Measles in the wild

Last night we were sent to a hotel that was more of a “hostel” according to the consensus at the UNICEF hq in Kaduna.  Rabiu generously drove us there, and we secured the most inexpensive room they had left, which was 6000N (~60Cedi, or $40USD).  It had A/C though, which I suppose could be a nice change after months of sleeping in sweltering Ghana heat with only a small fan.

We headed to dinner at a restaurant just up the street from our hotel.  We arrived to find it running on generator power — it seems Kaduna fairs no better than Abuja for electrical grid consistency.  The place was called Tropical Eatery and basically was like something you’d find in a food court of an American mall: rice, meat, and side dishes scooped out of steel tins by employees in an assembly line fashion and served to you on a tray.  We had a lot of difficulties conveying our vegetarianism, and finally just went with the logic that the rice LOOKED vegetarian (and came with meat afterwards, so probably wasn’t flavored with meat).  I had fried rice with plantaines, and after not eating all day it was quite satisfying.  This is the first time we’ve seen any African “fast food” outside of the Accra Mall … normally in Ghana it will take 90 to 120 minutes to get your order, no matter what it is (even if it’s a sandwich).

Back at our hotel we did some charging of electronics and fell asleep.  We awoke a few hours later to prayer call blaring from a nearby mosque.  The A/C wasn’t running, the fan was off too, and the batteries we’d plugged in were no longer charging.  So much for paying 50% extra for a room with A/C (although if we’d had a choice we’d have gone for non-A/C, but what’s the point of the extra cost if the power is always off?).

We caught a taxi in the morning for 500N (slightly too much), and got lost on the way to UNICEF because our driver didn’t know how to get there (despite initially saying he did).  The taxi drivers we’ve had in Kaduna have been much less fluent in English (as well as our servers at the restaurant last night).  This is the first of several observations I’ve made as to the indicators of wealth, education, and health in Abuja versus elsewhere in Nigeria.

After arriving at UNICEF we met with the Health Specialist, the WHO Health Consultant (who would be our guide today), and the Nigerian-MoH-attached consultant in charge of SIAs.  The meeting was very productive and I think we learned a lot as well as became quite aware that UNICEF Kaduna was not only happy to facilitate this portion of our project, but really understood what we were trying to show.

The UNICEF Health Specialist, Dr. Amina, made a very good point about people seeing news on satellite TV regarding the “huge cholera epidemic” in Nigeria (the largest in 20 years) this year, and calling her to convey concern.  In the story she was telling, they called around the time of 300 deaths having been recorded, and she made the point that although every life is important, in a country of 150 million 300 deaths is not that many — far fewer people were calling her concerned about child malaria deaths here despite the fact that there were orders of magnitude more in the same time period.  I’ve heard other public health officials make this sort of point before: that sensationalism easily captures the imagination, so we become concerned about bird or swine flu whilst millions silently die from tuberculosis every year.

We set out with the Health Consultant, Amena, planning a visit the Cold Store Warehouse as first on our list.  We met the doctors running the Cold Store, and saw a plethora of freezers holding various vaccines: meningitis, measles, polio, and so on.  Robed men were offloading vaccines from freezers to portable coolers and then into vans, with the vans were speeding off to whatever destination.  We also saw the adjacent store house where they keep the syringes, cotton wool, finger dye, and so forth.  The entire facility was running on generator power.

Next we set off to the MoH, to meet with the chairman of the State Action Committee on Immunization, to apprise him of our comings and goings within his state and to ask him some basic questions about health indicators in Kaduna state.  He was quite happy to see us (he remarked how he’d already met Melinda Gates and wanted to know if she shared her first name with Miranda — we pointed out the slight difference) and was not only happy to answer questions but also to call the local OPD and arrange for us to see the measles outbreak cases they had today.  We asked our questions, mostly about local attitudes toward immunization, and then departed for the OPD.

At the hospital OPD we found two active measles cases that had been severe enough to admit to the wards; normally measles cases here are simply treated and sent away.  The first child was recovering well, and had caught the measles a week or two ago from a cousin who later died of it, which was heartbreaking to hear.  None of the measles cases we saw today had been immunized properly — Kaduna State has just 21% coverage for applicable vaccines (nearby Jigawa State has 0%, however).  In contrast, Cape Coast has about 85% coverage for measles.

As we saw more measles cases, several themes recurred.  Either parents didn’t care to immunize their children or had heard something bad about the vaccines, and either way once the child fell ill, rather than a doctor visit they went to a pharmacist for cheaper treatment.  The pharmacists either treat for malaria (based on fever), or simply give acetametophin.  This lack of proper diagnosis and treatment leads to complications, and the children often end up in the hospital with severe issues.

