Thailand's anti-flu weapon: Nosy neighbors
13 February 2006
by Thomas Fuller
Benjapad, Thailand: Three years ago, they were doting mothers in this small farming village framed by rice and sugar cane fields.
But when their sons died from bird flu, Jongrak Boonmanuch and Jiranuch Suwannasingha joined an army of volunteers marshaled by the Thai government to fight the disease, a system that is today praised by international health officials.
Thailand has mobilized about 750,000 volunteers, one for every 15 rural households. They regularly advise neighbors never to touch a sick-looking bird with bare hands. They teach friends to stay on alert for birds that spend too much time sitting still, have untidy feathers, swollen necks or feet with red spots - all possible symptoms of avian influenza, according to a government pamphlet.
And they check up on neighbors when they get sick.
"To me it seems awfully impressive," said William Aldis, the representative of the World Health Organization in Thailand. "This is something that all over the world we've been trying to promote. And this is probably the best example that I've ever seen."
Countries such as Vietnam, China, Cambodia and Laos, by contrast, have much less sophisticated ways of tracking the disease.
Health experts say if bird flu ever reaches a point where human-to-human transmission is possible, early detection is crucial because there is a chance that an outbreak could be confined.
Since the first human deaths from bird flu were reported in Vietnam in 2003 the disease has spread westward and has now entered Europe, Africa and the Middle East.
At a conference in Beijing in January donor nations pledged $1.9 billion for prevention efforts, including better training of medical and veterinarian personnel.
The advantage of the Thai system is that it is cheap. "Volunteers do not receive a salary," said Darin Areechokchai, medical officer in the outbreak and investigation section of the Thai Department of Disease Control. "They have incentives."
Perks include discounts on health care and their children's education, not to mention the chance to help protect their communities.
In Vietnam the government has urged the media to uncover cases and encouraged the general public to report sick or dead poultry, but there is no nationwide network of volunteers, according to Dida Connor of the World Health Organization in Hanoi.
In China, surveillance efforts are haphazard, said Peter Cordingley, the spokesman for WHO in Asia. "The Chinese authorities have publicly recognized that their surveillance system is shoddy," he said.
Sonja Olsen, the acting head in Thailand of the International Emerging Infections Program of the Centers for Disease Control and Prevention, the U.S. government agency, says one of the reasons the Thai program is effective is because it was built on a decades-old practice of health checks for the general population.
Volunteers in rural areas monitor the health of children, the elderly and the handicapped in what Olsen describes as a solid public health program.
Chatchai Buasuan, a part-time driver and handyman, is the local health volunteer in the village of Nhongtabong, about a two-hour drive west of Bangkok. He does his rounds on a Honda scooter, inquiring about his neighbors' health but also asking whether they have seen birds that are not eating properly or are acting abnormally.
When he identifies a sick bird he dons a disposable white plastic safety suit and face mask, puts the bird in a bag and then buries it. This happens about twice or three times a month, he said.
"Before bird flu, some people used to eat sick birds," Chatchai said. "Not anymore."
Aldis of the WHO said, ideally, that other countries could implement similar systems. But setting them up might be challenging. "It is culturally easier to do in Thailand than other countries," he said. "There's such a group ethos here."
Health experts say Thailand has a history of responding well to a variety of health-related emergencies such as the AIDS epidemic and the aftermath of the tsunami of December 2004.
"People take charge and become responsible for the protection of their own communities," Aldis said.
But some villagers are stubborn, volunteers say. Chicken is an integral part of the local diet and cock fighting is very popular among men. During culls, prize-winning cocks were sent to neighboring provinces to avoid slaughter.
"People who are not afraid of death still keep chickens," said Pattama Wongeak, one of Jongrak's colleagues in the volunteer corps. Months after an outbreak, villagers often begin raising chickens again, she said.
The volunteer system is not foolproof. Last November, Pattama's neighbor died after slaughtering and eating as many as eight chickens during an outbreak. The victim's son also contracted the disease but has since recovered, perhaps because he was diagnosed early, according to Somjate Laoluekeat, the doctor in charge of bird flu efforts in Kanchanaburi Province, where Benjapad is located.
Somjate says the volunteer system generally works well but he worries some volunteers are not diligent about checking on their neighbors daily.
Yet the overall signs are good in Thailand: bird flu cases are declining, which some attribute to the monitoring system, which was established in November 2004.
Twelve people died from bird flu in Thailand in 2004 but only two died last year. In Vietnam, by contrast, fatalities have continued apace, with 20 deaths in 2004 and 19 last year.
"One of the reasons the situation seems to have stabilized in Thailand is that if a chicken sneezes these volunteers hear about it," said Cordingley of the WHO.
The system works this way: When a volunteer notices sick birds or people with flu-like symptoms he or she contacts the local health station, which then calls "Mr. Bird Flu," an official in each of the 75 provinces that uses the program.
Mr. Bird Flu coordinates the response and looks for patterns. Somjate, the doctor who holds the post in Kanchanaburi, says he receives about 10 to 20 calls a day on his cellphone, sometimes in the middle of the night. He then judges whether the case is serious enough to report it to the higher authorities.
The system is a far cry from the initial confusion when the disease first struck Thailand in late 2003. When her son became very sick, Jongrak said doctors were stumped by his illness. She remembered showing them a newspaper article about people in Vietnam who had contracted the disease and the symptoms they suffered.
"I said, 'I know that I'm not as smart as you but I think my son has bird flu,"' Jongrak recalled.
A few days later, just before his death, doctors acknowledged that her son, 6-year-old Captain Boonmanud, was Thailand's first confirmed human case of avian influenza.