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Battling a Virus and Disbelief
Sumatran Villagers With Avian Influenza Turn to Witch Doctors
By Alan Sipress
Washington Post Foreign Service
Wednesday, August 30, 2006; Page A12
JANDI MERIAH, Indonesia -- Dowes Ginting, the most wanted man on Sumatra island, lay dying. He had abandoned the hospital where he had seen his relatives succumb one after another, and he had fled deep into the mountains, trying to outrun the black magic he feared had marked him next. For four nights, witnesses recalled, a witch doctor hovered over him in a small clapboard home, resisting the evil spell.
Ginting, a wiry 32-year-old, had watched disease burn through his family over the previous two weeks, killing six and sickening two others, including himself. International health experts grew increasingly concerned when laboratory tests confirmed they were sickened by bird flu, the largest cluster of the disease ever recorded. But Dowes feared medical treatment more than he did the flu. And so he ran, potentially exposing villagers across the province to the highly lethal virus.
In the end, the outbreak in May did not presage the start of a worldwide epidemic. But the enormous difficulties that Indonesian and international disease specialists confronted in investigating the outbreak and protecting against its spread raised fundamental questions about whether bird flu could be contained if it mutated into a form more easily spread among people.
"If this were a strain with sustainable transmission from human to human, I can't imagine how many people would have died, how many lives would have been lost," said Surya Dharma, chief of communicable disease control in North Sumatra province.
Officials from the World Health Organization, drawing on sophisticated computer modeling of a theoretical bird flu outbreak in Southeast Asia, have suggested that a pandemic could be thwarted through a rapid containment effort in the affected area, including the right mix of drugs, quarantines and other social controls. To succeed, the antiviral drug Tamiflu would have to be distributed to 90 percent of the targeted population, roughly defined as those within at least a three-mile radius of each case. The drug would have to be administered within 21 days from the "timely detection" of the initial case of an epidemic strain. Residents would have to stay home, limit contact with others and take the medicine as prescribed.
In the case of the North Sumatra cluster, almost none of this happened, according to extensive interviews with health officers, family members and villagers in several areas of the province. The underlying problem was that most family members and many villagers were convinced that black magic, not flu, was to blame.
"How can you ever get people to cooperate if they don't even believe you?" Dharma said.
Tracking the Flu's Path
Scientists are still working to determine how bird flu is transmitted to and between humans. More than 200 people worldwide have contracted the deadly H5N1 strain of the virus since 2004. Most of the cases have resulted from direct or close contact with infected live or uncooked poultry, or with surfaces contaminated with secretions and excretions from infected birds.
Health investigators have concluded that the eight-person cluster in Sumatra began with Ginting's older sister, who fell ill in late April. They suspect she was infected with bird flu from live chickens sold in a market where she peddled oranges, limes and chili peppers, or from contaminated poultry droppings in manure used in her garden. She died and was buried before any samples were taken to confirm bird flu.
Several days after she became sick, the extended family gathered in the village of Kubu Sembilang for a feast of roast pig and chicken curry to celebrate the annual harvest festival. That night, many of the relatives slept in the same small room with the sister, who had developed a serious cough. By the time she died, a sister, a brother, two sons, a niece and a nephew had become ill. Flu specialists said the final victim, Dowes Ginting, in turn likely caught the virus from his infected son.
Health experts have concluded this was the first time the bird flu virus was passed from one person to another and then on to a third person.
"None of us thought it was bird flu. We thought it was black magic," said Anestia Tarigan, the wife of the youngest Ginting brother, Jones, the only victim to survive. "Everyone in the family was getting sick and no one else was. Someone had put a spell on our family. Black magic is very common in our place."
Indonesian and WHO investigators discovered that many residents in Kubu Sembilang were unwilling to share information or give blood samples that could reveal how widely the virus was circulating. Many villagers believed that claims of bird flu were a lie. Some even threatened the investigators. When a team of officers first arrived from the provincial health department, they were warned by their local counterparts that it was too dangerous to enter the village.
"We chased them away," said Hendra Tarigan, whose wife, one of the Ginting siblings, died. "Each time they came back, we gave them no information. We just told them to leave."
Despite a concerted effort to collect blood specimens, investigators were able to take samples from only two people in the village, including the local midwife, said Diana Ginting, chief of the district health department, who shares a common surname in the region.
Indonesian health officials working with an international team returned day after day to the village and made grudging progress. They recruited 20 local volunteers to monitor fellow residents for fever and set up a temporary health post on the soccer field offering free medical care. The investigators methodically pieced together the chronology of the outbreak. They traced those who had contact with the victims and provided them with Tamiflu.
