On a steamy February morning, Bernardino Albuquerque — a doctor in charge of combating infectious diseases in Brazil’s vast Amazonas state — received the text message he had been dreading for weeks.
We have two patients with symptoms.
That alert from Brazilian doctors near the Venezuelan frontier marked the start of an imported measles epidemic that is still ravaging the Brazilian Amazon. It was the first time in nearly two decades that the highly contagious virus had appeared in this tropical region, home to a growing number of Venezuelan migrants. The disease has also spread to Argentina, Colombia, Ecuador and Peru.
The economic and social crisis in Venezuela is increasingly spilling over its borders, with disease becoming the newest symbol of the disaster. Venezuela’s health-care system has virtually broken down, allowing once-eradicated illnesses such as measles and diphtheria to reemerge in a population facing acute shortages of food and medicine. Now, a historic outflow of migrants is helping spread infections to other countries.
“Venezuela’s crisis has become our own,” Manaus Mayor Arthur Virgilio Neto said.
Brazil’s patient zero for measles was a 1-year-old Venezuelan child brought over the border in February. Eight months later, more than 10,000 patients have contracted suspected infections in Amazonas state alone, as the virus hopscotched across a local population that was not sufficiently vaccinated. New cases are growing at the rate of 170 a week.
Seen as a manageable childhood illness in the United States, measles has taken a high toll in the crowded shantytowns and remote villages of the dense Amazon jungle. Amazonas state declared a health emergency in July, and hundreds of people have been hospitalized with complications including pneumonia. So far, two adults and four infants have died.
“We hadn’t had a single case of measles in 18 years; most of our doctors only knew it from text books,” said Albuquerque, recalling the start of the measles outbreak. “We were prepared for routine problems. But this was extraordinary.”
Border countries overwhelmed
Venezuela, an oil-rich nation of about 31 million, is in the midst of a societal collapse — the product of a five-year-long depression sparked by lower oil prices, failed socialist policies, government mismanagement and corruption. Aid agencies project nearly 2 million Venezuelans will abandon their nation this year, on top of 1.8 million who left over the past two years. They are leaving a country where food is scarce and the public health system is withering, with little money for drugs, outreach campaigns, epidemiological surveillance or insecticides.
Decades ago, Venezuela was lauded as a global pioneer in combating malaria, eradicating the disease from vast sections of the nation. But malaria cases have tripled in three years to 406,289 in 2017. Brazilian authorities cite that surge, and the increase in migrant flows, for a 50 percent spike in malaria in Amazonas state last year, to 72,000 cases. Peruvian health authorities have reported a new outbreak in a transit region for migrants where no malaria cases had been recorded since 2012.
“We’re facing a [malaria] epidemic in places that didn’t have it anymore, that were clean of it,” Albuquerque said. “They have not been doing effective malaria control in Venezuela, especially in the past few years.”
In Colombia, at least eight cases of diphtheria — a bacterial infection that can block airways and cause death — were confirmed in 2018, that nation’s first instances since 2005. All eight were recorded in border regions with a large flow of migrants from Venezuela, where a diphtheria outbreak has raged since 2016, according to the Pan American Health Organization (PAHO), a U.N. body.
Hospitals in countries that border Venezuela, particularly Colombia and Brazil, are already overwhelmed by a surge of sick Venezuelans, seeking treatment for grave illnesses from cancer to HIV that their home nation is increasingly unable to treat.
The PAHO said in a statement that Venezuela’s health-care system — including disease-prevention programs — had been continually deteriorating because of economic and political problems. “This has led to an increase in the number of outbreaks of infectious diseases, particularly of measles, diphtheria and malaria. The situation is being aggravated by population movements both within the country and to neighboring 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 more rapidly from Venezuela than measles. Viruses containing the same genetic markers as in the outbreak in Venezuela have spread across the continent, from neighboring Colombia to distant Argentina. Outside of Venezuela, the vast majority of the patients are in Latin America’s largest nation: Brazil.
