Reprint
Samoa’s perfect storm
Brian Deer reports from Apia, Samoa
The Telegraph, December 19 2019
As parents mourn their dead, Brian Deer unpicks the myths and missteps that allowed measles to traumatise a nation.
Crimson, scarlet, burgundy, vermillion. Flags, rags, scarves and sarongs. From the western shores of Savai’i to the eastern beaches of Upolu, the towns and villages of the Pacific islands of Samoa are peppered with splashes of red.
This is Thursday, December 5, 2019: the first of two days of a country-wide “lockdown” when, in a bid to quell a devastating measles outbreak, the government of this tiny Polynesian nation has resorted to banning all but essential movement on the islands.
By that day, three weeks since the government first declared a state of emergency, more than 4,000 confirmed or suspected cases of the disease were logged: a figure that’s since risen by nearly 1,400. All but emergency road traffic is banned.
Schools, shops, and businesses are shuttered. Children are forbidden from public spaces. And the entire population of 200,000 has been ordered to stay home and to hang out red fabrics if they want a mobile vaccination team to call.
“It’s the only cure we have to get immunised,” says mother-of two Maria Hastings, 37, when we pull in behind a white Toyota Hillix, carrying a nurse giving shots in front yards.
In fact, the nurse is this year’s Miss Pacific Islands, Fonoifafo McFarland-Seumanu. The Telegraph is trailing her convoy, down lanes of green bromeliads, orange-and-yellow crotons, and flowering hibiscus hedges.
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Like more than 100 such teams, fanning out across the islands for the globally unprecedented two-day action, her vehicle stops wherever a red cloth is spotted: tied to steel gates, nailed to breadfruit trees, and staked into chicken-cropped lawns.
Ms McFarland-Seamanu stays close to the nation’s capital, Apia, on the northern coast of Upolu. This morning she works a grid of middle class streets in the village of Vaitale, 10 minutes south west, where the density of population gives the exquisitely infectious virus an edge compared with rural locations.
“I need the protection, not for me, but for the family,” says Laine Alatise, 49, when we halt where a knotted red sarong wraps the trunk of an electricity pole. “We have six little ones under the age of five.”
The islanders can no longer afford the luxury of doubt. They’ve witnessed what measles can do. While Europe, North America, Australasia and other regions have seen growing misinformation over the benefits of immunisation, Samoa has had enough of such talk.
At Apia’s central medical centre, the Tupua Tamasese Meaole Hospital (TTM), on Ififi Street, children of the age of Alatise’s little ones have been dying, day after day after day. Between September 30, when tests confirmed the first four measles cases, and the two-day shutdown, the government’s national operations centre attributed 62 deaths to measles.
Fifty-four were children younger than five. And by the time I file this report, the toll had grown to 77 reported dead, of whom the vast majority were babies and young infants – among a population about the size of Peterborough, England.
“Most of the kids have severe pneumonia, often complicated by multi-resistant bacterial infections,” explains Stephen Owens, an infectious disease paediatrician working with an 18-strong emergency medical squad who flew in from the UK last month.
He’s part of a small army of overseas national disaster teams and international aid workers who have descended on this cluster of volcanic outcrops, four hours by air north east of New Zealand, and about 30 to 35 from London.
“Any one of the children I saw yesterday would have been a child being cared for in a high dependency unit at home, or even intensive care,” he says, comparing facilities at TTM with what he normally has access to in his work. “But here that’s not possible. There are not enough beds to provide that level of care for every child.”
Government data is dry. Statistics. Ages. But we saw what they mean to families. Days before the lockdown, we met two sisters-in-law who both lost sons, aged 14 months and six months, who died just two days apart.
“I saw him every day on the life support machine, and I saw him deteriorating,” says Selema Samuelu, 23, the mother of the older boy. “It’s very hard to accept, and to see my child suffer like that.”
Samoa’s grief is as tangible as the current wet season’s rain. In another home we visit, the Tuivales mourn the deaths of three children who died, days apart: a three-year-old daughter, Italia, a 17-month-old girl, Tamar, and Tamar’s twin brother, Sale.
“The first one died on the first of November, the other one on the eighth, and the last one on the 16th,” their mother, Fa’aoso, explains through a translator.
