31 Aug 2015
‘We could, we should and we will nail rabies’

Education is a key part of the projects. Image: Richard Murgatroyd/Dogs Trust.

We stood in front of the staff toilets. Shadows lay heavy in the tiny space. Rachel, a specialist infectious disease consultant, pointed to the floor. I stared down at the patch of worn concrete.
It was here she had found the girl thrashing and frothing, her mother crowding the cramped confines of the corridor; distraught and desperate for someone to help her daughter.
I strained to hear Rachel describe the scene, as the entrance to the hospital ward lay just to our right and it teemed with people. There was a constant bustle around us – bodies everywhere. Rachel explained guardians sleep under the beds of the patients, responsible for feeding, bathing and changing the sheets of their family members. It was always heaving with people. There was no privacy, anywhere, for anything. With no room in the ward, the girl had been deposited where we stood, on a paper-thin mattress, her guardian by her side.
“What did you do?” I asked, humbled by the scene.

“It was heart-breaking, Luke. I knew it was rabies as soon as I saw her – the girl was dying. I gave the mother some gloves, some diazepam ampoules and showed her how to break them and insert the contents up her daughter’s rectum, and then she was taken home to die.”
Her voice cracked. I felt my throat thicken. We stood there, almost frozen to the spot as Rachel recalled the event, both of us staring fixedly at the tiny cramped space in front of the toilet.
“You see, it’s all we had and if patients die in hospital, it costs families huge amounts of money to transport their bodies home. They really struggle to afford it. We try to help them to get back before they die – it is the least we can do.”
I looked down at Rachel. I was well over a foot taller than her, probably 10 stone heavier, but I marvelled at her colossal strength and wondered how she could work here, put herself through this and not be totally broken after the first hour.
Rachel continued: “It was really sad because her mother had been sharing feeding utensils and caring for her very intimately – and we had no post-exposure vaccine, no way of following up on her or anyone else who had been exposed to the virus. It’s why I set up the Blantyre rabies focus group.”
She tailed off, her eyes momentarily distant. I turned to look into the ward. The intensive care unit (ICU) was partially partitioned off with some plywood. It had six beds for the critically ill.
“If you don’t have a guardian, you have very little chance of surviving,” Rachel continued, explaining how the hospital functioned. “The ICU patients have more frequent ward checks by the nurses and doctors, but the mortality rate is very, very high. Come on – do you want to see where the rabid children are taken? The paediatric ward is just down the corridor.”
I couldn’t decide if I wanted to see this. I knew I should; I’d been mailing Rachel for the best part of a year, so surely I should stand shoulder to shoulder with her and see what she had been dealing with, but I also knew I just wasn’t as tough as her; not by a long way. I steeled myself to follow. It felt like I was wading through treacle.
“One of the problems is rabies presents a bit like malaria – and because the ward is so crowded, we sometimes have to double the children up in the cots – so children with rabies can be in the same cot as children with malaria until we realise. And because we have no vaccine – most of the staff aren’t even vaccinated – it’s very difficult.”

Standing outside the ICU of the paediatric ward will probably haunt me forever, and I was there for about five minutes – on a really good day. More than 60% of all human rabies cases are in children and the Queen Elizabeth Central Hospital in Blantyre, Malawi, annually records the highest incidence of child rabies deaths from any single institution in the whole of Africa.
As far as I can work out, the doctors and nurses who work in places like these are living saints. I’ve worked in refugee camps, I’ve visited some fairly desperate hospitals in fairly desperate places around the world – but nothing quite like this.
There is almost some excuse for horror in a refugee camp, you’re braced for it – but in a forgotten backwater in one of the world’s poorest countries, it seems so desperately bleak. A hopeless neglect pervades everything – from the buildings to the patients. The consultants, many from the UK, are among the most humbling and inspirational people I have met. There is the sense none of them will give up against almost desperate odds, in a place where life is seemingly cheap. How they protect themselves against the pressure of working in a hospital that serves several million people and regularly runs out of syringes and medicine is something that must require a very special mindset.
Frantically busy
I chatted to Neil Kennedy, dean of the hospital and head of the paediatric unit. He was frantically busy and I was conscious of taking even a single second of his time, but I had to meet one of the authors of The Lancet communication that had initiated this whole project.
“Funny the things you get involved with,” he chuckled, his Irish accent warm as he regarded the odd pairing of Rachel and myself sitting side by side in his spartan office. “We’d had a particularly bad day, we’d seen a three-year-old boy die of rabies in the ward, his last lucid words asking his mother why he couldn’t drink, and I said to the guys, we should just write this up. It was literally an email that got put into a short communication. I can’t believe you read that.”
I smiled. I couldn’t either. It was mere chance I had come across a few paragraphs on a random internet search trying to identify global rabies hotspots for the next project. Tackling rabies is the smallest drop in the ocean in a hospital bursting with patients dying of malaria, HIV and TB, not to mention the recent typhoid outbreak that had gripped the hospital, but at least it’s something we can help with.
“I’ve seen lots of children die and it’s always incredibly sad, but rabies is a particularly bad death. We can make them comfortable, but it’s frustrating because it’s so preventable.”
It’s also something that needs vets to sort. “One health” is the catchphrase of the past couple of years. It had taken 12 months of emails back and forth with Rachel, the Malawian Department of Animal Health and Livestock Development (DAHLD) and the local Botswana Society for the Prevention of Cruelty to Animals – but things had come together and thanks to Dogs Trust, WVS and MSD, the Mission Rabies charity had an army equipped and mobilised to take it on.
“It’s been quite a tough year actually, we had no power or water for two months after the floods. The hospital had a really bad time. Wonderful you are doing this though, great to see it all came to something. We’ll help you with human rabies data – it isn’t recorded for adults, but we have it for children – most months anyway. Do you think you’ll crack it?” Neil asked.
“More than 35,000 dogs in 20 days so far,” I replied. “Our baseline surveys estimated the population at about 40,000 so we’ve hit the target. It’s a good start.”
Outstanding success

