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DRC: How throwing a pen in the air helps us fight measles
Worldwide, tens of thousands of young children die from measles every year. After a recent outbreak in Walikale, DRC, MSF vaccinated 31,000 children against the disease, in a intensive, 15-day campaign. But will it be enough to stop the outbreak? Epidemiologist Alanah Jansen and her team are determined to find out...
I jolt awake to the Call to Prayer that is blaring from the neighbouring mosque. The drums and chanting from the church on the other side of the base start a few minutes later. You’d think I’d be used to it by now as it is the exact same routine every morning, but I’m not. I fell asleep to the music of a nearby disco party late last night and I’m still tired.
I’m up and ready to go. I managed to find some pineapple to go with my instant coffee this morning which is more than I have some days.
Most of the interviewers are already here and we go over the transportation plan that our logistics team lead prepared. MSF did a massive vaccination campaign in the Walikale region recently, and my team and I are travelling to survey families in the area, to understand what proportion of children under five years old were vaccinated in the campaign.
A coverage rate of 95% or greater is essential to stopping the spread of the measles virus, which is one of the leading causes of death in young children worldwide.
There are seven teams in total including six supervisors resulting in a group of 20 people. Not everyone is here this morning as some teams had to overnight in the field.
Today is the fifth and final day of data collection and I hope that it goes as smoothly as all the other days have.
We’re given the green light and my team hops into our Land Cruiser. It’s the toughest vehicle I’ve ever been in and I’m grateful that it seems to be able to get through even the roughest “roads”.
I buckle up and notice how tender my shoulder and chest are from being jostled around the day before. All I can say is thank goodness for seatbelts!
Just as I start to regret my breakfast, we arrive at the village. We manage to locate the health centre fairly quickly and then start asking around for either the head of the centre, or the “mobiliser”.
Mobilisers are the people who knew we were coming and communicated on our behalf with the chief and the village.
The participation of mobilisers is essential, and I appreciate all the time and work that they have spent passing on the information about our project as it has made data collection so much easier.
After speaking with the mobiliser, we track down the chief with the help of some friendly locals. They follow us in and stand quietly at the back to hear more about our project.
I greet the chief in Swahili and then ask him if we can communicate in French. Typically, Swahili is the preferred language, therefore my team takes over and explains more about our work.
I sit quietly as my extremely knowledgeable team reminds the chief about the recent measles vaccination campaign and how we are now here to determine if we achieved a high enough coverage rate in order to stop the measles epidemic.
We also go into the ethics of the survey, including voluntary participation by both the chief (who decides whether we can stay in the village) and the households themselves.
My team translates any questions he has and I answer slowly in French. After listening to all the information, he smiles and happily gives his consent.
Once all the questions are answered, he turns to me and starts speaking through my interviewers. He explains that children in his village were sick and dying all the time from the measles.
Since the MSF vaccination campaign, there have not been any more children who have died.
He is so happy that we chose his village to do the survey as it can be his way of saying thank you to MSF for all the work that we did and all the children that we have saved.
I am truly touched by his words and thank him for allowing us to be there.
I also tell him that I will be sure to pass on his message to the rest of the team that conducted the vaccination campaign as they are the real heroes.
We’re shown to the centre of the village in order to start our random selection.
To accurately evaluate how many people were vaccinated during the campaign, we need to survey families at random – not just choosing the nearest or most convenient.
To randomly choose our first family to interview, we follow the standards set out by the World Health Organisation (WHO). This means we throw a pen into the air and then start walking in the direction that it points us. Once we get to the edge of the village, we then take the pen and throw it again.
Looking in the new direction the pen is pointing to, we start to count the houses until we get to the edge of the village. Using our random number sheet, we close our eyes and land on a number between 1 and the number of houses we just counted. Let’s say we land on ‘nine’. We then walk back and knock on the door of the ninth house.
“Hujambo Maman!” we all say as we approach the first household.
