Five-year-old Malka lies on a bed in the corner of the paediatrics ward of Sujawal’s taluka hospital. She has a ring of the measles rash around her neck; she wants to scratch but has been told she can’t. The air in the ward is pungent, the atmosphere stuffy: the unbearable summer heat makes Malka’s stay in the poorly-ventilated hospital more agonising. Her grandmother sits besides her, trying to console the child.

“She is absolutely fit!” claims a lower cadre hospital staffer, as he chews on his paan and shows me around the ward. “There were lots more children here, but they have all been discharged after getting treatment from the child specialist,” he said.

Poor Malka is one of those unfortunate residents of Kandra village who has been hit by the latest outbreak of measles – an easily preventable and treatable illness, which can become life-threatening if not handled properly. Her village is located in Sujawal – a coastal strip, which has now become an independent revenue district due to a political decision.

Malka (top) struggles with measles with her grandmother (right) keeping a watch over her to ensure Malka does not scratch the rash. Another young man n the same village (below) lies under a neem tree, in the hopes of getting better

Somewhere along the line, in the midst of politics and promises, the system has failed.

Thatta and Sujawal districts have succumbed to an epidemic again this year. About a year-and-a-half ago, some 300-400 poor children in upper Sindh had perished due to measles. It’s a reprise this year, but in lower Sindh: independent reports estimate that in Thatta and Sujawal alone, the measles epidemic has already claimed around 60 victims. Sindh Health officials, however, have confirmed only 14 deaths as they rely on hospital records alone.

Besides Malka’s village, children from adjoining villages have also contracted measles this year. The rural community, as they admit themselves, have no idea about how to cope with this most-recent outbreak – all thanks to a lack of education, infrastructural inaccessibility, and an almost non-existent health system.

“My one-year-old, Chandni, and three-year-old, Zahra, have currently contracted measles,” says peasant Manzoor Ahmed, as his daughters looked on. A total of eight children in Ahmed’s family have suffered the illness this year.

Ahmed is a resident of the Mamo Kandra village. If you didn’t look closely enough, you could have missed his village altogether: a katcha road leads to the Mamo Kandra and Rawal Kandra villages in UC Jaar from the Amra stop on Mirpur Bathoro-Sujawal main road. A dusty passage and the bank of an irrigation distributary eventually guide you to Mamo Kandra village.

Much like its approach, the children of Mamo Kandra find themselves neglected too. Manzoor Ahmed’s children live in unsanitary conditions in a home that is constructed out of mud.

The story is the same for another measles-hit boy, 10-year-old Riaz Ali, who lies on a hammock tied to a tree. Ali seems feeble. He apparently contracted the measles virus from his younger sister, Najma, who remains engrossed in cooking bread for her family in courtyard of the house.

In many cases, villagers are unaware of their immunisation status, and specially, whether measles vaccination was administered to them after birth or not. On paper, a newborn has to be vaccinated against measles ninth months after birth, and then again, in the15th month.

Ahmed is unaware of the Expanded Programme on Immunisation (EPI) which, technically, governs the administration of vaccinations in all public sector hospitals. “The girls got some medicines when I took them to the hospital,” Ahmed says, of the current treatment being given to his daughters. He shrugs his shoulders when asked about routine immunisation.

State of health governance

“Its all about poor health governance,” observes a worried Prof Dr Salma Shaikh of the Liaquat University of Medical and Health Sciences (LUMHS). “Pakistan has to achieve 90 percent immunisation under the Millennium Development Goals (MDGs) but facts and figures indicate disturbing trends.”

The statistics are disquieting indeed, in part because the high rates of vaccination coverage do not correspond with ground realities. The routine immunisation coverage in 2010-2012, per official figures, was 100 percent in Benazirabad, both in 2011 and 2012, 93 percent in Kashmore, 97 percent in Naushahro Feroze, 92 percent in Larkana, and 89 percent in Khairpur.

And yet, measles have attained epidemic proportions in these areas.

