As Other Asian Nations Have Moved to Control Bird Flu, It Is Rapidly Spiraling in Indonesia
Date: 31.7.2006
The flu is ubiquitous in thousands of backyard flocks, and it appears to be killing more birds every month, increasing the likelihood of human cases. Forty-two people have in Indonesia died since the first human case was confirmed a year ago.
“It’s like trying to fix the roof while there’s a storm going on,” said Dick Thompson, a spokesman for the World Health Organization. “Until the animal situation gets under control, there’s going to be this steady drip, drip, drip of human cases, and that’s a problem.”
Although the A(H5N1) flu arrived relatively late in Indonesia, it soon spiraled out of control, and deaths have mounted quickly.
Unlike Thailand, which quenched outbreaks by killing millions of chickens, or Vietnam, which used mandatory vaccination, Indonesia has tried a mix of limited culling and vaccinating in rings around the cull — so far, with little success.
Mathur Riady, chief of livestock for Indonesia’s Health Ministry, said recently that more than a million birds had died of the flu between January and March, about the same number as died all last year.
The biggest obstacle to beating the disease, international flu experts say, is the country’s decentralized government. Health officials in the capital, Jakarta, have been described as having powers extending no further than their office walls, while real power resides with the governors of the 33 provinces and the elected bupatis, or regents, of 480 districts.
“It’s a real mishmash,” said Dr. Jeffrey C. Mariner, a veterinary medicine professor at Tufts University who is helping the United Nations Food and Agriculture Organization train new veterinary workers. “You have to sit down with each decision-making unit and get them all on board. It’s hard to mount a coordinated response.”
As a result, the country is not only slow to report human cases, it no longer even reports poultry outbreaks to the World Organization for Animal Health in Paris.
But decentralization is not a principle that Indonesians are likely to abandon. Like the former Yugoslavia, the country is contentious mix of ethnic and religious rivalries, with 245 million people living on about 6,000 populated islands formerly held together by harsh central control from Jakarta.
With the collapse of the Suharto dictatorship in 1998, independence movements sprouted from East Timor to Aceh, and Jakarta responded with different mixes of military power and grants of semiautonomy.
The regions prefer having more self-government, and “decentralized units get very wary when the center takes on emergency powers,” said Dr. David Nabarro, chief pandemic flu coordinator for the United Nations.
Dr. Mariner, of Tufts, said shortages of trained veterinarians and slow compensation of farmers have also been major obstacles to crushing the outbreak.
He and nine colleagues from Tufts and the F.A.O. are training local people to find sick birds and rapidly test them, cull flu-infected flocks and vaccinate others in a ring around the sick ones.
But each trainee needs two to three months of class and fieldwork to become proficient, he said, and then many of them must, in turn, become trainers.
“By February, we should have enough for 157 districts on three islands,” he said. Asked how long it would take to train enough disease-trackers to cover all 480 provinces, he said “I don’t have an answer — maybe two or three years?”
Another problem, he said, is the sheer profusion of backyard chickens. The outbreak is not a big problem in commercial flocks, but “in the country, every household has poultry,” he said. “Retired people here keep chickens like other retirees take up woodworking. It’s household food, and income, and something to do. Asking Indonesians to give up their chickens is like asking Americans to give up their dogs and cats.”
Until recently, he said, many farmers refused to let their birds be killed because they received only vouchers that could take six months to be paid.
“Now we’re seeing the districts willing to advance money, so people are paid in a few days,” he said. “That’s begun real cooperation.”
The government pays about $1 per bird — just a bit below market value, which veterinary experts suggest is the best way to get compliance but to forestall the temptation to breed just for the culling payments.
Indonesians also raise fighting cocks, songbirds and trained doves worth much more than $1, he said, but they are paid nothing extra, giving the owners little incentive to cooperate.
Making matters harder, some outbreaks begin in remote villages that may themselves be estranged from local government. For example, Kubu Sembilang, the village in the Karo District in northern Sumatra where the flu killed seven members of one family, was a Christian and animist village, while northern Sumatra is a center of highly observant Islam.
Some wary villagers there blamed witchcraft for the deaths and refused to take the antiviral drug Tamiflu that the authorities had offered.
Given Indonesia’s huge population — compared with Vietnam’s 84 million people — avian flu remains a relatively rare disease there, said Dr. Tim Uyeki, an epidemiologist with the Centers for Disease Control and Prevention who was part of the W.H.O. investigative team.
But the way Indonesian cases have clustered — often infecting just the blood relatives in one family in a village — has given support to the theory that some people are genetically more likely than others to get infected, he noted.
“We can’t prove that — it remains a hypothesis,” he said. “But when a village has a lot of people and a large outbreak, and they all have lots of contact — burying or slaughtering or whatever — and only one family gets sick, you have to ask: is there something unique in that family that creates susceptibility?”
Studies to test that are needed, he said.
Under the right circumstances, Indonesia can rouse itself to beat a threatened epidemic.
Just last year, it defeated an unexpected polio outbreak. After a polio-free decade, it had a lone imported case in May 2005, but that quickly grew to 303 cases, the world’s third-biggest outbreak, after Nigeria and Yemen. (Each detectable case of paralysis means there are 200 people with “silent” cases, who can still spread the virus.)
But a huge immunization campaign drove new cases down to a mere two this year so far.
"Source":[ http://www.nytimes.com/2006/07/21/world/asia/21flu.html]
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