Hunting Bird Flu on the Cheap in Cambodia

East Asia / Pacific - Cambodia
23 Mar 2005 - Washington Post

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The man who might save the world from a devastating bird flu pandemic makes $38 a month.

As Cambodia's chief of disease surveillance, Ly Sovann is responsible for spotting the stirrings of an epidemic in a country where the public health and veterinary systems are so impoverished that experts acknowledge they are probably failing to detect most of the human cases and have no idea how rampant the virus is among poultry.

That poses a profound danger well beyond Cambodia's borders. International health specialists warn that avian influenza could kill millions of people worldwide if it has a chance to develop into a form easily spread among humans.

Ly Sovann, 36, a physician, is a full-faced man with dark, playful eyes and sloping shoulders. He heads a team of 10 Cambodian flu hunters struggling to head off an epidemic from their 12-by-10-foot office on the third floor of the Health Ministry. They share one Internet line and even at times of crisis have to go home by 7 p.m., when the power in the building is switched off.

Ly Sovann's epidemic alert system is nothing more than a network of personal cell phones. But through his wide-ranging contacts and charisma, he has cobbled together a national network of informants. Cambodia is seeking $10,000 from foreign donors to purchase prepaid phone cards to allow local health workers to report on suspicious respiratory cases.

But the monitoring effort has stumbled. Cambodia's one confirmed human case of bird flu was not recognized by local doctors two months ago and was diagnosed only after the victim's family took her across the border for treatment in Vietnam, where the health system is more advanced.

So far, international health specialists report that the disease is less prevalent in Cambodia than in Vietnam and Thailand, another neighbor, where a total of 45 people have died since early last year. But health specialists are concerned about the rudimentary level of medical and veterinary care in Cambodia and its destitute neighbor Laos. They fear that those countries' primitive health care systems may not be able to diagnose or report human cases of bird flu, allowing the virus to spread.

The avian strain now has difficulty infecting people. However, each new human case gives the virus an opportunity to undergo genetic changes that could eventually allow it to be transmitted easily from person to person.

"The chain is as strong as the weakest link," said Klaus Stohr, director of the World Health Organization's global influenza program. "Cambodia and Laos are certainly the ones that need beefing up."

Bird flu was first confirmed in Cambodian chickens in January 2004. Since then, international health officials have speculated that human cases have probably gone unreported. Nevertheless, Jim Tulloch, WHO's top representative in Phnom Penh, said he was confident that a concentrated outbreak would be spotted. The question is how fast.

"If we start seeing the disease spread more quickly, speed will be everything to contain it," he said. "It's a matter of chance if we know about it as quickly as we like."

Still struggling to recover from decades of war and political instability, Cambodia's government spends only $3 per person on health care each year despite high rates of HIV/AIDS, tuberculosis, and infant and maternal mortality, according to Tulloch. Foreign donors contribute twice that amount for specific health programs, but because the money is earmarked, it cannot be used for tracking new diseases, such as bird flu.

Cambodia lacks trained doctors and clinicians, laboratory facilities, referral wards, epidemiologists and an overall health system tying them together for the fight against avian influenza, experts said. The government cannot even afford to produce warnings about the disease for radio and television.

"We've had over 30 years of war. We need time to build up our system of public health," Ly Sovann said from behind his modest metal desk while a small air conditioner whined in the window. He said he had secured his lone Internet connection only after prevailing on the health minister to seek help from the prime minister's office.

"We try our best to build up the system for detecting avian flu in Cambodia," Ly Sovann continued. "Five years ago, it was nothing. Now I have computers, paper and stationery. It's better."

Ly Sovann received his undergraduate medical degree from a college in Phnom Penh and a master's in clinical tropical medicine from a Thai university. He was promoted to his current post after distinguishing himself by crafting an aggressive national response during the 2003 outbreak in Asia of SARS, or severe acute respiratory syndrome.

Ly Sovann said that was when he realized he could make use of the country's extensive cell phone coverage.

Reaching behind him to a bulletin board, Ly Sovann showed the worn and smudged list of names and phone numbers he began assembling during the SARS program, covering scores of health care workers in Cambodia's cities and all 24 provinces.

Compared with Vietnam and Thailand, Cambodia is fortunate because it has fewer chickens and ducks to spread the disease, and its dense commercial farms, which could offer the virus a welcome roost, are few and well-monitored, according to international agriculture experts.

But the paucity of commercial farms also makes it difficult to track the disease. Large farms serve as a bellwether for bird flu outbreaks, because the death overnight of hundreds of chickens on a single farm is easy to detect. The vast majority of Cambodian chickens, however, live in the back yards of peasants, where the death of a few dozen birds typically goes unnoted, especially because many die of fowl cholera, Newcastle disease and other common poultry maladies.

Ly Sovann set out before dawn one day this month on a three-hour drive to Cambodia's southern Kampot province, the home of Tit Sukhan, a 24-year-old woman who had died of bird flu on Jan. 30. His goal was to repeat his frequent public plea that suspicious illnesses be reported.

Arriving at the local community hall, he set up his laptop computer for a visual presentation, fished his personal digital assistant from the breast pocket of his white dress shirt and waited his turn beneath the humming ceiling fans. The reception from officials, activists and farmers proved skeptical. Several approached the microphone to question whether the virus had even entered the province.

A week before Ly Sovann's visit, the father of the dead woman had said in an interview that he still doubted that bird flu had killed her, even though most of his 40 chickens had died without warning shortly before she and several other family members became ill.

Uy Ngoy said his 14-year-old son was the first to develop a fever, diarrhea, breathing problems and a bad cough. The family took the boy to a private clinic that provides basic care in the local town of Kompong Trach. A clinician took the boy's temperature and blood pressure. Two days later, after the boy's condition worsened, the clinician sent him home so family members could pray to their ancestors in case the illness was caused by an affront to the spirits. The boy died soon afterward and his body was cremated.

No tests were run, but WHO officials now suspect the cause of death was bird flu.

After embracing the boy's body at his funeral, Tit Sukhan, his sister, developed the same symptoms, Uy Ngoy recounted. The family took her to another, slightly better-equipped clinic, where an ultrasound test revealed lung damage. Then they took her across the border for medical care in Vietnam. Doctors there diagnosed bird flu, and she died soon thereafter.

The health workers who ran the two Cambodian clinics said in separate interviews that they had believed the siblings were suffering from pneumonia, extremely common among villagers, and never thought to report the cases to Ly Sovann's department or any other official.

After Ly Sovann learned about Tit Sukhan's case from news reports nearly two months ago, he rushed to Kampot province with his team and remained for a week. Blood samples were taken from family members, villagers were canvassed and health warnings were broadcast from loudspeakers mounted on motorbikes. Ly Sovann's mobile phone rang relentlessly, he recounted.

Even after that, until he was confident the outbreak had been contained, Ly Sovann said, he worked in his Phnom Penh office from daybreak until 7 p.m., when the power was cut. Every night, he found his way out of the darkened building by the light of his mobile phone.



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