Such death and suffering may seem far away, but 2019 has seen measles – once regarded as a candidate for eradication from the planet – surge back to kill more than 100,000 internationally.
Samoa’s perfect storm raises urgent questions. If its lessons can be learnt, countless children’s lives might be saved around the world.
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During the islands’ lockdown, Apia’s streets were silent. On the Beach Road seafront, where the magnificent Samoan Cathedral of the Immaculate Conception hosted prayers for the victims, only police or sporadic emergency vehicles prowled as the vaccination campaign (with shots now compulsory under emergency laws) moved from home to home.
Even on Ififi Street, cutting sharply inland, evidence of activity was minimal. At the redbrick and concrete TTM hospital, where for weeks security tables have defended the paediatrics ward and intensive care unit, life-or-death struggles play out in private.
We met families who described appalling scenes. One mother, Moana Lefauaitu, 38, spoke of being asked to wait in a TTM corridor while staff switched off the ventilator and detached the tubes from her 14-month-old daughter, Si’la’e.
“After 24 hours on the intensive care unit, they said her body cannot take any more treatment because she had already been given strong medicine,” she says quietly, as rain hammers a tin roof above us, in her family’s modest clapboard bungalow. “So they said they couldn’t give her more.”
An hour later she was presented with her child’s body, wrapped in a blanket, which her husband Oli carried to their car. The girl was then driven home and buried beneath a guava tree, three feet from the family’s front steps.
As such tragedies unfolded, Upolu was calm. But on the less developed island of Savai’i that Thursday afternoon, police broke the stillness by arresting Edwin Tamasese, a self-styled “traditional healer”. He’d not only contested the immunisation drive, but discouraged life-saving antibiotics.
“I’ll be here to mop up your mess,” Tamasese, also the chair of a coconut farmers’ collective, goaded the government in an online post. “Enjoy your killing spree.”
Hauled away to jail, and facing up to two years in prison, he had fallen foul of the most draconian measures yet invoked anywhere in the world to quell a measles outbreak.
Many countries, including France and Germany, have passed recent laws making vaccination compulsory. And, during an epidemic in a suburb of New York City last March, an emergency order was issued banning anyone without a doctor’s note from any place of public assembly. And yet, internationally, the stats are getting worse.
Preliminary World Health Organization (WH0) estimates for 2019 point to a tripling of reported infections over 2018: themselves double the previous year’s. In Europe, major outbreaks have burst from the East like cluster bombs.
Romania, Italy, Greece, Serbia, France and Britain have all been hit. In South Asia, the Philippines, Vietnam, India, Thailand and Myanmar have also suffered. And then there is the catastrophe unfolding in the Democratic Republic of Congo where estimates talk of 5,000 dead.
Confronted by such consequences, anti-vaccine campaigners like Tamasese have struggled to deny responsibility. “The issue is the vaccine compared to the individual,” he told Stuff, a New Zealand-based media group, before being detained and charged.
“If you’re putting the vaccine into a healthy, fully-functioning, fully nutritionally complete human being, this vaccine is probably likely not going to be an issue. “[But] if you put it into someone who has got a compromised immune system because they’ve got low nutritional profiles, then you’re going to have a dangerous vaccine.”
It’s a new line of gobbledegook currently being spread by anti-vaccine campaigners around the world, most notably in the United States. The American lawyer, Robert Kennedy, nephew of the murdered president, John Kennedy is one of the main proponents.
In an extraordinary four-page letter to the Samoan prime minister, Kennedy suggested that the measles vaccine itself might be the true cause of the crisis, somehow creating a “mutant strain” of the disease.
Calling the mass vaccination drive in Samoa a “travesty”, Sherri Tenpenny, an American osteopath and prominent anti-vaxxer, followed Kennedy’s prompt. In an online essay titled “The Real Crisis in Samoa,” she sought to link the arrival of more than 100,000 doses of MMR with the outbreak of the disease in October.
“Within a month, hundreds of cases of measles were reported and the government declared an emergency on November 15”, she wrote, suggesting that these supplies were somehow the cause of the illness, “leading to mass vaccination of everyone”.
Some have gone even further in their efforts to deny what amounts to a natural experiment in a society when you remove a vital protection.
