Cambodia: a patient waiting

The response in Cambodia to the emergence of the H1N1 virus is a singular example of how a predominantly rural country is preparting for the threat of an epidemic without borders, says Michel Thieren.

May the tevoda grant us good health and prosperity, freeing us from suffering and fear. [...]
I am finishing my call, o nineteen pralung, come back all together now.

There is no more suffering, no more fear, no more misfortune.

O my dears, your relatives are gathered together in great number."

- Hau Pralung, Treatise for Calling the Souls of the Sick

"Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity"

- the World Health Organisation, constitution

The emergence of a new threat to people's health is always refracted through the immediate and local circumstances of their lives. The worldwide reaction to the Influenza A (H1N1) virus is an example. Cambodia, where I work and live, offers a singular portrait of how a society - rural and poor, with its own unique cultural and ethnographic character - responds to and copes with an epidemic without borders .

The cost of ignorance

The World Health Organisation (WHO) reported that as of 06:00 GMT on 15 May 2009, there were had officially 7,520 cases of Influenza A (H1N1) infection in thirty-four countries; there had to that point been sixty-five deaths. The world has since 4 May been on level five (on a scale of six) of "pandemic alert".

This category, to health professionals, indicates a sustained community transmission of the virus in at least two countries within the same region (continent); a situation that in turn augurs the imminence of a global pandemic (active transmission in two continents). When it occurs, the emergency committee of the International Health Regulations (IHR) - an international legal instrument binding 194 countries to help the international community prevent and respond to acute public-health risks - can activate plans and preventive measures, publish daily updates, and make available knowledge about the evolving situation.

This mechanical precision is indispensable, but it also comes up against the limits of current understanding: for as yet, science knows very little about A/H1N1, and this opens the door to all sorts of allegations and interpretations of what is actually happening.

On 12 May 2009, for example, a leading online political magazine in the United States had as its main headline: "The List: Five Disease Outbreaks that are Worse than Swine Flu". There, A/H1N1 was retrospectively minimised by comparing it (already!) to five serial-killers: cholera, meningitis, HIV/Aids, Ebola, and dengue fever. By thus comparing numbers which should not be compared - because they denote different events, risks, patterns - the result is to remove readers and citizens from the core realities, instead of bringing them closer.

In any event, it will be a long time before the data on A/H1N1 will allow general inference for a long time, and therefore cannot now be subjected to (abusive) "analysis". The issue around A/H1N1 is not whether it spreads less or spares more lives than many other ongoing threats: it is that 7 billion humans are at equal risk of being infected by an entirely new virus against which no one is immune and whose epidemic and killing path cannot be predicted. This is what makes A/H1N1 different from any other disease - regardless of their respective morbidity and mortality totals.

The gaps in scientific knowledge are too easily filled by rumour, myth, hyperbole and attention-seeking media dramas. Many public-health practitioners have come to realise that fighting these requires much more work than solving a real problem.

In science's name

The WHO director-general Margaret Chan made her first official communication on A/H1N1 on 29 April 2009. She warned the world that "new diseases are, by definition, poorly understood and influenza viruses are notorious for their rapid mutation and unpredictable behaviour". The implicit message was that science - both virology and epidemiology - would restrict itself to support evidence-based communication on the new phenomenon. The tone was set that the WHO's messages with regard to A/H1N1 would for the foreseeable future operate with a degree of approximation and conditionality, all in the name of scientific exactitude.

However, when scientific evidence remains largely unsettled, the communication interface can be problematic. A messenger is scientifically accountable and needs to stand on the true ground of current knowledge; yet the recipient of the message requires a simplified and unambiguous formulation in order to take appropriate action. When an international health agency speaks within the strict limits of health and biomedical science, it may compromise its duty to preserve the collateral consequences on its auditors of the possible ambiguities these limits contain.
Yet if the same organisation presented user-friendly categorical statements without proper acknowledgment of doubt, it would to some degree sacrifice its commitment to scientific excellence. How to reconcile theory with practice? Only by stratifying messages through different audiences, from lay individuals to scientific experts, progressively loading them with technically complex and interpretable content.

