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Samoa looks untroubled but after a dramatic fall in vaccination rates was ill-prepared for the global measles epidemic of 2019. Photo/John William Banagan/Getty Images

Tragedy in paradise: How Samoa is faring after the measles epidemic

Avi Duckor-Jones reports on how the people of Samoa are responding to an epidemic that has claimed more than 80 young lives.

Things grew here. Climbers smothered coconut palms and entire fields of taro were lost under blankets of vines. Papaya trees carried the weight of their large green fruit and hibiscus bloomed as though ready to burst. Villagers collected mounds of ugly noni fruit on bright blue tarps. Young men batted at swollen breadfruit, hanging like fluorescent green beehives. There was a sense of abundance in this fertile soil and it wasn’t hard to imagine that anything introduced would flourish and spread like wildfire across the island.

So, when a passenger carrying measles boarded a flight from New Zealand to Samoa in August last year, spread it did. The result was that by early January, Samoa’s Ministry of Health had reported nearly 5700 cases of measles and 83 measles-related deaths, most of them children under five.

The theories as to  how this happened are vast. “There has always been measles here,” Kiona Lemoa says as her husband, Pastor Manuele Lemoa, preaches loudly inside the white Elim Church of Amaile, on Upolu’s south-east coast. The sermon was the last of several they’d been conducting about the various manifestations of the devil. “But this measles is different,” Kiona Lemoa continued. She fanned herself against the dense heat with her husband’s literature. “This one has come with an evil spirit.”

A father of a baby with the disease waits for medical help.

This evil spirit had attacked those who were fearful.

Although this religious rhetoric didn’t entirely explain the devastating epidemic that had swept across Samoa, there was an element of truth to her theory.

The story of this fear can be traced back to July 2018, when two nurses at Safotu Hospital on the island of Savai‘i injected two babies with a misassembled concoction of anaesthetic and the MMR vaccination, rather than the saline solution meant for the mix. The two babies died within minutes. These fatal accidents caused the population of Samoa to look at vaccinations with more than a sceptical eye and gave leverage to anti-vaxxers and conspiracy theorists to argue that vaccinations were against society’s interests and indeed harmful, possibly fatal, and should be avoided at all cost.

The measles immunisation rate fell from 74% in 2017 to 31% in 2019, the World Health Organisation (WHO) estimates, similar to the poorest countries in Africa. Ideally, the vaccination rate should be above 90%.

A father of a baby with the disease waits for medical help.

But fear alone cannot explain the epidemic. Many blame negligent medical institutions or the Government for not responding fast enough, instead waiting until 50 deaths occurred before springing into action. As early as March, the WHO and UN children’s agency UNICEF  warned all Pacific countries to take proactive measures to improve immunisation rates and prepare for the global measles outbreak.

The most common explanation for how this infectious disease spread so rapidly and took so many lives comes down to a lack of healthcare education. To many people, preventive healthcare was too obscure to warrant action.

Camilla Vili came from New Zealand three months ago to help her elderly mother run their shop in Lalovi. “People here haven’t been educated about health,” she says. When they have no sickness, then why worry? People don’t know that healthcare is free. To many of our people, the hospital is just the place where old people go to die.”

Dorothy Margaff, a volunteer at a community-based organisation, says there isn’t really such a thing as a family doctor here. “If you are out in the villages, and don’t have much money, just living off the land, things like vaccinations are not a priority.

Read more: Samoan doctors say the measles epidemic is 'a warning to New Zealand'

Camila Vili. Photo/Avi Duckor-Jones/Supplied

“Traditional methods have been around forever. They are used for things such as colic and tummy bugs … so when this came, people did what they knew.”

When Sia Taueva’s two-year-old son, Benjamin, became feverish eight days earlier, she did exactly that. “We tried applying the  leaf,” Taueva says, miming the act of spreading the pulp of a plant on her child’s skin. She lives on Manono Island where only three cases of measles have been reported among the 1000 residents. After applying the leaf, Taueva noticed a rash appear half an hour later accompanied by a redness of his lips. “We also tried drinking [herbal] tea. For the older two boys [on Manono], it worked,” she says, “so we waited until it would work for my boy, too. For a while, it did.”

Benjamin’s rash bloomed after a shower, covering his entire body. “It was like a flood. I couldn’t see the real colour of his body.” Then, the fever went down and he was able to walk and eat, so they thought it had passed. “But then he started fainting, so we showered him and washed him with a cold sponge to decrease the fever.”

Taueva took Benjamin to Leulumoega Hospital, where he was given antibiotics and vitamin B. “I just thank God,” Taueva says, looking down and clasping her hands in prayer. “I didn’t know any of that.”

One family who shared the ward with Benjamin had nine children, all with measles. When asked why she, or the family of nine, hadn’t had their family vaccinated, Taueva pauses. “When the nurses came to Manono, people didn’t take the babies to them because they thought the nurses would come to the house, instead. It wasn’t strict. Not compulsory.”

So, why hadn’t she taken Benjamin in at the first signs of measles? “I don’t want him to be admitted into the hospital with the ones who had it worse.”

Sia Taueva. Photo/Avi Duckor-Jones/Supplied

Into the unknown

“In the Samoan language there is no word for bacteria or virus,” says Henrietta Aviga, a nurse travelling around villages to vaccinate and educate families. “There is a lack of understanding about how this disease works.” Aviga gives examples of families she’s met who had no idea of the extremely contagious nature of the disease. One family had two adult sons with measles, but thought that, since they were adults, they didn’t need treatment.

She has also encountered resistance towards the unknown. She describes a household of 18 people; 14 had measles and no one had been vaccinated. “I just don’t think people understood the magnitude of this.”

