Scientific medicine, the weight of history, and the measles epidemics in Samoa and New Zealand

It appears that the measles epidemic in Samoa is finally waning. It is now a week since the government of Samoa implemented emergency measures to combat the disease, centred on a mass vaccination campaign. Samoa received the assistance of medical teams and supplies of vaccine from a number of other countries, including New Zealand, the United States, Britain, Australia and France. On December 5 and 6 it ordered a complete daytime curfew of the country, shutting down schools and universities and other large gatherings to curb the spread of the disease, and halting all business activity for two days as the medical teams fanned out across the country, visiting people in their homes to vaccinate them. Any household where there were unvaccinated people living was instructed to display a red flag on the street to alert the mobile medical teams.

Mobile vaccination team in December 2019. Photo: Samoan Government

The campaign was very successful: by the end of the two-day curfew, more than 90% of the population had been vaccinated, and that figure has since increased to 93%. Although the vaccine requires two weeks to take effect, it is expected that the number of new infections will drop rapidly over the next week. As of 13 December, just over 5,000 of Samoa’s 200,000 people had been infected with measles. There have been 72 deaths, 61 of whom were children under 5 years old. A number of people are still critically ill in hospital, so there will likely be more deaths in the week to come.

Red flags displayed on the street signalled to the mobile vaccination teams that there were people needing vaccinations Photo: Alex Perrottet RNZ

It is also now confirmed that, contrary to an earlier denial by the New Zealand Minister of Foreign Affairs, Winston Peters, New Zealand was almost certainly the source of infection for the Samoan epidemic. New Zealand has had its own outbreak of measles in 2019, with more than 2,100 cases reported since 1 January. Auckland, which has a large population of Samoan and other Pacific Islands peoples, was the centre of this outbreak. It appears that the Auckland health authorities took no special steps  to prevent the spread of the disease to Samoa, despite being alerted to the danger presented by the high level of passenger traffic between Auckland and Samoa.

Measles is one of the most infectious viral diseases known to humankind; it can have serious side-effects and cause permanent disabilities, including mental retardation, and can be deadly, especially among children. These facts have been known for at least a century. But for more than half a century, there has been a vaccine available which is very safe, cheap to produce (costing less than a dollar per dose) and easy to administer, and which provides a high level of protection against the disease.  Appropriate hospital care for those who do get infected can also greatly reduce the rate of death and disability. None of this knowledge prevented the outbreak in Samoa, nor the high death rate among those infected.

When it was introduced in 1963, the vaccine proved so effective that a number of developed countries declared that measles had been effectively eradicated as an endemic disease. However, those declarations have been withdrawn in recent years, as the disease has re-appeared in developed countries. It was never eliminated in the semi-colonial world, where it still wreaks a terrible toll. While deaths from measles worldwide went down by 80% between the years 2000 to 2017, the World Health Organisation (WHO) has reported a new surge in measles cases, with an estimated ten million cases and 142,000 deaths from measles in 2018.

An outbreak of measles in Democratic Republic of Congo has claimed more lives than Ebola. Photo: Olivia Acland, Reuters

The WHO also reported that worldwide the number of cases notified by early December 2019 is nearly three times the number at the same time last year. A catastrophic outbreak in Democratic Republic of Congo, where vaccination and other medical care are severely hampered by war, has claimed more lives than the Ebola epidemic. Several European countries have been affected. 58,000 people have been infected in Ukraine this year, where there have been 42 measles deaths since 2017. Military conflict, loss of confidence in the health system, and in government generally, are major factors in Ukraine.

Demonstration in Kiev, August 2019, protesting decision to deny unvaccinated children entry to schools. Placard at left reads ‘Protect rights of the child’. At right: ‘This is more compulsion’. Photo: Glab Garanich, Reuters

One obvious reason for the rapid spread of the disease in Samoa was the very low vaccination rate at the time of the outbreak. This has been largely attributed to a health system failure that occurred in 2018, when two children died soon after receiving their MMR (measles, mumps, and rubella) vaccinations. The nurses administering the vaccines had mistakenly mixed the vaccine powder with an expired muscle relaxant instead of water. The tragedy caused a catastrophic loss of confidence in the vaccination programme by the Samoan people, and led to the suspension of the programme altogether for a period of months. False rumours began circulating that the vaccines themselves were substandard. Nurses Luse Emo Tauvale and Leutogi Te’o pleaded guilty to manslaughter and were sentenced to five years in prison.

