Measles outbreaks that infected thousands and put youngsters in intensive care could have been avoided if the Government heeded expert advice and closed immunity gaps. Nicholas Jones and Mike Scott report from a Samoan village where at least 10 children died in a catastrophe that savaged the Pacific nation.
Small graves in front gardens, memories and heartbreak are all that's left of the children and babies taken by measles.
Death kept coming for the Samoan village of Toamua, into late December and as a national epidemic neared its catastrophic end.
At least 10 babies or children died in this village some 6km outside Apia; a terrible toll for a community of about 1800.
Lologa Samuelu succumbed after two weeks in hospital. The 14-month-old was a tearaway before getting sick; careering around his home and keeping an ear out for any vehicles pulling up outside.
"Whenever Lologa saw the taxi we were coming home in, he'd quickly run out and I'd open the door and he'd jump inside, and when we got to the house he'd laugh and be happy," recalls his grandmother, Tafoe Moors-Samuelu.
Lologa's fever and coughing began just before White Sunday celebrations in October, and he died on November 9. Ten other people in the extended household were fighting the highly contagious disease, and just two days later his 6-month-old cousin, Isaac Junior, died.
The boys now lie together in a concrete-covered burial plot in a corner of the garden, under an umbrella and flowers, with the rumble of passing traffic coming through the surrounding hedge.
Their mothers - sisters-in-law and both in their early 20s - have on special T-shirts for our visit, each depicting Lologa and Isaac Junior at the same age as babies.
The grief is still raw, in a quieter-than-usual house, with no Lologa running in happiness to a returning car. Too many other families, including an immediate neighbour, feel the same absence because of measles.
"It's a heartbreak for my family," says Moors-Samuelu. "We miss them all the time, the two boys. We watch their videos all the time and cry, cry, cry."
'Something to be ashamed of'
A line can be traced from that pain to New Zealand.
Ministry of Health documents obtained as part of a Weekend Herald investigation show outbreaks that put Kiwi kids in intensive care could have been avoided had the Government acted on expert advice to close gaping immunity gaps.
It's likely the disease then spread with travellers to Samoa - a situation that dismays scientists, including Dr Helen Petousis-Harris, a vaccinologist at the University of Auckland.
"Exporting a disease to a country with fragmented health care is something to be ashamed of," she says of that probability, judged highly likely by government officials.
The ministry report was compiled by its communicable disease team with input from the national verification committee for measles and rubella elimination (NVC), a group of the country's top experts that reports to the World Health Organisation.
Measles outbreaks had hit New Zealand, particularly South Auckland with its large Pasifika population, when the report was finalised in August, but hadn't taken off in the Pacific, where 83 Samoan lives - mostly babies and children - would ultimately be lost.
"Outbreaks have been fuelled by the immunity gap in the New Zealand population," the ministry report warned. "No funding has been available nationally to support supplementary immunisation activities to increase immunity against measles."
For years the expert committee made unsuccessful pleas for "catch-up" and targeted vaccination programmes, and its members - chaired by Dr Nikki Turner, director of the national immunisation advisory centre - were clear about the cost of inaction.
"The NVC has not been advised as to progress of their recommendations and government response [and] notes with disappointment that the recent increase in measles importation and subsequent outbreaks could have been avoided had its recommendations been acted upon in a timely manner," the ministry report stated.
Those recommendations were first made in May 2017 and included the urgent need to close measles immunity gaps, and start MMR catch-up vaccination work. A regional meeting of the United Nation's health agency in 2018 reiterated the need for action.
The ministry noted in the August report that it was planning targeted immunisation for 2020 - however, that is subject to funding, and "to date there has been no resource commitment to ensure this happens systematically and effectively throughout the country".
Money is finally set to be found, with Associate Health Minister Julie Anne Genter confirming an imminent announcement about closing immunity gaps she says have persisted for decades. Genter blames National for funding happening only in the last year of the Government's term.
"We were elected at the end of 2017, at that point the 2017/18 financial year is already committed. And then certainly we had a huge list of things we needed to do [in health]. And now I have asked the Ministry of Health to fast-track work to ensure that this couldn't happen again - so we are going to get that work done. That is what I can do.
"What it demonstrates is why it is so important to have a well funded health system. We are constantly juggling different needs, and the previous government underfunded health and that meant that there were a lot of competing needs by the time we came into government."
That reasoning was disputed by National's health spokesman Michael Woodhouse, who says the previous Government boosted immunisation rates for children from 67 per cent in 2007 to about 93 per cent in October 2017.
