Casualties of War

In Congo, civil strife allows polio to survive

Mbuji-Mayi, Democratic Republic of the Congo—In a dusty field in Kinshasa earlier this month, a military guard snaps its rifles to attention. Fixed bayonets gleam, and the crowd settles into a hush broken only by the sound of babies crying. Laurent Kabila—former guerrilla, one-time smuggler, and now president of the embattled Democratic Republic of the Congo—bends over one of the bawling babies and squeezes a few drops of pink liquid into her mouth. This is the commencement of the Congo's polio eradication campaign, and while it is grotesque that an effort to save lives begins with a military fanfare, it is also sadly appropriate. For the greatest obstacle to eradicating polio is not poverty or international indifference, but war.

Polio has been extremely rare in the United States for more than four decades. But in the Congolese city of Mbuji-Mayi, 1500 children died or were maimed in a 1995 polio outbreak. Earlier this year in neighboring Angola, where vaccination had been delayed by civil war, 1100 children fell prey to the disease. One of the most common sights in African cities are polio beggars, many of whom scuttle crab-like or simply pull themselves along with their hands, dragging their withered legs behind them.

Yet polio, a scourge so ancient it is depicted on Egyptian stele, is on the run. Before Jonas Salk and Albert Sabin developed their vaccines, its toll topped half a million a year. In 1988, when the World Health Organization launched a campaign to eradicate the disease, that number had already fallen to 35,000. Last year, in strong evidence that the world eradication effort is succeeding, the virus claimed 6000 people, mostly young children.

According to WHO, "Two types of countries are now priorities for the global eradication effort: 'Reservoir' countries, which are large geographical areas with high population density, low immunity levels and poor sanitation; and 'countries affected by conflict.' As the only country which falls into both categories. The Congo is the single highest priority for the global effort."

Indeed, notes Martin Mogwanja, the UNICEF representative in the DRC, "Congo is the size of Western Europe." He pauses to let that sink in, then continues: "It has borders with nine other countries, so as long as polio exists in the Congo, those nine countries must keep vaccinating." But they can't, because some of the DRC's neighbors, such as Zambia and Uganda, are among the world's poorest nations, while others, such as Angola and Congo-Brazzaville, are, like the DRC, engulfed in war.

On the first of this month's three immunization days, WHO's Bernard Fabre, chief of logistics, is most worried about Equateur province in northern Congo.

The original plan had been to distribute all vaccines and equipment through Kinshasa, seat of the DRC government, which has energetically supported the polio campaign. But then a rebel faction captured two-thirds of Equateur, making deliveries from government-held areas impossible. Scrambling, the UN rerouted the supplies through Kisangani, main city of the rebel region. But then that town fell victim to fighting by rival rebel factions and, explains Fabre, is now "split in half." Fabre shrugs. "Because of the fighting last weekend, the equipment was delayed. I don't know where it is now. My guess is it's in Kisangani."

At least there are no reports of conflict at the moment. The "Days of Tranquility," negotiated specifically for the polio vaccination, seem to be holding. So, Fabre says, dryly, "It'll be better than last year." Two weeks before last year's vaccination campaign was to begin, the war started, forcing the immunization program to be drastically scaled back. More than 70 percent of the Congo's children were left unvaccinated.

The polio virus lives only in humans, so if enough people are immunized the virus will run out of hosts and perish. That is the logic behind the polio campaign, which is trying to vaccinate every child in the world under five—10 million in the DRC alone.

That would be a tall order even if the country were at peace. "There are practically no main roads," says Mogwanja. "Imagine that no road connected New York and Washington—not that the road was bad or blocked, just no road." Equateur province, covered in dense rain forest, is one of the country's least developed regions. Almost the only transportation route is the Congo River, which Marlow traveled in Conrad's Heart of Darkness. Some sites are supplied by canoe. In other provinces, equipment is distributed by bicycle or by people carrying the load on their heads.

Then there are the man-made headaches, such as the fact that civil servants in the DRC get paid only once every few months—and just a pittance, devastating morale. But despite such difficulties, Fabre repeats a phrase on everyone's lips: "The problem is the war."

If the rebels even remember that Mbuji-Mayi was the epicenter of the horrible 1995 polio outbreak, they don't care. They covet the town for its rich diamond mines, and they have advanced so close that the city is now almost on the front line. Many observers expect an assault imminently. But on day two of the polio campaign, peace is holding, people are relaxing at street festivals, and the polio news is mostly good. Overall, more than 50 percent of Mbuji-Mayi's under-fives were vaccinated on the first day; one site reports that it has already hit 95 percent.

There are problems, of course. A UNICEF report says that 12 zones are inaccessible due to "insecurity." Mogwanja, however, believes most of these can be reached from the rebel side.

On day three, the bad news hits. Fabre's hunch was right: The supplies for Equateur province, including about a million doses of vaccine, were indeed in the divided town of Kisangani. Now, fresh fighting has broken out between the rebel factions. Mothers and children are trapped in vaccination sites, terrified to set foot in streets thick with bullets. Just as bad, the vaccine hasn't left town. About a million children—a million hosts to harbor the polio virus and keep it alive on this earth—live in the territories of Equateur province, where the stranded vaccine should have gone, and almost a third of Kisangani's children didn't get immunized.

In Kisangani, the wounded need care. In some areas, disrupted water supplies raise the specter of cholera and other disease, as do putrefying bodies. And while fighting has subsided, the city remains hair-trigger tense. So the polio vaccinations, says Abou Moudi, head of WHO's office in the DRC, will have to wait.

Two more rounds of immunization days are scheduled for the DRC: one each in September and October. Moudi is frustrated but emphatic. "We've been working on this for 11 months, and we could vaccinate everybody," he says. "If there is peace."

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