In the end, however, there must be a consistent thread that links the two ends of the discourse, and in a way that the recipient at each point along the way can make sense of it for their own purposes: the virologist researcher who typified the A/H1N1 virus or decoded its ADN sequence; the epizootic expert who implements the food-standard guidelines, the Codex Alimentarius; the epidemiologist who estimates the lethal risk and the contagion of the virus (and who establishes the principles of the IHR); the economist who estimates the macro- or micro-economic consequences of a pandemic on a household's purchasing-power; all the way to the pig-farmer in the Argentinean pampa or among the Cambodian ricefields, whose only income depends on the readiness of people to eat pork.

The fact that there is very little in common in the knowledge, beliefs and daily lives of the people who exist along the communication "thread" makes it vulnerable to conflicting or overlapping messages. Often, experts speak from their respective scientific locus with no concern that different locuses may conflict with each other. Even as individual statements are pronounced in the name of scientific excellence, the "excellence" of an influenza epidemiologist may collide with the one of a public-health

veterinarian or an economist. When science leaves interpretation on pork-safety open with regard to A/H1N1, the consumer may start to see the threat coming from the food rather than from the person coughing and spluttering in the vicinity.

Cambodia in the world

Cambodia, like its immediate neighbours in southeast Asia - Vietnam, Laos, Thailand - has at the time of writing experienced no case of A/H1N1, and the situation has remained in preparedness mode. In the three weeks since (on 24 April 2009) the World Health Organisation released its first report of an "Influenza-like illness in the United States and Mexico", Cambodians have been waiting for their "public enemy". Many predicted that it would kill in massive numbers - something not so hard to conceive in a country which in 1975-78 experienced genocide at the hands of the Khmer Rouge.

It is indeed often the case that contingency planning is - rightly - planning for the worst scenario, even if it is rarely the worst scenario that ultimately prevails. So, in Cambodia, "pandemic contingency plans" were discussed, updated and activated at all levels. The international organisations operating in Cambodia reviewed their procedures on how to protect their personnel and maintain business continuity. Cambodian health authorities refreshed their plans too with the support of international-aid agencies; they received up-to-the-minute messages from Mexico, Atlanta, Ottawa, Geneva; and they took the necessary actions to broadcast basic prevention measures to the Cambodian population.

For example (albeit a weak example, as the measure generates a very low transmission-limiting dividend), a thermal scanner was installed at Phnom Penh and Siem Reap international airports to monitor returning travellers over possible contamination with the virus. This was complemented with quarantine and medical evacuation of screened suspected cases at Calmette general public hospital - perhaps not necessarily the one that people who can afford international travel would select, but the one where effective mass patient management could be organised.

A stoic response

The Cambodian media has done a good job in relaying what the country's 13.4 million people needed to know about the new disease without either distortion or panic. In most parts of the country, it quickly became clear that this was an enemy to be watched but from afar rather than an immediate danger; and that this new disease was a human-to-human problem and not about animals - a piece of information Cambodians can't but be very receptive to.

The common sense of the rural population has been strikingly evident. There is no sign that the pork-based economy in provinces like Kompong Thom is in any way affected. Cambodian farmers continue to raise and sell pork to smoking factories, and people continued to consume pork without further questioning.

But discreet signals of fear have been visible in the cities - mostly among the higher economic end of the Cambodian population and the expatriate community. Pork-meat and pork-based products were left in piles on the shelves of main supermarkets. In Phnom Penh, there was a roaming undercurrent of worry - of a new flu virus that would spread fast and kill in numbers (the memory of "severe acute respiratory syndrome" [Sars] in 2003 was ever-present here). The louder fears expressed by leading global voices and media outlets were softly replicated. The fact that Vietnam and Hong Kong had been epicentres of recent flu outbreaks added to the concern.

In short, Cambodians' relatively stoic attitude has not reflected a lack of public concern. The signs are that the country's government - doubtless aware of the political gains and losses associated with good and bad pandemic management - is truly committed to protect the health of its people. The response to A/H1N1 in Cambodia has been free of what have been regarded as democratic malpractices.