But many of those closest to the Gintings refused to take it, according to interviews with villagers in Kubu Sembilang and nearby Jandi Meriah.
"The doctors gave us Tamiflu, but we didn't take it," said Mamajus Boru Karo, 38, a relative of the Gintings, scrunching up her face as she retrieved the unpleasant memory. "We should we take it? We don't have bird flu."
'I Was Losing Hope'
At the hospital in the provincial capital, Medan, members of the Ginting family were proving uncooperative. More than a dozen relatives had come down from the mountains. They had been sent there by a smaller clinic, and they remained unconvinced that bird flu was what ailed them.
They initially balked at taking Tamiflu or receiving injections of antibiotics, doctors said.
"They tried to refuse all treatment," said Nur Rasyid Lubis, the hospital's deputy director. "We could treat them only because their condition made it impossible for them to resist. But if they had been healthy enough to walk, they all would have run away."
Jones, the youngest sibling, did just that.
"I was losing hope. I thought I was going to die," he said in a raspy voice, his stare blank beneath thick eyebrows and his cheeks sunken. He had once been a young tough, but his arms and legs, covered with elaborate swirling tattoos of red and green, had grown scrawny after more than two months of battling the disease.
Jones Ginting fled the hospital, moving around Medan and the Sumatran highlands despite his fever and increasing difficulty breathing. He returned after villagers told him that the police were looking for him and might arrest him.
But he continued to resist treatment, initially refusing to take medicine or give blood samples, and threatened to attack the nurses with his fork. Finally, doctors reached a deal with family members, allowing them to invite a witch doctor to the hospital in return for blood specimens from Jones Ginting.
Agenda Purba, a witch doctor from Jandi Meriah, traveled six hours by van to the hospital. It was midnight by the time he started the ceremony in the special bird flu ward, he said.
Purba chanted over 21 betel nut leaves, each about the size of his calloused palm and filled with blossoms, a pasty white lime, brown chunks of an astringent and bits of an orange-colored nut. He prayed for the young man's recovery. Then Purba lifted the first of the leaves to his lips. He chewed, puckered and softly spit onto Jones's forehead. Bending over the patient, he gently blew the slime over the flesh. The witch doctor lifted the second leaf, chewed it and spit it onto Jones Ginting's chest, repeating the process. He continued until he had finished the leaves, slathering the torso, arms, legs, hands and feet, alternating between left side and right, making sure to cover all the joints.
None of the staff at the hospital ever cautioned Purba that he might be exposing himself to a killer disease, he said. No one suggested he take Tamiflu. No one sampled his blood or monitored his health. But had they tried, Purba said, he would have considered it silly.
"I'm the one to save Jones," he said. He grinned, baring a mouthful of teeth stained black by decades of betel nut. "There will be no more casualties. Seven is enough. I drew a border around them at the hospital." Purba stood up to demonstrate and etched a line in the dirt with the tip of his flip-flop. "It stops here," he said, "because I protected the family with my magic line."
A Turn for the Worse
When Dowes Ginting developed a fever and began coughing, he fled in search of a witch doctor, just as his younger brother had done a week before.
In the home of another medicine man in Jandi Meriah, Suherman Bangun mumbled the unintelligible words of an incantation over Dowes, recalled the healer's wife and Dowes's relatives, who had helped him while he was in hiding from the health inspectors. The witch doctor doused Dowes with cooking oil and massaged his aching muscles. He put a hefty chunk of betel nut in the corner of his own mouth and chewed, his lips turning red from the juice of the mild narcotic, and then with surgical precision spit the concoction bit by bit over his patient's head, face and chest and along his extremities. To control the surging fever, the healer pounded a bowl of rice laced with galangal ginger, applying the pasty preparation called beras kencur to the man's sweaty flesh.
After three days, Indonesian and international health investigators tracked the sick man to the village and urged his family to take him to a hospital. The relatives demurred: They said he required two more days of traditional treatment.
That night, Dowes took an abrupt turn for the worse. The medicine man repeated his treatment several times in the night.
Shortly before dawn, Dowes rose to use the bathroom. Because there was no toilet there, his uncle helped him walk next door. Dowes could hardly breath. He was staggering, on the brink of collapse. His uncle lugged him to his Suzuki SUV parked out front and set off for the district hospital. Before they made it, Dowes had died.