Mission Rabies Malawi, to date, has been an outstanding project. It’s only the first month of a three-year plan, but once again the core team of Kate Shervell (international director), Andy Gibson (epidemiology manager), Ros Johnston (global education Manager), Fred Lohr (international liaison officer), Jordana Burdon Bailey (international project manager) and Dagmar Mayer (WVS international veterinary manager) have worked tirelessly for eight months to organise and plan all the various components to make this a flagship endeavour for the Mission Rabies charity.
It is the first opportunity for us to expand our ongoing projects in south-east Asia into Africa and, with a visit from two representatives from the World Health Organization over the past week to assess our competence with a view to, hopefully, official endorsement and partnership, the pressure was on.
Volunteers representing 12 nationalities, about half of whom have previously volunteered with Mission Rabies projects, have taken holidays, raised money and found sponsorship to drive the project – all this combined with a hundred local Malawians who had been recruited, and the dedication and passion of the whole team has been totally inspiring.
The project comprises four key components:
- canine rabies vaccination (70% of the city population)
- concurrent community education through school workshops
- humane population control through sterilisation
- active canine rabies surveillance – setting up a hotline, a rabies response team and supporting/training local government staff in how to take/collect samples safely.
One of the key aspects that has marked the programme is the science and utilisation of in-house-developed mobile technology to GPS-tag all the dogs vaccinated and collect the demographic data of the local dog population. The Mission Rabies app (free to download from Google Play or iTunes) has enabled the population estimates to be calculated with a high degree of accuracy, as well as logistically and strategically direct the teams through mapping areas to be targeted. The Mission Rabies Malawi project is ground-breaking in using modern technology in a field project of this scale.
The implementation strategy involved a three-month planning/mapping phase; followed by a two-day staff training workshop and practical training with the DAHLD staff who were key to running the project. This was combined with concurrent community sensitisation and awareness. Planned vaccination areas were targeted by teams a week before the drive, announcing the project with loudhailers, conducting school visits and leaflet drops. The thrust was to gain maximum community commitment and support within the country’s veterinary infrastructure to make the project as sustainable as possible as we build it up.

The actual teams comprised two vaccinators, two animal handlers, two data collectors and a driver. Eight teams were established – a mix of international and local staff who all got on brilliantly and the team spirit and morale throughout the project has been phenomenal. Dogs were vaccinated with the ultra-reliable MSD vaccine, and then marked with a non-toxic stock marker paint on the head and back. Each owner was then given a vaccine card with the batch number of the vaccine. Wristbands and leaflets were also distributed in the local language (30,000 over the month) as an army in Dogs Trust yellow descended on Blantyre.
One of the highlights was a Guinness Book of World Records attempt for the largest pet health awareness lesson. We’d all like to thank the thousands of children who came to learn about rabies and how to get on with dogs. The cynics might think it was because we hired a break-dancing crew to entertain them after we had finished the lesson – either way, they listened and we nailed the world record.
So what next? We can’t change everything and we can’t inject millions into places like the Queen Elizabeth Hospital in Blantyre no matter how much it tugs our heartstrings. But we can get behind people like Neil and Rachel, who, among all the other incredible things they do, also deal with the tragedy of rabies on a regular basis.
We can also support the poorest of the poor who are afflicted by this terrible virus, champion the populations of dogs that are often brutally poisoned or clubbed through fear of it and, under the guidance of the Malawian DAHLD, we can solve the rabies issue in Blantyre over the next three years.
We can then build on this project and push forward to other global hotspots in the world and, as a team, we can, without a shadow of a doubt, make a fundamental difference in our little corner and the rabies issue we have chosen to champion.
Mission Rabies Uganda starts in July, Namibia in September, India is ongoing and we are building up to running mega projects six months of every year. Now separate charities, WVS and Mission Rabies are working synergistically to support veterinary training and humane population control on one side with strategic mass vaccination and education campaigns on the other. It’s an amazing partnership and one that would never work without Dogs Trust, MSD, WSAVA, AFSCAN and all the other incredible key sponsors at the helm.
What we really need now is you. Sign up, join a team, be part of the crew – we could, we should and we will nail rabies.
Don’t miss the boat – it’s too much fun and and as far as holidays go, I guarantee you’ll just want to keep coming back for more.
