out as a special mission, in which camaraderie complemented planning.
"I've never lived, worked and eaten with my team members around the clock before," said Frawley. "I enjoyed that. The quiet moments sipping tea and breaking bread during a hectic daily schedule - these are nice memories. There were no power lunches on this mission."
By Michael Benediktsson