Anti-vax graphics posted by US anti-vax campaigners on Samoan government information website. Source: TVNZ

The 2018 deaths provided an opening for anti-vaccination campaigners. Prominent anti-vaxxers including Robert Kennedy Jr and Australian campaigner Taylor Winterstein visited Samoa to spread their message. The vaccination rate in Samoa fell from about 60%  in 2017 to 31% at the time of the new outbreak. Even after the new epidemic began, the anti-vaxxers continued to spread panic and confusion. The Facebook page set up by the Samoan government to advance the public discussion and promote the emergency vaccination campaign was inundated with anti-vax memes and messages. The anti-vaxxers linked up with local faith healers who offered vitamin and water remedies to measles patients.  One of these faith healers has been arrested and charged with obstructing the vaccination campaign.

Poster advertising tour of anti-vaccination campaigner Taylor Winterstein, including Apia stop. Source: Vaxopedia

As criminal as the activities of these anti-scientific charlatans were, they cannot be held entirely responsible for the particular vulnerability of Samoa to the measles epidemic. Even before the tragic and catastrophic accident of 2018, and the deeper distrust of vaccines that it generated, Samoa’s measles vaccination rate of 60% was extraordinarily low, and far lower than the 95% rate needed to maintain ‘herd immunity’ against the disease. By way of comparison, people in the neighbouring island nations of Niue, Nauru, and Cook Islands are 99% vaccinated.

The lack of confidence of the Samoan population in vaccinations, and the continuing popularity of traditional faith healers, have long historic roots. The imperialist powers, and the New Zealand rulers in particular, who present themselves as the bearers of scientific medicine, also carry a historic legacy of criminal irresponsibility with respect to infectious diseases in the Pacific region. While the work of the New Zealand medical personnel in the current crisis has been entirely commendable, this legacy takes the form of an enduring distrust among the Samoan people towards doctors and hospitals.

Colonel Robert Logan, Apia, Samoa, 29 August, 1914, the day he assumed responsibility as military administrator. Logan was the administrator at the time of the influenza epidemic of 1918 Photo: Malcolm Ross – http://natlib.govt.nz/records/22830439

From the earliest days, European colonial expansion into Australasia and the Pacific was accompanied by catastrophic epidemic diseases. There is plenty of circumstantial evidence that these diseases were introduced deliberately, for the purpose of de-populating the land. In 1789 the Aboriginal population of Sydney Cove was decimated by an outbreak of smallpox, which is believed to have been introduced among them deliberately as a means of relieving the military pressure on the struggling British penal colony. In the middle nineteenth century, 60% of the indigenous people of Erromango, and island in present-day Vanuatu whose sandalwood forests were coveted by traders, perished in a smallpox epidemic in 1853 and a measles epidemic in 1861. The measles epidemic also killed one-quarter of the population of New Caledonia. Missionaries at the time blamed the sandalwood traders for these outbreaks. In 1875 Fiji was hit with a measles epidemic, once again almost certainly introduced deliberately, in order to give military advantage to the settlers. 40,000 Fijians died, about one-third of the entire population.

New Zealand, which seized the German colony of Samoa in the opening days of the First World War, bears responsibility for one of the most devastating of these epidemics, the influenza epidemic of 1918, which killed 8,000 people in Samoa, about 23% of the population. Neighbouring American Samoa, which observed proper quarantine measures against the disease, was completely untouched. This shameful episode of New Zealand’s imperialist history is usually presented as a matter of colossal ineptitude and bungling, however there is circumstantial evidence of intent, at least on the part of the New Zealand colonial administrator in Samoa. The indifference to the suffering of the Samoan people in this epidemic consisted not only in the failure to observe quarantine, but also in the refusal of an offer of medical aid from American Samoa, and the total abdication of their responsibility to provide any kind of medical care to the indigenous population. Such medical personnel as there were in Samoa occupied themselves exclusively with tending to the European population. The same pattern repeated itself, on a smaller scale, in the case of outbreaks of measles and whooping cough twenty years later. Small wonder, then, that reliance on traditional healers remains strong in Samoa even today.

