Understanding Avian Influenza
Poverty and Superstition Hinder Drive to Block Bird Flu at Source
By KEITH BRADSHER
Published: November 3, 2005, The New York Times
PREY ROGNIENG, Cambodia - When the half-starved chickens started dying this summer and the barefoot children developed fevers here in this village of thatched huts and emerald rice fields, residents were terrified and deeply divided about the cause of their misfortune.
Some blamed bird flu and took their weakened children to a clinic in a nearby provincial city, where a medic diagnosed human influenza instead. But other residents said it was witchcraft by the only village resident not born here, 53-year-old Som Sorn, who moved here eight years ago when she married an elderly local farmer.
When Mrs. Som Sorn's husband went into the jungle to cut wood one afternoon and she began cooking rice over a fire on the dirt floor of her hut, a local man with a machete took action and later collected $30 in donations from grateful neighbors, a month's wages.
"The assassin grabbed her hair, pulled her head back and cut her throat," said Ya Pheorng, the village leader. "Her neck was almost completely severed."
The sorcery allegation and grisly killing underline what United Nations and American officials describe as the difficulty of preventing a global human epidemic of bird flu: the disease is most prevalent among poultry and wild birds in impoverished rural areas of Southeast Asia with low levels of literacy, high levels of superstition and very little health care.
If the disease does make the jump from transmission by birds to person-to-person transmission, the crucial question will be whether the first few cases can be isolated quickly. If not, frightened people nearby could start fleeing, carrying the disease to big cities and then around the world by jet. In a telephone interview at the end of a recent weeklong trip to Southeast Asia, Michael O. Leavitt, the secretary of health and human services, compared the early stages of a flu pandemic to the beginnings of a forest fire.
"If one happens to be at the source of the spark, it's simple to put it out with your foot," he said. "The question is, will we be there?"
Only four countries, all in Southeast Asia, have had laboratory-confirmed human cases of bird flu so far: Cambodia, Indonesia, Thailand and Vietnam. Cambodia is the poorest, with the most rudimentary health system outside urban areas.
Cambodia's difficulties and small successes in fighting bird flu are indicative of the struggle that lies ahead. Scientists predict the struggle could last for many years and may have to be fought in other poor areas as well, notably in India and Bangladesh and East Africa. But United Nations officials say the disease will probably remain most prevalent and most dangerous here in Southeast Asia, where chickens wander freely in and out of homes and even apartment buildings, mixing constantly and intimately with people to an extent not found in most other countries.
In two decades of turmoil beginning in the 1970's, most of Cambodia's doctors died in the Khmer Rouge's killing fields or fled the country. Many of the country's current generation of health care professionals can scarcely read or write and received rudimentary medical training in Vietnamese, a language they barely speak, during the Vietnamese occupation in the 1980's.
Since the first chickens began dying of bird flu in Cambodia in January 2004, the country has made some progress, with modest foreign assistance, in controlling the disease in poultry and keeping people healthy. Yet formidable gaps linger in the country's defenses.
Those gaps highlight the continued mismatch between limited efforts to slow the spread of bird flu among poultry in developing countries and increasingly large efforts by industrialized countries to prepare for a possible human outbreak. The United States and other industrialized countries are spending billions of dollars to stockpile antiviral medicines and other gear for treating people who may become infected. But the United Nations' Food and Agriculture Organization has been able to collect only $30 million from industrialized nations since February for a campaign to delay or prevent an epidemic, a little over one-sixth of the $175 million and rising that the F.A.O. says is needed.
In Phnom Penh, Cambodia's capital, American and German foreign aid has just helped supply the latest Western equipment to a virology lab at the Cambodian government's animal health department. But the virus samples are taken for testing from chicken carcasses brought in from all over the country to a moldering building next door. Researchers cut apart the carcasses in a room with no air-conditioning and a fan that blows air out the windows and across an alley. A crowded elementary school with no glass in its windows is just 10 yards away.
"They need to completely seal this area," said Dr. Lu Huaguang, a Pennsylvania State University avian virologist temporarily working in Phnom Penh to help set up the virology lab.
At the Food and Agriculture Organization's office a few blocks away, Tsukasa Kimoto, the chief representative, talks proudly of an innovative program to train the country's 6,000 village animal health workers to identify bird flu and report it immediately. But only 500 of these workers have been trained so far, he acknowledged, and the virus may be back soon, as it appears to be most active here from December through March.
Most of the poultry in Cambodia roams so freely that if one bird is found sick, it is practically impossible to catch and kill nearby birds to curb the spread of the disease, Mr. Kimoto said.
"Chasing those chickens one after another is a rather tedious thing - we don't have the people," he said.
At Cambodia's Health Ministry nearby, Dr. Chea Chhay, the under secretary charged with leading his country's fight against avian influenza, proudly described how teams of researchers were ready to drive on an hour's notice to regions reporting bird deaths. But many villages lack phones, to say nothing of doctors, and it may take a day or two during the rainy season for anyone from a remote village even to reach a phone.
[President Bush asked Congress on Nov. 1 to approve $7.1 billion for bird-flu prevention and treatment, including $251 million for early detection overseas.]
Drive just 35 miles west from Phnom Penh to this small village and the logistical challenge of confronting bird flu is even more apparent. The government built a small concrete-walled clinic eight years ago in an adjacent village, but electrical lines were never extended from the nearest town and no generator was installed so the clinic's lights have never worked.
The clinic's director, Pol Wana, was about to complete junior high school when the Khmer Rouge took over in 1975 and shut all schools. He never returned to school, but leads a staff of 10 in diagnosing ailments and prescribing and distributing medicine.
The government asked him to look out for bird flu, he said, but has not given him a clear list of symptoms.
Mai Morm, a 76-year-old farmer, stopped by the clinic late one morning to pick up medicine for a chronic cough. He said if any of his chickens fell sick, he would not tell anyone for fear the government might arrange for the rest to be slaughtered without compensation. "If they were very sick before they died then I might throw them in the brush," he said. "But if they were only a little sick, I'd probably eat them."
The killing of Mrs. Som Sorn was first reported by the small Cambodia Daily in an article about sorcery. The killer had not expected anyone to identify him to the police, and was surprised to be arrested and sentenced to 15 to 20 years in prison, Mr. Ya Pheorng said. Neighbors who paid her killer were not prosecuted after making further payments to the police, the village leader added.
Besa Korn, a 51-year-old village resident who was not among those making donations to the killer, said the true cause of the summer illnesses might never be known. But life has clearly improved since Mrs. Som Sorn's death, she added.
"Everyone in the village has been very happy since then," she said. "And we have had no more illness."
Understanding Avian Influenza