The Fatal Strain (44 page)

W
hen I met the man who might save the world, he was making thirty-eight dollars a month. Ly Sovann was a physician in the Cambodian capital, Phnom Penh. He was full-faced with dark, playful eyes and sloping shoulders. He had a tendency to lecture, and when he did, he would stretch out his arms and gesture with open hands. But he was also quick to laugh, often at his own straits.

The first time I encountered him, Ly Sovann was planted behind an aging metal desk in a tiny room that passed for the headquarters of Cambodia’s disease surveillance bureau.

He was the director, responsible for spotting the stirrings of an epidemic in a country where the public health and veterinary systems were so impoverished that experts acknowledged at the time they were probably failing to detect most of the human cases and had no idea how rampant the virus was among poultry. He shared the twelve-by-ten-foot office with the rest of his ten-member team. The room was crammed with four other metal desks and tables, filing cabinets, shelves heavy with bound reports, and five boxes stuffed with the health ministry’s stockpile of protective gear, including gloves, goggles, masks, and aprons. There was only enough space for three people at a time, so his staff rotated through. They all shared one Internet line, which was just about the sole way they could follow the inexorable progress of the virus in neighboring countries, and Ly Sovann had secured that connection only after prevailing on the health minister
to seek help from the prime minister’s office. Even at times of crisis, they could work only until 7:00 P.M. each night. That was when the power in the health ministry was shut off and Ly Sovann had to find his way down the stairs from the third floor and out of the darkened building by the faint glow of his mobile phone.

“We’ve had over thirty years of war,” Ly Sovann said as a small air conditioner sputtered and whined in the window behind him. “We need time to build up our system of public health. We try our best to build up the system for detecting avian flu in Cambodia. Five years ago, it was nothing. Now I have computers, paper, and stationery. It’s better.”

Still struggling to recover from decades of conflict and political instability, Cambodia’s government had only three dollars per person to spend on health care each year despite high rates of HIV/AIDS, tuberculosis, and infant and maternal mortality. The country lacked trained doctors, clinicians, laboratory facilities, referral wards, epidemiologists, and an overall health system tying them together. For a time, the government couldn’t even afford to produce radio spots warning about the risks of bird flu.

Out in the provinces, the health system was even more primitive than Ly Sovann’s operation. Local clinics couldn’t recognize cases of bird flu when the sick came in for treatment, raising the prospect that the virus would evolve into a more pernicious form and spread before anything could be done to stop it. This posed a danger not just for Cambodians but for those well beyond the country’s borders. “The chain is as strong as the weakest link,” warned Klaus Stohr when I first asked him in 2005 about his concerns over Cambodia and its destitute neighbor Laos. As the virus raced westward during the following year, WHO began raising a similar alarm over the threat posed by sub-Saharan Africa.

The situation would be less dire in some countries confronting the virus, but only by degree. Along the breadth of the battlefront, from Vietnam and Indonesia to Bangladesh, Egypt, and Nigeria, public-health and veterinary services have remained precariously short of the money needed to corner the disease in birds, detect and treat those people who contract the virus, and stem its onward spread.

For the wealthy of the world, geographic distance affords little protection from an emerging flu epidemic. There is no strategic depth, as war planners say. But the danger posed by limited resources goes beyond the shared vulnerability of all countries.

Inequality itself has a corrosive effect on efforts to confront this disease. WHO and its wealthier member states have urged developing countries to battle the novel strain on everyone’s behalf. Yet these countries have been told they must do so without any solid assurance they’ll get a fair share of antiviral drugs, vaccines, or other medical aid if an epidemic erupts. This despite some projections that a pandemic would take a disproportionate toll on developing countries.

