Werra Maulu Botey could not bear to close his daughter’s coffin. Waiting to bury her, he slid the rough wooden lid back, again and again, to adjust her small head and smooth the cloth that cradled it away from her cheeks.
Olive died of measles, at the age of 5, the evening before. She was the first child to die that weekend in an emergency measles treatment center in the town of Bikoro, in the northwest Democratic Republic of Congo. The second was her cousin, a 1-year-old girl.
Measles is sweeping through the children of Bikoro, as it does every couple of years, creeping, then flaring, across this vast country.
It is on the rise in other parts of the world, too — including in some communities in the United States — though the measles vaccine has been in use since 1963 and is believed to have saved more lives than any other childhood immunization.
There were more than 311,000 reported cases of measles in Congo last year. Some 6,000 of them ended as Olive’s did: with a child buried in a small coffin days after first running a fever and breaking out in a red rash. This year, cases have been fewer — about 97,000 — but the virus has become more lethal, killing more than 2,100. It’s not clear why.
Globally, there were 20 percent more measles cases in 2023 than in the year before, according to the World Health Organization, for a total of 10.3 million, and more than 107,000 people died. Fifty-seven countries had “large or disruptive” outbreaks, the W.H.O. said, nearly 60 percent more than in 2022.
There are more measles outbreaks in places such as Minnesota and New Brunswick because parents mistrust vaccines or don’t believe their children will be seriously affected if they catch the virus. In the United States, President-elect Donald J. Trump’s choice for federal health secretary, Robert F. Kennedy Jr., has fought vaccine mandates and said parents should have the right to chose not to vaccinate their children.
But many parents in places such as Congo never have the chance to vaccinate their children, however much they want to.
Olive lived about 28 miles from Bikoro, in a village called Ikoko Ipenge, where there is no health center. Her father worked in Bikoro, her mother far off in Mbandaka, the regional capital, so she stayed mostly with her grandmother. On Nov. 29, when her breathing turned to shallow gasps, her grandmother gathered her up at dawn and persuaded a neighbor to take them, balanced on the back of a bicycle, to a slightly bigger village. That took four hours. There she hired a motorbike driver to take them one more hour to Bikoro.
There, they reached a measles treatment center, which was set up by the international medical aid organization Doctors Without Borders a few months ago when the disease began to overwhelm the pediatric ward of the hospital next door.
The center was made of wood and tarpaulin. There were 10 children already admitted when Olive arrived; she was one of 18 more who came throughout the day.
She needed oxygen and a blood transfusion, but the hospital had no blood bank, and so a donor had to be found.
Her aunt came to sit by her bedside, gently holding the child’s hands at her sides so that she could not pull out the tube from her nose.
By 7 p.m., Olive was dead.
Her mother, Gisele Mboyo Ekongo, arrived from Mbandaka the next morning, having traveled through the night. The cellphone network is so weak in the region that the first she heard of her child’s illness was news of her death.
She said she had done her best to have her children immunized, but it was difficult for people who farmed or traveled for work to seek out vaccines.
“The vaccines don’t come; the care is so far away,” she said.
Measles causes a high fever, vomiting and diarrhea, as well as a characteristic rash that is provoked by the immune system’s T cells trying to fight viral infection in skin cells.
It is a serious illness anywhere — 40 percent of children in the United States who catch measles are hospitalized. But it is particularly brutal for children who live in places with little or no medical care.
Measles causes “immune amnesia,” wiping out immunity to other infections that children may have built up and making them vulnerable to gastrointestinal and respiratory infections such as pneumonia — which seems to have been what killed Olive. Diarrhea can quickly kill a child who is already frail from undernutrition; an estimated 4.5 million Congolese children are acutely malnourished.
Severe cases of measles can also cause deafness, blindness and encephalitis. But those are seen less often in Congo, said Dr. Eric Mafuta, a professor at the school of public health at the University of Kinshasa, because a child such as Olive will succumb to what he called “the lethal cocktail” of pneumonia and diarrhea before the other conditions have time to develop.
