October 15, 2004
Over the past 18 months, Doctors Without Borders/Médecins Sans Frontières (MSF) has vaccinated more than 500,000 children in a continuing campaign against measles in some of the most inaccessible areas of the Democratic Republic of Congo (DRC). The next stage of the campaign will cover another 100,000 children in hundreds of villages across the region of Basankusu in the northeastern Equateur Province; an area slightly larger than Connecticut, but only accessible by dugout canoe or, at best, motorbike.
On August 14, I left the pollution of Kinshasa, the capital of the DRC, to head to Equateur Province, where I will be running a measles vaccination campaign for the next six months.
he heat is really striking. Mbandaka, the provincial capital is situated right under the equator. The dampness in the air rots everything fast and it is impossible to keep anything dry. Seasoned international volunteers have told me that the clothes start to rot on the shelf if they are not used fast enough.
The Basankusu area is where we will do the vaccination. There are 245 villages along the trails in the forest accessible by motorcycle and 251 small villagesâ€”that we know ofâ€”by the rivers. With an additional number of 41 villages hidden deep into the forest, extremely inaccessible. It all adds up to 540 villages in total, although we suspect that there are a lot more along the rivers. All these villages have to be visited even if there is only a single child in a village of just a few people. The aim of the campaign is to track down 100 percent of the target population.
But before this can even get started, we have to plan, which includes identifying the villages, routes, and staff. So it will begin with a series of exploratory missions, visiting the health posts to lay the groundwork for the campaign. The map we had was virtually useless, but we estimated that it would be possible to visit all 18 health posts in one week.
We left Mbandaka in the small MSF Cessna plane that does all the surveys in the area. Before we left, I had been to the office to pick up the survival kit and camping gear for living in the bush. I really do not like flying, but through the front window I was able to have a good look at the terrain where I will be working for the next few months. As I sat there and watched everything pass by I began to understand why this area was a white spot on the map long after all other continents of the world had been explored. It is just dense rainforest. As the pilot said, "like a head of broccoli."
Into the Bush
My team consists of a Congolese logistician, a driver, and me. I sit jammed between the luggage and the driver. Some of the rivers we cross are so deep we have to use a dugout canoe. Sometimes there are the remnants of a bridge, but they are usually half sunken and so narrow that it is useless, even on foot. As for the bike travel, I hurt my knees from constantly crashing through branches and vegetation. I finally had to stop and put bandages over my jeans as protection. After I put some big leaves in the bandages, it worked quite well.
Finding the Health Posts
Throughout the journey, we stop at different health posts and talk to the staff to find out about the population, complete the number of villages on the map and ask about distances, if it is possible to use motorcycle, canoe, or if you have to go by foot. You rely on maps for basic information, but everything has to be checked with the locals.
We also have to try to identify if there are people in the villages around the health posts that we might use in the campaign, people with medical background, or people who can simply just read and write. The years of war in the DRC have left few people with access to education.
Since there has been a small measles epidemic recently in the Basankusu area we ask at each health post about how many cases were reported. The information given was usually an estimate and many of the children who had suffered from measles had, in fact, already been vaccinated.
This is not a good sign as it indicates that the previous vaccination had been done badly. Another factor may be that the mothers of the children who are sick just do not remember, or know, if the child was vaccinated for measles or not. That is why we try to give different vaccinations in different places of the body; a mark on the bottom means measles and on the arm, polio.
A Bed for the Night
By the time we finish in the evening it is usually dark and we still have to find somewhere to sleep. We sleep wherever we can, in consultation rooms, tents and in people's huts. One night I stayed in one of the two rooms of a villager's house that was close to the health post. Since it was quite a large family, there were people coming and going all the time. I was so tired I wasn't even bothered that people were standing looking into my tent through the mosquito net. It was actually quite cozy to lie there and listen to the whole family talking, singing, and getting ready for bed.
You get filthy after a day of riding on a motorcycle through the bush. My once white MSF t-shirt is always brown and my body covered in a layer of dust. In one place they gave me bucket of cold water and I found a spot to take a shower. It was a bit out in the open, but nice to be outside in the moonlight.
The noise always wakes me up early. It almost seems prohibited to sleep after half-past five here. The sounds and the light of the jungle grow stronger and stronger. It is as if the whole jungle wakes up at the very same time.
Some villages are deep in the forest, only accessible after an entire day by canoe. No one seems to know how many people are staying in all the different villages along the rivers, since they are a moving population. This could potentially be a very difficult to try to reach all these villages and maintain the cold chain with only ice packs and cool boxes for the vaccines, which have to be kept between 2 and 8Â°Celcius.
