“Every time I visit my baby, I see a morgue full of dead babies,” says a mother sitting at Tupua Tamasese Meaole National Hospital in Apia, the capital of Samoa.
The woman’s one-year-old died in the measles outbreak that has wracked the Pacific nation over the past two months. She now comes to the morgue day after day, awaiting the release of her child’s body.
“It is the most unnatural thing you would ever see in your life, these babies should not have died,” she says.
Since October, a measles outbreak has gripped the Pacific nation, killing 76 people – more than 60 of them children under the age of four.
A state of emergency has been declared in the country, which is 4,300km east of Sydney and has a population of nearly 200,000. A mass vaccination campaign has been implemented, with health workers going door to door to carry out immunisations. Experts feel the emergency response is working and they are over the worst of the outbreak.
But as funeral homes report running out of children’s coffins and young parents make their way to morgues to retrieve the bodies of their babies, they are questioning how it came to this.
A tragic event with tragic consequences
In one sense it is an easy question to answer. Samoa’s vaccination rate was too low to protect its people when measles arrived, probably brought by a traveller from New Zealand, which has suffered its own measles outbreak over the last year.
The World Health Organisation (WHO) recommends that in order to have immunity, there needs to be at least 95% coverage of people who have had two doses of measles-containing vaccine. Four years ago, roughly 85% of one-year-olds in Samoa were vaccinated, in 2017 that dropped to 60%.
The rate plummeted sharply after a scandal that rocked Samoa in July 2018, when two Samoan nurses administered MMR vaccines to babies who subsequently died. The problem was not with the vaccine, an investigation determined, but rather its administration, after it emerged that one of the nurses mixed the MMR vaccine powder with expired muscle relaxant anaesthetic instead of water.
But the impact on public trust in vaccination was profound.
The Samoan government suspended the country’s vaccination programme for 10 months, despite advice from the WHO that the country immediately restart the programme. By 2018, only 31% of infants had been vaccinated.
“When you pause for 10 months that’s enough time for thousands of kids [without immunity] to accumulate,” said Jose Hagan, regional immunisation specialist for the WHO.
The country had already been a target for anti-vaxxers, but the MMR incident provided fertile ground for their messages to take hold.
“It’s really hard to know how much to attribute to the anti-vaxxer messaging,” said Hagan. “They’ve certainly been extremely active in Samoa, for perplexing reasons. They’re flying all the way to Samoa to spread this message.”
While these events played a part in reducing the immunity level; health experts and government sources in Samoa have told the Guardian that once the disease arrived on Samoa’s shores, its impact was worse than it needed to be because of mismanagement.
The Guardian spoke with health workers, government and ministry of health sources – including those involved in the measles emergency response programme – who all said the situation had been mishandled from the start.
The Samoan government sources who spoke to the Guardian did not wish to be named out of fear they may lose their jobs. The prime minister has shut down criticism of his government’s handling of the crisis, saying that those who have suggested an inquiry into the outbreak show a lack of “common sense” and that such calls were a “political gimmick”.
‘I was told I was being a paranoid mum’
One local senior health expert who did not want to be named said that tragically many of the measles cases were probably contracted at hospitals and clinics when people went to get vaccinated in the early days after the outbreak was declared.
“Once the public were encouraged to vaccinate after the outbreak declaration the hospital was not properly prepared for the safety measures that are required for such a virulent disease. As such most of the cases would have been contracted from the clinics and hospital where the people went to get their initial vaccination once the outbreak was declared.”
Hagan, from the WHO, says that this is something the organisation sees “constantly”.
“This is a feature of almost every measles outbreak I’ve ever been a part of, including in highly-developed countries. Measles is so incredibly infectious, whenever people are gathering, if there is a measles case, it will rapidly find people who are not immune and it’s very difficult, even in the most prepared setting, to prevent.”
Hagan says it is unlikely that people who attended clinics to be vaccinated themselves would have been infected, as the vaccine would have protected them, but that anyone who attended a clinic for other reasons, including parents taking their children to receive the vaccine, were at risk.
The senior health expert also said that the government response was too slow to take action to prevent the spread of the virus, with schools allowed to remain open after the outbreak was declared.
“The late declaration of the outbreak delayed appropriate response from government, WHO, Unicef and donors. There was a clear misunderstanding by MOH [the ministry of health] of their role and their responsibility in a state of emergency. They did not realise that the state of emergency would give necessary support and resources outside their capacity,” the source said.
He said that despite the surge of humanitarian assistance from other governments and development partners, they were not put to good use immediately.
“There was a noted delay in acceptance of humanitarian support such as doctors, nurses and emergency health workers, even with the growing numbers of cases. There was no system in place, no plan or established coordination in the health sector itself.”
While Hagan calls the response from the Samoan government “extraordinarily aggressive over the past weeks”, people report being turned away from understaffed and overrun hospitals with their sick children.
Joyetter Fa’apouli Feagaimaali’i, a reporter for the Samoa Observer, says she was repeatedly turned away from Tupua Tamasese Meaole II hospital in Apia after her seven-month-old daughter was showing early symptoms of measles several weeks ago.
Despite the fact that the outbreak was well under way, she told the Guardian that doctors said her baby’s symptoms, which included fever and refusing the bottle, were most likely the result of teething and growth spurts and she was accused of being a “paranoid mum”.
Feagaimaali’i took her daughter to the hospital five times over several days before the child was finally admitted for treatment.
“I cried hysterically, as her breathing was getting worse, the sound of her cough was heartbreaking. As a mother you know her body is changing, she was deteriorating.”
Her daughter had intensive treatment for eight days in hospital and has recovered.
‘We owe it to the children’
Devastating measles outbreaks like this one do not happen in a vacuum.
Last year there were nearly 10 million cases and 142,000 deaths from measles worldwide and the figures for 2019 look set to be worse, with three times more cases reported so far this year than at the same stage in 2018.
“These outbreaks just don’t happen by themselves in places like Samoa,” says Hagan. “They’re really isolated and they haven’t had any cases in years and years … the fact that this measles outbreak is whipping around the world on airplanes, which is really a global failure to protect children against this horrible disease.”
Pacific nations, which often have remote communities, developing health systems and infrastructure, are often at risk. One nurse educator said the low numbers of nursing staff graduating from Samoa’s national university meant that there weren’t enough nurses to carry out the necessary extensive village outreach programme.
For now, the mass vaccination campaign seems to be working. The immunisation rate in the country is now at 93% and Hagan says “It feels comfortably like we’re over the peak … We’re already starting to see the beginning of the impact of the campaign, I think we will start to see a rapid drop-off in the next weeks.
But there are questions to be answered.
Olo Fiti Vaai, an MP, has called for the government to launch a special commission of inquiry into the way the epidemic was managed.
“We owe it to the children of Samoa that have passed on and their loved ones whom to this day are in mourning. There has to be an investigation as to where the lapse is and how the measles came into the country,” he told the Samoa Observer.
Both the Samoa government and the CEO of health were contacted for comment.