Is A Human Pandemic Next?

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Before he slipped into unconsciousness, six-year-old Kaptan Boonmanuj told his mother, "Mum, my chest feels like it's going to explode." On Jan. 26, after two weeks in a coma, Kaptan died in Bangkok's Siriraj Hospital, becoming Thailand's first victim of avian flu. His parents returned home to the hamlet of Ben Ya Pad, deep in the country's rural western province of Kanchanaburi. Two days had passed since their son's death, and rice farmer Chamnan Boonmanuj and his wife Chongrak sat receiving friends and relatives, the smell of burning incense heavy in the front room of their concrete house. Behind them, Kaptan's body lay in a white coffin. Propped against it was his bicycle, along with a picture of Kaptan wearing his school uniform. Outside, a row of ornate wreaths was placed beside the wall of the house. One was from the Ministry of Public Health.

The gesture brought little consolation to Kaptan's parents. Though Kaptan had been hospitalized since Jan. 9, ministry officials only confirmed on Jan. 23 that Kaptan was suffering from avian flu—the same day the government finally reversed weeks of denials and admitted that the disease that had raced through Asia's chicken populations was also present in Thailand. Chamnan and Chongrak believe their son's death was the direct result of the authorities' deceit. "The government is to blame," says Kaptan's father, who describes how his son liked to spend hours each day at his uncle's nearby fighting-cock farm. "If we'd been told earlier about the bird flu, we wouldn't have let our son go near the birds."

There are still many mysteries about the eruption of bird flu that has swept across Asia in recent weeks—where and when the epidemic originated, how it spread so swiftly to so many countries. But one fact is undisputed: this is not a fight that Asia can afford to lose. The economic and social fallout will be bad enough, starting with the deaths of millions of chickens and the resulting loss of countless jobs and tens of millions of dollars in revenues. But a far more dangerous threat exists: the possibility that this particularly deadly strain of the avian-flu virus—often described using a shorthand for its genetic makeup, H5N1—could mutate and mix with human-flu viruses, and suddenly start spreading as swiftly and devastatingly among people as it has among chickens.

So far, there has been no evidence of the disease being passed from one person to another. By the end of last week there were still just 10 confirmed human deaths from this outbreak, most of them children like Kaptan who spent time in close contact with chickens. Although scientists say it is impossible to predict the odds that the virus will alter its genetic form radically enough to start leaping from human to human, there is no argument that the longer H5N1 is out there killing chickens, the more opportunities the virus will have to mutate. "The real risk [of a lethal mutation] does exist," says Professor Paul K.S.

Chan, a microbiologist at the Chinese University of Hong Kong. "The concern is that we don't know how much time it will take for the virus to gain the ability to transmit from human to human." The task at hand is clear and could hardly be more urgent, says Chan: "We have to destroy the source of the infection."

How to do that is no great mystery, especially in Hong Kong, where in 1997 bird flu first demonstrated an unprecedented ability to infect humans. On the advice of influenza specialists from around the globe, the government ordered all 1.4 million of the territory's chickens and ducks to be slaughtered. Although 18 Hong Kongers were infected, of whom six died, the swift culling headed off a potentially much greater disaster. "We believe we averted an incipient pandemic," says Kennedy Shortridge, the flu specialist who was at the core of the 1997 effort to prevent h5n1 jumping into the human population. "We need to eliminate the virus again. But this time it could take years."

The sheer geographical scale of the current outbreak is, of course, one critical reason why eradicating it this time will be so much harder than in 1997. Already, there have been confirmed flare-ups of bird flu in 10 Asian countries and territories: mainland China, Japan, South Korea, Taiwan, Thailand, Vietnam, Indonesia, Cambodia, Laos and Pakistan. Many scientists believe that migratory wildfowl, which can carry numerous viruses without being infected, were most likely to blame for the initial spreading of the disease. Then other factors—the transport of infected chickens across borders, both legally and illegally, as well as months of government inactivity despite mounting evidence of avian-flu outbreaks—came into play, combining to produce the current nightmare.

