When the virus arrived on its shores, the Pacific island nation was grievously unprepared. It had left the door to contagion wide open, and thousands of children have suffered.
From the beginning, Nuu Lameko's baby daughter radiated happiness. She clapped and danced to the songs of praise at church. Often, Lameko would roll a coconut across the floor of their home to hear her giggle.
"Whenever I'm having a bad day, she would have that smile to cheer me up," Lameko said.
Late last month, that joy turned to despair. The baby girl, Lemina — called Mina for short — contracted measles as a calamitous epidemic swept the Pacific island nation of Samoa. Days later, Mina, just 10 months old, died in her mother's arms.
"I don't really accept it," Lameko said. "God, why? Why my baby?"
That question has consumed Samoa as the epidemic has killed dozens of young children in the past two months and infected thousands more, leaving virtually no one in this nation of big families and communal living untouched.
When measles arrived on its shores, Samoa was grievously unprepared. The government had left the door to contagion wide open, allowing the vaccination rate to fall to a staggeringly low level and putting thousands of children at risk.
The failure started with government complacency, compounded by a misguided decision to suspend a vaccination program after a medical scare. And the country's scepticism about immunisation was amplified by both anti-vaccine activists and traditional healers.
Samoa is an acute example of how unfounded mistrust of vaccines and gaps in routine health care have led to a resurgence of measles around the world.
Outbreaks of measles have hit every region of the planet this year, with the virus emerging in places like the United States where it had once been considered eliminated. Worldwide, reported cases jumped 300 per cent in the first three months of 2019, compared with the same period last year.
In Samoa, an independent nation that is part of the same island chain as American Samoa, the government has taken sweeping measures to control the disease's spread after initial delays in the response to the outbreak.
During a mass vaccination campaign in early December, the fear that had washed over the country was clear. Families hung red flags outside their homes to alert health workers that they needed a shot, with some bearing messages like "Help!" or "I want to live!"
That effort has put Samoa on the cusp of achieving a 95 per cent vaccination rate, seen as the threshold for "herd immunity" — effective protection from the spread of the disease.
For many, it came too late. Overall, 77 people have died in the epidemic, and at least 5,400 cases of measles have been reported among the population of 200,000, though the numbers are most likely higher.
For weeks, families have been holding burials all over the island nation. Funeral homes, used to handling the elderly, are preparing tiny coffins for the bodies of young children and babies, with many offering their services at no charge.
In the village of Faleasiu, the family of Valisa Talosaga, 2, kissed and caressed her body last week before burying her in front of their home. In Vailele, another village, Timoteo Fuatogi, 29, wiped tears with his shirt as a pastor prayed over the open grave of his baby brother. Then the mourners filled the dirt back in with a bucket.
The family, who are street vendors, had taken the child to traditional healers after he contracted measles from his twin brother. He later died in a hospital.
"We worked hard to buy nappies and baby formula," Fuatogi said. "It's really hard for me."
A blueprint for disaster
Measles is one of the most contagious diseases known to humans. One person with it can infect 12 to 18 others. Doctors can treat only the symptoms: fever, cough and a rash. Deaths in babies occur from complications like pneumonia. And for those who survive, measles can leave a lasting mark — the possibility of weakened immune systems and neurological complications later in life.
In 2013, 90% of infants in Samoa were receiving the measles-mumps-rubella, or MMR, vaccine around the time they turned a year old.
But the rate gradually declined in the years that followed. "We've been slack on the routine immunisation," said Dr. Take Naseri, the director-general of Samoa's Ministry of Health. "I think we have been quite complacent."
He added, "We never expected the measles outbreak."
In 2018, the immunisation rate bottomed out at about 30 per cent, on a par with some of the poorest countries in Africa. That year, the country's faith in vaccination was shaken after two infants who had received the vaccine died — a tragedy that was later attributed to a medical mistake. Nurses had inadvertently mixed a muscle relaxant into the vaccine instead of sterile water.
"After the incident, every parent feared losing their child," said Taupau Siimamao, the grandfather of Valisa Talosaga, the 2-year-old in Faleasiu who died from respiratory complications after contracting measles. He said the family had planned to vaccinate his granddaughter before the two babies died.
