Accessing and communicating with populations and workers
Because of their remoteness, the villages were not often visited by outsiders and were accessible only by boat. No radio, television, or newspaper media exist, ruling out advertising educational campaigns through the mass media. Due to this difficulty of accessing local populations, villagers were visited by local health workers about once a month. Workers went to the villages a few weeks before the MDA campaign, and the upcoming campaign was mentioned. Attempts were sometimes made to send out dates of the MDA through the District Health Office (DHO), but these notices were often not distributed.
Local health workers however did not perform much health promotion, with most of this task handled by MSF. For example, some puskesmas (local health center) staff did not receive invitations for training since postal service is nonexistent in the villages of Asmat, though radio communication to the puskesmas was present at times. Messages were often conveyed word-of-mouth and depended on the next boat that arrived from Agat, the capital.
In the village of Yahoi in Fayit, there had been some deaths from snakebites the previous 2 years, and the villages asked for antivenom. Later, on the day of MDA, some villagers were agitated that MSF was treating filariasis in people who had no obvious signs of the disease, when they needed basic health care for diseases like malaria and diarrhea. The physician happened to be there to explain to the people that filariasis can be eradicated with these drugs, but means to eradicate malaria and diarrhea, for instance, have not been found yet.
MSF faced program difficulties in Sawa Erma, the subdistrict with the largest population. Rumors in the subdistrict included, "you drown if you take the drugs" and "someone died in Agat after taking the drugs." With the vastness of this subdistrict (Sawa Erma) and a little under 2 weeks allotted to it, we experienced a marked fall in drug administration compliance, averaging only 37% population coverage. Convincing the local population was difficult, as they had little trust in the MDA program. To try to remedy this, the village chief in Sawa took the drugs to demonstrate their safety (a practice often repeated throughout the campaign), but the people watching still would not register to take the drugs. Talking to reassure them was also not helpful. This difficulty was not encountered in other subdistricts.
In other subdistricts, for instance in Atsy and Pantai Kasuari, where there was insufficient health care, people came to us and requested health care. Some people narrated the number of infant deaths from diarrhea in the previous year, or the high number of asthma cases in a village. When we explained that we were just working on filariasis in collaboration with the DHO, it was hard to gain trust. The population, rightly, had concerns about other diseases that were life-threatening. In the face of health care difficulties such as these, just telling the needy villagers we would pass the word along, and that our task here was only MDA, may have sounded superficial. This has been the experience in other MDA campaigns as well .
The village headmen were often absent, so finding a person the villagers trusted, who would help convince them, was also a challenge. Villagers were sometimes absent from villages, lowering coverage. The reasons given were "they have gone to Agat" or "they are in the forest looking for food." Visits to bewaks (temporary river shelters) were not always fruitful since people were in the forest.
Population numbers were often unreliable. The numbers provided by the DHO were projections from the 2000 census when Asmat was still part of the district of Merauke. No newer numbers were available at the time of the intervention. These numbers were found to be inflated when one talked to village authorities and tallied numbers. For instance, in the village of Yomoth, our population figure was 647, the village head told us 502, and a village elder told us only about 300 people actually lived in the village. A total of 180 people were treated with the drugs. Drug coverage could not therefore be accurately determined.
One or two hours of health promotion, depending on village size, was not always sufficient to convince people of the importance of taking the drugs. Establishing trust took more time and effort than anticipated.
Mapping of bewaks
No maps were available indicating each village's bewaks, probably because they are temporary structures. But accessing people living in bewaks was crucial to the success of a campaign of this nature, which necessitates high coverage. Knowing the locations of bewaks was difficult, especially in the largest subdistrict of Sawa Erma. Information on bewaks was not available, nor attempted to be obtained, at the time of MDA planning. Exploration was not done in this subdistrict since mobile clinics had been conducted here, but the populations who came for mobile clinics had sought medical attention for other ailments.
The bewaks tended to be scattered and only villagers could take us to them, something not factored into the time frame of the campaign. In the time table for the campaign, one day was allotted for each village of a subdistrict. To return to base by 5:00 PM, a team may sometimes have to leave 2 hours beforehand, and that left no time to visit a large portion of the populations in bewaks. Also, bewaks were often inaccessible even when there was time to visit them for drug distribution.