Rabid (28 page)

On March 14, the girl received a dose of rabies vaccine and immunoglobulin therapy. She remained in the hospital until March 22, receiving only basic supportive care during that time. She made two follow-up visits to the emergency department after her discharge, complaining each time of a recurrence of headaches. On her final visit, she reported relief following a spinal tap. This was the last contact between the girl and her doctors: they record her as being “lost to follow-up.” One hopes that medical science will eventually reconnect with this potentially historic case of rabies survivorship.

Is Willoughby correct in his belief that the Milwaukee protocol, refined over time through repeated use, could eventually serve as a reliable treatment—one that transforms rabies from a death sentence into a frequently survivable disease? Or is Alan Jackson correct in his conviction that a very few, fortunate individuals are just naturally predisposed to fight off the disease? Only years of further experimentation can answer these questions definitively. In the meantime, though, we can agree with the assessment of Dr. Rupprecht, back in 2008, when he cautioned both supporters and detractors of the protocol that “we need to focus more on prevention.” The protocol provides hope for patients already infected, he observed, but “the odds of coming out without neurological deficits are remote, even with the best care.” Three years later, despite the exciting success of Reynolds, this assessment still stands. It’s impossible to imagine that developing-world countries would ever have the resources to deploy controlled-coma therapy on
more than a tiny fraction of the more than fifty thousand people who currently die of rabies each year. By contrast, it’s surprisingly cost-effective for those countries to prevent rabies, through the mass vaccination of dogs.

In our next and final chapter, we consider the ins and outs of canine vaccination but in the dramatic context of a real-world crisis: an outbreak on the Indonesian tourist island of Bali, which until 2008 had been entirely rabies-free.

Vaccination campaign in Jembrana, Bali, 2010.

L
ooking back to the beginning—past the scores of Balinese dead from rabies, past the thousands of dogs brutally put down, all the way back to the cold forensic facts of who bit whom—it was probably Thomas Aquino’s dog that caused all the trouble. In May 2008, Aquino and a friend, known only as Freddy, sailed to Bali from their native island of Flores, which protrudes from the sea a few hundred miles east down the chain of Indonesian islands that spray off from Singapore toward Australia. Like many travelers on those waters, the two men brought along a dog, the company of which is held to protect the sailor not only from pirates but from more spiritual dangers, too—the mysteries of the animistic Hindu faith extending beyond the iconic beaches and into the deeps of the Bali Sea. For all recorded history the island of Bali had been rabies-free, and so, at least in principle and according to law, dogs could be imported only from other nations where the disease lacked a foothold. But enforcement of this law, fairly reliable at the airport, was entirely absent on Bali’s shores. Dogs trotted freely off ferries, pleasure craft, and fishing boats, with no one examining their papers or scanning them for signs of disease. Once on land, these four-footed immigrants mixed easily
with the other dogs of the waterfront, where strays (unusual across Bali as a whole, where more than 95 percent of dogs are owned) stalk the beaches in a friendly crush, living off handouts from tourists. The locals, for their part, paid little attention. Among the Balinese it is typical not to acknowledge any dogs except for their own, and sometimes those only cursorily.

So the arrival of Thomas Aquino’s dog—silently harboring in its body, somewhere along its nervous system, the seeds of an island-wide epidemic—went wholly unnoticed by anyone, or at least by anyone who understood the scope of the damage that one imported dog could do.

The dog and the two men from Flores settled in Ungasan Village, on the arid Bukit peninsula that hangs like a hammerhead from Bali’s southern tip. There, nuclear families make house in compact, densely constructed dwellings, rather than in the sprawling extended-family compounds that are common on the rest of the island. All of Bali thrives on tourism, which every year brings in some two million foreigners and $2.8 billion of their money in search of South Pacific paradise. But lately that business has particularly boomed in Bukit, where large resorts—owned by such luxury conglomerates as InterContinental, Four Seasons, Ritz-Carlton, and Orient-Express—have proliferated. Jobs in and around these resorts have lured many more Indonesians to the peninsula. Muslim and Hindu families live side by side in its neighborhoods, as transplants from the northern part of Bali mix with immigrants from other islands, all seeking to profit from the incessant, explosive growth.

Two months after Thomas’s dog made landfall, it bit both him and Freddy. Soon a three-year-old in the village, a boy named Ketut Tangkas, was bitten by his own, suddenly furious dog. By that September, rabies had claimed its first human victim on Bali: a forty-six-year-old woman in the village named Putu Linda. Although a postmortem test for rabies came back positive, public-health officials did not follow up on the implications of that fact for more than two months.

In October, another boy in Ungasan—Muhammad Oktav, also three—was bitten on the face in front of his home by a stray. When his mother took him to the hospital and asked about a rabies vaccine, the doctors refused to provide one. Bali was “rabies-free,” they pointed out. They sutured up his wounds and sent him home. Over the next few weeks, the boy seemed to be recovering normally from his injury. He went back to playing as usual in his family’s tiled front garden. But a month following the bite, Muhammad abruptly fell ill with chills and, soon, the hallmark fear of water; within two days he was dead. It took two more deaths in Ungasan before the government finally acknowledged, on November 30, 2008, six months after Thomas Aquino and his dog made landfall, that rabies had come to Bali for the first time in history.

