Kok Chamkar, Cambodia — The death of Tit Sokhan from the bird flu here in January may seem inconsequential to anyone outside this idyllic farming village 120 miles southwest of the capital, Phnom Penh.
But given that Sokhan’s brother died just before her from bird flu-like symptoms and that the World Health Organization (WHO) says Cambodia could have many more undetected bird flu cases, the likelihood of a global bird flu pandemic is increasing.
At a conference on bird flu that opened on February 23 at Ho Chi Minh City in Vietnam, Shigeru Omi, Western Pacific regional director of the WHO, said such a pandemic was “imminent,” and urged the representatives of the 20 governments present to act swiftly to control the spread of the disease.
Today, a bird flu pandemic could kill about 180 million people according to Michael Olsterholm, an infectious disease expert at the University of Minnesota. While that seems high, the WHO’s Omi has said that should a bird flu pandemic occur, 25 to 30 percent of the world’s 6 billion-plus population could become infected.
What’s worrying scientists the most is the possibility that the H5N1 virus that causes bird flu, which until now has mostly passed to humans from birds and other animals, could mutate and begin to pass from human to human. In a recent issue of the New England Journal of Medicine, researchers from the Oxford University Clinical Research Unit in Ho Chi Minh City reported that the H5N1 virus was showing up in the feces of affected people.
The virus hasn’t mutated yet, but Dr. Julie Gerberding, head of the U.S. Centers for Disease Control and Prevention, said in late February that the likelihood that it will do so poses “the most important threat” to health throughout the world.
The weakest link
First identified in Hong Kong in 1997, the bird flu is known to have spread to nine countries, including Cambodia’s neighbors, China, Thailand and Vietnam.
So far official reports say the current bird flu outbreak has killed 12 people in Thailand and 29 in Vietnam, and only one, maybe two, in Cambodia. But health experts say they’re worried that Cambodia might be the weak link in the region that precipitates a wider problem. The country’s health services are limited and its population is uninformed about the risks they face.
Oi Ngoy, 47, is the father who bears the heavy burden of knowing his daughter, and possibly his son, were the first Cambodians to die of the bird flu. Although the story of his personal tragedy is well known in the area, its lessons are still not well understood — even by Oi Ngoy himself.
“They said [my daughter] died of this bird flu, but I still don’t know what it is,” Oi Ngoy said, as his daughter’s husband stood silently beside him. “I’m worried about my family and the future. But I don’t know what to do.”
Over the last few months, the deadly H5N1 virus was clearly spreading in neighboring Thailand and Vietnam, and the WHO had warned countries in the region to take firm preventive steps. But Oi Ngoy and his neighbors say they’d received no warnings or information from the government.
So when the three dozen chickens Oi Ngoy kept around his traditional stilted house started to fall ill and die, he and his family thought nothing of eating them instead of burning them, as is recommended for birds thought to be contaminated by the H5N1 virus.
“We just plucked them and cooked them,” he said. “No one told us not to.”
A few days later, Oi Ngoy’s 14-year-old son Tit Chiang fell ill.
“He had a fever and couldn’t breathe normally so we took him to the hospital,” Oi Ngoy said. “The doctors gave him two bags of saline solution [but] then they told us to take him home. They said maybe we’d done something to offend our ancestors, and we should make an offering to them.”
Oi Ngoy dutifully complied, but on January 19 Tit Chiang died in his home. Whether he died of bird flu was never established, and his body was cremated.
Tit Sokhan, Oi Ngoy’s 24-year-old daughter, rushed home when she heard of her brother’s death. She’d been away at a clinic with her sick eight-month-old infant, who had a fever and respiratory problems. When she saw her brother’s body, Oi Ngoy says, she hugged and wept over it. The funeral was the next day, and just after that Tit Sokhan came down with a fever as well.
This time, Oi Ngoy took his child across the border to Vietnam, just three miles away, where locals say health services are better and cheaper.
“But they said they couldn’t do anything for her,” Oi Ngoy said quietly. “She died on January 30.”
Vietnamese authorities, who’d been on high alert after 11 people died of bird flu in the country in January, confirmed that Tit Sokhan had died of the disease.
“Some officials came here after that,” Oi Ngoy said. “They took our blood and told the neighbors not to pass through my house. But people still passed by our house, [and] no one told us anything more.”
While bird flu-affected Vietnam has culled 1.5 million chickens and ducks, only 100 chickens have been ordered killed in Cambodia.
Kong Ngoi, 35, who lives just around the corner from Ngoy, said that when his “pigs began falling sick and couldn’t use their forelegs,” and his “chickens were getting swollen eyes,” he promptly sold them to another villager — who in turn took them across the border and sold them in Vietnam.
Recipe for disaster
It’s this potentially deadly combination of public ignorance and official inefficiency that’s leading health experts to worry.
“Cambodia’s facing very significant challenges compared with other countries,” said Jim Tulloch, the WHO representative in Phnom Penh. The government spends just $3 per capita per year for health and even with another $6 per capita being spent by international donors, “that’s not enough to provide even a basic health service,” he said.
Sok Touch, director of Communicable Disease Control in the Cambodian Ministry of Health, said the government is aware of the threat and is doing all it can. “We’re training workers and teaching people how to identify sick birds and what needs to be done to avoid contact with sick and dead poultry,” he said. “We’ve also set up a hotline for people to call if there’s a suspected case so we can track any new outbreaks.”
But it’s not clear if such measures can really arm Cambodia against the threat of a pandemic. The country’s administrative capabilities and public health services have remained frail and ineffective.
The grassroots impact of this is clear at the Angkor Chey Referral Hospital, about 30 miles northeast of Oi Ngoy’s village. This is where smaller health clinics in the area send serious cases. Nieng Chantou, a medical assistant who, like most of the medical staff here, gets paid about $20 a month, said he wasn’t sure what he could do if he had to treat someone with the bird flu.
“I missed attending the workshop on that,” he said from a bench in the center of the hospital’s leafy compound. “But I think my boss attended, and he said that if we get a patient we should isolate them.” But Chantou said the hospital didn’t have any isolation facilities. “We’re very short of rooms, so we’d just have to put the patient, even though we know he has the symptoms of bird flu, in the same room as others,” he said.
Given the bird flu’s 76 percent fatality rate in known cases, prevention is even more important than cure. But here, too, Cambodia is struggling.
In Phnom Penh, people are reasonably educated about the bird flu, and restaurants and shops say chicken consumption has fallen sharply. But in villages, few seem to know they’re at risk.
In Tram Kok, a dusty highway town 25 miles northeast of Oi Ngoy’s village, a group of chicken sellers sat along a shady side street surrounded by live but dazed-looking chickens and ducks tied together in clumps of six or eight. The birds lay about them in their own excrement, squawking and pecking at each other as the women arranged and rearranged them like bales of cloth. To fatten the birds before sale, some women were holding them by the neck and forcing clumps of gruel down their throats.
The exposure to the birds’ blood and excrement make places like this prime breeding grounds for the bird flu. But the women said no government inspector had visited them in over a year and they didn’t seem to care.
“It’s all a rumor and I don’t believe it’s true,” said Doung Ohn, 28, one of the chicken sellers. “There is no such disease and no one ever died of any bird flu.”