“They [70 Samoan children] are dead because of lack of nutrition, lack of hygiene and sanitation,” claimed Angelika Stalman, an anti-vaxxer and self-styled “brand strategist” on Twitter on December 9. “Their bodies are being assaulted with toxic vaccines improperly stored and made in India; and then wrongly treated with glutathione depleting acetaminophens and antibiotics.”
Such soups of speculation and amateur science can be traced back over three decades to a man who many consider to be the architect of the anti-vaccine revival. This is Andrew Wakefield, 63, the disgraced former British doctor who in the late 1990s falsified research to undermine the MMR vaccine.
Although struck off the British medical register in May 2010, Wakefield has continued his mission in the United States, not only to to provoke parents’ fear of MMR, but to suggest that all vaccines are unsafe.
“If I had a baby, I would not vaccinate them,” he says, sometimes turning up at disease outbreaks himself, or supporting surrogates such as Kennedy. If Wakefield appeared in Samoa, he would probably face arrest. But he and his associates have reached into this nation. His hand in the crisis, like the virus itself, has been mediated through passage in New Zealand.
Like much of the English-speaking world, New Zealand – with which Samoa has a long historic bond – has suffered the impact of Wakefield’s efforts ever since he came to prominence in the 1990s.
After New Zealand had achieved MMR coverage levels up to 92 per cent of young children, publicity for his claims – spuriously linking the vaccine initially to bowel disease and then to autism in children – sent them tumbling to dangerous lows.
Measles outbreaks followed across New Zealand’s North and South Islands. In 2009, nearly 250 cases were officially notified. In 2011, it was almost 500. In 2013, another 133 were reported – since when it has barely gone away. Until that time, Wakefield’s weapons had been the media and the web. But, in August 2017, he extended his reach into this southern seas tinderbox with a full-on campaign against the vaccine.
Sending a partner, Polly Tommey, an English autism entrepreneur, to tour with a film called “Vaxxed”, making untrue claims, he galvanised campaigners in Samoa’s former colonial ruler, laying the ground for what has now followed. New Zealand’s next outbreak would be the biggest yet.
Taking off in February, just 10 months ago, this would see the country shaken by a resurgence of such severity that, by the time of Samoa’s two-day lockdown, it would total more than 2,000 confirmed measles cases. Almost 80 per cent of those were in New Zealand’s biggest city, Auckland, where on the south side is a large Pacific Islander community.
And not only does this enjoy family links to Samoa, but daily flights to and from Apia. Last year, more than 80,000 such journeys were logged between the nations. And it is believed that from a passenger on one such trip, last August, the virus jumped from Auckland to Upolu.
On day two of the lockdown, we witnessed the results. In the lanes and tracks around Apia, we stopped at the homes of yet more families who had lost sons or daughters to measles. Since I had last met Wakefield, he had announced a new theory that perfectly meshed with Kennedy’s.
Sidelining earlier claims that the live measles virus in MMR caused bowel disease and autism, the ex-doctor had decided that measles infections were evolving to be “mild”, and that the historic fall in deaths and sickness from the disease had “nothing to do with vaccination”.
He had no qualifications, or specialist training, to validate his unsupported opinions. Virologists I spoke with denied his claims as efforts to escape culpability. And if he and Kennedy could have toured with The Telegraph that Friday, they might have left better informed.
Likewise, those such as Tamasese who discounted the deaths as the result of poverty and poor nutrition. Samoa isn’t rich, but it is not a Third World nation. It’s classified as “lower-middle income”.
“We’re not really seeing evidence of acute malnutrition,” says the British paediatrician Dr Owens, who arrived from the UK on the same flight as me. “As I understand it, there is very little evidence of clinical vitamin A deficiency. And I’ve not met a patient yet with a defined immune deficiency.”
Yet measles ripped through the communities around Apia, as it did other hotspots on Upolu and Savai’i, with a horrifying, life-stealing speed. The first house we called at was a blue-walled bungalow, near the Vaisigano River, where most of the local community of maybe 1,000 prepares and sells street food around the markets in Apia, a 10-minute drive north west.
We met Selima Masoe, aged 67, the grandmother of a 15-month-old boy, Rispani, who had died just three days before. Unlike Lefauaitu’s daughter, he was admitted to the morgue at TTM hospital, and the family were still waiting for his body. “The government should have done something,” Selima complains, in translation. “And the people forgot to pray.”