One rabid dog had become many. Now, with human lives at stake, no dog could be trusted. With no means of early detection of rabies on the island, the government had recognized the outbreak only after an obvious cluster of human deaths laid bare the extent of the problem. Now the challenge before the Balinese authorities was one of bringing a limited regional epidemic under control before it could spread to the rest of the island.

Barring some miraculous revolution in vaccines, on the one hand, or a near-total obliteration of all animals on the other, the worldwide war against rabies will never be entirely won. Isolated islands like Bali and Britain can win themselves reprieves, at least for a time. But on the larger landmasses, even in nations (such as the United States) where the disease has been largely controlled, its stubborn carriers in wildlife populations reside too far away from man, dispositionally if not always geographically, for us to snuff the devil out very easily. Even if we do somehow succeed in purging rabies from four-legged creatures, we would be left with the problem of the bat, which harbors its own specialized strains of the virus and does not submit easily to the needle.

The great divide in worldwide rabies control is between those nations where the disease has been largely eliminated in
dogs
and those where it has not. This gap is not precisely the same, it should be noted, as the divide between rich and poor. In Brazil, where bat rabies remains rampant but dog rabies has been curtailed through mass vaccination, human deaths from rabies have numbered fewer than ten per year since 2006; in Kazakhstan, which boasts less than a tenth of the population and nearly the same per capita income, the death tally from rabies is significantly higher. The special role of dogs in spreading rabies is due not just to the way they live with us, and all around us; it’s also due to the way the virus is perfectly matched to the dog as host, expressing itself in canine saliva at levels rarely achieved in other four-footed wildlife. Rabies coevolved to live in the dog, and the dog coevolved to live with us—and this confluence, the three of us, is far too combustible a thing. According to the CDC, dog bites are still responsible for 90 percent of human exposures to rabies worldwide and more than 99 percent of human deaths.

To be sure, poverty and its attendant ills—governmental corruption, social unrest, poor health overall—help greatly to explain why the two most rabies-afflicted continents, Asia and Africa, have failed to quell the disease. If controlling rabies is in some sense equivalent to keeping dogs healthy, this latter effort is in many ways a proxy for bringing order to civilization itself. Stray dog populations, and rabies along with them, tend to flourish in places where government has broken down; in the former Soviet republics, for example, rabies has resurged during the past twenty years. The problem becomes especially acute under circumstances of radical depopulation. In South Africa’s KwaZulu-Natal Province, where some 39 percent of residents are infected with HIV, local veterinarians have reported a tremendous upswing in populations of feral dogs, leading to more cases of rabies. More extreme still, in Ukraine, is the “exclusion zone” around the former Chernobyl power plant, where scientists report an eruption of rabies in the proliferating dogs and other wildlife that haunt the zone.

Even where government functions reasonably well, the peculiarities of rabies often cause officials to become shortsighted. Preventative treatment in dogs often seems like an unaffordable luxury, especially given that the countries where rabies still runs rampant are also countries where other diseases, such as malaria and tuberculosis, kill far more people. But vaccination campaigns in dogs are always much cheaper, over the long haul, than giving out postexposure treatment to humans. The World Health Organization points out that the cost of a full course of postexposure treatment is 4 percent of the average gross national income for Asia and nearly 6 percent of that figure for Africa. As it stands, antirabies campaigns worldwide consume more than a billion dollars per year, and that is just to keep the number of deaths roughly equal to where it stands right now, at approximately fifty-five thousand per year.

As a rabies-free island, Bali was not supposed to add more than 150 victims to that tally. But one wayward dog ensured that it did. Indeed, Bali serves as an instructive story about how quickly any gain in rabies control can be reversed. For all its First World tourist revenue, Bali’s per capita income is less than two thousand dollars per year—making residents reluctant to vaccinate at their own expense, and making postexposure treatment hard to afford as well. Just like in the fictional British outbreaks sketched by
The Rage
and
Day of the Mad Dogs,
Bali’s rabies-free status wound up becoming a psychological hindrance, as hospitals and residents and governmental officials were too slow to recognize what they were seeing. And when officials did finally awake to the scale of the problem, their response began with the same misguided impulse that tends to strike most government officials when faced with a rabies outbreak: the brute-force killing of dogs.

Dr. Anak Agung Gde Putra is a veterinary epidemiologist at Bali’s Disease Investigation Center (DIC), which is not technically part of the government—its funding comes from the United Nations—but which closely advises Bali officials on animal disease control. Dr. Agung
is elegant and middle-aged, crisply uniformed in khakis and delicate wire spectacles. His English is excellent, if deliberate, and he talks proudly of the professional visits he has made to Australia and the United States.

On the subject of Bali’s rabies outbreak, Dr. Agung felt strongly that his government had acted responsibly given the circumstances. After rabies was confirmed by the laboratory in November 2008, Bali’s governor—Made Mangku Pastika, who was elected to his office after becoming well-known as police commissioner for rooting out suspects in the 2002 terrorist nightclub bombing—notified the public within twenty-four hours. The following day he issued a decree laying out the government’s course of action, which had been prescribed by Dr. Agung and his colleagues at the DIC. The main thrust of this plan was mass slaughter. It called upon the residents of Bali to kill, personally and by any means necessary, any and all street dogs they came across. In addition, all boats arriving in Bali were to be thoroughly searched by port officials, who would immediately confiscate and destroy any cats, dogs, or monkeys they found.