Special correspondent Yayu Yuniar contributed to this report.
http://www.washingtonpost.com/wp-dyn/content/article/2006/08/29/AR2006082901603.html
Sumatran Villagers With Avian Influenza Turn to Witch Doctors
By Alan Sipress
Washington Post Foreign Service
Wednesday, August 30, 2006; Page A12
JANDI MERIAH, Indonesia -- Dowes Ginting, the most wanted man on Sumatra island, lay dying. He had abandoned the hospital where he had seen his relatives succumb one after another, and he had fled deep into the mountains, trying to outrun the black magic he feared had marked him next. For four nights, witnesses recalled, a witch doctor hovered over him in a small clapboard home, resisting the evil spell.
Ginting, a wiry 32-year-old, had watched disease burn through his family over the previous two weeks, killing six and sickening two others, including himself. International health experts grew increasingly concerned when laboratory tests confirmed they were sickened by bird flu, the largest cluster of the disease ever recorded. But Dowes feared medical treatment more than he did the flu. And so he ran, potentially exposing villagers across the province to the highly lethal virus.
In the end, the outbreak in May did not presage the start of a worldwide epidemic. But the enormous difficulties that Indonesian and international disease specialists confronted in investigating the outbreak and protecting against its spread raised fundamental questions about whether bird flu could be contained if it mutated into a form more easily spread among people.
"If this were a strain with sustainable transmission from human to human, I can't imagine how many people would have died, how many lives would have been lost," said Surya Dharma, chief of communicable disease control in North Sumatra province.
Officials from the World Health Organization, drawing on sophisticated computer modeling of a theoretical bird flu outbreak in Southeast Asia, have suggested that a pandemic could be thwarted through a rapid containment effort in the affected area, including the right mix of drugs, quarantines and other social controls. To succeed, the antiviral drug Tamiflu would have to be distributed to 90 percent of the targeted population, roughly defined as those within at least a three-mile radius of each case. The drug would have to be administered within 21 days from the "timely detection" of the initial case of an epidemic strain. Residents would have to stay home, limit contact with others and take the medicine as prescribed.
In the case of the North Sumatra cluster, almost none of this happened, according to extensive interviews with health officers, family members and villagers in several areas of the province. The underlying problem was that most family members and many villagers were convinced that black magic, not flu, was to blame.
"How can you ever get people to cooperate if they don't even believe you?" Dharma said.
Tracking the Flu's Path
Scientists are still working to determine how bird flu is transmitted to and between humans. More than 200 people worldwide have contracted the deadly H5N1 strain of the virus since 2004. Most of the cases have resulted from direct or close contact with infected live or uncooked poultry, or with surfaces contaminated with secretions and excretions from infected birds.
Health investigators have concluded that the eight-person cluster in Sumatra began with Ginting's older sister, who fell ill in late April. They suspect she was infected with bird flu from live chickens sold in a market where she peddled oranges, limes and chili peppers, or from contaminated poultry droppings in manure used in her garden. She died and was buried before any samples were taken to confirm bird flu.
Several days after she became sick, the extended family gathered in the village of Kubu Sembilang for a feast of roast pig and chicken curry to celebrate the annual harvest festival. That night, many of the relatives slept in the same small room with the sister, who had developed a serious cough. By the time she died, a sister, a brother, two sons, a niece and a nephew had become ill. Flu specialists said the final victim, Dowes Ginting, in turn likely caught the virus from his infected son.
Health experts have concluded this was the first time the bird flu virus was passed from one person to another and then on to a third person.
"None of us thought it was bird flu. We thought it was black magic," said Anestia Tarigan, the wife of the youngest Ginting brother, Jones, the only victim to survive. "Everyone in the family was getting sick and no one else was. Someone had put a spell on our family. Black magic is very common in our place."
Indonesian and WHO investigators discovered that many residents in Kubu Sembilang were unwilling to share information or give blood samples that could reveal how widely the virus was circulating. Many villagers believed that claims of bird flu were a lie. Some even threatened the investigators. When a team of officers first arrived from the provincial health department, they were warned by their local counterparts that it was too dangerous to enter the village.
"We chased them away," said Hendra Tarigan, whose wife, one of the Ginting siblings, died. "Each time they came back, we gave them no information. We just told them to leave."
Despite a concerted effort to collect blood specimens, investigators were able to take samples from only two people in the village, including the local midwife, said Diana Ginting, chief of the district health department, who shares a common surname in the region.
Indonesian health officials working with an international team returned day after day to the village and made grudging progress. They recruited 20 local volunteers to monitor fellow residents for fever and set up a temporary health post on the soccer field offering free medical care. The investigators methodically pieced together the chronology of the outbreak. They traced those who had contact with the victims and provided them with Tamiflu.
