The Washington Post

Bernardino Albuquerque, 69, an infectious

disease specialist and president of the Health

Surveillance Foundation of Amazonas State,

debates strategies to combat the latest measles

cases in the Brazilian state.

‘Venezuela’s crisis hasbecome our own’

As the health system collapses, disease is spilling over Venezuela’s borders.

By Anthony Faiola, Marina Lopes and

Rachelle Krygier

Photos by Gui Christ

OCTOBER 31, 2018

MANAUS, Braziln a steamy February morning,Bernardino Albuquerque — a

doctor in charge ofcombating infectiousdiseases in Brazil’s vast

Amazonas state — received thetext message he had beendreading for weeks.

We have two patients withsymptoms.

That alert from Brazilian doctorsnear the Venezuelan frontiermarked the start of an importedmeasles epidemic that is stillravaging the Brazilian Amazon. Itwas the first time in nearly twodecades that the highly contagiousvirus had appeared in this tropicalregion, home to a growingnumber of Venezuelan migrants.The disease has also spread toArgentina, Colombia, Ecuador andPeru.

The economic and social crisis inVenezuela is increasingly spillingover its borders, with diseasebecoming the newest symbol ofthe disaster. Venezuela’s health-care system has virtually brokendown, allowing once-eradicatedillnesses such as measles and

O

diphtheria to reemerge in apopulation facing acute shortagesof food and medicine. Now, ahistoric outflow of migrants ishelping spread infections to othercountries.

“Venezuela’s crisis has becomeour own,” Manaus Mayor ArthurVirgilio Neto said.

Brazil’s patient zero for measleswas a 1-year-old Venezuelan childbrought over the border inFebruary. Eight months later,more than 10,000 patients havecontracted suspected infections inAmazonas state alone, as the virushopscotched across a localpopulation that was notsufficiently vaccinated. New casesare growing at the rate of 170 aweek.

Seen as a manageable childhoodillness in the United States,measles has taken a high toll inthe crowded shantytowns andremote villages of the denseAmazon jungle. Amazonas statedeclared a health emergency inJuly, and hundreds of people havebeen hospitalized with

complications includingpneumonia. So far, two adults andfour infants have died.

“We hadn’t had a single case ofmeasles in 18 years; most of ourdoctors only knew it from textbooks,” said Albuquerque,recalling the start of the measlesoutbreak. “We were prepared forroutine problems. But this wasextraordinary.”

Amaba Waimiri, 48, from Novo Airão in Manaus’s metropolitan region, visits her daughter Wakixi,

15, who has the measles, in an isolation unit at Delphina Rinaldi Abdel Aziz Hospital.

Border countriesoverwhelmed

Venezuela, an oil-rich nation ofabout 31 million, is in the midst ofa societal collapse — the productof a five-year-long depressionsparked by lower oil prices, failedsocialist policies, governmentmismanagement and corruption.Aid agencies project nearly 2million Venezuelans will abandontheir nation this year, on top of 1.8million who left over the past twoyears. They are leaving a countrywhere food is scarce and the

public health system is withering,with little money for drugs,outreach campaigns,epidemiological surveillance orinsecticides.

Decades ago, Venezuela waslauded as a global pioneer incombating malaria, eradicatingthe disease from vast sections ofthe nation. But malaria cases havetripled in three years to 406,289 in2017. Brazilian authorities citethat surge, and the increase inmigrant flows, for a 50 percentspike in malaria in Amazonasstate last year, to 72,000 cases.Peruvian health authorities havereported a new outbreak in atransit region for migrants whereno malaria cases had beenrecorded since 2012.

“We’re facing a [malaria]epidemic in places that didn’thave it anymore, that were cleanof it,” Albuquerque said. “Theyhave not been doing effectivemalaria control in Venezuela,especially in the past few years.”

In Colombia, at least eight cases ofdiphtheria — a bacterial infectionthat can block airways and cause

death — were confirmed in 2018,that nation’s first instances since2005. All eight were recorded inborder regions with a large flowof migrants from Venezuela,where a diphtheria outbreak hasraged since 2016, according to thePan American HealthOrganization (PAHO), a U.N. body.

Hospitals in countries that borderVenezuela, particularly Colombiaand Brazil, are alreadyoverwhelmed by a surge of sickVenezuelans, seeking treatmentfor grave illnesses from cancer toHIV that their home nation isincreasingly unable to treat.

The PAHO said in a statement thatVenezuela’s health-care system —including disease-preventionprograms — had been continuallydeteriorating because of economicand political problems. “This hasled to an increase in the numberof outbreaks of infectiousdiseases, particularly of measles,diphtheria and malaria. Thesituation is being aggravated bypopulation movements bothwithin the country and toneighboring countries,” it said.

TOP: Patients wait to get vaccinated at José Rayol Dos Santos public health clinic in downtown

Manaus, Brazil, where about 50 patients are vaccinated each day. BOTTOM LEFT: Students Sabrina

Coelho, 18, and Edilene de Andrade, 16, got the measles vaccine for the first time at Josué Claudinho

de Sousa state school. BOTTOM RIGHT: Larissa Henrique, 22, also a student, received a triple

vaccine for measles, mumps and rubella at the health clinic in Manaus.

Too little, too late

No illness has spread morerapidly from Venezuela thanmeasles. Viruses containing thesame genetic markers as in the

outbreak in Venezuela havespread across the continent, fromneighboring Colombia to distantArgentina. Outside of Venezuela,the vast majority of the patientsare in Latin America’s largestnation: Brazil.

