The Public Health Emergency in Indonesia — One Patient at a Time
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《新英格兰医药杂志》
When my team arrived on the east coast of Sumatra, Indonesia, two weeks after the tsunami, dry land was scarce. Although the largest settlement camps had formed around mosques and schools in dry areas, the camp to which my team was assigned was wet. Trenches that had been hastily dug between the tents were full of stagnant water and garbage — potential breeding grounds for mosquitoes. There were no latrines, only a defecation field, and the trenches were being used for human waste.
More than 40 tents, separated by less than a few feet, housed at least 15 families each. Inside were hastily constructed wooden platforms, stacked with belongings and children. In the darkest recesses of these tents, we found the sickest children, lying on mats, with someone fanning them in the humid, 90° weather.
My first patient, a little girl named Inda, huddled in her mother's arms, peering out with suspicion. She had a temperature of 104° and a rattling cough. Her lung examination and respiratory rate were normal, so we gave her acetaminophen and promised to see her again. By the next day, an angry, raised, scarlet rash had blossomed across her face, and her eyes were swollen and red. The alarm bells started ringing. Inda was now a measles epidemic — it takes but a single case. We gave her vitamin A, antibiotics, and ointment for her eyes. I sent her back to the camp with instructions for isolating her, but then it dawned on me that isolation would probably be impossible. I called a nurse from the local clinic to look for her in the camp, but he couldn't find her.
Photograph by H.H. Cranmer.
The search began in earnest the next day. I had Inda's picture on my digital camera, and we showed it to everyone we encountered. We traveled to the ravaged remains of her village and found where her house had been; only the foundation remained. At a nearby camp, we found her mother but not Inda. Her mother had put her in a neighbor's house for isolation, apparently possessed of a better operational definition of public health than I was. Inda was still febrile, the rash now covered her entire body, and she refused to eat or drink. We drove her back to the clinic, where we isolated her and gave her a mosquito net.
My misguided decision to send Inda home led serendipitously to valuable insight into the mobility of the population and the powerful potential for epidemic disease. The immediate issue addressed, we turned our attention to prevention.
At the regional health clinic, we taught the staff — who had never seen measles — the importance of measuring temperature, administering antipyretics, and using antibiotics in certain cases. We provided thermometers, blood-pressure cuffs, stethoscopes, and a scale. We also took the staff members into the camp, where they were loath to go, so that we could immunize against measles and scan the corners of the tents for children with diarrhea or skin infections. Many such children never made it to the clinic, because their mothers were unable to leave their other children and their fathers were out looking for work or food during the day. Some children with measles had gone to the clinic but had been sent back into camp with a diagnosis of dermatitis.
We reported our cases to the World Health Organization, which began to assist with case identification and confirmation and to support the ministry of health in providing measles vaccination. Our reports alerted the authorities to the measles outbreak and kept them informed of the extent of the epidemic. A measles outbreak is serious: in a refugee camp, one in four children younger than five years of age may die of measles, which is reportedly the leading cause of death among children in this age group during the initial phase of emergencies.1
Dealing with small numbers of patients in my role as an emergency physician allowed me to discover the gaps in the overall public health response. Inda was the tip of an iceberg. And like an iceberg, the measles epidemic unfolding in front of me was mostly occult and highly lethal. Inda's diagnosis launched a massive strategy for identifying, treating, and immunizing every child in her camp and in every camp and home she had visited. This strategy bore secondary fruit, as we found severe dehydration, diarrhea, and skin infections in people lining up for vaccinations. Thus, my microscopic view of Inda had grown rapidly into the bigger public health picture.(Hilarie H. Cranmer, M.D.,)
More than 40 tents, separated by less than a few feet, housed at least 15 families each. Inside were hastily constructed wooden platforms, stacked with belongings and children. In the darkest recesses of these tents, we found the sickest children, lying on mats, with someone fanning them in the humid, 90° weather.
My first patient, a little girl named Inda, huddled in her mother's arms, peering out with suspicion. She had a temperature of 104° and a rattling cough. Her lung examination and respiratory rate were normal, so we gave her acetaminophen and promised to see her again. By the next day, an angry, raised, scarlet rash had blossomed across her face, and her eyes were swollen and red. The alarm bells started ringing. Inda was now a measles epidemic — it takes but a single case. We gave her vitamin A, antibiotics, and ointment for her eyes. I sent her back to the camp with instructions for isolating her, but then it dawned on me that isolation would probably be impossible. I called a nurse from the local clinic to look for her in the camp, but he couldn't find her.
Photograph by H.H. Cranmer.
The search began in earnest the next day. I had Inda's picture on my digital camera, and we showed it to everyone we encountered. We traveled to the ravaged remains of her village and found where her house had been; only the foundation remained. At a nearby camp, we found her mother but not Inda. Her mother had put her in a neighbor's house for isolation, apparently possessed of a better operational definition of public health than I was. Inda was still febrile, the rash now covered her entire body, and she refused to eat or drink. We drove her back to the clinic, where we isolated her and gave her a mosquito net.
My misguided decision to send Inda home led serendipitously to valuable insight into the mobility of the population and the powerful potential for epidemic disease. The immediate issue addressed, we turned our attention to prevention.
At the regional health clinic, we taught the staff — who had never seen measles — the importance of measuring temperature, administering antipyretics, and using antibiotics in certain cases. We provided thermometers, blood-pressure cuffs, stethoscopes, and a scale. We also took the staff members into the camp, where they were loath to go, so that we could immunize against measles and scan the corners of the tents for children with diarrhea or skin infections. Many such children never made it to the clinic, because their mothers were unable to leave their other children and their fathers were out looking for work or food during the day. Some children with measles had gone to the clinic but had been sent back into camp with a diagnosis of dermatitis.
We reported our cases to the World Health Organization, which began to assist with case identification and confirmation and to support the ministry of health in providing measles vaccination. Our reports alerted the authorities to the measles outbreak and kept them informed of the extent of the epidemic. A measles outbreak is serious: in a refugee camp, one in four children younger than five years of age may die of measles, which is reportedly the leading cause of death among children in this age group during the initial phase of emergencies.1
Dealing with small numbers of patients in my role as an emergency physician allowed me to discover the gaps in the overall public health response. Inda was the tip of an iceberg. And like an iceberg, the measles epidemic unfolding in front of me was mostly occult and highly lethal. Inda's diagnosis launched a massive strategy for identifying, treating, and immunizing every child in her camp and in every camp and home she had visited. This strategy bore secondary fruit, as we found severe dehydration, diarrhea, and skin infections in people lining up for vaccinations. Thus, my microscopic view of Inda had grown rapidly into the bigger public health picture.(Hilarie H. Cranmer, M.D.,)