Obstacle in bird-flu battle: black magic

JANDI MERIAH, Indonesia — Dowes Ginting, the most-wanted man on Sumatra island, lay dying. He had abandoned the hospital where he had seen relatives succumb one after another, and he had fled 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, resisting the evil spell.

Ginting, 32, had watched disease burn through his family, killing six and sickening two others, including himself. International health experts grew increasingly concerned when lab tests confirmed they had bird flu, the largest recorded cluster of the disease. But Dowes feared medical treatment more than he did the flu. And so he ran, potentially exposing villagers across the province to the lethal virus.

In the end, the outbreak in May did not presage the start of a worldwide epidemic. But the difficulties 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 human form.

"If this were a strain with sustainable transmission from human to human, I can't imagine how many people would have died," said Surya Dharma, chief of communicable disease control in North Sumatra.

Officials from the World Health Organization (WHO) have suggested that a pandemic could be thwarted through a rapid containment effort, including the right mix of drugs, quarantines and other controls.

To succeed, the antiviral drug Tamiflu would have to be distributed to 90 percent of the targeted population. 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 health officers, family members and villagers. The underlying problem was that most family members and many villagers were convinced black magic, not flu, was to blame.

More than 200 people worldwide have contracted the deadly H5N1 strain of the bird flu since 2004. Most cases have resulted from direct or close contact with infected live or uncooked poultry, or with surfaces contaminated by 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 or contaminated poultry droppings in manure used in her garden. She died and was buried before any samples were taken to confirm bird flu.

Family members fall ill

Several days after she became sick, the extended family gathered in the village of Kubu Sembilang for the annual harvest festival. That night, many of the relatives slept in the same 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 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.

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.

Indonesian health officials, working with an international team, recruited 20 local volunteers to monitor fellow residents for fever and set up a temporary health post 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. At the hospital in Medan, members of the Ginting family were unconvinced bird flu was what ailed them.

"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. He moved around Medan and the Sumatran highlands despite his fever and difficulty breathing. He returned after villagers told him the police were looking for him.

But he continued to resist treatment. 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, chanted over 21 betel nut leaves, 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 chewed the first of the leaves and softly spit onto Jones' forehead. Purba repeated the process until he had finished the leaves, slathering the torso, arms, legs, hands and feet, making sure to cover all the joints.

"I'm the one to save Jones," Purba said. "There will be no more casualties."

Seeking a witch doctor

When Dowes Ginting developed a fever and began coughing, he fled in search of a witch doctor. Another medicine man in Jandi Meriah, Suherman Bangun, began the incantations and betel-nut spit treatment. 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.

That night, Dowes took an abrupt turn for the worse.

Shortly before dawn, Dowes rose to use the bathroom. Staggering, he could hardly breathe. His uncle lugged him to his SUV and set off for the district hospital. Before they made it, Dowes had died.