In the current crisis, the one thing that could have built people’s confidence in doctors, hospitals and scientific medicine would have been if the hospitals had been capable of caring adequately for those infected with the disease. But this level of care was clearly beyond the capability of the impoverished Samoan health system to deliver. Not only were there stories of children showing measles symptoms being sent back home with paracetamol, but the intensive care facilities for those in the advanced stages of the illness were completely incapable of treating them adequately. In the Samoan epidemic there were 5,000 cases and 72 deaths; in the New Zealand epidemic there were 2,000 cases and not one death.

New Zealand Immunisation Advisory Centre director Dr Nikki Turner said, “The disease is exactly the same [in Samoa and New Zealand], but it is not unusual to see more people die of measles in low-income countries than other countries. Children in low-income countries are often malnourished and access to primary healthcare is more limited, she said. Moreover, hospitals in Samoa are not nearly as well-resourced as hospitals in New Zealand. “New Zealand has fantastic resources available for when children get very sick [from measles]. Doctors have seen a few incredibly sick children at Starship and Middlemore [hospitals], but intensive care services are so much better than in Samoa, all these children survived.”

Thus, despite the best efforts of the Samoan medical personnel, the popular belief that hospital is where you go to die received further reinforcement, and the faith healers got to stay in business another day.

Frederick Engels

Writing about the great industrial cities of England in the middle of the nineteenth century, Frederick Engels observed that the bourgeoisie’s indifference to the poor health of the working masses even compromised the health of the bourgeois class itself: for out of the filthy, vermin-infested and disease-ridden slums in which the working class was condemned to live emerged contagions which then infected even members of the bourgeoisie. The wealthy mourned their dead, but never moved to tackle the source of the problem, since that would have required raising wages.

This dynamic still operates today, albeit somewhat less visibly.  MMR vaccination rates remain extremely low in the working class suburbs of Auckland, where Samoan and other Pacific Island migrants are concentrated. A survey during a previous measles epidemic in 1991 showed that only 42% of Pasifika two-year-olds were vaccinated. While there was some progress since then, these workers remain, for whatever reason, largely beyond the reach of the ‘fantastic resources’ of the New Zealand health system. The numbers in these suburbs who actively refuse vaccination are very low – the influence of the anti-vaxxers’ fear-mongering is far greater in other regions and social layers – however the working class suburbs of Auckland nonetheless still have some of the lowest vaccination rates. This pool of unvaccinated people provides the conditions in which such epidemics as these can break out.

A similar dynamic operates between the rich and poor countries, as the history of measles in the twentieth and twenty-first centuries demonstrates. So long as measles rages unchecked in the Congo, Samoa and elsewhere in the semicolonial world, the declarations of its eradication in the imperialist centres remain an empty boast.

A stark illustration of this relationship in the current epidemic was the case of a 15-month-old Samoan boy visiting New Zealand whose parents, afraid for his health due to the measles epidemic spreading in Samoa, tried to have him immunised before returning to Samoa. He was refused a vaccination by a New Zealand clinic because he was not a New Zealand citizen. That refusal was condemned by Prime Minister Jacinda Ardern, and the health authorities issued a directive that children under 18 in New Zealand are eligible for vaccinations irrespective of immigration status. However, since the partial dismantling of the free health system in the early 1990s, it has been the general policy to refuse free health services to most people who are not citizens or permanent residents, and that policy remains in place.

Moreover, the huge inequalities between Samoa and New Zealand also act to obstruct the development of world-class healthcare facilities in Samoa. Wages in Samoa remain extremely low – the legal minimum wage is unchanged since 2012 at WST $2.30 per hour (approximately equal to US 85 cents.)  This inevitably exerts a downward pressure on incomes even of the professional layers in the hospitals and clinics, and makes it difficult to recruit. A medical qualification, on the other hand, represents a ticket to a comfortable life in many other countries of the world. These pressures impoverish the Samoan health care system from all sides.

Vaccines to combat infectious diseases have been one of the greatest and most unequivocally beneficial of all the advances of scientific medicine in the last two hundred years. Yet in unexpected and seemingly irrational ways, the capitalist crisis is obstructing, undermining, and even reversing this great achievement of medical science. When the working class rises up, as it has in the past, once again demanding free health care for all, it will be with a truly international understanding of the words ‘for all.’

 

 

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