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Matthew Coldiron: Where the road ends—treating yaws in the Republic of Congo

We’re in Kpeta, a village of nearly 400 Aka pygmies in the Department of the Likouala in the northern Republic of Congo. Our team has driven five hours from the nearest functioning hospital, paddled an hour in a leaky pirogue to cross a river, trudged through a swamp in knee deep mud for half an hour, and then walked another six kilometres through the dense tropical forest to arrive in the village.

Over the course of our 24 hour stay, we see clinically active yaws in nearly 10% of the children under 15 in the village, which doesn’t include those children with the latent forms of the disease. The old saying, “where the road ends, yaws begins,” has certainly held true here.

After seeing almost 100 cases of yaws in 2011 among the Aka in its mobile clinics in the remote areas of the jungle, MSF decided to undertake a yaws elimination campaign in the area. Historically, yaws control was based on treating active cases with injectable benzathine penicillin, but this is painful, does nothing for latent cases, and is logistically difficult to do in places like Kpeta.

We were the first to carry out a new WHO yaws eradication strategy: universal treatment of affected communities—treating everyone, with or without symptoms of active yaws—with a single dose of oral azithromycin. This universal treatment with azithromycin is easy to administer (imagine taking an entire Z-pack at once) and well tolerated.

Yaws eradication almost happened once before, in the 1950s and 1960s, when 300 million cases around the world received injectable penicillin. This massive effort came close, but was so successful that yaws fell off everyone’s radar screens—it now persists in isolated pockets, like amongst the Aka of Congo.

Its symptoms include disfiguring ulcers, papillomata, and painful periosteitis and arthritis in children, who represent 70% of active cases. These primary and secondary forms last several months but are self limited: the lesions disappear, but the infection remains in a latent phase. Untreated, up to 10% of infected persons will develop tertiary forms in the decades to come, characterised by disabling deformations of the bones and cartilage.

The new strategy is exciting, and quite easy to implement from a purely medical point of view. On the other hand, out in the jungle, we learned that it’s everything else that becomes tricky.

For starters, teaching hundreds of villagers who had never seen pills to swallow five or six capsules in one go led to more than a few comic moments. Some people got frustrated, others laughed it off, and quite a few ended up rather wet after unsuccessful attempts to get the pill to go down. Like anywhere else I travel, I made a point to learn basic greetings and how to say thank you in the local language, but I’m also now able to say essential phrases like “Don’t chew the pills!”

Our biggest challenges were logistical in nature. We walked to Kpeta in a torrential downpour, pitched our tents in the mud, scrounged around for what food the villagers were willing to sell us, and were in bed, soaked to the bone, by 8 pm. On its own, a tough day. But this was just one day out of 13 in a row we spent in the jungle, with the same routine every day—up and out of the tents at sunrise, working until sundown. We usually ate local delicacies for the evening meal—gazelle, porcupine, caterpillars, or crocodile—all (sometimes uncomfortably) fresh from our doorstep. We quickly got used to drinking the urine coloured river water stained dark yellow by decomposing organic material on the forest floor. The frequent heavy rains and constant humidity meant that nothing ever dried. Bathing was, well, infrequent.

On the other hand, the hardships were softened by the reception we often received: living in isolation, the Aka don’t have many visitors. We were warmly greeted and saw ecstatic dancing. Our hosts were happy to guide us along the forest paths and to share the bounty of their forest with us. One night, a village chief came to our campsite with a bowlful of honey, the Aka’s greatest delicacy—freshly scavenged, dark and smoky, like no honey I’ve ever eaten. (Not the least because we had to remove all of the dead bees—which can still sting—before chewing the waxy comb!)

As the leader of an eight person team, and its only doctor, there were also nightly rituals—taking malaria prophylaxis as a group, patching up the inevitable boo-boos and blisters, and administering paracetamol and ibuprofen for all the aches and pains!  I came back with more than a few ant bites, and even a chique—an insect which had burrowed itself into my right foot, where it laid its eggs…

But despite my aches and pains, and my preoccupations with my own team’s health, nothing could compare to the precarious situation of our Aka hosts. Marginalised by their Bantu neighbours for generations, at times living in forced servitude, this nomadic group of hunter/gatherers is extremely vulnerable. Things are slowly getting better, but their access to medical care and education is nearly non existent. In addition to the universal treatment for yaws, we came ready to treat other conditions like malaria, diarrhoea, and pneumonia. But every day, we saw adults suffering from advanced leprosy. Children are routinely crippled because of extreme chique infestations on their feet. My single chique was eventually removed with a sterile scalpel at the hospital, but many Aka children have tens (hundreds?) of them in each foot, infected after unsterile attempts at extraction and a lifetime of walking barefoot in the forest.

All of the MSF teams worked hard and had once in a lifetime experiences, and we made a great start at eliminating yaws in northern Congo. But this was the tip of the iceberg for yaws eradication. Whether in central Africa or the Pacific islands, the majority of the remaining 500 000 cases of active yaws live in equally isolated and challenging environments. To be successful, we’ll truly have to go where the road ends.

Matthew Coldiron is a medical doctor working with MSF in Paris and in the field.

Photo credit: Benoit Finck