Back in Town
Back at Basankusu town, we have to organize the data collected during the 5-day exploration. Not easy since we have a lot of contradicting information. The health authorities here have some data on the map that I jotted down before we headed out. But now we have done the long journey, it turns out that they have different data in their files. Plus, it is always difficult to get the information out of the villagers when visiting the health posts.
But the map has improved. We have changed a lot of things from our original as well as the information we started out with. In the end we just decided to trust what we had seen during the exploratory mission. Over the next days we will sit from morning to evening to organize the information. My evenings are spent putting everything in Excel files.
I spent some hours comparing different maps and then drawing my own with the correct distances on it. We have started to make lists of all the villages. There are hundreds of them. We will use this when we start drawing up all the different teams and how we will organize the stock and preparation sites.
Karl, a logistician on the campaign, and I need to go to Mbankdaka to prepare all the things that have arrived from Lukuto. It takes two days. On the way back we will probably go together with our vaccination materials (fridges, cool boxes, generators, gasoline). If we do this, we will be able to see that everything is put on the canoe and we will also be the ones to unload it.
We just received word that the canoe going from Mbandaka to Basankusu and Djolo has tipped over and all the things sunk. They tried to get the military and the villagers to help out to retrieve everything. For the hospital here this means that all their medical supplies have probably been destroyed. Maybe it is possible to save some of the medical supplies, but most likely not.
The plan for the moment is to start the campaign in two or three weeks. We will divide it in three zones and cover each one in about 10 days.
The last zone to the north we will probably not be able to visit beforehand. It is smaller than the one we visited in this exploratory mission and the only way to get there is by canoe. This will consume a lot of fuel so, for the moment, it is not possible.
Organizing Vaccination Teams
We've finally made it back to the main MSF base in Mbandaka to work on the information sessions for the 147 vaccination teams and the planning for the medical materials we will need for this vaccination effort. We had started to head back from Basankusu yesterday, at 5:30am, when the sun was rising and we hoped to make it here before it set. Unfortunately, that didn't quite happen. We didn't arrive at the port here until after dark, having spent the full day travelling, under the merciless sun, down the Ikilemba, one of the little tributaries of the larger Congo river.
We had gotten up so early that we didn't have any breakfast before leaving. Instead I bought 12 bananas and planned to buy bread on the market before heading off. In the end we didn't have time to get the bread and I left all the bananas on the kitchen tableâ€”so much for my plans.
After searching my bag for something edible (13 hours without any food is a lot) I found some chewing gum. We had just one each for breakfast, saving the rest for lunch and dinner. Fortunately, mid-afternoon we did a 10-minute stop with the pirogue at an old Catholic mission station in the middle of the jungle.
This little mission station is little more than a small village with a big church in the centre. However it is a very important toilet opportunity and not to be missed since we could only make one stop during the whole day. Initially I had thought it would be possible to just stop anywhereâ€”after all this is a jungle. But you cannot, since the rain forest is so dense that it is impossible to get into it. Instead, every stop has to be well planned. Oh well. We managed to buy some bananas and bread at the mission station so we could finally eat something.
Each vaccination team will be made up of five people. We have made lists of how many teams are needed and we are still trying to decide where we place the site to stock the vaccines and where to keep the preparation sites.
Maintaining the "Cold Chain"
There will be 100,000 vaccination vials used in this effort and keeping the vials healthy is essential. For this we need to create a 'cold chain', where the vaccinations are constantly kept at low temperatures before use. If the cold chain breaks, the vaccinations will be useless.
The preparation site is the heart of the cold chain (needed to constantly keep the vaccines between 2Â° and 8Â°C) and that site is then used to supply all the stock sites.
That is where we will keep the generators used for running the refrigerators, a kin to a spider in the middle of his web. At the stock sites we keep the vaccines in large cool boxes and go back and forth from there to the preparation site to supply the stock site with cold ice packs. It all needs to be meticulously planned, or at least as meticulously as the realities of Basankusu allow.
When the vaccination campaign starts, we will have split the area in three different pools. Pool One is Waka, situated southeast of Basankusu. Pool Two is Bokakata to the south and finally Djombo, Pool Three, is to the northeast. The easiest will be Waka, so we have decided to start with that. The last pool, Djombo, is going to be the toughest since we have to transport everything by river and set everything up from one preparation site.
To complicate the matter, two thirds of the people in Djombo live in the bush and so are only accessible by foot or canoe. The third that will be reached by motorcycle seems to be easier, although we have had reports that some stretches of the road are in miserable condition and it will be horribly difficult to come through with the heavy cool boxes on the back of the motorcycles.
Plus we have not had the chance to visit the area. This is not ideal although, with the help of some people from the area, we have managed to complete the very inaccurate map. There is page after page of information on all the health centres and the villages. And all of this has to be prepared for the report due in Kinshasa by the end of the week.
© 2013 Doctors Without Borders/Médecins Sans Frontières (MSF)