We saw a third child at the OPD, who was maybe two-years-old, and had now recovered from the measles but was taken ill with complications.  The nurse referred to these complications as “emphyzema” but I think was being confused with adema, because he was covered with a generalized swelling — his eyelids looked like he had black eyes, his abdomen was swollen, and so on.  I hesitate to post a photo here because his condition was so graphic.  We saw the child naked and his scrotum was extremely swollen, probably the size of a large orange.  Another child we saw who was now recovering has prolapsed his rectum from the severity of his diarrhea.

The final measles case we saw at the OPD was a woman from Rigasa, one of the most ‘non-compliant’* neighborhoods in Kaduna, where there is still belief in the rumors that the vaccines are tainted.  There is a government clinic in Rigasa that offers both free treatment of under-5 children and free drugs, so we set out to find the clinic.

This would prove more difficult than previously imagined and we stopped several times to get conflicting directions.  Partially this is because Rigasa is very large and the clinic has a catchment area that is challenging for it to handle, but also because the people here don’t use the clinic, so they don’t know where it is.  When we eventually found the clinic there were more measles patients there, they see an average of one or two a day, all for outpatient treatment (so they have no idea as to the outcome of the child).

Amena talked to the nurse running the clinic, to find out why they weren’t reaching the surrounding neighborhood.  Partly it’s poverty, and partly ignorance about vaccines, but also partly people just don’t know they are there, or the clinic is understaffed and women who come with their children leave unserviced because of long lines.  They gave recent examples of husbands who won’t let their wives come to the clinic to vaccinate their kids because of religious beliefs, or because of plain obstinance.

We asked the two measles cases we saw there, in depth, why one hadn’t vaccinated her child and why the other hadn’t sought treatment for hers after the child fell ill.  The two answers we received: one had refused to vaccinate her child when health workers came to her house because of rumors she’d heard about the safety of the vaccine; the other had gone to a chemist rather than the clinic because of cost issues.  It is hard to be anything but frustrated with these answers.  Not frustrated with the women, but frustrated with the structure of society that would create a situation for these answers to exist and seem valid.

In the case of the latter I found myself most upset as the neighborhood already has a free clinic, with free drugs — a monumentally rare thing, and thus the impediment for this woman treating her child wasn’t actually the cost at all, but that she just didn’t know the clinic existed.  It wasn’t until a neighbor whose child had also had measles told her about where to go for free treatment that she came to the clinic.

We went to see community leaders afterwards, to try and urge them to work with the clinic to do outreach to the neighborhood, to let them know that these services exist, are safe, and best of all are free.  The leaders agreed with us about the importance of social mobilization, although it is hard to say whether we were just getting lip service … time will tell.

At the community center we met an American from Atlanta, Yolanda, who works for the CDC and is here consulting for UNICEF/WHO.  We agreed to go to dinner with her, and afterwards she took us to a pricey but nice French restaurant (although I had pizza and Miranda spaghetti, so you be the judge on the origin of the cuisine).  It’s Thanksgiving though, so a bit of splurging is in order I suppose, and it was nice to chat with another American about our experiences here.  We also managed to transfer to a cheaper hotel room (saving over 2000N per night), so that covered much of the dinner cost.  Our new hotel room doesn’t have A/C or the other electrical amenities, but given the nearly constant lack of electricity here anyway I don’t think it’s a big loss!  Paula at UNICEF in Abuja told us of employees of hers who have so little (read: no) electrical service at their homes that they have to charge their cell phones at work.  The power at the restaurant kicked off once or twice while we were there.  Edison once proclaimed (in the late 1800s) that we would make electricity to cheap that only the rich would burn candles — perhaps that day will come, but in West Africa it is not yet here.

We’re back in the hotel room now, it’s 9 o’clock and I’m copying footage and getting ready to call my parents.  I’m glad we brought a netbook (low power usage) with a six-cell battery (6-8hr life), so that the absence of electricity doesn’t throw too many grenades into my digital workflow for our footage and photos.  The lack of Internet access for us in Nigeria (my cellular modem won’t work here) does mean that I’ll have to backdate these posts and flood them all in at once, however, so I hope you all are ready to do a lot of reading, haha.  More to come soon.
*non-compliant is a dirty little term that implies a failure on the part of the patient.  Paul Farmer writes extensively about this, but often (at least in his view, and dare I say mine) non-compliance is really an indication that the structure of the system is designed to exclude certain patients and thus force non-compliance.  So in this sense I use non-compliant to easily convey that Rigasa has a low prevalence of vaccination and a low turnout on Child Health Days (and acceptance of vaccination workers’ efforts), but not to cast aspersions on the people of Rigasa.  Where ‘non-compliance’ feels an apt term, I think it is often best to look first at the system’s structure and attitudes of its practitioners, and only last at the patients to find the failure in delivery of care.  In this case I think it means more must be done to ensure people know of the clinic and its benefits, and more must be done to educate people in Rigasa as to the safety of its services and medicines and to win their trust; for people who have been marginalized and abused by the system for generations, trust is bound to be a difficult thing to garner.

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