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Last thoughts on the cost of public health (Turkey)

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  • Last thoughts on the cost of public health (Turkey)

    (an intentional dup is posted in GR's backyard flock thread)
    http://www.turkishdailynews.com.tr/a...?enewsid=64079

    Wednesday, January 17, 2007



    CALEB LAUER
    ISTANBUL - Turkish Daily News



    Ali, a young man who worked in a Doğubayazıt internet caf?, said his mother loved her chickens so much that during the bird flu outbreak here in 2006 he had to wait until his mother was out of the house before he called the government to come and kill the chickens.

    At around the same time, the Food and Agriculture Organization of the United Nations (FAO) reported that a village chief who had similarly called the authorities said that, ?Our women were really angry with us for calling authorities. I even had to leave the village for a couple of weeks until things blew over.?

    Yaşar, a hotel manager in Van, recalled the flip side of the mass cull in Doğubayazıt and Van that was designed to stop the spread of the bird flu virus. The outbreak would end-up killing four local children. ?[It was] very voluntary. They would give their poultry to the government. Even at my home, I had nine chickens. I gave them to the government. They were very healthy, but honestly, I didn't like them anymore.?

    In a restaurant, Baran, a local translator, wouldn't eat the chicken. He said it made him nervous. But taxi drivers laugh and brush their hands together at any mention of ?Kuş grippe.? Ali said, ?People aren't scared anymore.? When told of Baran's fear of eating chicken, Ali laughed and couldn't believe it.

    ?The public awareness of chicken danger has changed,? Yaşar, the hotel manager, said. ?Before people wouldn't do anything with sick chickens except eat them. Now they won't even touch them. Everybody in this area realizes that if a chicken is ill they will not touch it. Now they get rid of it. Even the children, they will never.?

    But some villagers still keep chickens, secretly and illegally. Dr. Ahmet Faik ?ner of Y?z?nc? Yıl ?niversitesi Hospital in Van, where most bird flu victims received care during the outbreak here, said only 95 percent of the chickens are gone. Yaşar guessed every thousandth household might still keep some chickens.

    Baran was more declarative. ?Yes,? people still keep chickens, he said. ?They have to.? No one in the city keeps chickens, he said, because it is too easy to get caught. But in the villages you can still find chickens.

    ?People in Doğubayazıt, they are not rich, they're poor people,? said Ali.

    ?They'll open a little shop or a small market to take care of their family and when the bird flu came, they couldn't sell chicken, or the chicken they had they had to throw away and they really lost a lot of money.?

    Take me not my chicken:

    The Turkish government did eventually give money to chicken owners who handed over their chickens, once the owners applied for compensation.

    The government paid ?market prices? for each bird: about YTL 6 per chicken or duck, YTL 17 per goose, and YTL 23 for a turkey. But the FAO estimates that the eggs, chicks, and meat from a single chicken might yield as much as a 700 percent return per year on costs. By this estimate, a family who handed over 10 chickens during the cull and was compensated YTL 60 gave up YTL 420 of income for the year ? the ?give a man a fish and he eats for a day, teach a man to fish and he eats everyday' proverb dumped on its head. Baran said some villagers, in a theatrical protest, offered their necks and a knife to authorities in place of their chickens.

    Since the current global outbreak of bird flu began in 2003, authorities in different countries have been trying to figure out the best way to compensate people for handing over their poultry during a mass cull.

    Promise too little compensation, or none at all, and farmers will hide their chickens. Promise too much compensation and farmers may have an incentive to infect their flocks.

    Still, a cull of all local poultry is considered the most effective public health emergency measure against bird flu. Hong Kong may have prevented a pandemic in 1997 when they killed all chickens (1.5 million) in the city inside of three days.

    Making it work:

    Dr. Nikki Shindo arrived to Van on Jan. 6, 2006. She was part of the World Health Organization (WHO) response team in Turkey during the outbreak. Dr. Shindo is an infection control specialist and she advised local doctors on how to protect themselves from the H5N1 virus and advised how to control infections within a hospital.

    ?The WHO cannot just come into a country and order doctors around, we need to be invited,? said Dr. Shindo from Geneva. ?Turkey has a basic public health response capacity and a country like that may want to try to manage the outbreak alone. But Turkey's invitation came immediately.?

    When the WHO gets to a country ?we need to learn culturally and socially acceptable ways of implementing infection control measures,? Dr. Shindo said. ?In an outbreak, the WHO's mission is to reduce human suffering and contain the outbreak.? She said that unless there are already contacts made, getting to know the people and the local medical culture uses-up valuable time. It is important, says Dr. Shindo, to establish relations ? trust-building ? beforehand so there is a history and familiarity between WHO officials and local medical professionals. This is a lesson of emergency management mentioned by veterans of emergencies like Sept. 11, 2001 ? whose numbers you have in your mobile phone can determine how effective you'll be. Personal contacts move information and get things done as much as established protocols.

    After the last confirmed bird flu infection, the WHO team waited for two full incubation periods before they declared the area clear of bird flu.

    (When someone is infected with the bird flu virus the virus incubates before symptoms show up. The exact period is debated, the WHO says the best guide is seven days.) After the outbreak, WHO teams stayed in Van to organize training to improve future responses. Poverty may make future responses worse.

    In eastern Turkey, water sanitation and waste management are inadequate, says Dr.?mit Sahin, a public health specialist in Istanbul, but the basic problem, he says, is the lack of a real public health system in eastern Turkey, one that would emphasize surveillance and prevention, not just treatment.

    Under Turkish health reforms, Dr. Sahin says, all treatment is becoming privatized. ?The government doesn't call it privatization, they call it reform,? says Dr. Sahin. ?If you don't have access to free and public health it's up to the money in your pockets,? Dr. Sahin said this is especially consequential for children's health and pregnant women. Poor people will simply not be able to afford being inside a hospital.

    This will have serious consequences for surveillance efforts designed to detect the next bird flu outbreak.
    Dr. Shindo, of WHO, says that along with public awareness the most important element in a public health strategy against bird flu in humans is having a well-connected and well-informed ?sentinel? hospital such as Y?z?nc? Yıl ?niversitesi Hospital in Van. These are the hospitals that receive reports of suspect illnesses from surrounding hospitals and issue warnings and updates to the medical community.

    For a similar reason, the WHO maintains contact with Y?z?nc? Yıl in order to monitor any new cases of severe acute respiratory illnesses (SARI).

    During the bird flu outbreak, doctors at Y?z?nc? Yıl were aware and watchful enough that they could appreciate the cases of mystery illness in neighboring Doğubayazıt for what they were, before they were diagnosed. When the Ko?yiğit children arrived to Van, Dr. ?ner and his team could immediately begin treating them as bird flu patients and send out warnings and watch lists to other hospitals. This probably saved lives. But if sick people aren't getting into the hospital because they can't afford to get inside, then poverty will have rendered a good surveillance system shortsighted.
    "The next major advancement in the health of American people will be determined by what the individual is willing to do for himself"-- John Knowles, Former President of the Rockefeller Foundation
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