Lack of education and understanding wasn’t exclusive to the families. Health professionals had turned away many people who weren’t displaying the symptoms they were trained to focus on.

“All they were looking for was a rash and a fever,” Aviga says. “They weren’t looking at the other ways measles could present in a patient, such as sores in the mouth.” In the village of Lauli‘i, a young family were sent home for exactly that reason, and subsequently lost three children to the disease.

A state of emergency was declared in November, ordering the closure of all schools, keeping children under 17 away from public events and making vaccination mandatory. On December 14, the state of emergency was extended to December 29.

But travelling to Lauli‘i, east of the capital, Apia, there is little sign that anything has happened at all. Surf rolls on to black rocks. Fales painted bright pinks, blues and yellows are surrounded by flowers in bloom. Samoan flags whip in the wind above small Christmas trees decorated with tinsel. At the end of the paved road, where a track tapers off into the bush, is a family home. A young girl holding a baby kicks away a puppy nipping at her ankles. Two young boys chase each other around a dirt yard. Beyond them is a white-painted grave with three bouquets of flowers in small plastic pyramids.

Tuivale Pu‘elua with photos of his children. Photo/ADJ

Tuivale Pu‘elua, a plantation worker and 36-year-old father of 18-month-old twins Sale and Tamara and three-year-old Itila, explains how the trio succumbed to the disease. The parents first noticed that Sale and Itila had a fever, so took them and Tamara to hospital. They were told Sale and Itila didn’t have measles, so they were discharged, but Tamara was admitted. Three days later, Sale and Itila’s symptoms worsened so they rushed the children back. Within hours, Itila died. Tamara followed shortly after. Two weeks later, Sale was dead.

While we talk,  their two remaining sons, Lui, six, and Edison, four, play with a scooter donated by an aid organisation. It’s hard to imagine such immense loss, the vacant spaces left in their small wooden fale that used to sleep seven and now sleeps four.

Apia and surrounding villages such as Lauli‘i have been the most severely affected. Although most tourists cancelled their travel to Samoa – Saletoga Sands Resort says occupancy is at half of capacity and Leuaina Beach resort is 90% down, both with cancellations through to April – people on the south side of the island feel far away from the disease, protected by the mountain ranges that separate them from the infected north coast.

“It’s over the other side,” says Ruta Faleao, mother and shop owner in Malaela. “It’s not here.” She hands over a bag of taro chips and bottle of cold water. “So, when we can’t see the measles, there is no sickness. People don’t think about what they cannot see.”

Ruta Faleao and grand-daughter Fuifu. Photo/Avi Duckor-Jones/Supplied

However, other young parents know that the threat is not so easily contained.

“We are scared,” says Kilisi Alaimanu, a 28-year-old plantation worker in Tiavea. He has three children under five, none of them vaccinated.

Whether the threat of disease felt close or distant, the community has rallied. Eka Arp, 39, set up community-led organisation Helping Hands after six measles-related deaths. She and her sister, Apu, turned their house into a soup kitchen and began supplying local hospitals. They gave out nappies to paediatric wards. Before long, demand grew as the infection spread.

“The hospitals were so overwhelmed … There were mattresses on the floors and families were waiting outside for hours on end,” Eka Arp says.

They created a Facebook page and support poured in. Now, they are able to feed 500 people a day and give out food vouchers to every family directly affected.

“The positive side of this whole thing is how the community has come together,” she says. “There are people showing up here every day with anything they can afford to give – a potato peeler, a chopping board.”

Arp, who has visited the hospitals almost daily since the early stages of the epidemic, says they have turned a corner. “Although there are new cases every day, there are empty rooms now. There are still a lot of babies in ICU, the ones that came in too late.”

Eka Arp. Photo/Avi Duckor-Jones/Supplied

Faith and community

So, what happens now? Tuatagaloa Joe Annandale, 73, is one of two paramount chiefs in the village of Poutasi on the south coast. Annandale lost his wife, Tui, and mother-in-law in the 2009 tsunami that destroyed the village. He is no stranger to loss. “It’s the health of our people,” he says. “Obesity, diabetes – lower immunity makes us susceptible to these things. The environments in which some of these families live … Lack of space, no flushing toilets. So many sweet and sugary products, far less walking. Now is the time to reassess our situation and our habits.”

He sees a great need to educate parents and children in healthier choices and plans to trial a school lunch programme in Poutasi this year.

Komiti tumama

Many Samoans speak fondly of the Komiti Tumama, women’s groups that have traditionally played a vital role in the delivery of public health and in improving access to services. Similar to New Zealand’s Plunket nurses, members of Komiti Tumama would visit homes each month to make sure they were clean and, more pertinent to the measles epidemic, monitor vaccinations. Their role has diminished. “They’ll bring it back now,” Annandale says. “I guarantee it.”

Tuatagaloa Annandale and his wife, Tammy. Photo/ADJ

There is little discussion of who is to blame: the two nurses in Savai‘i, anti-vaxxers, the Government’s late response, families, health standards and/or education. It’s all been a terrible cocktail. “Even after the vaccination mix-up was resolved, they didn’t reactivate the vaccination programme.”

The reaction of the community is what Annandale wants to focus on. “What makes the Samoan people so resilient is family. When the tsunami happened, I had my brother and sisters and we went through it together. Fortunately, we have our family and we have our faith.

“People have shown their heart to Samoa. It reaffirms to me that humanity is very much still alive.

“This is the beautiful spirit of equality. It’s the Samoan way. A person might be down to their last cent, but if they see a need, they’ll give it away. For me, I’m humbled by what’s happening.”

This article was first published in the February 1, 2020 issue of the New Zealand Listener.

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