By Stephanie Nolen and Arlette Bashizi
Werra Maulu Botey struggled to close his daughter’s casket. As he waited to lay her to rest, he repeatedly slid the crude wooden top back, adjusting her tiny head and smoothing the fabric that cushioned it away from her face.
Olive succumbed to measles at the age of 5, just the night before. She was the first child to die that weekend at an emergency measles treatment facility in Bikoro, located in northwestern Congo. Her cousin, a 1-year-old girl, was the second death.
Measles is ravaging the youth of Bikoro, as it does every few years, lurking, then erupting across this extensive nation.
Its resurgence is also evident in other regions globally — including within certain U.S. communities — despite the measles vaccine being utilized since 1963, which is thought to have saved more lives than any other childhood vaccination.
Last year, Congo recorded over 311,000 measles cases. Approximately 6,000 of these concluded as Olive’s did: with a child interred in a small casket days after showing the first signs of fever and developing a red rash. This year, numbers have decreased to around 97,000, but the virus has turned more deadly, claiming over 2,100 lives. The reasons for this surge in lethality are unclear.
On a global scale, measles cases rose by 20% in 2023 compared to the previous year, according to the World Health Organization, totaling 10.3 million, with more than 107,000 fatalities. The WHO reported that 57 nations experienced “large or disruptive” outbreaks, nearly a 60% increase from 2022.
Outbreaks are occurring in areas such as Minnesota and New Brunswick due to parental vaccine distrust or the belief that their children will not suffer serious consequences if they contract the virus. In the United States, President-elect Donald Trump’s appointee for federal health secretary, Robert F. Kennedy Jr., has been a vocal opponent of vaccine mandates, asserting that parents ought to have the choice to not vaccinate their children.
Nevertheless, many parents in regions like Congo lack the opportunity to vaccinate their children, despite their desires to do so.
Olive lived about 28 miles from Bikoro in a village named Ikoko Ipenge, where a health center is absent. Her father worked in Bikoro while her mother was in Mbandaka, the regional capital, which left her to primarily stay with her grandmother. On Nov. 29, when her breathing shifted to shallow gulps, her grandmother gathered her up at sunrise and convinced a neighbor to ride them, balancing on a bicycle, to a nearby larger village; the journey took four hours. From there, she hired a motorbike driver for an additional hour to Bikoro.
Upon arriving, they reached a measles treatment center established by Doctors Without Borders a few months prior when cases began to overwhelm the pediatric unit of the adjacent hospital.
The center, constructed from wood and tarpaulin, had 10 children already admitted when Olive arrived, with 18 more joining throughout the day.
She required oxygen and a blood transfusion, but without a blood bank at the hospital, a donor was necessary.
Her aunt remained by her side, gently holding the child’s hands to prevent her from removing the tubing from her nose.
By 7 p.m., Olive had passed away.
Her mother, Gisele Mboyo Ekongo, arrived from Mbandaka the following morning after traveling all night. The weak cellphone coverage in the region meant that the first news she received about her child was of her death.
She expressed that she had tried her utmost to ensure her children received vaccinations, yet it was challenging for those who farmed or needed to travel for work to seek out vaccines.
“The vaccines don’t arrive; the medical care is far away,” she lamented.
Measles results in high fevers, vomiting, and diarrhea, along with a distinct rash triggered by the T cells of the immune system battling the viral infection in skin cells.
It poses a significant health risk anywhere — 40% of U.S. children who contract measles require hospitalization. However, it is especially harsh for kids living in areas with minimal or no medical care.
Measles causes “immune amnesia,” eliminating immunity to other illnesses that children may have developed, rendering them susceptible to gastrointestinal and respiratory infections like pneumonia — which seems to have been the direct cause of Olive’s death. Diarrhea can swiftly prove fatal for a child already weakened by undernutrition; approximately 4.5 million children in Congo are severely malnourished.
Severe measles can lead to deafness, blindness, and encephalitis. However, as Dr. Eric Mafuta, a public health professor at the University of Kinshasa, noted, these conditions are less frequently seen in Congo because a child like Olive is likely to succumb to what he referred to as “the lethal cocktail” of pneumonia and diarrhea before additional complications can develop.
Congo is among four populous nations that have never succeeded in controlling measles (the others include Ethiopia, Nigeria, and Pakistan). Containing the disease necessitates a vaccination coverage rate exceeding 95%, substantially higher than Congo’s current level. (In the U.S., coverage has declined to 93%.)
UNICEF and the WHO estimate that measles vaccine coverage in Congo stands at 52%. Investigations reveal that in the nation’s most isolated or impoverished provinces, as few as 13% of children possess measles antibodies, either from vaccination or prior infection.
The measles vaccine costs under a dollar and is provided free to families. The Congolese government receives support from Gavi, the international organization responsible for purchasing vaccines for low-income countries, for procuring vaccines, alongside UNICEF for distribution.
However, multiple obstacles hinder the delivery of these vaccines to Congolese children.
Firstly, logistics pose a significant challenge: all vaccines destined for Congo enter through Kinshasa, the capital, yet transporting them from urban areas to rural health posts is an arduous task.
Congo spans an area comparable to Western Europe, but the United Nations estimates only about 1,800 miles of paved roads exist. During the prolonged rainy season, these roads frequently become impassable.
To maintain effectiveness, the measles vaccine requires refrigeration until it is administered, a requirement that can be daunting in a nation with a hot climate and an unreliable electrical infrastructure.
Vaccination efforts depend on nurses and outreach workers who travel to communities, often on motorbikes equipped with megaphones to motivate parents to bring their children to designated points. However, nurses seldom receive their nominal wages, and outreach workers are only compensated during emergency vaccination campaigns by aid agencies, which diminishes their motivation to travel great distances for their tasks, according to Mafuta.
Congo has endured internal conflicts for decades, resulting in over 7 million Congolese being displaced within their own country — 740,000 people have been forced from their homes this year alone. Ongoing violence can make children inaccessible to healthcare services, although aid organizations conduct focused immunization efforts in camps where internally displaced individuals reside.
Even when vaccines are available, and health workers are present, reaching the children for vaccinations is another hurdle. Olive’s parents, working in agriculture, leave home before dawn and return at nightfall. If a vaccination team passes through the village, her parents might not be present.
Mafuta, who conducts annual assessments of Congo’s vaccination rates, mentioned arriving at villages only to find a handful of elderly individuals and young children present. Infants are often taken to the fields by their mothers, while 6- and 7-year-olds are left to look after toddlers.
There is hope for improvement, as rapid diagnostic tests for measles are expected to become available in the next year or two, aiding countries in swiftly identifying outbreaks. Dr. Natasha Crowcroft, who heads the measles response at the WHO, indicated that a significant change would be the rollout of the vaccine in patch form, which would eliminate the necessity for refrigeration and facilitate distribution. These patches are currently in clinical trials.
