It’s an uncomfortable
experience, watching Red Cross volunteers hand out literature
on avian influenza amid the flashing blades, gore and giblets
of a poultry market in rural Indonesia. The traders give Rahmet
Encep and his leaflets a frosty welcome despite the sweltering
heat in Parang Kuda market, three hours’ drive south
“Always wash your hands after touching meat.”
“Don’t store different types of meat together.”
Rahmet hurries from stall to stall, trying to deflect the
angry glares that make it clear he’s as welcome as an
environmentalist at an oil baron’s ball.
The inconvenient truth that Rahmet is peddling is that over
80 people have died from bird flu in Indonesia infected from
ingesting contaminated meat, handling infected birds or getting
germs from bird droppings. And he’s trying to get public
hygiene messages across to chicken vendors on tight margins.
Eventually, he seems to have an epiphany, or at least remember
his training. He stands up straight and addresses a young
butcher in a clear, confident, friendly voice. It seems to
do the trick as 23-year-old Lucas Naryani takes a poster,
depicting a succulent piece of fried chicken next to practical
health advice, and pins it to the wall of his stall.
“I wash my hands three, five, maybe seven times a day,”
says Lucas, although there is no running water (or refrigeration)
at his stall. “All the chickens that come in the morning
are sold today or thrown out. I know how to keep meat safe,”
says this graduate of the local tourism school.
“But I don’t know what to do if I get sick from
avian flu. We get information on TV and the radio but it’s
not enough. Where can I get medicine? How much does it cost?
You should be going face to face with the public, not just
talking to the chicken sellers.”
Down the road, the Chianjar Red Cross branch is doing just
that, and has an easier time of it. Led by Hari Hiddayya,
fellow volunteers Cecen Suryana and Dewi Lesnasar help take
the campaign into schools and village halls. Their style is
interactive, and they have everyone, from kids to pensioners,
alternating between sage nods, riotous laughter and mobbing
the presenters for the posters, leaflets and health education
material disguised as games like snakes and ladders.
“The interaction is so important,” says Dewi
Sitompul, the International Federation’s avian influenza
programme coordinator, as we drive to an inter-agency meeting
that will draft Indonesia’s pandemic preparedness plan.
“There’s no point in just handing out leaflets;
we have to really engage with the communities. We are targeting
housewives who deal with chicken every day. We are reaching
out to the sellers, and we target kids who play in the dirt
or shoot and kill wild birds for fun.
“When you look at the message of the [Red Cross] campaign
it’s basic public hygiene. It’s applicable to
all health epidemics because it’s basic hygiene promotion.
A lot of people think we are OK because being Muslims we wash
our hands five times a day but we have to reinforce the message
that you have to wash your hands every time you come in from
Her colleague P.G. Jenssen, the International Federation’s
health coordinator in Indonesia, notes that the country’s
high case fatality rate (81 out of 102 cases, compared with
a global rate of under 60 per cent) is a mystery that needs
“Are doctors able to recognize avian influenza early
enough? Are patients seeking help promptly? Are people hiding
sick animals to avoid having stocks slaughtered? And the whole
question of adequate compensation to farmers that have lost
their stocks needs to be constantly monitored,” he says.
One of the biggest challenges in Indonesia is geography.
The country is huge, and people live on thousands of islands
scattered between the Andamans and Australia. This makes the
Indonesian Red Cross Society essential to the national prevention
and preparedness work, says Lily Sulistyowati, head of public
communications at the Indonesian Health Ministry.
Treading a fine line
Sulistyowati is also vice-chair of COMNAS, the national committee
of human influenza pandemic preparedness. She hopes that with
the new draft plan Indonesia will be ready for a pandemic
“The Red Cross has been very supportive,” she
says. “We need their volunteers to do the social sensitization,
to spread our four messages — wash hands, separate birds
from humans, cook poultry well and report any signs of infection
to the head of your village.”
The work is crucial, with one expert warning, “If the
flu mutated and moved into the human population in Indonesia
we would be in big trouble. What we have now is close to chaos.”
The plan includes sensitization of health workers, seen as
a particularly important aspect — a newspaper on Sumatra
reported that the body of someone with avian influenza was
left in an ambulance overnight before being handed over to
The Red Cross Red Crescent has a fine line to tread: keeping
bird flu front and centre whilst refraining from panic-mongering
or “crying wolf”, as the International Federation’s
special envoy for avian influenza, Pierre Duplessis, puts
it. He puts the lack of headlines down to the simple fact
that the virus has not proved itself very adaptable to the
human body. But the situation, while encouraging, is still
“We have a little break just now,” says Duplessis,
“which is good, and it allows us to carry on refining
our preparedness and prevention work. If we can limit the
pandemic in birds, then down the road we might be able to
say H5N1 is gone.
