They were scattered beneath the sprawling shade of a lone tree reaching for the far-flung gray clouds in a blue sky. When our Toyota pulled up and we all clambered out, no one shifted anything more than a gaze. A child continued to suck from her mother’s breast, another crawled away from his twin, and women from a range of ages, talked quietly to each other. The air cooled dramatically under the shade of the tree, and in that shaded cool, a few dozen women and children waited.

They had walked for two hours; instructed to come to this place by the door-to-door polio teams, armed with drops of the live vaccine and chalk to mark the doors of the vaccinated – in some scrambled prevention Passover. Liberia is in the middle of a Polio Campaign. After being certified polio-free in 2008, 2009 brought 11 cases in six counties. This year there is one confirmed case – a four-year-old girl who has lost most of the use of her legs. And so this three-part campaign (march, april, may) was launched to fortify Liberia’s failing defenses against the ravages of polio.

Measles was added as a quiet outbreak sweeps slowly through the country – affecting those as young as 1 month and as old as the 22-year-old mother of two left blind from her bout with the disease.

In rural Liberia, however, vaccinations aren’t simply a matter of stopping by the doctor on your way to work – or even catching children at school. The roads, where they exist, are mostly dirt and rock, the walking paths narrow, the schools –few and unable to reach all the children. So the vaccines – along with the de-worming medicines and vitamin A – move up-country, into the expanse of landscape with villages and lone houses nestled randomly amid the green.

OPV, the oral polio vaccine used here, is portable in a way that measles, an injectable one, is not. Limited trained administers, dangerous biohazard, and possible reactions, forced the measles teams to anchor themselves to specific locations with children coming to them. And so the women under the tree had walked for hours through the heat, children hoisted onto their backs or walking slowly by their sides. and they waited.

Only, the measles’ team had moved to another village. An austere budget – the planning and monetary synergy of WHO, CDC, UNICEF, and the Liberian government – could only afford to fund 50 measles teams (two people per team) and 200 polio ones for the entire country. The result was a lot of walking.

Polio teams mobilized and walked hours, even days, into the dense green bush; rocky brown roads narrowing to serpentine foot paths beyond the reach of cars and motorcycles. Mothers and children in a reverse journey of rural to town, searched out the often distant measles’ sites.

Each day a new set of challenges. Grumbles abut insufficient team numbers, flowed into ones about insufficient vaccine quantities. By day five, the final day of the polio campaign (the measles will run for seven days) word came down from the Ministry of Health, in Monrovia, that the age-range for measles vaccinations had been increase from 9 to 59 months to 6 to 59 months. What about all the children that had already been missed? What would one mother think when her seven-month-old child was not vaccinated and another’s was?

But age issues weren’t the only concerns. Tally sheets were scarce. Training was assumed unnecessary because the first round campaign took place a month prior. Targets were insufficient, which lead to inadequate Mambendazone (for de-worming), vitamin A, and OPV supplies. Ice packs were melting.. And supervision was almost impossible.

Supervision was my part in all of this. To ensure that teams were busy meeting their targets the County Health Teams and partner representatives dispatched district supervisors– in complement to the national ones. Of course the logistics of this were complicated. Each morning the team of supervisors gathered at the County Health Department (CHD)before making their way to that day’s district. After driving, sometimes for hours, the teams usually arrived at a measles’ site because those were stationary.

the polio teams proved more elusive. Chance was the greatest predictor of supervisors meeting up with polio teams in the field. Instead, we looked for clues of their previous presence. The darkened finger on the left hand of the children who had received the vaccine; the chalked notation on the door or window; the brief chat with people washing clothes in the front of the house or napping under a tree – “were your children vaccinated?” then a pantomime of dropping the OPV into an open mouth or dispensing a shot into the arm.

It is a feat of epic proportions that is done often in the country. There are routine vaccinations that the CHD administers throughout the country in addition to these emergency campaigns. And they meet the same obstacles. In fact, someone mentioned that in a few weeks the whole process will begin again for hepatitis vaccinations. And maybe a little after that, the final leg of the polio campaign – set to comply with the hoped for global eradication date of June 2010.

It is impossible to tell how successful it has been. Instead success is fragile game of waiting to see if in a month or a year another four-year-old girl or seven-year-old boy nestled in a hard-to-reach corner of Liberia’s lushness loses the use of limbs…in the absence of that, we are cautiously optimistic.

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