But many of those closest to the Gintings refused to take it, according to interviews with villagers in Kubu Sembilang and nearby Jandi Meriah.
"The doctors gave us Tamiflu, but we didn't take it," said Mamajus Boru Karo, 38, a relative of the Gintings, scrunching up her face as she retrieved the unpleasant memory. "We should we take it? We don't have bird flu."
'I Was Losing Hope'
At the hospital in the provincial capital, Medan, members of the Ginting family were proving uncooperative. More than a dozen relatives had come down from the mountains. They had been sent there by a smaller clinic, and they remained unconvinced that bird flu was what ailed them.
They initially balked at taking Tamiflu or receiving injections of antibiotics, doctors said.
"They tried to refuse all treatment," said Nur Rasyid Lubis, the hospital's deputy director. "We could treat them only because their condition made it impossible for them to resist. But if they had been healthy enough to walk, they all would have run away."
Jones, the youngest sibling, did just that.
"I was losing hope. I thought I was going to die," he said in a raspy voice, his stare blank beneath thick eyebrows and his cheeks sunken. He had once been a young tough, but his arms and legs, covered with elaborate swirling tattoos of red and green, had grown scrawny after more than two months of battling the disease.
Jones Ginting fled the hospital, moving around Medan and the Sumatran highlands despite his fever and increasing difficulty breathing. He returned after villagers told him that the police were looking for him and might arrest him.
But he continued to resist treatment, initially refusing to take medicine or give blood samples, and threatened to attack the nurses with his fork. Finally, doctors reached a deal with family members, allowing them to invite a witch doctor to the hospital in return for blood specimens from Jones Ginting.
Agenda Purba, a witch doctor from Jandi Meriah, traveled six hours by van to the hospital. It was midnight by the time he started the ceremony in the special bird flu ward, he said.
Purba chanted over 21 betel nut leaves, each about the size of his calloused palm and filled with blossoms, a pasty white lime, brown chunks of an astringent and bits of an orange-colored nut. He prayed for the young man's recovery. Then Purba lifted the first of the leaves to his lips. He chewed, puckered and softly spit onto Jones's forehead. Bending over the patient, he gently blew the slime over the flesh. The witch doctor lifted the second leaf, chewed it and spit it onto Jones Ginting's chest, repeating the process. He continued until he had finished the leaves, slathering the torso, arms, legs, hands and feet, alternating between left side and right, making sure to cover all the joints.
None of the staff at the hospital ever cautioned Purba that he might be exposing himself to a killer disease, he said. No one suggested he take Tamiflu. No one sampled his blood or monitored his health. But had they tried, Purba said, he would have considered it silly.
"I'm the one to save Jones," he said. He grinned, baring a mouthful of teeth stained black by decades of betel nut. "There will be no more casualties. Seven is enough. I drew a border around them at the hospital." Purba stood up to demonstrate and etched a line in the dirt with the tip of his flip-flop. "It stops here," he said, "because I protected the family with my magic line."
A Turn for the Worse
When Dowes Ginting developed a fever and began coughing, he fled in search of a witch doctor, just as his younger brother had done a week before.
In the home of another medicine man in Jandi Meriah, Suherman Bangun mumbled the unintelligible words of an incantation over Dowes, recalled the healer's wife and Dowes's relatives, who had helped him while he was in hiding from the health inspectors. The witch doctor doused Dowes with cooking oil and massaged his aching muscles. He put a hefty chunk of betel nut in the corner of his own mouth and chewed, his lips turning red from the juice of the mild narcotic, and then with surgical precision spit the concoction bit by bit over his patient's head, face and chest and along his extremities. To control the surging fever, the healer pounded a bowl of rice laced with galangal ginger, applying the pasty preparation called beras kencur to the man's sweaty flesh.
After three days, Indonesian and international health investigators tracked the sick man to the village and urged his family to take him to a hospital. The relatives demurred: They said he required two more days of traditional treatment.
That night, Dowes took an abrupt turn for the worse. The medicine man repeated his treatment several times in the night.
Shortly before dawn, Dowes rose to use the bathroom. Because there was no toilet there, his uncle helped him walk next door. Dowes could hardly breath. He was staggering, on the brink of collapse. His uncle lugged him to his Suzuki SUV parked out front and set off for the district hospital. Before they made it, Dowes had died.
Special correspondent Yayu Yuniar contributed to this report.
http://www.washingtonpost.com/wp-dyn/content/article/2006/08/29/AR2006082901603.html