“But there is still significant viral activity (widespread,
mutating viruses) in the environment; in Indonesia there have
been 2,000 separate pandemics in birds since 1998. We have
to remember that a human pandemic is overdue; there were three
in the last century so we mustn’t let our guard down.”
Duplessis believes that the International Federation and
its National Societies have come a long way in their avian
influenza programming since 2005, when the World Health Organization’s
(WHO) special representative for avian influenza, Robert Nabarro,
warned the General Assembly in Seoul that between 5 and 150
million people could be killed in an avian influenza pandemic.
“It would depend on the magnitude of the outbreak,
but I believe the International Federation and its National
Societies would respond well. It would be a major disruption
of course, and if the absenteeism rate of our staff went up
to 40 per cent then it might affect all our work,” says
Miro Modrusan, avian influenza programme manager with the
International Federation, agrees. “If we are to respond
successfully to a large-scale pandemic, everybody involved
needs to know who is doing what. We need to look at things
holistically, and we have not gone far enough down that road.
Everyone agrees that there is a high likelihood that a pandemic
will develop sometime over the next ten years, but no one
can predict when, where or on what scale. This proposal is
all about getting ready and defining National Society roles
in national plans.”
Although governments are taking measures to address the threat
of avian influenza and human influenza pandemics, the virus
that is circulating in Asia, Africa and Europe is of particular
concern in poorer countries, where due to insufficient infrastructure
to cope with the magnitude of the problem, as well as the
tradition of poultry rearing in the backyard, it is difficult
to implement prevention and control measures, including comprehensive
poultry vaccination and other bio-security measures.
Strengthening public health
“We can isolate key steps that we know will help us
manage the challenge of a pandemic,” notes Keiji Fukuda,
head of the WHO’s influenza programme. “One of
the biggest benefits is that investments in strengthening
the overall public health capacity will allow us to invest
limited resources effectively and build protection against
other public health threats.”
The WHO checklist for influenza pandemic preparedness planning
describes key steps member states can take to evaluate their
preparedness, including surveillance systems, case investigation
and treatment, vaccine and antiviral programmes, and plans
to maintain essential services.
“One critical key to pandemic preparedness is the broadening
of participation outside government public health authorities,”
says Fukuda. “A pandemic represents a societal challenge
whose impact will be felt beyond the health sector and therefore
by extension, preparedness demands the involvement of multiple
sectors. The efforts of the private sector as well as specific
organizations such as the Red Cross Red Crescent will play
a crucial role in helping manage a pandemic.”
The primary goal for public health is to make sure people
and countries are as prepared as possible for a pandemic.
One of the critical roles for media is to keep the public
“As with any longer-term public health risk, we should
expect media profile and even risk perceptions to vary. It’s
normal to see behavioural adaptation over time to an elevated
public health risk. Communities tend to adapt and get on with
life,” says Fukuda. But the fact is, although media
reporting may wax and wane, the risk itself and dangers posed
by a pandemic have not changed and in the estimation of WHO,
the threat of a pandemic remains elevated.
“A straightforward and open dialogue on what we know,
what we don’t know, and what people and partners can
do to help manage this risk is the most effective communications
strategy — through periods of intense interest, and
otherwise,” says Fukuka.
Risks of panic
Up to now, there are no confirmed human-to-human transmissions
of H5N1 — only highly suggestive family clusters. Yet,
if human transmission occurs, the impact from the pandemic
may be immense. WHO estimates that, based on the scenario
of a mild pandemic, mortality could range from 2 to 7.4 million
deaths worldwide. According to World Bank estimates, the next
pandemic might cost the world economy US$ 800 billion per
There is no reliable treatment or vaccine and, faced with
a human influenza pandemic, health authorities will have to
rely mainly on public health measures such as health education,
quarantine and case management. It is highly likely that in
the event of a pandemic, the greatest impact may arise not
from the number of cases and deaths, but from the economic
and social consequences of the general public’s panic
reactions to avoid infection.
This is why, notes Amgaa Oyungerel, an Asia-based International
Federation regional health delegate, the private sector has
taken a lead in “business continuity”. She dismisses
suggestions that the investment in avian influenza and human
influenza pandemics leads to the neglect of diseases like
malaria or measles, which are actual, rather than hypothetical,
“A devastating pandemic would reverse much of the economic
development we have seen in recent decades,” she says.