"Since then the immunisation rates of 19 of our 20 DHBs have gone backwards. If Julie Anne Genter wants to find someone to blame for last year's measles outbreak she should look in the mirror.
"This is an issue entirely of this Government's making and she should step up and improve immunisation rates rather than playing the broken record of blaming the previous Government."
Genter took on responsibility for measles at the end of July, and prior to an Official Information Act request by the Weekend Herald she hadn't seen the August ministry report. An independent review of the measles response is expected by the end of next month, and will "include communications to decision-makers", she says.
A cluster of death
The sound of children singing has come back to Toamua Congregational Christian Church. During the terrifying months of the measles outbreak, young people weren't allowed to attend services as the disease went from house to house.
"It was indeed strange to have no children in church," recalls Reverend Dr Eletise Suluvale. "The singing was sorely missed by our congregation. For me as a pastor it seemed unreal that half of my congregation were not present."
Suluvale's family moved out of their home across the road from the church so an emergency vaccination clinic could be set up. When they returned more than two weeks later the area was water-blasted and every surface scrubbed.
The prolonged fear was something he has never experienced before. Only the 2009 tsunami compares, he says, but the invisible threat of measles is a different terror.
"The tsunami was a one-time occurrence. The measles was like one dying, another dying, another dying. It got to the stage where it was frightening...for the whole village, and the whole of Samoa - to see this threatening, life-taking disease, that was seemingly unavoidable.
"Young children dying, almost together. We are used to one child in a year, or in two or three years. But what we had was seven in one month."
Suluvale, who studied in New Zealand as a young man before gaining a PhD in water quality in Australia, has noted media reports of coronavirus. At Faleolo International airport, new arrivals have their temperature taken by officials in medical gowns and masks, and those from countries with confirmed cases must produce a medical certificate.
Another outbreak is hard to think about, just as everyday life - and the church singing - returns to normal.
"We are hearing another virus is coming from China," the Reverend says. "Maybe if that one comes to Samoa it will be even harder. Hopefully not babies [this time]."
About 90 per cent of Kiwis are immune to measles, below the 95 per cent officials want to ensure herd immunity, which helps interrupt the disease's spread.
Children should get two MMR (measles, mumps, rubella) vaccinations, one at 15 months (12 months in Auckland) and the second at four years.
The biggest measles immunity gap is for those born from around 1980 to 2000, with about 73 per cent immune. From 2006, coverage reached about 93 per cent for MMR dose one, but Māori and Pacific children still have lower rates, as do those living in poorer areas.
Documents show experts on the NVC pressed officials to "address the system factors (including institutional racism) that create equity gaps".
Institutional racism is a term that means the procedures or practices of particular organisations result in some groups being advantaged over others. In the health context, this could include Māori feeling less welcome at health services, for example.
The problem is getting attention in health circles. Auckland and Northland DHBs put staff through special training after concluding institutional racism is a major reason for poor health suffered by Māori and Pacific New Zealanders. And the Health Quality & Safety Commission recently released a landmark report finding that institutional racism severely harms Māori, with its chair, Professor Alan Merry, warning, "services are not as accessible for Māori, and even after services are accessed, Māori do not experience the same benefits".
Genter avoids using the term in our interview, but says overcoming inequity is the key to closing immunity gaps - much more so than countering anti-vaccine sentiments.
"The research I have seen in New Zealand suggests that vaccine-hesitancy, or outright anti-vaxx, is a very small percentage, about 1 per cent. Really, the main barrier to getting high levels of immunity are logistical barriers . . . that's one of the reasons why we have now made it possible for community pharmacists to administer MMR vaccines."
In concluding its report in August, the ministry communicable disease team warned: "If measles is not controlled, the current situation in New Zealand may become a threat for other less-resourced countries in the region". It wanted "measures to ensure that travellers into and out of New Zealand are vaccinated" considered.
The World Health Organisation in 2018 encouraged authorities to think of innovative ways to try to contain measles, but the ministry conceded not enough was done, including "no successful engagement with the travel booking sector to ensure all bookings are reminded that pre-travel immunisation catch-up is recommended and free".
Measles' ease of travel contrasts with obstacles put before coronavirus, including New Zealand blocking all travellers from mainland China. Were authorities too lax?
"New Zealand did follow the World Health Organisation recommendations, which did not recommend travel restrictions," Genter says. "Certainly with coronavirus, because it is completely new, a more cautionary approach has been taken than what is strictly in the WHO recommendations."