But geography is by no means the only enemy. There are other equally formidable forces arrayed against Asia's drive to avert a devastating pandemic: ignorance about the disease and its transmission, official stonewalling and reluctance to acknowledge mistakes, insufficient money and manpower to implement preventive measures, and simple incompetence. Taken together, says World Health Organization (WHO) director general Lee Jong-wook, they will make the task of crushing h5n1 "hard, costly work."

 

The Politics of Disease
If there was one clear lesson from last year's SARS outbreak, it was this: when it comes to fighting viciously contagious diseases, nothing is more important than decisive government intervention and unvarnished candor about the dangers at hand. Yet in their early handling of bird flu, governments across Asia have, with depressing frequency, displayed a dangerous tendency to resort to denial and secrecy.

No country, perhaps, has handled the current crisis more ineptly than Indonesia—and the results have been devastating, as Indonesian farmer Ah Tong can attest. As early as mid-October, says Ah Tong, his chickens began to die in tens every day. At first he wasn't too alarmed. After all, officials insisted that the birds were merely suffering from Newcastle disease, a viral infection that's deadly to chickens but which poses no threat to humans. So Ah Tong's vet treated his 180,000 chickens with a vaccine for Newcastle disease. But it didn't seem to work, however, and by late November, about 100 chickens were dying each day. The vet then sent a blood sample from a dead chicken to the veterinary research bureau of the Bogor Institute of Agriculture, near Jakarta. "They found it was not Newcastle disease that killed my chickens, but AI—avian influenza," says Ah Tong. "But the government still insisted it was Newcastle disease."

In the end, Ah Tong lost about 150,000 of his chickens in one gruesome month. "About 90% of the chickens in all farms around here were hit at the time," he says, making a total of about 3 million chickens in just his area. "It feels funny now, watching the officials on TV telling you to be cautious of AI, when all you have are empty chicken pens. Where were they when we were battling the disease, when our chickens were dying by the thousands?"

Marthen Malole, who heads the virology laboratory of the Bogor Institute of Agriculture's faculty of animal husbandry, says he suspected an outbreak of avian flu as early as August 2003. "I told the Agriculture Ministry people in October, but they were very angry at me. I don't know why. I just wanted them to take immediate action." Indonesian officials finally admitted on Jan. 25 that the country was in the grip of a major outbreak of bird flu. Even then, however, Agriculture Minister Budi Tri Akoso said the government would leave it up to farmers whether or not to cull chickens in infected areas, citing the high expense. After heavy pressure from the WHO, Jakarta finally reversed its stance and on Jan. 29 President Megawati Sukarnoputri promised to begin a comprehensive cull. Again, though, there were damaging displays of official indecision. Tata Trisatyaputri, Indonesia's director for the development of animal husbandry, told the press on Jan. 30 that there would be cullings only in areas with new infections: "In other regions we will do vaccinations. A mass cull will cause restlessness among the people, and the people are already restless."

In Thailand, it wasn't just the bureaucrats who were reluctant to face reality. Politicians also publicly vilified would-be whistle-blowers. Senator Malinee Sukavejworakit, a medical doctor who represents one of the worst-affected provinces, had been concerned about the large numbers of chickens dying as far back as November. Despite her growing suspicions, she initially accepted government assurances that the situation was under control, and that the deaths were due to chicken cholera or a diarrhea epidemic. Then she received a phone call on Jan. 17 from a doctor friend in her province asking her to visit a patient of his. "He suspected it was a case of bird flu," she says. "He had sent a specimen to the Public Health Department for testing but hadn't heard back. He felt that if he pushed it with the government he would be told to stay quiet. So he told me." When Malinee went to see the patient, a 49-year-old butcher, he displayed classic symptoms of h5n1 infection: weight loss, rapid pulse, high temperature, and muscle pain. "He told me he'd been butchering chickens on a farm and he'd come across a whole lot of birds with insides like he'd never seen," she says. "They smelled rancid."

Malinee then went to visit the farm and the farmer told her "whatever this is, it isn't cholera." She convened a meeting of the Senate Committee on Public Health, for which she is chief adviser, and revealed her findings. The same day she held a press conference, asking the government to release the results of tests on the hospitalized butcher and to explain what was killing chickens in such terrifying numbers. For Malinee's efforts, Deputy Agriculture Minister Newin Chidchob accused her of being "irresponsible to the motherland" and endangering its economy. This attitude of aggressive denial went right to the top: a few days earlier, Prime Minister Thaksin Shinawatra dismissed the idea of a bird-flu epidemic as "fantasy and imagination," warning that such "exaggeration will damage the country's poultry exports and leave chicken farmers and workers in the field to suffer."

