Disease Control by Decree

How not to deal with epidemics.

By | April 1, 2007

An epidemic of half-truths is breaking out all over the world. Consider:

• A year ago, an epidemic of acute watery diarrhea broke out in Ethiopia. As of February 21 of this year, the country officially admitted having 60,000 cases and more than 680 deaths. But, contrary to concerns of the World Health Organization (WHO) and neighboring states, which are being affected by the disease, the Ethiopian Health Ministry refuses to declare an emergency and denies that the disease is cholera, saying the outbreak is being contained. To admit that the epidemic is cholera, the country, which signed on to the International Health Regulations, would be obliged to report it to WHO.

• Bangladesh hosts the world-famous International Center for Diarrheal Disease Research. Every year the institute publishes a report on its activities, which include the identification of cholera in local patients. However, Bangladesh officially has no cholera within its borders, only "acute watery diarrhea." The reason for the fiction: Seafood, especially shrimp, is one of Bangladesh's principal exports. Any mention of cholera triggers a ban by importing countries, regardless of the fact that in the factory the product is rigorously washed with filtered water under the most hygienic conditions.

• Egypt (which calls it "summer diarrhea"), Indonesia, Pakistan, the Philippines, and Thailand also deny having cholera for similar reasons, despite the tourists regularly returning to Japan, Europe, and the United States with acute diarrhea that is laboratory confirmed in their home countries as due to Vibrio cholerae. Until importing countries show more sense about reacting to reports of cholera in countries with which they do business, it is unlikely that the exporting countries will begin to call a spade a spade.

• In 2004, plague appeared in Turkmenistan. The then-megalomaniac dictator's solution was to ban the word "plague" from the country's vocabulary. It could not be mentioned in the media, or even in conversation, and therefore it need not be reported to WHO. (This is the same late dictator who had a heroic statue of himself made to rotate so that it always faces the sun.)

• In 2006, dengue broke out once again in Cuba. Sanitation workers went from house to house destroying mosquito breeding places and exhorting the citizens to maintain sanitary conditions, without any official acknowledgement of an ongoing epidemic. As on previous occasions, the health services were not permitted to write the word "dengue" as a diagnosis on patients' charts. Also as on previous occasions, WHO will be officially informed of the epidemic only when the government has brought it under control - despite the fact that Havana has one of the best dengue diagnostic and research laboratories in the world at the Pedro Kouri Institute. The reason for this silence? To avoid discouraging tourists, and to continue with participation in international congresses and sporting events in Cuba.

We need to look no further than China's reluctance to admit to the epidemics of SARS, and more recently, avian influenza, to see the international repercussions of denial or delay in reporting infectious disease. Atypical pneumonia cases from which the usual causes had been excluded had been filling the military and civilian hospitals in Guangdong for weeks before the SARS epidemic was officially admitted. It first came to public knowledge outside China when an American public health physician picked up news of it from a chat group on the Internet and posted a query on ProMED (www.promedmail.org). Avian flu came to Hong Kong from the mainland and killed six people in 1997-1998; drastic action by the government, culling 1.3 million chickens, ended it there. Nonetheless, Mainland China has never admitted that an outbreak occurred.

In July, all this will hopefully change. That's when the new, improved International Health Regulations come into force, giving WHO the right to publicly report an epidemic with international implications if a country delays in reporting it. The best way for countries to deal with epidemics is to be transparent about the numbers of cases and their locations, to provide the isolated pathogens to WHO reference laboratories, and to spell out the specific steps being taken for prevention and control. The sooner all countries accept this, the better off their people will be, and everyone else, too.

Jack Woodall is director of the Nucleus for the Investigation of Emerging Infectious Diseases in the Institute of Medical Biochemistry at Brazil's Federal University of Rio de Janeiro. jwoodall@the-scientist.com

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