Some Asian countries have done what they’ve been asked, even as they appeal for more money to do it. Others, at times, have resentfully rebuffed instructions from abroad, vowing to pursue their own national interest even if that puts the wider world at risk. Vietnam, for instance, was so sure it would be neglected in the event of a pandemic that local scientists pursued a homegrown vaccine using unorthodox techniques, though WHO warned that this effort could lead to tragic consequences. In Indonesia an aggrieved government went even further, turning the tables on the developed world. Indonesian health officials discovered that they controlled some of the most precious resources of all—actual virus samples urgently required by WHO’s labs to monitor mutations in the strain—and stopped supplying these specimens. Indonesia demanded that its claim to these virus samples be recognized and any benefits, for instance vaccines produced from them, be more equitably shared.

At the very bottom of the heap, Cambodia has been in no position to insist on anything. Beaten down by history, it was already heavily dependent on foreign assistance just to keep from closing down. A full half of the central government’s budget was financed by aid.

Ly Sovann was born in Phnom Penh in 1969, the year that the United States began its secret bombing of eastern Cambodia during the Vietnam War. This withering aerial campaign was aimed at eliminating the base camps of the Vietnamese Communists. But the upheaval caused by the four-year bombardment fueled the insurgency of Cambodia’s own Communists, the Khmer Rouge, who were fighting
to topple the Phnom Penh government allied with the United States. When the Khmer Rouge captured Phnom Penh in 1975 and established their genocidal rule there, the capital was emptied. Ly Sovann’s family, like most others, was banished to the countryside.

After the Vietnamese army ousted the Khmer Rouge from Phnom Penh four years later, he returned to the capital, where he went on to study medicine at a local college. This was a break with tradition. Like many Cambodians of Chinese ancestry, his was a family of merchants and traders. So was that of his future wife, and her relatives would later help support him as he pursued his medical passion. With few options for advanced study in Cambodia, he left for Bangkok, where he received a master’s degree in clinical tropical medicine. Once he returned, he joined the health ministry. He was promoted to director of disease surveillance after distinguishing himself during the SARS outbreak by crafting an aggressive national response.

That was when he began devising an epidemic alert system tailored for austerity. Ly Sovann told me he realized the one thing Cambodia had going for it was cell phones. They were in wide use because landlines were so rare, and cellular coverage had already reached two-thirds of the country. He’d taken advantage of this rare asset, he told me. Reaching backward to a bulletin board, he pulled down the roster of names and phone numbers he’d been compiling since SARS. The stapled sheets, worn and smudged with fingerprints, listed contacts for scores of health-care workers in Cambodia’s cities and all twenty-four provinces. He had cobbled this network together with little more than charisma and extensive personal contacts. “He just knows everybody,” a doctor in the local WHO office said to me. But calls cost money. He didn’t have enough even to buy gas for his investigators’ motorbikes, much less pay their salaries on time. So Cambodia applied for ten thousand dollars from foreign donors to purchase prepaid phone cards to allow local health workers to report suspicious respiratory cases that could be flu.

The effort stumbled at the start. Local doctors missed what would be Cambodia’s first confirmed case of avian flu. It would have been overlooked altogether if the victim’s family had not brought the twenty-four-year-old woman across the border for treatment in Vietnam,
where the health system was more advanced. Though Vietnamese doctors could not save her, they did identify the virus. This first reported case in January 2005 drew intense international concern and several weeks later brought me to Cambodia’s southern Kampot province.

When I arrived, I discovered that the woman was not the only one in her family who’d been stricken. I tracked down her father squatting in a sandy lot by the side of the road. With a homemade sledgehammer, he was pounding into place the wooden foundation of a new house. He was barefoot, and his narrow eyes squinted in the sun. He wasn’t sure what was cursing his home in the parched rice fields across the road, but cursed it was. He had also lost a teenage son, he told me, and two others in his family had fallen ill.

The man, Uy Ngoy, related that his fourteen-year-old son was the first to get sick, complaining of a fever, diarrhea, and trouble breathing. The boy was brought to a storefront clinic with peeling paint and muddy tile floors in the local town. The clinician took the boy’s temperature and blood pressure. His condition continued to deteriorate. Two days later, suspecting that the disease was somehow caused by an affront to the spirits, the clinician sent the boy home so his family could pray to their ancestors. The boy died soon after.

