A Day in the Fight Against Tropical Disease in Papua New Guinea 14 September 2018
[This article has been published originally in Spanish in The Conversation]
We live on the remote island of Lihir, in Papua New Guinea. We are a small team, just three or four people from the ISGlobal research centre in Barcelona
We live on the remote island of
Lihir in the province of New Ireland, Papua New Guinea. The island is located in the middle of Melanesia and surrounded by hundreds of kilometres of ocean in every direction. We are a small team, just three or four people from the ISGlobal research centre in Barcelona. However, in our everyday tasks, we work together with other researchers and Papuan people.
The team leader is Oriol Mitjà, a doctor who came to this island eight years ago and has since investigated numerous diseases that affect this remote population
The team leader is
Oriol Mitjà, a doctor who came to this island eight years ago and has since investigated numerous diseases that affect this remote population. His work has been particularly focused on yaws, an infectious disease caused by the bacteria Treponema pallidum pertenue, which causes ulcers in the skin of the island’s children. Yaws is a neglected disease that today only affects poor and remote populations: the study carried out by Oriol eight years ago was the first research done to investigate yaws since the 1950s.
It is hard to estimate how many people may have the disease worldwide. We know that there are 13 countries currently known to be endemic for yaws, 8 of which reported a total of 46,000 cases in 2015. An estimated
89 million people live in these places and are, therefore, at risk of contagion. What is more, the disease was endemic in 73 other countries in the 1950s, and since then the situation has not be re-evaluated to see whether this is still the case.
To further complicate matters,
20% of patients are asymptomatic. Infected individuals can develop new ulcers at any time, months or years after initial infection, and they can transmit the disease to others.
The documentary film Where the Roads End (Noemí Cuní, 2016) tells the story of how Oriol Mitjà came to Lihir in 2010, where he encountered an epidemic of a disease that was all but unknown to him.
Papua New Guinea is called "the land of the unexpected". And, after a few years working here, I can assure you that this is absolutely true
Papua New Guinea is called “
the land of the unexpected.” And, after a few years working here, I can assure you that this is absolutely true. Nothing ever goes according to plan: there always has to be a plan B, and plans C, D, E, and even F. You always have to be ready to change everything and improvise a new solution at any moment. This means that routine is not something that characterises our day to day.
Nevertheless, broadly speaking, the following is a description of
our day in Lihir.
We get up around 5.30 AM and soon after we leave our bungalow to face the tropical heat. At that time the sun has not yet risen completely, but temperatures are around 30℃, and within minutes our clothes are sticking to our bodies because of the extreme humidity.
We walk over to the camp dining room, a huge building where we have breakfast every morning in the company of several hundred people who work for the mine.
Yes. Here, in the middle of the jungle, there is a huge, open-pit gold mine.
The mine allows us to use its facilities (bungalow, office and dining room) during our stay in Lihir; hence our multitudinous breakfast.
Then we go to the health facility, the Lihir Medical Centre, our small base of operations: a container that serves as an office with an internet connection and air conditioning. A luxury!
The Future of the Island’s Youngest Inhabitants Depends on an Antibiotic
We work primarily with the island communities. Nearly every day, we visit schools and villages
We work primarily with the
island communities. Nearly every day, we visit schools and villages. The day begins with a team meeting held to plan how many vehicles will go out and who will be responsible for each area.
A thousand variables that might affect the plan for the day have to be taken into account. If it has been raining in the last few hours, we know that certain areas will be flooded and inaccessible until the afternoon—and then only if the rain does not start again. Maybe some event, a funeral for example, will prevent us from visiting certain villages. We have to take everything into account before we leave.
Once the meeting is over, we load our equipment into the Toyota 4 x 4 and
head out to visit villages, schools and homes in search of patients with yaws.
Without antibiotic treatment, yaws is not only very infectious it can also cause permanent bone malformations and seriously affect the child’s future
On this island, where yaws is endemic,
everyone is familiar with the condition. Grandmothers use traditional remedies, including the leaves of certain trees and papaya-based ointments, to treat and dress the ulcers. These methods can help to prevent new infections, but without antibiotic treatment, yaws is not only very infectious it can also cause permanent bone malformations and seriously affect the child’s future.
In a place where physical work—farming and fishing—is a very important in everyday life, yaws poses an even greater problem. The community is conscious of this and, after years of seeing our work and working with us,
they know that the medicine we bring is a good thing, so our reception in schools and villages is always welcoming and very positive.
I ask the children to raise a hand if they have a sore and we examine them all. In a classroom with 20 children, it is easy to find 7 or 8 cases of yaws, sometimes more
Yaws and other ulcerative diseases mainly affect children between the ages of 5 and 15 years. At this age, the children infect each other through physical contact, when they play together or share a desk. For this reason, our first stop is always the school, where we talk to the teachers and ask for their permission to interrupt classes for a while. I ask the children to raise a hand if they have a sore and we examine them all, one by one, arms and legs. In a classroom with 20 children, it is easy to find 7 or 8 cases of yaws, sometimes more.
We record a large amount of information for each patient. This is when our language skills come into play as we converse in tok pisin, the lingua franca of Papua New Guinea, which looks a lot like English. This is a basic example:
“Hamas chrismas blong yu?”
The phrase comes from the English
“How much (many) Christmas belong to you?” In other words, “How old are you?” Same Ulcers, Different Suspects
As well as personal information, we also collect
a sample from each ulcer on a cotton swab to identify the pathogen responsible in each case. A number of different bacteria cause these ulcers, but we treat all the affected children (and those closest to them) with a single dose of the antibiotic azithromycin which, according to our studies, is effective against almost all the suspected pathogens present in the area.
The ultimate goal is the eradication of the disease, something most experts believe is possible
The ultimate goal is the eradication of the disease, something most experts believe is possible. To eliminate yaws from the island it would be sufficient to administer a single dose of azithromycin to the whole endemic population every six months for a year and a half (3 times). This is the project our team is currently working on.
Follow-up is very important: antibiotic resistance can arise from a single case in which the patient is not cured by the treatment
We revisit each patient two weeks after the treatment to make sure that they have been cured. If the infection is still present, there are other treatments we can use. Follow-up is very important: antibiotic resistance can arise from a single case in which the patient is not cured by the treatment.
Follow-up is also one of the
most complicated aspects of the process. More than once we have driven for hours to visit a patient only to find that he or she is not at school or at home that day. Since very few people have telephones (or mobile coverage), it is very difficult to organise these visits. No matter, we will keep on trying, over and over again, to see the sick patients.
We repeat the same process in all the schools we can fit in during the morning. At noon, after two or three visits, we take a break under a shady tree. But never a palm tree! Rule number one for surviving in the jungle: When a coconut falls off the tree, you do not want to find yourself in its path.
After this, we visit the houses in the village to look for more patients. Very often,
the worst cases, that is, the children who have the largest ulcers, do not work or attend school because of stigma or the fear of infecting others.
At the end of the day, we return to the health centre, where
we put our samples in the freezer before sending them to the US for analysis. We finish our day with some exercise, if we have any energy left, or with a cold beer. Whatever we do, we do it very carefully, because sunset is “malaria time”. Just when you relax and think that your long day is over, the mosquitoes attack and you end up with a dozen bites before you realize what has happened.