Measles Vaccine Mix-Up Kills Dozens of Syrian Children
An accidental mix-up of measles vaccine and a common muscle relaxer killed at least 15 Syrian children, and possibly many more.
Yet another tragedy has been reported this week, adding to the biblical sorrows already endured by the people of Syria. At least 15 children, and perhaps many more, have died after receiving an injection thought to be the measles vaccine.
A preliminary investigation has suggested that somehow, though providers had intended to vaccinate the children against measles, they instead gave them a potent muscle relaxant called atracurium sulfate. This drug paralyzed the muscles of the infants—who ranged in age from 18 months to six years—including the muscles that control breathing, resulting in a horrible death by asphyxiation.
The investigation is still ongoing and may take several twists and turns as evidence and rumor fight for space. As soon as the government announced the sad story, for example, conspiracy theorists jumped into the fray. How could a mistake like that be made? Surely it was intentional and perpetrated by Assad or ISIS or a still-unrecognized radical group. Or maybe even the U.S.
Indeed, any tragedy brings together disparate groups, united in their claim that they know “who dun it,” never mind that each suspects a different person, or more likely, has fingered each other as the one holding the smoking gun. Surely little Assad or ISIS has done recently makes it inconceivable that deliberate murder of infants might be something they would consider. That said, a more common and likely explanation of these deaths is this: Someone fucked up. Big time.
According to the preliminary report, the packaging for the measles vaccine and the injectable paralytic look more or less the same. And atracurium is a common drug—in fact, it is one of the U.N.’s essential medications [PDF], and therefore likely to be in the same medicine cabinet as the vaccines. So a plausible scenario is that a busy, distracted, worried, well-intentioned, local health care worker reached for something familiar-looking, went about his business preparing the injections, and didn’t take the extra moment to double check that everything was as it seemed.
Though the catastrophe occurred in war-torn Syria, a place strapped for resources, this sort of mistake—a non pre-meditated “honest” mistake—also occurs here in the U.S., Western Europe, and everywhere each and every day. The famous U.S. Institute of Medicine (IOM) report entitled “To Err is Human,” published in 2000, signaled the start of the “safety movement” in health care with each facility admitting, finally, that unthinkable screw-ups happen, sometimes with catastrophic consequences. Per the IOM white paper, about 100,000 people a year die because of medical mistakes.
Oddly, this sort of explanation of why bad things happen to good people, a collective admission on the part of doctors coast to coast that took decades of progressive swallowing of pride and dropping of hubris to accomplish, is unlikely to satisfy those looking for a plot or a motive or something more sinister than simply humans being humans. The stakes surely are high in a war-riddled country; a hint of government or insurgent involvement in something as brutal as the murder of infants would supply one group with the moral upper hand against another, as well as provide a rallying point going forward.
In this regard, it remains to be seen whether the omnipresent and relentless Western anti-vaccination group will seize the issue and try to make hay. It seems to me to be too unsavory a step but time will tell. But surely, the deaths in Syria are directly related to vaccination and so might appear to prove their point, sort of, about vaccination safety.
Actually though, the tragedy reveals the very opposite about vaccines. First, even war-strapped regions recognize the need for this critical medical intervention. Even countries with extremely limited resources still choose to prioritize the health of children above everything else. Second, the round of measles vaccines that the Syrians were conducting was the second go-around—it takes two doses of measles vaccine to protect children. The first round went without a hitch, as do millions of vaccinations given each year worldwide.
So the tragic story about vaccine-associated deaths is, in fact, a story about the remarkable safety of vaccination, as well as the critical importance vaccination plays in the health of people worldwide. The local heartbreak around the Syrian disaster is this: Even as Syria fights to vaccinate its children against all odds of danger, resource constraint, and all the rest, we here in America, 6,000 miles away from war, are spending our time fighting to prevent our children from receiving the exact same life-saving vaccines.