HHS - Journal: Putting a Face on Avian Influenza

In mid-October, Secretary Mike Leavitt led a combined U.S. and international delegation of health experts on a 10-day, 5-nation trip to Southeast Asia. One purpose of the trip was to learn from countries that have first-hand experience in dealing with Avian Influenza.

On Saturday, October 15th, we drove about three hours out of Hanoi to the Vietnam’s third largest city, Hai Phong. It has about 1.8 million people. I wanted to get out of Hanoi to get a feel for other parts of the country. I also wanted to visit the commune/village where a family of five came down with bird flu late March. I think it was their case that caused me to conclude that we needed to begin having flu briefings every day in the Secretary’s office. I had followed their case closely and thought meeting them would be a way to put a face on Avian Influenza.

This is our meeting in the offices of the Hung Dao commune/village. Note the statue of Ho Chi Min. The man standing is the Director of Public Health for the Province. Next to him is the Chairman of the commune. On the Chairman's right is the Doctor in the village.

During the morning we had meetings with senior officials of the government, visited HIV-AIDS counseling centers that HHS supports financially, and then visited a hospital. We had lunch with the Vice Chairman of the Hai Phong Province; talked about their economic pitch to outside investors and then set out to find the family of five.

The Vietnam government is organized in a highly hierarchical way. The country has 64 Provinces. The provinces are divided into Districts; the Districts into Communes; the Communes into villages.

Each level of the system has a People’s Committee, which is essentially organized and run by the communist party. One rises through the party by demonstrating loyalty and competency within the party.

From left to right: The Chairman of the People's Committee of the commune, the village doctor, a member of the steering committee, and me. We are in front of the meeting place for the village.

Nguyen van Voi is young, articulate and sure of himself. He is head of the People’s Committee for Hung Dao, a small village commune on the outskirts of Hai Phong. He appears to be a comer in Vietnam’s communist style party system. The small meeting room at the offices of the commune where we met featured a bust of Ho Chi Min, and the flag of the Communist Party.

He described March 9, 2005, the day he got a call any mayor would dread; the H5N1 virus had found its way to Hung Dao.

We sat on a square of wood flooring that appeared to be the conversation place. Mr. Son greeted us by offering tea and smoke from a water pipe. The little girl on my lap was one of the victims who became sickest in the village.

Suddenly, all the briefings and discussion about Avian Influenza were no longer ethereal. Poultry, primarily chickens and ducks were dying in hundreds of pens that surrounded the tiny homes and shelters of his people.

Voi reported the news to the District, then on to the Provincial Health Director, Dr. Nguyen Van Vy. The People’s Committee Steering Committee, a 15-person group made up of different party interests that govern the commune had previously given instructions and news through the party mechanism for months about Avian Influenza. Dozens of Vietnamese citizens in other regions had contracted the disease in the past year; many had died. With the entire world watching, the Vietnam government was mobilizing to be ready but Dr. Van Vy described the call as a shock.

By March 12th they were culling and killing flocks. More than 8,000 birds were killed. None were in poultry farms; these were subsistence farmers with flocks of 100 to 300 chickens used for their own protein and to contribute to the $700 average annual income they used to make a life for their families. In addition to killing the birds, villagers worked together to spray chemicals and spread lime, a traditional Vietnamese way of disinfecting.

Vu Van Son and his wife live in Hung Dao with their three daughters. The two met at a community event, married 12 years ago when both were age twenty-four. By my observation they appear to be slightly more prosperous than some in that area, probably because of their ingenuity, a trait illustrated by a complicated freely suspended winding staircase that Mr. Son engineered himself in the main room of his home.

Getting to the simple narrow and stylish home they built with their own hands is easy enough. It’s a quarter mile down the main road from the commune office, requiring only a two-turn diversion on dirt alleys that barely accommodate an automobile. We were greeted by Mr. Son and two of his three daughters. The oldest is seven, the younger four. The baby is asleep in the only room on the second floor.

The Sons physically built their home and are extremely proud of it. It has only two large rooms on the ground floor and one room in the upstairs. Note the suspended stairway and the design. Keep in mind that these are people of extremely modest means.

It was obvious they are a hard working couple. They raise poultry and pigs and grow rice, which they make into wine to be sold at a local restaurant. Their world seems to revolve around the tiny 20-foot by 80-foot dot of land on which they combine their home and economic activities and what I presume is the average 400 square meter plot of rice most Vietnamese families cultivate.

Mr. Son is a happy, warm man who warmly welcomed us to come into his home and invited us to sit down. There is no furniture in the room other than a television and stereo. We sat on a small square of wood flooring that is obviously the talking place. He offered us tea from a little pot that sat in the middle of the floor and began to fire up a water pipe that is generally passed among guests. He set it aside when someone whispered to him that one of his quests does not use tobacco.

I really fell for this little girl. She was extremely sick along with her father. She has recovered completely.

The People’s Committee Chair and Director of the Provincial government then joined us as did Michael Marine, the U.S. Ambassador. Mr. Son’s four-year old daughter came into the room. She is a stunningly beautiful little girl with soft dark eyes and jet-black hair. There was a rubber band on the floor and I picked it up and twisted it in a funny shape to attract her attention. Soon she sat down on my lap and listened to us talk.