Amid a public outcry, the government recalled the vaccine nationwide, suspending its measles immunisation program for nine months as it conducted an investigation. "I had to reassure the population that the vaccine is safe," Naseri said.
But the World Health Organisation said the decision helped create "a pool of susceptible children under the age of 5 years who are now the most affected" in the current epidemic.
Even after the program was restored this April, the ongoing criminal case against the nurses continued to feed doubts about vaccination.
Siimamao, whose granddaughter died, said he believed that the government should have pushed harder to persuade parents to vaccinate their children after the scare. But he does not fault officials for what followed. "We blame ourselves in part for not taking care of her," he said.
The scare also provided a new opening for anti-vaccination voices, both from Samoa and abroad. "It allowed the speculation and fear and anti-vax to emerge," said Penelope Schoeffel, a social anthropologist at the National University of Samoa.
This month, the government arrested a Samoan anti-vaccination activist, Edwin Tamasese, who has promoted supposed alternatives to vaccines like vitamins A and C. He has called mass vaccination "the greatest crime against our people by our own people."
Approached outside court last week, Tamasase declined to comment.
Another prominent voice in Samoa against vaccinations is Taylor Winterstein, the Australian wife of a Samoan rugby player. In June, she met in Samoa with Robert F. Kennedy Jr., one of America's best-known vaccine opponents.
At that meeting was an employee of the US Embassy.
"The reported meeting amongst individuals known for their anti-vaccine views did include a local staffer of the US embassy, but these meetings were conducted on his own time in his capacity as a private citizen and do not in any way reflect the position of the embassy nor the U.S. government," the State Department said in a statement.
The government responds
The current epidemic, according to the Ministry of Health, began when a person with measles travelled to Samoa from New Zealand, which is struggling with its own outbreak.
Naseri, the Samoan health official, acknowledged that there was a delay in the government's announcement of the outbreak. He said it had to confirm the initial measles case with an Australian lab, which took two weeks. Labs in New Zealand were overwhelmed, he said.
"I'm not trying to defend what I did," Naseri said, "but I had to say with confidence that we have a measles outbreak."
The government announced that there was a suspected case of measles on Oct. 9, then officially announced the outbreak on October 16. A month later, as the death toll reached 15, it declared a state of emergency, shuttering schools and barring children from public gatherings. On Saturday, the government extended the emergency through December 29.
In early December, the government shut down for two days to carry out a nationwide vaccination push, aided by global groups like the World Health Organisation and UNICEF. The Samoan parliament is set to consider legislation that would make vaccinations compulsory to enter school.
"I've never seen as high a level of political commitment in a country to conduct a measles campaign," said Dr. David Sniadack, a representative of the Global Immunisation Division at the Centers for Disease Control and Prevention.
While the epidemic is slowing, it has been hard to contain.
One complication is that some parents first take their children to traditional healers, some of whom use machines purchased from Australia that they claim produce water with immune-protective properties.
"People go to traditional healers and present really late, and that's why we have a lot of critical cases," said Frances Vulivuli, a doctor with UNICEF, adding that many babies had been close to death on arrival.
In the hospitals, some of the Samoan staff members have worked every day since the epidemic began, even taking 24-hour shifts. Teams of doctors, nurses and other health workers from at least a dozen countries are offering needed relief.
Last week, mothers kept vigil over their children as they lay in wooden beds in the isolation wards. Makeshift toys were scattered near each bed.
For Lameko, whose daughter Mina once laughed at coconuts rolling across the floor, her time at the hospital still haunts her sleep.
As her baby was being sedated by doctors, she whispered in her ear. "Mina," she said. "I want to be able to hold you and take you home."
She asked if she could hold her daughter one last time. She did not want to scream, like the other parents, because Mina hated yelling. So she sang to her instead.
"Who would have known God chose me to raise and give birth to an angel?" Lameko said. "But it still breaks my heart that I have to let my angel go."
Written by: Isabella Kwai
Photographs by: Ivor Matthew Abbott
© 2019 THE NEW YORK TIMES