BUSHUJU, Democratic Republic of Congo -- In this mountaintop village near the hilly eastern border with Rwanda, the vaccination rates are as dismal as the sweeping views are breathtaking.
Measles: 28 percent. Diphtheria, tetanus, whooping cough: 22 percent. Tuberculosis: a mere 16 percent.
The nurse's assistant who is the sole health provider for Bushuju's 4,500 people listed some reasons for the low rates - besides the general postwar chaos and confusion: He was busy. He had trouble telling the drugs apart.
"I was afraid to give the vaccinations," Mugosa Lwendja admitted sheepishly. Heart-breaking words in a country where 20 percent of children die before age 5, most from treatable or preventable diseases.
The picture might soon brighten with help from a Carroll County nonprofit group called IMA World Health. The New Windsor-based association of 12 Protestant relief and development agencies has launched a three-year, $42 million effort financed by the United States to improve basic health care for 7 million people in war-racked eastern Congo.
Though nearly a half-century old, IMA in recent years has expanded its reach globally by gaining the confidence of the American government to take on health in Congo, one of the biggest and most troubled countries on the troubled continent.
IMA knows the terrain. In western Congo, it recently completed a $28 million project, also U.S.-funded, that scored notable successes, such as sharply higher child immunization rates and lower malaria incidence. It did so by boosting an existing if frayed medical infrastructure, relying mostly on local health workers and spending less per capita than many international aid groups.
Both the new program and the old share a key principle that is controversial in aid circles: Patients must pay something for their care. After all, Congo does not have free health care, and the national government has never provided much financial support for its 60 million people.
Charging fees has an up side, organizers of both programs say. Congolese people "have to have a sense of responsibility. If everything is given to you, you care less," said Dr. Leon Kintaudi, the Congolese medical director of the programs.
Critics say the fee-for-service approach is a flaw that will effectively deny health care to many poor people. "Our experience is that even an extremely small symbolic fee can be a barrier for the population," said Dr. Leslie Shanks, a physician working in Congo for Doctors Without Borders.
But Larry Sthreshley, IMA's leader of the new program and a veteran public health expert in Congo, says the argument for generalized free care is flawed. It might be vital in refugee situations or humanitarian disasters, he said, such as during the worst period of the 1998-2003 war in which 4 million Congolese died. But he said he believes Congo's fledgling postwar stability - rising employment, growing business investment - makes that approach wasteful, except for the poorest of the poor. "If I can cover 80 percent of the health needs for 100 percent of the population," he said, "that's a lot better than 100 percent coverage for 25 percent of the population."
One overcast morning, a blaze of colorful skirts and head scarves filled an expansive mud hut. Later, Christians would gather inside to pray. But now, two dozen mothers, their babies snugly strapped to their backs, come seeking a kind of earthly miracle: drugs to help keep their children healthy. It's vaccination day in the village of Nkonko-Tshiela.
This village lies 400 miles southwest of Bushuju. For five years, it was part of Sanru III, IMA's first Congo project and first major foray into on-the-ground development work, which began in 2001. Back then, this village's immunization rates were almost as low as Bushuju's. No longer. Nkonko-Tshiela's rate has eclipsed 97 percent. On this day, mothers looked on as their babies received injections or oral polio vaccine.
The vaccinations occur on a regular basis around this impoverished district. One mother, Claude Kulandi, 25, sold potato leaves at the market so she could afford shots for her 3-month-old son.
"I made a choice between the health of my child and the death of my child," she said bluntly.
"It's dramatic," Nancy Haninger said of the program's impact across this health zone, a community of 90,000 divided among urban areas and small villages.
When Haninger and her husband, Michael, arrived as Presbyterian medical missionaries in 2001, things were bleak. Although a dedicated nurse carried vaccines to outlying areas, often by foot, only about 30 percent of children got them. Drugs often spoiled in the heat.
Women usually gave birth on the dirt floors of huts, often with lethal consequences for them and their babies. Dirty drinking water sickened young and old alike. A paucity of medicine meant that malaria, the area's top killer, met scant resistance when it began bursting the red blood cells of its mosquito-bitten victims.