Matthew Coldiron / MSF Doctor
When Matthew Coldiron first found out that he would be working on a mass treatment campaign for yaws, he had to struggle to remember what the disease was. In his words – yaws puts the “neglected” into the phrase “neglected tropical disease”. Most of us haven’t even heard of it, let alone the serious conditions it can cause, so Matthew gives us a summary and then tells us about his mission with MSF to help eradicate it amongst the Aka pygmies. (Photos: Benoit Finck.)
Yaws is an endemic treponematosis – a close (non-venereal) cousin of syphilis. It thrives in humid tropical areas, and is transmitted by direct cutaneous contact. Like syphilis, it has primary, secondary, and tertiary forms, as well as long latent periods. The primary and secondary forms are mainly cutaneous lesions, though periosteitis is not uncommon. 10% of untreated cases will develop tertiary forms decades after the initial infection. The most common of these involve hyperkeratosis of the soles and palms, complete destruction of the nasal cartilage (called gangosa), and severe bowing of the tibia, which results in serious disability.
Massive treatment campaigns with injectable penicillin in the 1950s and 1960s nearly resulted in the eradication of the disease. But the hardest-to-reach areas didn’t get treated, and the disease persisted in some of the most forgotten corners of the world – largely in central African forests, Indonesia, and the Pacific islands.
A single dose of oral azithromycin was recently shown to be non-inferior to penicillin for the treatment of yaws, which resulted in a new push for yaws eradication by 2020. An oral antibiotic can be administered to a whole population, which takes care of the problem of latency and reduces the logistical burden of administering injections in isolated areas. Médecins sans Frontières/Doctors Without Borders (MSF) decided to put this new eradication strategy into action for the first time in a remote region of Congo-Brazzaville, among the Aka pygmies, a nomadic group of hunter-gatherers greatly affected by yaws, during September and October 2012.
In some ways, I knew what to expect when I arrived in September. I had gone to the area well before the campaign to start our preparation, visiting the Aka camps (often only accessible after several hours’ walk through the dense forest). I had crossed rivers in leaky dugout canoes, trudged through waist-deep mud, and arrived in the heart of the pygmy homeland. But my planning visits couldn’t have prepared me for the reality of our campaign. The vast distances, the extreme living conditions, and the sweat, dirt, and mud posed major challenges for MSF’s three teams.
As a result, my team’s communal life together was intense. In total, we were eight: a doctor, two nurses, a logistician, a translator, an ‘advance man’ who preceded the teams in the villages to inform the population of our upcoming visit, and two drivers. We had wildly different professional and personal backgrounds – from an American doctor with lots of field experience, to a French nurse on her first mission, to a Congolese pastor working as the advance man. We worked up to 13 days in a row without a break, trekking for hours through the muddy jungle, sharing tents and meals, and bathing only occasionally. It was a true team effort, and we all brought different talents to the table – from the drivers who did double-duty registering patients, to the translator who unfailingly found bush meat to cook at dinner time, to the nurse who could pitch a three-person tent by herself in under two minutes.
By the end of the campaign, we had treated nearly 17,500 Aka with azithromycin, a great success by any standard. We also offered measles vaccinations and a very basic mobile clinic that cared for malaria, respiratory infections, diarrhoea, and other common easy-to-treat problems. On the other hand, I was always frustrated at my inability to treat many other conditions that affect the Aka. Leprosy is rampant, and I saw many patients whom I suspected to have tuberculosis. The saddest condition is infestation with chiques – a type of burrowing louse that lays its eggs under the skin of the feet. In many villages we visited, every child had them. Some had what looked like hundreds in each foot, and because of the pain, itching, and super-infections, were forced to walk on their heels.
The Aka are a geographically isolated group, and like many of the pygmies of central Africa, very marginalized. Historically, they lived in conditions of forced labour at the hands of their Bantu neighbours. Things are slowly changing in that regard, but their isolation means that they have little to no access to health care and education. Functioning structures are few and far between, and even then, the distances are too long to be practical for them, to say nothing of the cultural factors that affect their willingness to seek allopathic medical care.
So in this campaign, we went to them, and it was an unforgettable experience. As a doctor, I’m used to seeing patients who come to see me in a clinic. At MSF, we do lots of out-of-hospital care, but usually in the form of mobile clinics. But during this campaign, we had the privilege to live among the people we were serving, sleeping in their villages every night, eating the food they had hunted that morning, sometimes even dancing with them around a fire late into the night. Spending so much time in the Aka villages was a great way to gain their confidence. I’ll never forget eating caterpillars and smoked porcupine, the village chief who shared fresh honey – bees included – with us, and entering a village in the middle of a funeral rite whose centrepiece was a person covered in reeds twisting and twirling, representing the spirit of the deceased.
MSF first came to the area because of an influx of refugees from the neighbouring DRC which doubled the region’s population almost overnight. It supports the District Hospital in Betou, and has fixed and mobile clinic sites in the surrounding areas. Our yaws campaign also included the much larger district of Enyellé. In the coming months, MSF plans to revisit the areas of high yaws prevalence that we saw during the first phases of our campaign to ensure that any new cases and their families are treated. On a broader level, MSF is working to raise awareness both of this disabling and deforming neglected disease, and also the immense challenges faced by the isolated and vulnerable Aka.
You don’t have to trudge through the tropical rain forest to get involved, even though it is an amazing experience. You can learn about working with MSF, or make a donation to support our activities here. Medically speaking, yaws should be easy to eradicate, though obviously, the logistical side will be more complex. But as I’ve come to realise, solving the problem of this neglected disease will also involve concerted efforts at providing access to a basic level of care to the neglected people it affects.
Médecins sans Frontières/Doctors Without Borders (MSF)