Venezuela’s health ministry did not respond to repeated requests for comment. PAHO records, however, show hundreds of suspected measles cases were reported there in 2016. The government launched a targeted vaccination campaign in the most affected area — the illegal mining zones in Bolivar state — after cases were recorded there in mid-2017.
But vaccination programs had been slipping nationwide for years, according to Venezuelan doctors — providing a recipe for disaster even as the government was slow to respond to new outbreaks.
Two Venezuelan physicians familiar with the country’s vaccination program said failing infrastructure has contributed to the problem. At Caracas University Hospital — one of the capital’s largest — there are holes in doors in the infectious disease ward where measles patients are kept, compromising containment efforts, according to doctors. Refrigerators are often broken in Caracas clinics, making storage of vaccines challenging. Also, cars used to deliver vaccines are frequently out of service because of a lack of spare parts, according to the doctors, who spoke on the condition of anonymity out of fear of government reprisals.
The Venezuelan government, with the aid of the PAHO, launched a more comprehensive, nationwide measles vaccination program this year. But the damage, doctors say, had already been done.
“When a virus enters a country, what you do is protect the population, and the government simply didn’t,” said Julio Castro, professor at Caracas University Hospital’s Tropical Medicine Institute. “Once the virus was here, they did nothing to truly stop it from spreading. Knowing that so many of our kids weren’t vaccinated, they should have raised a national alarm. They didn’t.”
International agencies — including the PAHO and the U.S. Agency for International Development, the U.S. government’s overseas development organization — have launched emergency health programs in Venezuela’s neighboring countries to contain the outbreaks, including ramped-up vaccination and detection operations in Colombia and Peru. But nowhere has the response been more massive than in Brazil.
‘I wasn’t vaccinated’
The road to Venezuela passes by Northside Emergency Hospital in Manaus, a sprawling city of 2.1 million that boomed under 19th-century rubber barons.
Here, 600 miles from the Venezuelan border, the hospital’s littlest patients are struggling for breath in an infectious disease ward that was converted months ago 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 days earlier, his measles-related pneumonia had been so bad he needed to be incubated. He was still not out of danger — but doing better than an infected infant in the room next door who doctors said might not pull through.
Authorities have strung up measles advisory posters around town, and the outbreak is constantly in the news. Miranda had been counting the days until her son was 6 months old — the date when doctors said it would be safe to vaccinate him. But then she caught measles herself and passed it on to him.
“I don’t blame the Venezuelans; they’re just looking for a safe place,” she said, fighting back tears. “I blame myself. I wasn’t vaccinated. He got it from me.”
Indeed, the spread of illnesses like measles has underscored the dangerous weakness of the vaccination programs in countries like Brazil. When measles swept in from Venezuela, almost one-third of Amazonas state’s 4 million inhabitants were unvaccinated.
Officials have scrambled to respond. The government set up a situation room in Manaus, with dozens of maps on the wall, and tracked the disease as it invaded the city. Doctors unfamiliar with measles underwent urgent training. Health authorities went to universities and medical schools, recruiting more than 1,000 trainees who were taught how to give vaccinations. A door-to-door operation began — from moss-covered colonial buildings and teeming slums to jungle settlements reachable only by days-long trips in canoes.
Yet the mobilization failed to prevent a major outbreak — by late summer, medical personnel were receiving 900 suspected measles victims a week. Overwhelmed, health workers moved from sending patients to hospital isolation wards to recommending home containment for all but the worst cases. Emergency vaccination points were set up at schools and churches.
After the delivery of 1 million vaccinations, the number of suspected new cases is dropping — down to 170 a week.
Few in Manaus are angry at the Venezuela migrants, who generally have been met with sympathy here. Residents are, however, blaming the Venezuelan government.
“The epidemic is the result of a despotic, incompetent government in Venezuela,” said Virgilio, the Manaus mayor. “Their lack of attention to national health care has created these negative consequences, and we have to pay the price.”
Krygier reported from Caracas.