A fragile balance

This balance of communication and precaution was somewhat jeopardised by a report in the leading newspaper the Cambodian Daily on 7 May 2009 on the sensitive subject of meat-consumption. The approach was precisely to pick some dissonances from among leading voices on the pandemic, each one speaking from its own specialised interpretation of partial evidence. An expert warned that "meat from sick pigs or pigs found dead should not be consumed under any circumstances"; another attested that "all pork products are safe for consumption"; a further said that "this new strain of influenza virus does not contaminate humans easily and has a very low pathogenicity for both humans and pigs, unlike the avian flu which killed millions of poultry".

The appearance of scientific cacophony makes the consensual and reassuring message of the WHO director-general even more essential, in reaffirming that "influenza viruses are not known to be transmissible to people through eating processed pork or other food products derived from pigs". The relatively low intensity of the new disease abroad and its absence in Cambodia have played a role in holding rumours at bay. The consumption of pork is safe because there is no case of A/H1N1 in Cambodia, not because the virus is primarily associated with human-to-human transmission. But if any proof of A/H1N1 transmission appears in the country, the mixed messages in the 7 May report could revive and eclipse the WHO's efforts to achieve coherence in communication.

The result could then be stories about the power of A/H1N1 to attack humans and animals, followed by people ceasing to eat pork and the sudden imperiling of an entire vernacular economy of subsistence. In an instant, tens of thousands of people in Cambodia would move from daily subsistence to daily survival; and in a country where five mothers still die every day in childbirth, and where 127 children in every 1,000 born to the poorest families already die before reaching the age of 5, the fragile health gains that have been made may be wiped out. In short, to overestimate the food-borne risk of A/H1N1 in the name of (incomplete) science and consequent difficulty to estimate and aggregate risks could lead to underestimating the one of sudden poverty-induced illness. The media too has a crucial role in matters of life and death.

Thinking in Cambodia

Even those international public-health doctors who now mostly sit in research laboratories or other institutions once sat at the bedside of a patient. It is important for all of us to maintain the doctor's ethos at the heart of our work, and preserve direct contact with the realities and lives of the population we serve. In Cambodia and for Cambodians, good public-health practice must begin by integrating two basic features of Khmer culture: how illness is represented, and how the language accommodates semantic nuances.

Cambodia is predominantly a rural country; the Cambodian farmer is the socio-cultural nexus, at the core of the country's identity and heritage. The Cambodian farmer - and by extension every Cambodian - carries some sense of a direct line of descent from the ancestors of the ricefield; it is routine to be at the same time loaded with animist convictions while riveted to an unequivocal pragmatism.

All Cambodians - including public-health officials - can accept and understand that the "early signs of Influenza A (H1N1) are flu-like, including fever, cough, headache, muscle and joint pain, sore throat and runny nose, and sometimes vomiting or diarrhoea". They also know that "when a person is gravely ill, on the verge of losing consciousness, it is understood that the person's pralung (independent soul-entities) are no longer in his or her body"; thus, traditionally, to call the pralung to return to their residence within the patient's body requires a ritual to be performed. Moreover, the pralung are "also found in certain objects, plants and animals, whose integrity at particular moments is likewise essential to the integrity of the community". The way illness is conceived in this profound and affectively rich context presents singular challenges to the communication of scientific argument that disaggregates animal-to-human and human-to-human transmission of new viruses.

The Khmer language does not formally mark the distinction between different conditionals, nor easily accommodate assumptions, understatements, or subordinate and multifaceted assertions. The semantic nuances of "could be", "should be", "can be" and "will be" are easily lost in translation; in most cases they would end up by converging on the last one. The development of WHO-style consensual messaging using multivariate conditionality to incorporate initially dissenting opinions is not easy in this context.

The outcome of a situation where being scientifically right can generate conceptual or semantic ambiguities is, where A/H1N1 is concerned, yet to be fully tested in Cambodia. So far, its people are continuing to handle everything the world can throw at them with characteristic yet extraordinary grace and fortitude. The global is everywhere local. In the end people will, within their own cultural and social reality, find ways to manage a threat and protect themselves against it.