An official health source says that an overall 83 percent measles vaccination coverage is reported across Sindh in 2012. Of 8,479 suspected measles cases, 2709 were confirmed. Similarly, 96 percent coverage is shown in 2013 and out of 5,768 suspected measles 3014 cases were confirmed.

Malka (top) struggles with measles with her grandmother (right) keeping a watch over her to ensure Malka does not scratch the rash. Another young man n the same village (below) lies under a neem tree, in the hopes of getting better

The ground realities paint a different picture – of an epidemic that is already underway and might transmit elsewhere in Sindh and even to other provinces. In the current year, 739 suspected measles cases have been reported in Sindh, of which 133 are confirmed.

Dr Aneela Attaur Rehman, LUMHS’s Dean of Community Medicine & Public Health Sciences, backs Dr Shaikh. “Why are children facing measles every now and then if the EPI coverage is 80 percent? On the face of it, these figures are either false or exaggerated,” argues Dr Rehman. The LUMHS dean also cast aspersions on the efficacy of vaccines sent across Sindh, arguing that an effective cold chain is virtually absent in the province.

Health experts like these two are not wrong altogether.

If EPI coverage figures are to be relied upon, then the incidence of measles ought not to be there in huge numbers. This factor what is underscored in the Pakistan Demographic Health Survey 2012-13, issued by National Institute of Population Studies and often referred to by health experts. The survey says that coverage of all basic vaccination in Sindh is just 29.1 percent while that of measles alone is 44.6 percent.

“The pace of progress is still far from satisfactory, falling below the increase needed to achieve MDG target of more than 90 percent by 2015,” reads the survey. The differential in coverage has declines in Sindh, from 37 percent in 2006-07 to 29 percent in 2012-13. “It [coverage] is also considerably lower for children in rural areas (48 percent) than in urban areas (66 percent),” notes the survey.

Dr Rehman considers malnourishment as the main culprit that exposes children to measles. “The rural community is poverty-stricken; there is bound to be malnourishment in those areas. Rural people might have access to livestock for milk, ghee and butter, but they don’t keep produce for themselves. They sell it for their survival and subsistence,” she says.

While nutritionists advise a balanced diet for children to remain healthy, where is this balanced diet going to come from? “In poor economic conditions, we have a perfect recipe for health disaster! To cap it all, we have ineffective vaccination coverage,” remarks Dr Rehman.

Between taboo and treatment

When it comes to treatment, many in the rural sector turn to superstitions for the management of measles. For them, measles is a “Hindu” disease and thus, only a Hindu faith-healer can handle it easily. Per cultural practices, children are not to be taken outside the house when symptoms of measles – spots on body, inflammatory eyes or reddening – first appear.

“Villagers usually bring a child to us after they start suffering post-measles complications, such as high-grade fever, diarrhoea, or acute respiratory infections,” explains Dr Ameer Hyder Shah, paediatrician at Sujawal’s government hospital. “But these complications become the ultimate cause of death,” he asserts, adding that literacy and lack of education are major causes of ignorance in the rural sector.

“A child is brought to a hospital covered in rallies (bed-sheets) so that he or she is not exposed to the external environment. This is part of many people’s belief,” he remarks.

Dr Shah points out that many villagers strongly believe that an injection cannot and must not be administered to a suffering child on the pretext of it aggravating the illness. “Measles is a highly contagious disease….if a child in a village suffers from it, the disease is bound to affect other children of the same village,” he says.

Sindh EPI Project Director Dr Mazhar Khamisani also finds negotiating with superstition tough. “During our visit to upper Sindh in 2012-13, we were in Saleh Pat, which had been adversely affected by the measles crisis. We come across a family that told us that they followed the advice of a Hindu faith-healer, who wanted them to listen to bhajjans to treat measles,” he recalls.