A bad neighbour
Samoa declared a measles epidemic in mid-October. Unlike its Pacific neighbours it had very low immunisation rates - fertile conditions for a disease that is the world's most contagious, with a single case able to infect a further 12-18 people, on average.
Foreign Affairs Minister Winston Peters, who visited Samoa during the outbreak, has previously talked down the probability that the disease came from New Zealand. However, the Ministry of Foreign Affairs and Trade (Mfat) later confirmed it was "highly likely" that New Zealand was the main source, a position shared by the Samoan Government.
Samoan authorities are facing their own criticism. Vaccination rates were among the lowest in the world, and the country's MMR immunisation programme was suspended for months because of the deaths of two toddlers in 2018. It was later confirmed those cases were because of human error when nurses (subsequently jailed for manslaughter) incorrectly prepared vaccines with expired anaesthetic. Fear spread among parents, fanned by anti-vaxxers, and measles immunisation didn't resume until April 2019.
Opposition MPs are calling for an inquiry, saying the government didn't have an epidemic plan. This week the Samoa Observer wrote a stinging editorial that highlighted low immunisation rates and under-resourced hospitals, concluding, "83 innocent lives were lost during the measles crisis; many of them could have been spared".
New Zealand stepped up during the outbreaks, Genter says, including medical teams and funding and donation of more than 100,000 vaccines. Asked if we nonetheless share blame, the Associate Health Minister says measles' spread was global.
"There was a risk of outbreak anywhere where there was an immunisation gap and that was particularly true in Samoa. It is an absolute tragedy, and I agree - we now have to do the work so this never happens again; that we close our immunity gaps in New Zealand."
Petousis-Harris of the University of Auckland says it is shameful if New Zealand did export measles to a vulnerable neighbour. However, Samoa had halted its immunisation programme against all expert advice.
"If measles didn't come from New Zealand then it could come from somewhere else. If not last year then this year or next year. It is just a matter of time . . . all countries are at risk if they do not have an effective immunisation programme in place. Every single one."
That proved the case in New Zealand, Petousis-Harris says, and it was extremely fortunate that nobody died here.
"The cost of the [New Zealand] epidemic will have been enormous, many people were admitted to hospital and some required intensive care. This comes at both monetary costs and lives affected. It was always the risk of not addressing the immunity gap."
Dr Nikki Turner, speaking as director of the University of Auckland's national immunisation advisory centre, says both New Zealand and Samoa "learnt a hard lesson last year around where we chose to prioritise our health focus". Her view is if her committee's recommendations had been acted on, then "if not entirely stopping measles, at least there would have been lower rates as the spread would be less".
"New Zealand has focused on improving childhood immunisation coverage and has been getting good progress from our historic very poor record, but we haven't continued this improvement adequately to focus on obtaining and maintaining high measles coverage across the whole population, which has tragic consequences for our children."
Measles is an international traveller, Turner says, so blaming one country or another for its spread isn't useful. Instead, New Zealand and others should help Samoa improve and maintain immunisation coverage.
"While it is really disappointing that New Zealand transmitted measles, currently measles is being extensively transmitted between many countries.
"High immunisation coverage is hard to achieve and maintain…[but] measles is preventable. I lose sleep over the children in Samoa who have died and have been severely ill, and those who were severely ill in New Zealand."
Taugata Launiu is buried outside her family's front door and beside a bed of purple flowers. From here you can see the homes of two more families who lost a child to measles.
Lima Launiu and Launiu Time took their 9-month-old daughter to the hospital when she fell ill, but say they were sent away and told their youngest child was okay. Two days later she died at home after coughing and gasping for breath.
Lima nearly went mad with grief, she says. Because of the risk of transmission the November funeral was restricted to family. It was conducted by Reverend Suluvale.
He buried two more children from his congregation, in quick succession.
"It seems that the disease was going from one family to another. It was quite a frightening experience for our village," he says.
"At that time the state of emergency was in place, and that's why at the burial only family members were there, and me and my wife. It was harder on her, because as a mother she can feel the loss of the mothers."
Death isn't hidden in Samoa and as daily life gets back to normal it does so around Taugata, Lologa, Isaac Junior and 80 others lost in the terrible months at the end of 2019.
"The children buried from this epidemic were mostly buried in front of the houses, so you can easily see their graves when you pass around," says Reverend Suluvale. "They will always be a reminder to us."