Venezuela’s health ministry didnot respond to repeated requestsfor comment. PAHO records,however, show hundreds ofsuspected measles cases werereported there in 2016. Thegovernment launched a targetedvaccination campaign in the mostaffected area — the illegal miningzones in Bolivar state — aftercases were recorded there in mid-2017.

But vaccination programs hadbeen slipping nationwide foryears, according to Venezuelandoctors — providing a recipe fordisaster even as the governmentwas slow to respond to newoutbreaks.

Two Venezuelan physiciansfamiliar with the country’svaccination program said failinginfrastructure has contributed to

the problem. At CaracasUniversity Hospital — one of thecapital’s largest — there are holesin doors in the infectious diseaseward where measles patients arekept, compromising containmentefforts, according to doctors.Refrigerators are often broken inCaracas clinics, making storage ofvaccines challenging. Also, carsused to deliver vaccines arefrequently out of service becauseof a lack of spare parts, accordingto the doctors, who spoke on thecondition of anonymity out of fearof government reprisals.

The Venezuelan government, withthe aid of the PAHO, launched amore comprehensive, nationwidemeasles vaccination program thisyear. But the damage, doctors say,had already been done.

“When a virus enters a country,what you do is protect thepopulation, and the governmentsimply didn’t,” said Julio Castro,professor at Caracas UniversityHospital’s Tropical MedicineInstitute. “Once the virus washere, they did nothing to trulystop it from spreading. Knowingthat so many of our kids weren’t

vaccinated, they should haveraised a national alarm. Theydidn’t.”

International agencies —including the PAHO and the U.S.Agency for InternationalDevelopment, the U.S.government’s overseasdevelopment organization — havelaunched emergency healthprograms in Venezuela’sneighboring countries to containthe outbreaks, including ramped-up vaccination and detectionoperations in Colombia and Peru.But nowhere has the responsebeen more massive than in Brazil.

Theo Silva, 4 months old, and his mother Talia Miranda, 21, are in isolation at Delphina Rinaldi Abdel

Aziz hospital because they have measles.

‘I wasn’t vaccinated’

The road to Venezuela passes byNorthside Emergency Hospital inManaus, a sprawling city of2.1 million that boomed under19th-century rubber barons.

Here, 600 miles from theVenezuelan border, the hospital’slittlest patients are struggling forbreath in an infectious diseaseward that was converted monthsago into a measles isolation wing.In one room, Talia Miranda, 21,stroked the hand of her 4-month-old son, Theo.

When he had come in nine daysearlier, his measles-relatedpneumonia had been so bad heneeded to be incubated. He wasstill not out of danger — but doingbetter than an infected infant inthe room next door who doctorssaid might not pull through.

Authorities have strung upmeasles advisory posters aroundtown, and the outbreak isconstantly in the news. Miranda

had been counting the days untilher son was 6 months old — thedate when doctors said it wouldbe safe to vaccinate him. But thenshe caught measles herself andpassed it on to him.

“I don’t blame the Venezuelans;they’re just looking for a safeplace,” she said, fighting backtears. “I blame myself. I wasn’tvaccinated. He got it from me.”

LEFT: From left, Lucimei Martins, 57; Nataly Queiroz, 20; and Alessandra da Silva, 43, of the Health

Surveillance Foundation, prepare vaccine doses. RIGHT: Every week about 100 new suspected blood

samples arrive at Amazonas State’s Public Health Central Laboratory for measles examination.

Indeed, the spread of illnesses likemeasles has underscored thedangerous weakness of thevaccination programs in countrieslike Brazil. When measles sweptin from Venezuela, almost one-third of Amazonas state’s 4 millioninhabitants were unvaccinated.

Officials have scrambled torespond. The government set up asituation room in Manaus, withdozens of maps on the wall, andtracked the disease as it invadedthe city. Doctors unfamiliar withmeasles underwent urgent

training. Health authorities wentto universities and medicalschools, recruiting morethan 1,000 trainees who weretaught how to give vaccinations. Adoor-to-door operation began —from moss-covered colonialbuildings and teeming slums tojungle settlements reachable onlyby days-long trips in canoes.

Yet the mobilization failed toprevent a major outbreak — bylate summer, medical personnelwere receiving 900 suspectedmeasles victims a week.Overwhelmed, health workersmoved from sending patients tohospital isolation wards torecommendinghome containment for all but theworst cases. Emergencyvaccination points were set up atschools and churches.

After the delivery of 1 millionvaccinations, the number ofsuspected new cases is dropping— down to 170 a week.

Few in Manaus are angry at theVenezuela migrants, whogenerally have been met withsympathy here. Residents are,

however, blaming the Venezuelangovernment.

“The epidemic is the result of adespotic, incompetentgovernment in Venezuela,” saidVirgilio, the Manaus mayor.“Their lack of attention to nationalhealth care has created thesenegative consequences, and wehave to pay the price.”

Krygier reported from Caracas.

Read more

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Lawyers as sex workers. Ex-bureaucrats as maids. HowVenezuelans became LatinAmerica’s new underclass.

Millions of Venezuelans arefleeing to Latin American cities.The region may never be thesame.

Credits: By Anthony Faiola, Marina Lopes and

Rachelle Krygier. Photos by Gui Christ. Designed by

Joanne Lee. Photo Editing by Chloe Coleman.