Monday, December 6, 2010

Mother Child Week

Last week was “Mother and Child Health Week” throughout Rwanda. Which contrasted nicely as I was “reading” (ie – listening to) Jodi Picoult’s House Rules on my iPod.

Let me flesh out that comparison:

Mothers, potential mothers, and children under 5 receive amazing healthcare in Rwanda. Absolutely all preventive visits are free, even without insurance. Community health workers are employed to track pregnant women and children: to give the women vitamins and mosquito nets, to track the children’s growth, to remind the mothers of vaccination appointments at the health center. During Mother and Child Health Week, these efforts are multiplied…let’s just say tenfold as a hyperbole.

This focus on mother and child health has produced impressive results: its maternal mortality rate was 383/100,000 in 2009 – down from 750 in 2005 and much more impressive than the 440 in and 560 in neighboring Uganda and Kenya, respectively. Similarly, under-5 mortality is down from 152 per 1,000 live births to 103 – much less than the 130 in both Kenya and Uganda.

These results do come at a cost. Health centers are pressured/forced/required to achieve 100% vaccination coverage – under threat of not receiving vaccinations the following year if they do not. According to herd immunity theory, only about 85% of a population needs to be vaccinated against a disease for the others to be protected from it. Yes, these vaccines are free for the recipients (under 5), but they do come at a cost to somebody/something. I wonder if it’s the best use of NGOs’ monies to demand – and then pay for – 100% vaccination coverage, when 85% will do the trick.

(A particular frustration of mine is that vaccines are free only for children under 5. Rwandans must pay for – and most insurance does not cover – booster vaccines (tetanus for example) or annual flu vaccines. The international focus on the “under-5 mortality rate” has seemed to decrease national focus on the under-10, under-15, or “preventable” mortality rate. I wonder if aid money could be better spent vaccinating 85% of children, and also providing discounted vaccinations to the older population.)

In Rwanda, it seems, that the only reason a child would not be vaccinated is because the health center is too far away, or because the vaccination day falls on a particularly lucrative harvest day/market day, or because the mother forgot the appointment (hard to keep track of these things when your society doesn’t use calendars).

And finally, the connection to House Rules…a book (so far) about an autistic boy. Being about an autistic boy, the point of vaccinations causing autism is obviously discussed. In the US, it seems, there are 2 reasons a child would not get a vaccination: the mother cannot afford it, or the mother has the luxury of choosing to not vaccinate her child, for fear of autism. And given public school requirements…it might actually only be the fear of autism that keeps children from receiving vaccines.

And I laugh. Because this seems to quintessentially capture the difference between Rwandan culture and American culture. While Rwanda struggles to achieve its goal of 100% coverage, trying to overcome the hurdles of distance, ignorance, and enforcement (when you’re also struggling to get 100% attendance at primary school…do you really want to add requirements – such as vaccination – in order for them to attend?), Americans struggle to avoid vaccination requirements – by enrolling their children in private schools, or fighting lawsuits.

I did make the point earlier about herd immunity – so I don’t think that these “overly-protective” parents are putting other children at risk by not vaccinating their children (unless the over-protective ones start to exceed 15% of the population). But I just had to smile, when the argument against vaccinating a child came onto my ipod, as I was tallying Shingiro health center’s vaccination coverage rates (94% in 2009!) because it is…so…American…to fight vaccination.

Dear America, I miss you.

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