At the funeral, the boy’s older sister had embraced his body. Soon she came down with the same symptoms. The family took her to a slightly better clinic, where an ultrasound scan revealed lung damage, and then across the nearby border for medical care in Vietnam. It was too late. By the time the next two fell sick, Uy Ngoy had lost faith in modern medicine. “I decided to try another way,” he recounted. He dispatched them first to a Buddhist priest and then to a witch doctor in the mountains. These family members later recovered.

There was no public education about the virus, and local public health was hardly any better. The health workers at the two local clinics told me in separate interviews that they had believed the siblings had routine pneumonia, common among villagers. The clinicians never thought to report the cases to Ly Sovann’s bureau or any other official. After Ly Sovann learned about the woman’s death from media reports, he rushed to Kampot with his team and stayed 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.

Several weeks later, he returned to the province, setting out from Phnom Penh before dawn on the three-hour drive. He had put on a white dress shirt with sleeves buttoned to the wrists and a dark striped tie fastened with a clip. His black hair was slicked to the side. He wanted to look as authoritative as possible. He had to convince the villagers to start reporting suspicious illnesses. Too many lives could be at stake. When he arrived at a community hall in Kampot town, he set up his laptop computer for a slide presentation and fished his PDA from the breast pocket. Then, over the hum of the ceiling fans, he made his pitch. The farmers, provincial officials, and community activists in the audience were skeptical. Some approached the microphone to question whether bird flu was even real.

Foreign governments were far more unnerved than these locals. Flu specialists worried that cases were being missed and warned of a stealth outbreak in an utterly unprepared land. Over the following two years, foreign donors provided $13 million in emergency assistance. It wasn’t a lot, but in a small country it went a long way. Cambodia established rapid-response squads in every province. Composed mostly of doctors, these two-member teams were trained to investigate any suspected human case. Twenty-nine thousand village volunteers were mobilized to report rumors of unusual illnesses. Antiviral drugs and protective gear for health-care workers were purchased and pre-positioned in each province. Building on Ly Sovann’s cell-phone network, Cambodia pioneered a program in which local health officials could report a variety of diseases, including unusual respiratory outbreaks, by text message directly to a central computer.

Cambodia soon had more foreign aid for the flu fight than its tiny cadre of medical professionals could handle. Yet the funding was short-term, good only for about three or four years. Cambodian health officials and their WHO colleagues remained anxious. After the emergency funding for bird flu was exhausted, who would pay to keep the rapid-response teams trained and send them to the field? Who would pay to replenish the antiviral drugs as they expired and conduct lab
tests on samples? Who would pay to print the flyers and brochures distributed to villagers warning of the virus? Who would pay for the cell-phone calls?

Nearly a year after I wrote about Ly Sovann for the
Washington Post,
I happened across a surprising item in
Vanity Fair
magazine. It was a long piece about bird flu that mentioned this Cambodian hero. Turns out, the magazine reported, the
Post
article had done Ly Sovann some good. The publicity had gotten him a raise. Two dollars more a month.

 

 

David Nabarro was an effusive speaker. Yet when it came to money for fighting flu, the world’s wealthiest countries got him to bite his tongue. Nabarro was an Oxford-trained physician, a veteran of development efforts in Asia and Africa, and, as a senior United Nations official, he had worked some of the world’s most horrifying disasters, including the Indian Ocean tsunami and the genocidal conflict in Sudan’s Darfur region. He had been in the UN’s Baghdad headquarters in 2003 when it was devastated by a car bombing that killed twenty-two of his colleagues. After all that, he had become the global flu czar. As United Nations System Senior Coordinator for Avian and Human Influenza, he was responsible for coordinating the alphabet soup of UN agencies involved with flu.