Congo is one of four big, populous countries that have never managed to reign in measles (the others are Ethiopia, Nigeria and Pakistan). Stopping the disease requires vaccination coverage above 95 percent, far higher than Congo has achieved. (In the United States, coverage has slipped to 93 percent.)
UNICEF and the W.H.O. estimate Congo’s measles vaccine coverage rate at 52 percent. Research based on analysis of children’s blood showed that in the most isolated or poorest provinces, as few as 13 percent of children had measles antibodies, either from vaccination or infection.
The measles vaccine costs less than a dollar and is given at no cost to families. Congo’s government is helped by Gavi, the international organization that buys vaccines for low-income countries, to purchase them, and by UNICEF to deliver them.
But many things stand in the way of delivering those vaccines to Congolese children.
The first is logistics: All vaccines sent to Congo enter through Kinshasa, the capital, but getting them beyond the cities to rural health posts is daunting.
Congo is the size of Western Europe, yet the United Nations estimates that it has only about 1,800 miles of paved roads. In the lengthy rainy season, those roads often become impassable.
To be most effective, the measles vaccine must be kept chilled until it is used, which can be challenging in a country with a hot climate and a frail electrical grid.
Vaccination relies on nurses, and on outreach workers who visit communities, traveling on motorbikes with megaphones to tell parents to bring their children to a central point. But nurses rarely receive their nominal salaries, and outreach workers are not paid at all unless an aid agency gives them a stipend during an emergency vaccine campaign. So they are not always motivated to do the job, which can involve arduous travel, Dr. Mafuta said.
Congo has had civil conflicts within its borders for decades, and at least seven million Congolese are internally displaced — 740,000 people have had to flee their homes this year alone. The ongoing fighting can put children beyond the reach of the health system, although aid organizations do targeted immunizations in camps where displaced people live.
Even when vaccines arrive and health workers are on hand, the inoculations still need to reach the children. Olive’s parents, agricultural laborers, leave home before dawn and return at dusk. If a worker passes through the village to vaccinate children, they won’t be there.
Dr. Mafuta, who leads annual surveys of Congo’s vaccination coverage, described arriving in villages to find only a handful of elderly people and small children. Infants are taken to the fields with their mothers; 6- and 7-year-olds are left in charge of toddlers.
“You see this, and then you know there is no possibility those children are getting vaccinated,” Dr. Mafuta said. “Perhaps a mother knows there will be a vaccination that day, and her choice is: I go to gather food, or I go to sell some things in the market, so that my children eat today, or I take them to the vaccination. Which will she choose? At the root of it, it’s a question of survival.”
The first measles shot is routinely given at 9 months (before that, maternal antibodies can interfere with the effectiveness), and by that point, parents who took newborns to get shots may have stopped thinking about vaccination.
That, he added, is a failure of public education, because parents worry about measles, but do not realize their child is not protected. “If you ask any parent in Congo what illnesses they are afraid of, they will say first measles, then malaria,” he said. “Because the ones at the forefront of their mind are the ones they see kill children.”
The situation could improve. Rapid diagnostic tests for measles should be available in a year or two, helping countries identify outbreaks more quickly. Dr. Natasha Crowcroft, who leads the measles response at the W.H.O., said another significant shift would be the delivery of the vaccine in a patch, which would eliminate the refrigeration requirement and ease distribution. The patches are in clinical trials.
Controlling measles in a country such as Congo is doable, she said, but will require political commitment and the strengthening of basic aspects of the health system. Currently, the country relies heavily on sweeping catch-up campaigns every few years, but those are disruptive and pull attention and resources away from the weak routine immunization program, she said.
When her extended family gathered to take Olive’s body to a field to be buried, her mother stayed behind, unable to watch her daughter be put in the ground.
Olive, she said, loved the family’s plot of land, where she had her own small collection of cassava plants. Olive loved to play football in the rain. And she loved to dance. Just before the burial, her friends and her cousins gathered in three rows, and danced for her.
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