The mother sticks her head out the door and looks a little confused, but she motions for all of us to come into her home built of sticks and mud.
After some traditional Swahili greetings (yup, even me!), my team starts to explain why we are here.
After confirming that she has children in our required age group (6-59 months), she gives her consent and we start on the questionnaire.
My team is so quick at this now that it doesn’t take long to collect all the information.
The news that MSF and a muzungu (white person) are in the village has spread quickly.
We already have a group of children following us from house to house and the mothers and even fathers are waiting for us in front of their homes with their children’s vaccination records in hand.
We have already collected the required sample size of 21 households. We turn to the group of children that have been following us all morning and start to say our goodbyes.
The women in the next households come up to us and ask why they are not being chosen for the survey. We explain how our sampling and random selection works and they are very disappointed.
Some of them have stayed home from the fields or church in order to participate. It was their way of saying thank you and I feel so bad. If it was only one or two, I might have said that we can keep going but there are dozens of women around us and this is not how random sampling works!
We are all as gracious as possible and the women eventually understand that they will not be included in the sample.
After saying goodbye to the chief, we jump back in the Land Cruiser. Our driver, Kilokilo, looks surprised that we’re done already.
The team that I was with most of the week are two other women, Generose and Severine, and they are hilarious.
They are convinced that the reason my team is always done so quickly is because I am a muzungu and everyone wants to see me. I think that it’s because my team is fantastic.
They laugh and we all agree that it is probably both.
On the drive home, my team is comfortable enough to start asking me more questions.
It is very common for the first question in any conversation to start with my ‘état civile’ (marital status). I have quickly learned to change my response from boyfriend, to fiancé, to husband (surprise, sweetheart!).
Otherwise the follow-up questions are typically regarding how I feel about taking a Congolese husband. It’s awkward, at least for me, and I would rather avoid that part of the conversation.
Once my marital status is confirmed, I then get asked about how many children I have.
My driver quickly offers to give me at least 10 children. I kindly decline. He proudly tells me that he already has 11 children.
The two women say that they have four and six children and are both planning on having more.
I’m comfortable with my team and I know it’s a long ride, so I start explaining that Canadians typically only have one to three children and many are choosing not to have any at all.
They have a hard time accepting this but once I mention the cost of raising a child in Canada, they start to understand.
They still think that it’s unfortunate that Canadians don’t have more children as it is so important to have a large family in Congo. This is how the family lineage and cultural traditions get passed down, and it ensures that the parents will be taken care of later in life.
We arrive home and go over the completed questionnaires one last time. Everything looks good. I realize that I might not see these amazing ladies again and I get a little sad.
I’ve spent a lot of time with them over the last two weeks and they have easily taught me more than I could ever teach them.
After a lunch of rice, sombe (a cooked green leafy vegetable), beans and meat (maybe beef – I don’t ask), I crash.
It is so, so hot out and I have been sweating since 7 am. I’m grateful for the long lunch breaks that we typically take as I really don’t think that I could do anything other than doze in this heat.
2:30 – 6:00 pm
The rest of the teams start to return to the base. Some of them have been gone for several days as they have had to trek through the jungle to get to the randomly chosen villages.
They have checked in regularly and have reported that they have completed the required sample. Everyone has had a good experience and there have been no security or health concerns.
We’re back at work after a supper break of left-over lunch. Myself and the other epidemiologist review every single questionnaire and make notes of anything unusual or information we need clarified.
We are having a team debrief tomorrow so there will be one last opportunity to get feedback.
We go over how the survey went overall and both agree that we had an incredible team of interviewers, supervisors, drivers, and logistical support.
I honestly could not imagine data collection going any more smoothly, especially in a country like Congo.
It is time for bed after a quick cold shower. I’m exhausted even after my afternoon nap. I also know that the Call to Prayer and the church service are going to be starting in only seven hours and I can already hear tonight’s disco party starting up...