In 2001 in southern Sudan, it was a time of peace between wars. It was a time ripe for treating diseases that kill thousands of children every year. It was an opportune time for measles vaccination to halt outbreaks of one of the world’s most preventable diseases. The Measles Initiative, founded by the WHO, UNICEF, the CDC and the American Red Cross, was created to address this significant challenge.
In the rural county where I ran an NGO, over 1,200 young children died of measles over four months in early 2001. The death toll was devastating to our school children and their families: local villagers did not have the resources to combat the outbreak except to bury the dead.
When we reported the outbreak to the WHO, the officials we corresponded with expressed shock and dismay that our communities had no access to a vaccination program to stop the spread. But the WHO was caught in a Catch-22 of their own devising: they were unwilling to allocate resources and send doctors unless they could be certain the outbreak was measles, but they couldn’t be certain it was measles without a clinical diagnosis by qualified medical personnel.
Our NGO shipped out videotape of the infected children to one of the Measles Initiative partners. A medical doctor and global measles expert said the video was some of the best footage of children with measles he’d ever seen, but unfortunately Sudan wasn’t on the list to have a measles eradication program that year and he couldn’t be certain without seeing the patients. Even with the clear video footage, a senior WHO official still wouldn’t attribute the children’s deaths to measles nor send an investigative team. So, as far as we know, the children who died in eastern Upper Nile state in 2001 were never counted in the WHO’s official measles statistics.
Worse yet, the WHO wouldn’t supply vaccines to inoculate children and stop the outbreak without a refrigerator to store them, and the remote communities where we worked had no refrigerator and no reliable power source. UNICEF, we were told, would provide a fridge if the number of diagnosed deaths from measles was significant. But with no qualified medical personnel to diagnose a “significant” number of deaths in our area, we didn’t qualify.
In cooperation with Save the Children (US) and funded by USAID, our NGO set up a medical clinic and put qualified African medical staff in place. Training on running a vaccination program was provided and record-keeping started. The communities waited impatiently for the vaccination program as more children died in subsequent outbreaks. There were hundreds more deaths diagnosed from measles each time. Our NGO was repeatedly told it was “near the top” of the waiting list, but years passed with no refrigerator and no vaccines.
Another outbreak of measles started in mid-2008. In desperation, our NGO raised private funds to purchase a refrigerator and fly it into the isolated area where we worked. Within a few months, our new refrigerator was in place and ready to hold the free vaccines that the Measles Initiative promised to qualified organizations. We have found that “free” is a relative term in Africa, however. We quickly learned that a small number of vaccines were available to us at a regional distribution center, a $5000 air charter flight away.
Just last week, a second refrigerator was delivered, this time courtesy of Save the Children (US), nearly seven years after the original request was made. According to locals, thousands of children have died of measles in the mean time, but the major aid agencies still cannot work together to provide truly free vaccines. Seven years later, this community has two empty refrigerators and still no means to keep their children dying from measles. The refrigerator excuse is gone but the vaccines are effectively out of reach.
Even a time between wars is not the best of times for the poor in rural Sudan. As it turned out, it has been a time of bureaucratic “defer and delay” from the UN aid agencies who failed to provide the vaccines needed to save vulnerable children dying from a preventable disease. After seven years, Save the Children (US) is making the most progress, which is disappointingly slow.
It makes me wonder if the 90% drop in measles infection rate between 2000 and 2006 claimed by the WHO is accurate, or if the children who are dying are just too much trouble for them to count.
9 Comments
While the totally inadequate response on the part of the WHO (et al.) is maddening, I’m struck by the notion that the NGO in question let seven years pass without procuring the refrigerator through other channels. I appreciate that this would have been an awesome task, but if a fridge is what is required to take delivery of the vaccine then it seems that the NGO in question would endeavor immediately to procure one. This takes nothing away from the content of this entry, it just strikes me as odd.
The WHO would be well-served to give an earnest look at the notion of crowdsourcing as pertains to epidemiology, it seems. By embracing dispersed knowledge from sources on-site, they could drastically cut down on the kind of overhead that must be required to send doctors into places like Southern Chad. It seems to me that’s where the sick people of the world tend to congregate, so information flows coming from those places might be worth tapping into and acting upon.
Dear Russ,
Thanks for your comments. Regarding the NGO, it hired trained staff, built a clinic where there never had been one, and created infrastructure at substantial expense to prepare for the promised refrigerator and vaccines. If UNICEF and the WHO had not continually renewed their promises, the NGO might have procured and flown in a refrigerator sooner, but this was still no guarantee that the vaccines would materialize.
I agree that crowdsourcing is an efficient way of gathering data when there is widespread, inexpensive technology, so that more people can participate in decision-making and provide feedback to aid providers. The technology is not yet in place to do this in South Sudan where this NGO operates.