Mr. Son’s mother in law, who lives separately but spends most of her time there, wandered in and out of the room, listening from a distance. Finally, Mrs. Son joined us, and using the Ambassador’s interpreter, we settled into a conversation.

I instantly liked both Mr. and Mrs. Son. She is quick with wit, and seemed completely at ease, interrupting our conversation several times to direct child traffic. He is quieter but has a confident feel about him.

Alternating back and forth with details, the Sons explained that they were among those with birds that died. They had 300 birds living in pens that were stacked to the ceiling of a 12-by-20 concrete shed behind their home. Their birds began dying on the same day many others in the village began to report loses.

Mrs. Son described how painful it was for them when the Steering committee ordered all the poultry in the village killed. The chickens were a significant part of their livelihood. It was true for many in the village.

Since only five of the chickens had died, and the others seemed healthy, they made a decision to eat as many of the chickens as possible so they wouldn’t be a complete waste. They invited family and friends over to eat with them, knowing the meat would otherwise go to waste. The processing was done in the small area right outside their back door. I feel certain on the day Mr. Son killed the chickens the children were running in and out of the area just like they were the day we were there.

The Sons and the others in the village who lost poultry were compensated the equivalent of $.50 per chicken, which is only a small portion of their value. He also had ducks but they were not subject to the kill order.

This is in back of their house. Until recently he grew ducks in this space but he has now replaced them with pigs. He borrowed money from a bank to buy the pigs.

Seven days after the chickens were killed and processed, Mr. Son became nauseated, developed a fever and a cough. He went to a village medical clinic. Fortunately, the clinic was looking for people with his symptoms because of the H5N1 presence, and they began to observe Mr. Son closely.

Within a two-hour period, he became violently ill. The cough, he said, felt as though “he was throwing his lungs up every time he coughed.” Soon he was in excruciating pain along his sides and rib cage. He described his condition as “completely losing control.”

Two hours later, their four-year old daughter began to manifest the same symptoms. They were in crisis. His description of the pain and trauma was eerily familiar. It sounded like a passage from John Berry’s book on the pandemic of 1918, The Great Influenza.

The village doctor, Dr. Do Thi Tham, is a petite woman I would guess to be in her late thirties or early forties. Dr. Tham was at the commune meeting with me earlier and had explained that she immediately suspected it could be Avian Influenza. The problem is, Avian Influenza manifests with the same symptoms as many other common illnesses; things that she would send home with a hand full of Advil and instructions to rest and drink fluids (my words, not hers).

Once the more serious trauma started, Mr. Son, and I believe the daughter were taken to a hospital in Hai Phong. I had visited the hospital earlier in the day to observe an HIV-AIDS program. It is a typically Spartan facility with little or no equipment. At that point, the National Institute of Health and Epidemiology (NIHE) stepped in to take over the case. I had visited NIHE the previous day for different reasons and met Mr. Huem who had supervised the investigation and treatment of most of the other cases in Vietnam.

NIHE arranged for Mr. Son and the daughter to begin taking Tamiflu and began supervising the treatment.

I asked Mr. and Mrs. Son how they felt when they found they had Avian Influenza. Mr. Son said, that he was unconscious and did not know it until he began to improve two days later. Mrs. Son described her horror of her husband and child both on the verge of death. She then explained something quite relevant to general dilemma Avian Influenza presents. She was preoccupied by getting money to continue their care. She did not know the care was going to be paid by the government and assumed that unless she had money they would stop treatment and they would die.

Mrs. Son described frantically calling family; anybody she thought would help. The only asset they had that could be liquidated was the chickens and they were gone.

Her comments point out again how critical poultry is to subsistence farmers and how counterintuitive it is for them to abandon their current practices. It also illustrates the desperation people will feel in a mass pandemic when adequate health care is not available or affordable.

We brought puzzles as a gift. The children were delighted.

A day or two later, Mrs. Son and the other two children began to manifest symptoms. By that time Mr. Son and the daughter were beginning to improve. It is not clear to me whether Mrs. Son and the two children were not as serious because they got Tamiflu earlier or if they simply weren’t affected as severely. Dr. Fauci, the Director of the National Institute for Allergy and Infectious Diseases, who was on the trip with me, explained that there is a wide range of response to Avian Influenza. Some have violent and deadly reaction; others are just miserable for a while. One fact that is often ignored in the discussion of a pandemic is that most people do recover.

When we finished our conversation on the floor of the house, we walked into his small animal area. There was a large pile of rice on the ground, covered with flies. It was food for the pigs that had replaced the ducks. Mr. Son was able to finance the pigs at the bank, he told us.

The Son family's neighborhood; our visit gathered a crowd. The Vietnamese people seem gentle and kind. Over half the population is under 30 years old. They like Americans and have put the war behind them.

We inspected the small building that held the chickens before. It is now empty. Mr. Son says he will no longer raise chickens.

We had some small gifts for the children, took pictures and visited for a while. A significant group of adults and children had gathered, made curious by our visit. One man made a comment about the “bird flu family.” It was made in a way that lead one to believe there may be a little resentment about the attention they have received.

In parting, I attempted to explain to the Sons how the world had focused on their little home. I said, “I feel sure the people of Vietnam were watching and praying for you, but you should also know that you were in the thoughts of people all over the world, including the President of the United States. He was briefed more than once on your situation and condition. We are all glad it turned out so well.”