But it is not rural community alone that has a different set of belief systems. In the urban sector too, residents deal with measles much the same way as their rural counterparts, before eventually going to doctors. Many urban families hold the belief that measles completes its influence before disappearing, so it’s better not to touch the rash lest the disease gets ‘annoyed’ and causes more complications for the patient.

“Measles usually disappear in two-and-a-half days or seven days at the most,” says Sofia Iqbal, a resident of Karachi. “People keep a piece of the neem tree’s bark underneath the pillow of a child and dangle it on the main entrance of their homes. A small piece of gold wrapped in white cloth is often also used, sometimes kept in a patient’s pocket.”

Then there is the problem of infrastructure: not all districts have a fully functioning hospital. In districts where the health situation is better, access to the hospital can be difficult – not everyone can bear the heavy expenses incurred on transportation from their far-flung villages.

“It becomes very difficult for us to hire transport first from the main road and then shift our patient, adult or child, to a hospital”, says Babu Kandra, a social activist from the Rawal Kandra village. “In addition, there is the cost of medication.”

Whither Sindh’s EPI?

Aspirations for an ideal health system in Sindh remain a far cry, but the deaths of hundreds of children to a measles outbreak in successive years has put the province’s EPI wing firmly under the spotlight.

Sindh EPI’s management is largely based in Karachi. On record, the provincial government shows that there are around 1,850 EPI vaccinators as its employees. Then there are contractual employees hired by the Global Alliance for Vaccines and Immunisation (GAVI). In total and in theory, there should be around 2,300 to 2,400 vaccinators doing their job in the province.

“Vaccinators are handed money as mobility allowance and operational expenses. A vaccinator can claim a mobility allowance if they have to travel five kilometres away from their base for some outreach support. But nobody verifies whether an area has been covered by immunisation teams or not,” admits an official of the Health Department, while speaking to Dawn on condition of anonymity.

The Sindh Health Department also seeks the assistance of lady health workers (LHWs), even though on paper, these LHWs are only meant for polio vaccination or for community health education antenatal care. In nine districts, LHWs were imparted training for measles vaccination – that too with foreign funding – but the required targets for vaccination coverage could not be met. Health officials believe that LHWs tend to avoid visiting remote areas – a factor that contributes to the collection of misleading or fraudulent data.

Meanwhile, the provincial health directorate in Hyderabad has a post of public health director lying vacant since long. In practice, this leads to little micro-focus or planning regarding primary level health needs of the people (specially in rural areas), or even to reshuffle and strengthen the EPI wing. Without a director, district health officers cannot be held duly accountable for ineffective vaccination coverage or recurrence of the outbreak. Above all, there is nobody to keep sight of the efficacy of vaccines and its cold storage chain.

Health officials too can’t be absolved of their responsibility when it comes to routine vaccination of children. There is no independent surveillance system to ensure that children are properly vaccinated by an outreach team of the Sindh Health Department.

In the current year, 739 suspected measles cases have been reported in Sindh, of which 133 are confirmed.

“When the outbreak of measles was reported in 2012 and early 2013, a vaccination campaign was launched. Following the drive, a survey was also conducted by some officials who had to report back to foreign donors helping out,” says a noted health expert, talking to Dawn on condition of anonymity.

“The survey revealed that 60 percent of children who were affected by measles were left unvaccinated, while 20 percent were administered their first dose,” she says. “Nobody knows what happened to the EPI’s 2011-15 plan, which was ostensibly conceived to achieve 80 percent EPI coverage in Pakistan and reduce mortality and morbidity due to measles by 90 percent.”

While the Sindh government, in collaboration with GAVI, has launched a massive measles vaccination campaign across Sindh from May 19, the underlying issues remain the same. “The government should not focus on polio alone,” argues LUMHS’s Dr Shaikh.

“The government needs to declare routine immunisation as an emergency, while we need to fill all gaps in routine immunization programme for efficient service delivery,” she suggests. “Otherwise, vaccine preventable disease such as measles will keep killing our children.”

Published in Dawn, Sunday Magazine, May 25th, 2014