April 14, 2010
I have been too busy writing a speech and dealing with other deadlines (plus putting in new raised bed gardens and planting my snow peas — perhaps the subject for a future blog in conjunction with food-borne outbreaks I will avoid this way) to write a new blog, so here is an excerpt from Chapter 22 of Inside the Outbreaks called “L’Experience Fait La Difference.” This quotes from a journal I kept in Africa, and I may in the future put in some of that journal here. But for now, welcome to Niger:
Jan. 25, 2006, Niger, West Africa. After sleeping in a tiny mud hut, covered by my bednet, I arose and used the toilet – a four-square inch hole in the floor. Then I watched the village stir and come to life. Children drove donkey carts. A goat excreted by the dirt roadside. Women laughed and greeted one another as they got cook fires started in front of their adobe homes. A barefoot man in a blue satin robe and a white pillbox hat sat on a bench next to another whose head was swathed in a bright yellow turban. I was in the town of Tera, the middle of nowhere, but which, in comparison to the remote villages, seemed like the Big City, with its gas station, cell phone tower, Coca-Cola poster, and single restaurant.
After two years of research and hundreds of interviews, I was finally out in the field, following second-year EIS officers Natasha Hochberg and Melto “Jamie” Eliades in Niger, the world’s poorest country by United Nations criteria. The prior month, public health personnel had attempted to distribute insecticide-treated bednets to every household in the country with a child under five, along with vitamin A and oral polio vaccine drops. Hochberg and Eliades were training and directing a team of locally hired “enumerators” who would visit randomly selected villages throughout the country to assess how successful the distribution had been. I would tag along for the first week of the project, then fly to Kenya to follow another EIS officer.
The hanging bednets, which can repel mosquitoes within a 30-meter radius, were intended to prevent malarial mosquitoes from biting children and their families. This program had a very personal meaning for me. During a brief visit to Niger in August 2003, my friend Liz Lasser, who worked for an international health organization, had been bitten by a mosquito carrying the Plasmodium falciparum parasite. She hadn’t bothered to take anti-malarial medication. A vibrant, idealistic woman of 49, she developed fever, chills, and body aches. Her lungs filled with fluid, and she died of pulmonary edema shortly after entering a hospital near her home in England.
Each year over 500 million people become infected with malaria, for which there is (as yet) no effective vaccine. Nearly three million die, most of them young children in sub-Saharan Africa. Almost everyone in Niger has contracted malaria repeatedly. Having developed partial resistance, those who survive to adulthood usually have milder — but still painful — symptoms. The Niger villages I visited were in the southern part of the country, compounds of mud huts with thatched or pueblo-style roofs set on an arid plain surrounded by millet stubble and scrub bush, reachable by red dirt tracks or brown sand.
Trim and nearly six feet tall, Natasha, 31, was a Harvard graduate who had gone on to medical school. She had worked in clinics in Peru and Honduras, then matched with the CDC Parasitic Diseases Branch in July 2004. Her father, Fred Hochberg, had served as an EIS officer in the early 1970s.
Natasha was the lead EIS officer in Niger, keeping track of nine teams, getting enough gas, and dealing with money problems, glitches with the palm pilots with built-in Global Positioning Systems (GPS), and more. An intense perfectionist and worrier, she drove herself hard.
Jamie Eliades worked in the CDC Malaria Branch. In Tera the night before, he and I had eaten at the Restaurant L’Amitie (Friendship Restaurant), a shack of sticks with woven mats for roof and walls. We enjoyed our chicken and couscous, though I didn’t drink the water. (Natasha opted out, having once contracted typhoid from African fare.)
At 6’ 6”, with a relaxed manner and easy smile, Jamie, 37, was a “gentle giant,” according to Natasha. After a residency in emergency medicine, he had earned a masters degree in public health and eventually applied for the CDC program. By the time I met him, Jaime had been to 55 countries. He had helped with the first national bednet distribution and assessment in Togo, later volunteering for Niger as well.
