Nepalese porters carried measles vaccines across the mountains to the legendary city of Lo Manthang. The government, rights groups and health organizations have worked together to cut the number of measles cases in Nepal.

PART FIVE | On the Brink: Measles
Mothers of Nepal Vanquish a Killer of Children

April 30, 2006 | The NY Times | Graphic | Map

LO MANTHANG, Nepal - As dusk descended on this medieval walled city and its dirt lanes filled with horses cantering home from the mountains, the piercing voice of a woman could be heard over the pounding hooves.

"Come for the measles vaccination tomorrow!" Deki Gurung shouted to a neighbor.

"I know, I know, I got the invitation," the neighbor replied with a roll of her eyes as she peered over her balcony.

Across the impoverished kingdom of Nepal, 50,000 mothers like Mrs. Gurung, most of them illiterate, are foot soldiers in one of the great unfolding public health triumphs of modern times: the global push to slash the number of children who die from complications of measles.

Nepal's first national measles vaccination campaign last year cut by 90 percent the country's measles-related deaths, usually about 5,000 per year, the United Nations Children's Fund estimates.

But remarkable as it is, that tremendous success is overshadowed by the grievous toll measles continues to take in neighboring India. Experts estimate that more than 100,000 children a year still die there from complications of measles for want of a 15 cent vaccine.

The contrast between the nations highlights both the extraordinary promise of measles control, and the tragedy of its unfulfilled potential.

Nepal's campaign shows that quick, deep inroads can be made against measles with the proper financing and national will, as well as a tested strategy for winning public trust of vaccines.

"Vaccinating children against measles is the greatest return on investment for child health that we have," said Dr. Mark Grabowsky, who for five years was the adviser to the Red Cross for the Centers for Disease Control and Prevention. "It's the low-hanging fruit."

Still, measles kills 450,000 children worldwide each year. India, which has more measles-related deaths than any other country, has not made it a national priority in the way Nepal, Bangladesh and countries across Africa have. It has instead focused on its drive to eradicate polio, building a stronger rural health care system and bolstering immunization generally, in hopes of protecting children from other diseases.

Tackling a Disease

India's choice highlights a fierce but little noticed debate among international public health experts: whether it is better to attack a single disease with big campaigns or instead make long-term investments to improve public health systems.

Indeed, the crux of measles control is strong routine immunization, which is best provided by a solidly run health care system.

The vaccine is 85-to-90-percent effective in the first year of life. But the airborne measles virus is so contagious that a second vaccination, given either routinely or in a mass campaign, is often needed. It is that second dose that India does not yet provide all its children.

Such second-dose campaigns, reaching into the world's most remote corners, have saved a million children since 1999, the World Health Organization says.

The strategy, first used in Latin America in 1994, eliminated measles from the Western Hemisphere by 2002. In Africa, the approach has more than halved measles-related deaths in just four years. Measles weakens children's immune systems, making them vulnerable to fatal complications from diarrhea, pneumonia and malnutrition.

Nepal used the same plan, but several other things went right here. Not only has Nepal's measles effort been unburdened by competition from polio, which was wiped out six years ago, but also for more than a decade Nepal has used a highly organized network of volunteer mothers to deliver simple health services in the lanes around their homes.

Local human rights workers, part of a broad alliance of civic groups supporting the campaign, also played a critical role. They mediated disputes between government officials and Maoist rebels who have led a decade-long insurrection. "We have taken this campaign as an issue of national prestige," said Dr. Yasho Pradhan, Nepal's director of child health.

Nepal's crash campaign reduced the number of outbreaks to just one last year from 195 in 2004, Unicef reported. Vaccination teams combed the slums of Katmandu and trekked through treacherous mountain passes to reach every last child, 9 months to 14 years old.

"It was amazingly effective," said Dr. Suomi Sakai, the Unicef representative in Nepal.

Disparate Approaches

In the jangling, chaotic lanes of places like Ghaziabad, just an hour's drive from the Indian capital, New Delhi, people call measles "Mata," or mother, for the Hindu deity associated with the disease. The characteristic red rash is seen as a visitation of the goddess.