Those farmers are certainly suffering now. Bird flu has been detected in nearly half of Thailand's 76 provinces, and nearly 11 million birds have been culled across the country. In addition to young Kaptan, the disease is also confirmed to have killed another six-year-old boy. Twelve other people are suspected to have been infected, and seven of them have died.



 

The China Syndrome
No country is more important than China in the battle to control avian flu. With its vast population of chickens and ducks living in intimate proximity to each other and their human owners, southern China in particular has been the source of many of the major flu viruses to hit the world in the past 100 years. In China, any outbreak of flu has the ability to be amplified on a scale that dwarfs what is happening anywhere else in the region. Moreover, China's record of dealing with the SARS outbreak was profoundly mixed: after initially denying it had a problem, the central government executed a dramatic about-face, ordering bureaucrats to come clean on the number and location of cases and to cooperate fully with agencies such as the WHO.

This time around, China has shown alarming signs that it has somehow failed to learn the lessons of SARS. For weeks, while avian flu rampaged through much of Asia, Chinese officials insisted—to the disbelief of many experts—that the disease had not struck their country. During that time they made little effort to tell farmers what to do if their flocks began dying, and failed to offer timely information to U.N. organizations in Beijing that had requested briefings. The delays almost certainly cost local governments in the mainland valuable weeks in preparing to deal with the emergence of avian flu.

On Jan. 27 the central government acknowledged that the outbreak had reached China, and a more open approach seemed to take root. The state-controlled media announced that 14,000 birds had been culled in Longan county in the southern province of Guangxi. A day later President Hu Jintao took time out from his state visit to France to call on local governments to remain on "high alert." The Ministry of Agriculture demanded that all outbreaks be reported within 24 hours. And in an obvious nod to the SARS debacle, it added that "any cover-ups or false reports are strictly prohibited." It also called on local governments to lay plans for slaughtering infected flocks and vaccinating neighboring ones.

In Dingdang, a sleepy town in southern Guangxi, which abuts the duck farm that was the first officially acknowledged site of China's bird-flu infection, authorities appear to be taking the outbreak very seriously. When reporters from TIME visited the area last week, women in its main market were selling carefully arranged fresh vegetables; but in the covered section where the meat vendors work, there was neither live poultry nor a single piece of chicken or duck meat. "Ordinarily, this place would be packed with chickens and ducks," said a man searing the outside of a goat's head with a blowtorch, "but the government confiscated everything two days ago." Local residents said that officials dressed in full protective gear—disposable isolation suits, masks, gloves and goggles—went from house to house, taking away all of the poultry within a 3-km radius of the outbreak on a nearby duck farm. The officials sprayed disinfectant and distributed bottles of it to residents. They also compensated people for their lost fowl, paying up to $3 per bird.

Such efforts seem more necessary than ever, now that the disease appears to be spreading inexorably to other parts of the country. By late last week, officials had confirmed outbreaks in Hunan and Hubei provinces in central China. Suspected cases were also being reported across eastern China: Anhui and Guangdong provinces were potential hot spots, according to state media, as well as Kangqiao, a suburb of Shanghai. On Friday morning, a Kangqiao doctor surnamed Chen was summoned to an urgent meeting by town cadres. There, he was handed a disposable isolation suit and told that he and 100 or so other local residents were to round up all the poultry in the area. The official reason? A private duck farm in nearby Yiyuan village had 200 ducks that had succumbed to suspected bird flu the day before. But Kangqiao is a small, chatty place, and the rumor mill quickly hit high gear among the makeshift bird-collecting team; they traded gossip about a child from Yiyuan who might have been hospitalized for suspected bird flu. Another doctor at the local Zhoupu hospital said he had been told about the child's case, although he denied the child was checked into his hospital.

