News - Laos, Apparently Without Bird Flu, Is Still Pressed by the West to Join Global Fight - New York Times

Khamla Sengdavong, the manager of a state-owned farm here, still remembers his horror and dismay when bird flu suddenly killed a quarter of the farm's 2,000 chickens in five days in January 2004.

"They bled from the nose and the backs of their heads turned purple and then black, and then they died," he said, gesturing with his hands.

But bird flu seems to have disappeared almost as quickly as it appeared in Laos, and Mr. Khamla and others in this impoverished Communist country on China's southern border have restocked their coops.

Not one human case of bird flu was ever confirmed in Laos, and thousands of chickens have been tested in recent months without finding the slightest trace of the disease.

Despite the seeming disappearance of bird flu here, it has consumed most of the time and attention of Laos's best doctors and veterinarians for the past two years.

Pressed by United Nations agencies, the United States, the European Union and other big donors, top officials at the health and agriculture ministries have set aside previous priorities - deadly scourges like tetanus, rabies, swine fever and poultry cholera - to focus on a disease that could someday set off a global epidemic but poses less of an immediate threat here.

As the global effort to combat bird flu has increased, Laos and other poor countries have become the front lines, expected to manage extensive programs to battle bird flu despite struggling to marshal enough doctors and veterinarians against diseases even in the best of times.

Next week, those pressures will reach a new level when health ministers, leaders of United Nations agencies and top officials from the World Bank and other lending institutions gather in Beijing to raise as much as $1.5 billion to fight bird flu.

Almost nobody questions that a global campaign is needed to stop the disease: if the bird flu virus, A(H5N1), evolves to be able to pass easily from person to person in the next few years, it could kill enormous numbers of people. But health experts are starting to raise questions about the trade-offs involved in such a huge effort.

The danger, even some managers of bird flu programs are starting to say, is that donors focus so intently on a single disease that they unintentionally disrupt many other health programs. "We could overlook that people could quite literally be dying because of this," said Finn Reske-Nielsen, the top United Nations official in Laos.

In separate interviews, Mr. Reske-Nielsen and two of Laos's top disease fighters - Dr. Phengta Vongphrachanh, the country's foremost epidemiologist; and Dr. Somphanh Chanphengxay, the director of veterinary planning - said continued routine testing had not yet shown a resurgence here of other diseases despite the preoccupation with bird flu. But they and other officials in Laos and at aid agencies elsewhere said participants in the Beijing conference would face a series of hard choices.

Among the first of those trade-offs will be between short-term programs, useful mostly for fighting bird flu, and longer-term programs that may carry broader health benefits but do less to stamp out bird flu this winter or next winter.

The Asian Development Bank, a Manila-based multilateral lending institution like the World Bank, is one of the first organizations to start worrying about the bird flu trade-offs, partly because it has already had to make a hard choice.

Indu Bhushan, the leader of the bank's bird flu task force, said that after approving a $40 million preventive health program in Vietnam last year, the bank decided this winter to turn the effort into a bird flu project instead, saving time over having to design a program from scratch.

The redesigned project will still address other communicable diseases, like dengue fever, because it may improve detection. But it will no longer cover noncommunicable diseases like hypertension and diabetes, Mr. Bhushan said.

He noted that the Asian Development Bank was also preparing $68 million in new grants for bird flu that do not involve taking money from other programs. But he said it would be important at the Beijing conference that donors not redirect large sums previously approved for other programs.

"While emergency response is great, let's not get carried away here," he said.

The emerging debate over spending on bird flu closely parallels the debate in the 1990's over whether donor nations were paying so much attention to AIDS in the developing world that they were neglecting diseases like malaria and tuberculosis. That debate has helped lead to increased aid for research into tropical diseases, mostly from rich countries and the Bill and Melinda Gates Foundation.

Following that example, it is possible that bird flu may yet prompt broader and more strings-free aid to poor countries in areas like veterinary care. But for now, much of the money being offered to poor countries to fight bird flu involves loans, not grants.

And health officials in poor countries are leery of borrowing heavily; no country has yet tapped the Asian Development Bank's $300 million in loans available for bird flu programs.

Laos is one of the world's poorest countries, rivaling Chad in Central Africa in having one of the world's highest maternal death rates - problems related to pregnancy kill one mother for every 2,000 births, mainly in childbirth.

With the government able to spend less than $2 per person annually for health care, officials have been reluctant to take on debt.
"We try our best to utilize the grants first, and we reserve the loans for emergency response," Dr. Phengta said. That emergency response has not been needed.

Unlike in neighboring Vietnam, Thailand and China, where live poultry is often transported large distances to markets, sometimes on bicycles, most chickens and ducks in sparsely populated Laos are raised in backyards and eaten by their owners. That limits the spread of the disease, Dr. Somphanh said.

Turkey has captured international attention with 18 human cases, three of them fatal, in the past two weeks.

But Dr. Shigeru Omi, the World Health Organization's regional director for the Western Pacific, noted Thursday that Asia remains the center of the disease because contact between infected birds and humans is greatest in this region.

Laotian government officials reported to the W.H.O. within hours on a weekend last September the country's only suspected human case of bird flu so far. A lab in Japan determined it was a false alarm.

The quick notification was one of several signs that Laos does not appear to be concealing any bird flu cases, although it may be hard at times even for the government to determine what is happening in the one-third of Laotian villages that lie a day's walk or more from the nearest road of any sort, said Dr. Dean A. Shuey, the top World Health Organization official in Laos.

Dr. Shuey's aunt and grandmother died in the Spanish influenza outbreak of 1918, which scientists now attribute to another avian influenza virus. Despite that family history, Dr. Shuey of Nebraska says he worries that too much emphasis now on bird flu may create problems for Laos's health system.

"The intense donor meetings, the number of conferences, the travel is taking a lot of time for people who have other things to do," he said.
The United States, Japan and the European Union have donated advanced virus freezers and other high-tech gear to help Laotians gather any viral samples and ship them to labs in rich countries as fast as possible, where they can be analyzed for the possible creation of a vaccine.

But with flu vaccine production capacity short in industrialized countries, no one expects Laos, with no vaccine factories, to receive more than a few doses of any vaccine.

American aid has included hundreds of sets of masks, goggles and full-body suits that would be sweltering in the tropical climate here and that have limited use except for slaughtering sick birds.

Dr. Phengta called for general-purpose protective equipment. Health workers in Laos now receive only one gown and one surgical mask each year.

Laos, Apparently Without Bird Flu, Is Still Pressed by the West to Join Global Fight - New York Times