What she might have told visitors such as Wakefield and Kennedy was how obviously the virus had spread. Three weeks before we met, a 28-year-old nephew had come to the house coughing, with a fever, and a blotchy pink rash on his face.
He stayed for a week and recovered from his ordeal. But he infected Rispani, Selima’s little grandson, who fell ill and was rushed to the hospital. At our next stop, the link was yet more striking. The deceased child – a 14-month-old girl named Adriana Leuluaialii – was infected by her father, a 26-year-old police officer, who had picked up the bug from a colleague.
The girl’s grandmother, Fuatino, 56, recounts the story, seated by the girl’s grave on the family’s six-acre plantation, 20 minutes west of the capital. Here they lived off the land, grew six banana varieties and three kinds of mango, plus coconuts, papayas, sweet potatoes, pineapples, breadfruit, and even planted their own coffee.
“He’s blaming himself for bringing the virus that killed his daughter,” Fuatino, 56, tells us of her son’s double agony. “I told him he was the reason she got sick.”
With my face running with sweat and tears in my eyes, I ask our translator, Pai Mulitalo Ale, to tell her that I’d followed the measles story for more than a decade, and that Adriana’s death wasn’t down to her father. Indeed, nor was Wakefield the proximate cause, despite all his efforts over the years.
According to estimates by the WHO and the United Nations Children’s Fund, Unicef, just six years ago Samoan uptake of MMR was running at around 90 per cent.
That’s just five per cent shy of the figure virologists cite as necessary to stymie the virus completely – and roughly the same as in Britain. But for the next four years the coverage was allowed to fall, to around only 62 per cent. And then, even under the watch of the WHO and Unicef, came a largely self-inflicted disaster.
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It was a lethal mistake that would send two nurses to prison. On July 6 last year, at a 20-bed hospital on the east coast of Savai’i, they administered a powdered version of MMR, which one of the nurses wrongly mixed with an expired anaesthetic. Two 12-month-old children – a girl and a boy – died, hours apart, and in minutes.
Both nurses were arrested. Confessions came quickly. And the reason for the deaths was known to the government within three weeks of the incident, or sooner. But, after suspending MMR as an initial precaution, they left it suspended for almost nine months, as if someone in the ministry of health, on the other side of Ififi Street from the TTM hospital, had forgotten to change the instruction.
In recent weeks, the ministry has offered no explanation. And when I meet the deputy director of health, Gaualofa Matalavea Saaga, to ask permission to visit the hospital, she makes it clear that publicity isn’t welcome. “Having our case blasted out to the world is the last thing we want,” she says.
Although the government has announced that mandatory vaccination would remain the law permanently, the health ministry’s earlier dawdling left MMR uptake falling to less than one third of children vaccinated by the age of two. And, despite a string of warnings about the epidemic in Auckland, little was done about Samoa’s mounting vulnerability until a few weeks before the crisis.
“It was obvious to me what was going to happen,” Sapeer Mayron, a New Zealander reporter with the daily Samoan Observer newspaper, tells us. “And I have no medical qualifications.”
What happened was death, suffering and family guilt on a scale that the Samoa’s tiny political opposition – calling for the health minister to be fired from his post – insists was an accident waiting to happen.
It was an accident, moreover, which the government won’t acknowledge, as I discover at a press conference, given by prime minister Tuilaepa Aiono Sailele Malielegaoi, outside the Central Bank of Samoa. Seated at a makeshift folding table under a white tent canopy, the 74-year-old head of government, in power since 1998, laughs and cracks jokes during discussion of the outbreak, and shrugs off questions from The Telegraph.
He had accused the public of a “lackadaisical attitude”, said he had seen red flags within yards of a hospital, and criticised traditional healers. But when I voice concerns, raised by families, that he appeared to blame his own people for a foreseeable calamity, and I ask him whether he thought that he ought to apologise, he changes the subject, asking where I’m from, and demanding to know what I’d written about Brexit.
“You are wrong, we’re not blaming them, we are educating them,” he says. “You do not know because you are not a Samoan.”
Brian Deer’s book on the origins of the anti-vaccine movement, The Doctor Who Fooled the World, will be published in May.
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