One morning last year, pushcart vendors, rickshaw drivers and laborers whose children had rashes or were recovering from them lined up in a small, dingy temple, tucked behind a candy shop.

The swami, Grishm Giri, 82, his long white beard hanging halfway down his stained tunic, explained that last year had brought twice the usual number of measles cases. He waved a staff of peacock feathers over each child and chanted prayers, collecting about 12 cents from each family.

His assistant, Niraj Giri, a middle-aged man in a saffron-colored shirt, measured the distance from the children's navels to their nipples with a string. "We try to find out if the center of the navel is in the right place," the assistant said. "If it is not, we correct it." He explained that this displacement of the center is the real cause of disease, a problem that can be fixed through the nerves by hitting the bottoms of a person's feet.

Among those waiting for help was Ram Pukar, a rickshaw driver, holding his 6-year-old daughter, Sujita, who was so sick her head lolled from side to side. Her long black hair hung like a matted screen across her face.

Mr. Pukar's wife, Lalita Devi, cradled their 18-month-old son, Bisnu, also limp in her arms. Both children had a rash. Mr. Pukar, who is illiterate, said Sujita and Bisnu had been given polio drops many times, but had never been vaccinated for measles.

The asymmetry in resources to tackle polio and measles in this country is striking.

India, home to one-sixth of the world's population, spent $216 million last year in its last-ditch effort to eradicate polio, which paralyzed 66 children in 2005. There was no comparable war chest for a measles drive.

The Measles Partnership, a coalition that includes the Centers for Disease Control and Prevention in Atlanta, the Red Cross, the W.H.O. and Unicef, has led the drive globally. Last year, the partnership asked the Global Alliance for Vaccines and Immunization, an umbrella group of donor countries and organizations, for $479 million to accelerate measles campaigns around the world, with the biggest chunk of the money for India.

The alliance has committed only $147 million, funds available only because Britain, France and other countries agreed to raise the money on the bond markets.

In India, 5-year-olds in the northern states of Uttar Pradesh and Bihar may well have been immunized against polio more than 20 times, while the overwhelming majority have never once been vaccinated for measles.

From 1998 to 2003, surveys found that the proportion of children fully immunized against measles, diphtheria, whooping cough, tetanus and other diseases actually declined in three-quarters of the Indian districts for which there was data.

An expert assessment sponsored by the Indian government pointed to a variety of culprits, among them poor supervision, inadequate training, vaccine shortages and the emphasis given to polio.

Dr. Jay Wenger, who manages the national polio surveillance project for the W.H.O., disputed the idea that the polio push is to blame for problems in routine immunization, which often reflect deeper problems of misgovernance.

"Clearly, a lot of time is being spent on polio," Dr. Wenger said. "It would be silly to say it's not." Nonetheless, there is still plenty of time to do routine immunization for measles, he said.

But Indian managers in the field say their workers, already stretched thin, have too little time for other tasks because large parts of the year are devoted to polio. "The big casualty is the routine immunization," said Dr. Sudha Yadav, who works at a small hospital in the city of Bareilly in Uttar Pradesh.

For now, India is hoping to reduce measles deaths by strengthening rural health care and routine immunization, developing a cadre of 250,000 village women dedicated, as in Nepal, to improving services.

Dr. Anbumani Ramadoss, India's health minister, said in a recent interview that he hopes India can turn to measles soon.

Julian Lob-Levyt, executive secretary of the Global Alliance for Vaccines and Immunization, defends India's approach. "In the long term, building a stronger basic health system will benefit many more people of all ages in all parts of societies," he said.

But for a country like India, forgoing measles campaigns will have a high price in deaths, particularly in states like Uttar Pradesh. Where state governments fail to deliver basic public health services, people often rely on traditional practices, like those at the temple in Ghaziabad.

After an outbreak in Ghaziabad last year, Dr. M. P. Singh, the chief medical officer in the district, conceded that many children had not been immunized for measles. "Before this outbreak, measles shots weren't given," he said.

Two of the confirmed deaths in Ghaziabad were the sons of a laborer, Kishore Lal. "The child was in my lap when he breathed his last," Mr. Lal said, tears spilling down his gaunt cheeks as he described the death of Ramjanak, 5, last April. Amit, the other dead son, was 3.