Sincerely,
Diane
Cash does not need refrigeration, is easily transportable, and has amazing purchase power.
I wonder if it would not be better for these organizations to set up (conditional?) cash transfers to the affected communities.
Then licensed NGOs on the ground would “compete” for “donations” from their patient “customers”.
The resulting flow of funds would ensure refrigerators and vaccines are supplied.
Has this ever been tried? and if not: Why not?
Dear Fred,
This is an innovative idea for an area where medicines or vaccines are available from multiple sources, such as NGOs or pharmacies. Unfortunately in this case, the supply is controlled and constrained by UN agencies and there is no other source for the vaccines within two days’ walk.
This NGO has used a similar solution when meds are not as constrained: vouchers for medicines. These can be carried to another village where there is a pharmacy or other NGO. They have used it much as we use a prescription. It has been used most often when one clinic runs out of a medicine and another has it.
I would advise against using cash, since it could be used for non-medical purposes.
Are our readers aware of other medicine distribution solutions that agencies have tried? Have they been successful or not?
Yours,
Diane
Dear Diane:
In your response to Fred, you said:
“I would advise against using cash, since it could be used for non-medical purposes.”
I agree with this statement. Yes indeed the money could be used for something else more valuable to the grantee/”poor” and their families (in their perspective) than medical related expenses. But what would be wrong with that?
Thanks,
Moussa.
This is a horrible situation, and I think the solution is obvious: get the vaccine to the site—and fast. Diane, thank you for bringing it to our attention.
Moussa, I would ask you how then the children’s lives would be saved? What would the money be spent on that would be better than the original goal?
It sounds to me like the beaurocracy of these aid organizations is really stealing help from those who have needed it desperately for a very long time.
Is there a way to get help to that NGO even now?
Cordially,
Gretchen
It seems to me that the tale of two refrigerators encompasses a great deal of what DRI is talking about, i.e., that bureaucrats who get paid to solve problems are incented to delay solutions rather than provide permanent ones.
Why should a WHO or UNICEF bureaucrat provide a refrigerator and vaccines to the NGO? If they do, then the problem is essentially solved. Perhaps the bureaucrat will see his/her funding reduced, or (horrors!) his/her job terminated because the problem has been solved?
So while WHO and/or UNICEF are funded by large governments to “fix problems”, their staff is incented to delay or even avoid permanent solutions so that they have employment in the following years.
I hope DRI will keep shining the light on these behaviours, because public scrutiny is the only “incentive” that bureaucrats understand better than the drive for continued employment and less-than-permanent solutions.
NYBNKR
Dear Gretchen:
I understood the implication of what Diane said but thanks for making it explicit.
You ask how then the children’s lives would be saved? The real question is what did the poor spent the money on that is more important than the vaccine? Was it to hide/protect the whole family from rebels in a war zone? Was it to provide food to the whole family instead of a vaccine to one child?
Now, if you argue that the poor faces no other challenges in this specific case, then it is Diane’s premise that is wrong. Meaning that the poor will actually spend the money to provide health care to the sick child.
It will be too pretentious to argue that the aid agencies care more about those children than the (poor) parents do.
To be explicit:
People spend their resources according to their priorities. Why would that be wrong when it comes to the poors?
This is a much general notion than just this specific case of health.
We should observe and listen more to the very ones we actually intend to help.
Dear Moussa and Gretchen,
Thanks for your concern for these children and their families. These people do struggle with some of the choices that Moussa suggests, such as physical safety and a steady food supply. However, this is a very remote area that doesn’t have much of a cash-based economy, so their limited choices from the only “importer” would be salt, rubber shoes, or alcohol. He brings these across an international border by donkey and on rare occasions he brings tea and sugar.
Other choices open to parents might be to hoard the cash to pay for a funeral. This might be tempting because they’ve seen lots of death and never a vaccination program, so they don’t understand how it can stop the spread of a disease. Wouldn’t it be irresponsible to give cash to parents who used it get drunk or pay for a funeral rather than than life-saving vaccines?
By the way, this NGO is not against free enterprise and does infuse cash into the local economy for services rendered, such as employing local school teachers, midwives, medical staff, and so on.
Paying for performance is a more instructive use of cash. By paying local staff running schools and medical clinics over the past few years, the NGO has helped the importer fund a second “vehicle” (donkey) to bring goods into this area through the mountains. He now brings salt which was desperately needed in their diet, for example.
This trader did not need microcredit, teaching him to borrow money. Instead, he earned enough money to increase his output. Now that he has two donkeys, he earns twice as much for each trip into the area, generating even more cash. He brings more goods, which the people were begging the NGO to provide at no cost. Now they earn money to buy them. I agree that expansion of the local economy can improve their health, but not through a vaccination program.
Diane