For their part, municipal authorities denied the existence of any suspected human cases in Shanghai, sending out a rare press release specifically rebutting charges of a cover-up and calling such allegations "sheer rumors." Their response was undercut by the lockdown mode hitting China's largest city. On Friday afternoon, local journalists were instructed by the Shanghai Publicity Bureau that they had to directly submit any stories about the potential bird-flu outbreak to government censors. A few hours later, police had blocked most major roads leading into Kangqiao, in part to stop journalists from entering. Meanwhile, Kangqiao's Dr. Chen still wasn't sure what was going on. By Saturday morning, he and the rest of the poultry team had collected tens of thousands of birds headed for slaughter. Rumors of a sick local child were still percolating, and now even the small road leading to his neighborhood had been blockaded by police.



 

Rural Roulette
Stern government intervention is clearly key. But even that isn't enough to guarantee the containment of bird flu. In Asia's countryside, almost everyone raises chickens or ducks, not just poultry farmers. Livestock is such a deeply entrenched part of rural life, and animals and humans live so closely together that the prospect of viruses spreading seems almost unavoidable. Reducing that risk requires a dramatic—and unlikely—shift in the way people live.

The busy main road between the Chinese city of Nanning, capital of Guangxi, and the town of Dingdang provides a vivid illustration of the problem. The road is lined with duck farms. They are primitive, unsanitary and crowded with birds splashing around in fetid ponds, waddling through garbage—and living practically on top of the farmers who raise them. In between the farms are groupings of low-rise buildings where people and their chickens cluster around small braziers to keep warm. In Dingdang, a 35-year-old woman surnamed Luo is belatedly realizing that what were once commonplace practices may now be unacceptably dangerous. "We're all very concerned here," says Luo. "The poultry farms in the area are very unclean. If you'd come more than two days ago, before they killed all the birds, you'd have seen that the waste from the poultry farms runs into the stream where lots of people in town wash their vegetables and do their laundry."

Anton Rhychener, who represents the U.N.'s Food and Agriculture Organization (FAO) in Vietnam, believes that rural animal husbandry practices are at the heart of the bird-flu crisis, especially in Southeast Asia. "This was an accident waiting to happen," says Rhychener. "It's very, very difficult to control everything because there are so many family smallholdings. The region is going to have to dramatically change."

For Manop Chaomeungkrung, the problem is no longer changing how he farms but having nothing left to farm. The 38-year-old Thai stands grim-faced in the shade of a shed, watching as 15 government officials dressed in masks, shower caps, rubber gloves and boots pull his chickens from their cages and stuff them into sacks for slaughter. It takes the team just six hours to destroy what Manop has spent nine years building. "When I bought this farm, there were 1,000 birds," he says. "Yesterday I had 9,000. Today I have nothing." Manop will receive the standard compensation offered to poultry farmers by Thaksin's government, about $1 per bird. Theoretically, that's enough to allow farmers to restock. But with little income between now and whenever the quarantine is lifted, Manop expects to spend most of the compensation money simply just to support his wife and three children. Still, he says, "Maybe things will get better."

Others may be less sanguine as they watch their livelihoods destroyed by cullings. "Compensation will be one of the key factors that will determine whether or not we stamp out these outbreaks,"

Hans Wagner, the FAO representative for Thailand, told reporters last week. "If the level of compensation is insufficient, then farmers will not carry out the culls. They may even resort to clandestinely selling the infected animals." On a duck farm on the outskirts of Nanning in China, farmer Li, 40, says he would not go to the local authorities if his birds fell ill. "Absolutely not. I'd give my ducks shots and get medicine for them. I'd nurse them back to health. The thing I'm most afraid of is that the government will come and take away my ducks."

In Ben Ya Pad, the Thai village shaken by young Kaptan's death, it's proving equally hard to change old habits. In the days after he died, Agriculture Ministry officials fanned out through the village, collecting all the chickens they could find for slaughter. But many of the birds were roosting high in the village's numerous fruit trees, residents say, and soon after the officials left, they could once again be seen strutting through the village. One hopped into a pigsty next to Kaptan's house and was scratching in the mire—a particularly alarming sight given that pigs are notorious for their ability to act as mixing vessels, carrying avian and human viruses at the same time and enabling them to exchange genetic material. The return of the birds didn't seem to disturb the villagers, even though they might be harbingers of more disease and suffering. With so many lessons unlearned, it is hard not to wonder if Kaptan died utterly and agonizingly in vain.