© Bruno Abarca | 2013 | A nurse vaccinates a boy in Muquinda Health Centre, Bie (Angola). The civil war in Angola finished only 10 years ago. It lasted 25 and left the entire province with almost no health services. Recently, they began to build new centres, restoring health services, that will help to reach appropriate vaccination coverages.

Where health begins

A photographic essay about the challenges of vaccination in rural areas around the world.

© Bruno Abarca | 2012 | A group of women wait ouside the Kanjungo Clinic in Kamacupa, Bie (Angola). Women usually take care of the health of their children. To take one of them to the health centre, the older sons and daughters must stay in charge of the rest, so that their mothers can take one day off from labouring in the field and walk to the health centres.

© Bruno Abarca | 2012 | Community health workers draw the map of their community in a participatory appraisal in Katabola, Bie (Angola). The role of community health workers and activists is key to identify families with children under five non vaccinated, map the houses of the zone, and become a link with the health staff in the clinics.

© Bruno Abarca | 2012 | Community health worker and volunteer vaccinator in Kamacupa, Bie (Angola). Community health workers also help in conducting surveys, to assess the level of knowledge and understand the beliefs and practices of their neighbours. That will help to define key messages in awareness campaigns.

© Bruno Abarca | 2013 | Nurses and supervisors in Umpulo health post, Kamacupa (Angola). Continuous and in-service training, as well as supervisions, are key elements of the monitoring of health programs. Supervisors also provide technical support to the staff responsible of vaccination in every clinic. Those nurses must guarantee the cold chain of vaccines in a rural area with no electricity in small refrigerated containers, and monitor twice a day the temperature of the vaccines, to ensure they are well kept and safe. If the temperature is not adequate, they could lose their effect.

© Bruno Abarca | 2013 | A cuban doctor from a medical brigade conducts a home visit to study a suspected case of polio in Kamacupa, Bie (Angola). Active epidemiological surveillance is essential after vaccination. In this case, a community health worker raised the alert as soon as she saw that the kid had paralysis in her legs. A team from the district health office went to visit the family and ascertain whether it was a case of post-vaccination polio.

© Bruno Abarca | 2010 | Rural community in Zapallo Grande, Esmeraldas Province (Ecuador). Ángel Añapa, nurse, makes a monthly planning to visit every village in Zapallo Grande to vaccinate their boys and girls. This region, where chachi indigenous and afro-ecuatorian communities cohabit disperse in the rainforest, has no paths or roads. To conduct the vaccination activities, a small team from the clinic uses a canoe along the chapalaa rivers, what usually takes a few hours. After visiting three or four communities, the neighbours will offer a small space in one of the houses, so that the vaccination team can stay overnight before continuing the following day.

© Bruno Abarca | 2010 | Chapalaa river, Esmeraldas province (Ecuador). Some families live outside the villages, near the rivers. The nurse must know the exact place where every family lives, to visit all of them, without exception.

© Bruno Abarca | 2011 | A group of miskito indigenous girls stay outside a house where the Laka Tabila health clinic team talk to everyone in the village, in La Moskitia (Honduras). Nurse staff plans periodic visits to every indigenous community to vaccinate of all children.

© Bruno Abarca | 2011 | A nurse prepares the vaccines in a rural community in Laka Tabila, La Moskitia (Honduras). The nurse chief has a motor for the boat, that they can use if they receive gas from the health district office. If they do not receive any on time, they must walk, sometimes as much as six hours (and another six hours back).

© Bruno Abarca | 2011 | Laka Tabila, in La Moskitia(Honduras). Vaccination is integrated in the basic community health package. Once the nurses arrive to the village, they meet with men, women and children in the school or some other place; they talk about health related issues, they laugh together to gain trust, and offer vaccines for the children according to their previous registries, chlorine solution for the mothers (so that they can drink clean water), medicines to treat and prevent diarrhoea and condoms.

© Bruno Abarca | 2011 | Laka Tabila, in La Mosquitia (Honduras). Health care provision in rural regions like this one needs a Primary Health Care approach able to reach the people outside the clinics, and that integrates vaccination as an additional element of the basic package. Population is more receptive to this visits and agrees to vaccinate their kids when they also receive health advice and preventive products during the visit.

© Bruno Abarca | 2010 | Prevention of Mother to Child Transmision of HIV/AIDS clinic in Butha-Buthe, Lesotho. Health provision continuity between reproductive health programs and child health programs is not easy if the health system is not strong enough. Pregnant women also must vaccinate against tetanus, and post-partum follow-up visits are usually a very important opportunity to help identify and later vaccinate babies.

© Bruno Abarca | 2014 | Vaccination day in Buccra clinic, Laayoune Sahrawui Refugee Camp in Tindouf (Algeria). In the Algeria Sahrawi Refugee Camps, the health system does not have enough resources to pay salaries to the health staff, that work as volunteers for a small incentive they receive three or four times every year. Those volunteers conduct the child health consultations, vaccination campaigns, data registry and monitoring of the vaccination coverages in all the camps.

© Bruno Abarca | 2014 | Vaccination day in Buccra clinic, Laayoune Sahrawui Refugee Camp in Tindouf (Algeria). Vaccinators, women usually trained in the nursing school at the camps, work together with community health workers in every daira. These women are responsible of telling all women in their neighbourhoods to bring their boys and girls to the clinic. The sahrawi health Sistem has small clinics in every daira, but it is still a challenge to guarantee a good vaccination coverage in a desert environment where temperatures go over 50ºC during some months, and where there is an absolute dependence of international aid. The refugee population receives through UNHCR, UNICEF, ECHO, AECID, as well as some NGOs and associations such as Doctors of the World Spain food, shelter, medicines and vaccines.

© Bruno Abarca | 2014 | Vaccination day in Buccra clinic, Laayoune Sahrawui Refugee Camp in Tindouf (Algeria). In the camps, and along the last few years, international aid has notably decreased. Hidden behind the excuse of the economic crisis, many donors have reduced their contributions for the basic services of the refugees.

© Bruno Abarca | 2012 | A nurse vaccinates a child in the Nangoma Mission Hospital (Zambia). In many countries, health services are sustained through vertical aid financing programs, that focus on specific diseases such as malaria, HIV/AIDS or Tuberculosis. However, vaccination programs, to be effective, also require a horizontal approach to reinforce the health system as a whole.

© Bruno Abarca | 2012 | A newborn in the Nangoma Mission Hospital (Zambia). Integral support to health systems allow that a mother that received proper care during pregnancy can also give birth accompanied by skilled birth attendants, in a fully working centre. Soon, her child will begin receiving the vaccines he need in the following months.

Originally published at El País Planeta Futuro & brunoat.com.