“It’s not surprising that governments and businesses
want to prevent it happening. And the money that is being
pumped into avian influenza and pandemic research is new money.”
Not prepared enough
Oyungerel says that the focus on bird flu has already had
notable benefits to health systems in South-East Asia, particularly
in Viet Nam and Thailand. From a standing start three years
ago, the latter has become one of the regional leaders in
the field of blood diagnostics for influenza. But she cautions
that vigilance is the best form of preparedness, recalling
that 90 per cent of diseases come from the animal world. People
are also living in closer contact with animals as when they
migrate from the countryside, they bring their animal husbandry
practices (such as keeping poultry in their yards) with them.
Meanwhile, animals are kept in ever-higher densities.
“World preparedness is not satisfactory, even though
considerable progress has been made in containing avian influenza
as a potential cause for the human strain in certain countries.”
Campaigns can help strengthen public health systems in general,
says Oyungerel. “Too much emphasis still is placed on
the medical issues such as vaccines, antivirals and so on.
We are advocating for more community-based and public health-oriented
preparedness and the establishment of better prevention mechanisms.”
A further risk is the increasing consumption of chicken and
ducks, she says. “As the economies of countries like
China grow, people have more money to vary their diet, and
as a result are consuming more poultry.”
Certain groups might be hard hit. ICRC doctor Eric Burnier
says “one of ICRC’s roles would be to remind governments
of their obligations to especially vulnerable groups such
as prisoners and internally displaced people”.
Were a human-to-human pandemic to occur, traditional international
assistance mechanisms would probably not be feasible (because
of border closures and travel restrictions), leaving the affected
developing countries to cope with negative consequences on
their own. It is also highly likely that the world’s
attention would be diverted to dealing with the pandemic,
so any parallel natural disaster or complex humanitarian emergency
would be neglected.
Despite the need to avoid whipping up panic, tough decisions
may ultimately have to be taken by governments and other agencies.
Words like “containment” and “quarantine”
have a sinister ring for civil libertarians, while for those
dealing with an epidemic in a crowded city they may seem the
most sensible options.
Through the preparedness campaign, the International Federation
is finding that there are unexpected opportunities for work
which might not otherwise have been undertaken.
Its International Disaster Response Laws, Rules and Principles
programme is carrying out pioneering work on legal preparedness
that might be used to help governments act in large-scale
disasters and widespread outbreaks of communicable diseases.
“There’s been a lot of talk about contingency
planning and business continuity but not much discussion about
the legal issues around control that could arise during a
pandemic,” says the International Federation’s
International Disaster Response Laws coordinator, Victoria
Bannon. Vital international support could be hampered by a
lack of legal recognition for foreign aid organizations; customs
and tax requirements could delay medication, relief goods
and equipment; visa complications could hinder aid workers;
and a lack of recognition of foreign professional qualifications
could stop them from helping in an emergency. Coordination
and information-sharing between response agencies might also
be lacking, as well as adherence to human rights, humanitarian
principles and standards of quality and accountability.
“We are preparing guidelines for how to work in non-conflict
emergencies, looking at legal preparedness at a national level,”
A pilot study is being prepared Cambodia, involving WHO and
the International Federation. “Our study in Cambodia
has three main categories,” says Bannon. “First
is national response, how the government will respond. It
may be that our study will show that some things we see as
problems may not be.
“Secondly we are looking at legal arrangements, like
how to transport medicines across borders, or the whole issue
of containment and how humanitarian workers will be able to
operate if there are restrictions on movement.
“The third area is the consequences of a government
declaring a state of emergency: what would be the ramifications
for private hospitals, how would quarantine work and so on.
SARS [Severe acute respiratory syndrome] threw out a lot of
moral and legal dilemmas,” Bannon notes. “This
pilot study will help us answer some of them.”
International Federation special envoy Duplessis is candid
when it comes to the awkward question. The millennium bug,
SARS and now avian influenza. All this preparedness, is it
all just jobs for the boys, quangoism? Is it all just a big
waste of money and emotion for something that may never happen?
“In the relief business,” he says, “we
don’t know where the next disaster is coming from. It
could be an earthquake, a flood, an act of terrorism, we just
don’t know. But we do know that there is a major threat
out there from avian influenza, so the sensible thing to do
is to be prepared. It’s certainly not a waste of resources.
We are better prepared to respond to all pandemics now; we
are learning a lot through our avian influenza work.”