A month after Amit's death, Mr. Lal and his wife squatted listlessly in front of their small hut. "We don't feel like working," he said. "We don't feel like eating."

In a nearby lane, Tuntun Paswan, 32, and his wife, Ramdhana Devi, 28, also mourned the death of their son, Karan, 2. He passed away in the middle of the night in his mother's arms.

They buried the toddler, with his rattle and plastic bat, by the Hindon River.

A Nation's Dedication

While the Indian parents were still immobilized by grief, three porters were huffing and puffing through the mountains of Nepal, each hauling 100 pounds of vaccines and other supplies. They scaled narrow, rocky trails that snaked along the deepest gorge on earth.

Winds roared with oceanic force, curling around them like giant waves. The shifting boxes of supplies, held in place by straps around the men's foreheads, scraped the skin on their backs.

It was only through extraordinary efforts like these last summer that the last Nepalese children to be vaccinated were reached in the nearly inaccessible Upper Mustang region. Similar, if less dramatic, scenes played out around the country as a carefully choreographed measles campaign unfolded over nine months.

Outsiders who came for the campaign, including health workers and monitors from Unicef, journeyed over desolate mountains, some rising more than 13,000 feet, into a time before cellphones and televisions.

When they finally crested the last bone-colored peak, the walled town of Lo Manthang lay before them. Some 600 years ago, this small kingdom sat astride a major trans-Himalayan trading route. Conditions are still medieval. Horses and cows live on the first floor of people's homes. Toilets are just holes in the floor above the stables.

Yet despite Lo Manthang's isolation and primitive facilities, the townspeople mounted a meticulous, if homespun, measles campaign.

The women who volunteered, organized by the government down to the ward level, delivered invitations to each household by hand, then followed up the night before with a reminder visit, shouting their message like town criers.

Over the years, they have distributed 2 cent doses of Vitamin A to children, an intervention that cuts child mortality by almost a quarter, studies have shown. They have handed out de-worming tablets that cost a penny and slash infant mortality. They have handed out packets of oral rehydration salts that cost only 6 cents to save the lives of children with diarrhea.

And they have gone door to door to take children to the clinic for immunizations.

In a country where the status of women is low, these illiterate mothers say they willingly do a job that pays no salary because it gives them a way to contribute and win respect.

"If I didn't tell them about vaccination programs or medicines, they wouldn't know," said Doka Gurung, a 30-year-old mother of four who has volunteered for a decade. "I do help them, and I feel good about that."

By 8 the morning of the campaign, parents and children were lining up at Lo Manthang's small, rustic clinic. The volunteers covered the eyes of children who howled in fear as health workers approached with needles, then hustled out to fetch the boys and girls who had not shown up.

Not so many years ago, before routine immunization took hold, measles outbreaks were common. The disease spared no one, not even royalty.

The king of Mustang, Jigme Palbar Bista, 73, a direct descendant of the original, 15th-century monarch, offered his own memories of a time before modern medicine arrived.

He held court on the top floor of his medieval palace, reached by a steep, narrow wooden staircase. Bearish Tibetan mastiffs with bloodshot eyes paced menacingly, guarding him.

Fingering prayer beads, the king recalled that as a child he had had measles, but survived while many others died. "I've seen myself, just 10, 15 years ago, three children in one family die within three days," he said.

The measles campaign in Lo Manthang, a bastion of Tibetan Buddhist culture, concluded this day at The Great Compassion Sakyapa Monastic School.

The principal, Wangdi Sangbo, 33, welcomed the vaccinators. He himself had almost died during a measles outbreak when he was 10 years old. "There were no doctors, no vaccinations," he said.

The next generation of boys he hoped to protect, he said, with help from the community. They gathered in the school's courtyard, laughing and teasing one another.

Phuntsok Sangbo, 13, was so scared he hid, but his friends tracked him down and led him back. He squeezed his eyes shut and blew out a breath as the needle went in.

The last in line was a bold 16-year-old named Karma Namgyal.

"They're going to give you the bigger needle," one of his friends taunted him.

Karma just laughed and stuck out his arm, eager for the life-saving prick.

Copyright 2006 The New York Times Company