He was a calming influence. “It’s good to have opposite personalities on a team,” he explained, finishing his meal. As we left the restaurant, I took a photo of its misspelled sign announcing: Specialite Afro-Eropenne, L’Experience Fait La Difference. Yes. Experience Makes the Difference could be the motto of my trip, or for that matter, of the EIS.
That day, after hours of rough driving, we had visited the village of Zoribi. As the interviewing team was choosing random huts and conducting the survey in Djerma, the local tribal language, a young mother carrying her daughter had approached Natasha to ask for help, pointing at the child’s grotesquely swollen heel. Natasha gently examined it and answered her apologetically in French. She advised her to go to the nearest health clinic to get antibiotics, since we didn’t carry any.
Why can’t someone give this poor little girl some medicine? I later wrote in my journal. I know that the argument is that we are doing public health, doing a bednet and polio vaccine survey, not primary health care. And if we get involved with trying to take care of everyone, we will go nuts and be diverted. But…
Later I gave Natasha a small amount of money and asked her to get it to the local health clinic for treatment of the girl’s foot. She thanked me and said, “You know, I get so wrapped up in our program, and so stressed out, sometimes I need a reminder that we can stop and help just one person.” One out of every four children in Niger dies before the age of five. It is through public health programs such as immunization, clean water, proper nutrition and vitamins, and bednet distribution that most of those deaths might be averted.
Since I would have been a distraction if I had gone into the huts during surveys, I stayed outside in the villages, where the children crowded round me. Most of the girls wore headscarves, bracelets, and traditional clothes, while the boys wore drab castoff Western tee-shirts and shorts. Most children smiled and laughed, pushing closer; a few shy kids hung back. They were beautiful. Intelligence and curiosity shone from their eyes. Over a quarter of the children die here, I thought.
To engage them, I sang, “If You’re Happy and You Know It, Clap Your Hands.” They began to clap. Then I gestured to them encouragingly, asking for a chanson, and after some hesitation one little girl sang in Djerma. Two children began to dance, stomping their feet, leaning in and circling one another, as the others sang and clapped around them. Finally, a man shouted at them, and they left, apparently ordered back to work, fetching water or carrying firewood.
One woman invited me into her hut. Like most of the women, she wore a startlingly bright traditional dress of white, yellow, blue and red, a shiny purple head scarf, two necklaces of tiny shells, and big hoop earrings. She proudly showed me the filter she used to keep guinea worm copepods· out of the water that she stored in carefully stacked clay pots, though she had no visible bednet.
At every village, Natasha and Jamie first visited the village elder. Because both of them towered over everyone, they usually squatted respectfully, explaining their mission. I was impressed with their ability to organize and train the teams (in sessions back in Niamey), plan this difficult survey of a vast and sparsely populated country, and maintain a sense of humor.
“Jamie and I made a great team,” Natasha told me after the survey was completed. “I tend to be compulsive, that’s how to get work done. He’d tell me it was OK to give the teams a day off.” There had been multiple flat tires, gas crises, cell phone inaccessibility, disgusting lodging, and software problems, but the teams actually finished ahead of time.
The effort revealed that 87 percent of the surveyed children under five had received polio vaccinations during the December 2005 campaign, and that 64 percent of the households with young children had received a bednet. Yet only 15.4 percent of the children had slept under an insecticide-treated bednet the previous night, presumably because the January-February survey took place during the dry season, when mosquitoes are not a big problem.
In September 2006, EIS officer Julie Thwing led teams that repeated the random assessment during the rainy season, finding that 55.5 percent of children under five had slept under an insecticide-treated bednet the previous night. Though not the official 80 percent goal, this was a dramatic improvement. From 2006-2009, ten other African countries have conducted similar bednet distribution campaigns in conjunction with immunization drives.
The bednet surveillance project in Niger is typical of the unsung work of EIS officers. It would have received little notice if I had not tagged along.
- · Guinea worm disease (dracunculiasis) involves a life cycle in which worm larvae are ingested by fresh-water copepods. When a person drinks water with Guinea worm copepods, female worms grow up to three feet long, emerging with painful ruptures. The worm releases her larvae into water, and the cycle begins anew. In 1985 the CDC/EIS joined a worldwide effort to eradicate the disease.