November 4, 2009

Planet Under Stress

As people and animals increasingly share habitats, Tufts veterinarians answer the call to safeguard public health

By Catherine O’Neill Grace

Chickens are part of the landscape in every village along the Indonesian archipelago. The birds are a mainstay of people’s livelihoods: they provide eggs and meat and are sold or bartered for emergency funds.

“Chickens are a community tradition,” says Stacie Dunkle Lawson, V07, a Tufts veterinarian who works in Indonesia. “It wouldn’t be normal not to have chickens.”

“Diseases emerging from animals tend to appear in countries that have the poorest surveillance and the worst ability to respond,” says Joann Lindenmayer, an associate professor of environmental and population health at the Cummings School. Illustration: Brian Stauffer

But since 2004, some of these backyard birds have become infected with a highly contagious strain of avian influenza, known as H5N1, and 115 Indonesians have died after coming into close contact with the sick birds, according to the World Health Organization (WHO). The H5N1 strain of avian influenza has spread to 24 of the nation’s 33 provinces.

And so Indonesia, the nation that has seen nearly half of the 256 avian flu deaths WHO has reported worldwide, remains the frontline in the fight against the disease.

Consider this: while the average Indonesian family may keep fewer than 20 chickens, the sprawling island nation is home to a collective 1.4 billion chickens. That, public health experts say, is a recipe for a global pandemic that could claim the lives of millions if nothing is done to stop the disease from spreading.

And who better to dispatch to quell a disease hot spot than veterinarians armed with public health credentials?

The arrival of avian influenza tested Indonesia’s capacity to control an animal disease of major public health and economic importance, says Joann Lindenmayer, V85, an associate professor of environmental and population health at the Cummings School. “We have known about emerging infectious diseases and the fact that they came from animals for 30 years. Yet we’re just getting to the point where we are thinking, Oh, we have to involve the vets.”

Collaborating with the U.N. Food and Agriculture Organization and the Indonesian Ministry of Agriculture, Cummings School veterinarians and students are on the ground in Indonesia, developing a program to detect avian influenza and control it by vaccinating poultry, from backyard chickens to commercially raised birds bound for market. Using a community-based educational approach, they have provided technical assistance and training for Indonesian veterinarians and the villagers who depend on their small flocks to make ends meet.

A Portable Model

The community-based approach to managing disease outbreaks is a powerful weapon in the public health arsenal, says Lindenmayer. The model Cummings helped create to respond to avian influenza in Indonesia could easily be replicated in other countries to respond to outbreaks of new diseases, including the latest threat—H1N1, or swine flu.

“If you learn evaluation, you can apply it anywhere,” Lindenmayer says. “If you learn surveillance, you can apply it anywhere. You can then become leaders for advocating for better surveillance systems and better evaluations.”

There is an important difference between the avian and swine flu viruses. Almost three-quarters of people infected with avian flu had direct contact with sick birds. And while the H1N1 virus that is dominating the news now is a cocktail of human, bird and pig genes, it is not spread by contact with animals and is no more lethal than common seasonal flu. However, some virologists fear that a more dangerous strain of influenza could emerge if H1N1 combines with avian influenza.

Global awareness of these kinds of diseases “focuses the spotlight on the role of veterinarians,” Lindenmayer says. “Veterinarians can be a force for change and agents of influence in global health.”

What is clear is that the need for veterinary expertise in combating public health threats will only continue to grow in a world made smaller by progress. This fragile planet has become a simmering stewpot for emerging infectious diseases. Population growth means that people and animals are living closer together than ever before. Wildlife populations have had to migrate to new habitats. Modern transportation systems move food, animal feed and other products between countries and continents with ease.

“Veterinary science offers a broad understanding of a whole range of biological issues—from animal health in domestic and wild species to how animal owners influence our local ecosystems and more broadly, the planet,” says Robyn Alders, a Tufts veterinarian who is working on the Indonesian avian influenza project.

Prevention Is the Key

Indonesia’s size and geography presents an uncommon challenge for a public health campaign. The world’s fourth most-populated country, it is inhabited by 235 million people living on 6,000 islands; they speak 170 local dialects. Another 11,500 islands are uninhabited. The island of Java alone is home to 128 million people and more than 900 million chickens.

“Our goal is to empower,” says Alders, an associate professor of environmental and population health who is the senior technical advisor for the Indonesian H5N1 control project, known as the Participatory Disease Surveillance and Response program. Eric Brum, A99, V04, a staff veterinarian with the Cummings School’s International Veterinary Medicine Program, is a chief technical advisor who is working with Lawson and a veterinarian from Pakistan on the surveillance project.

This bottom-up approach to disease control and management has significantly strengthened veterinary services in Indonesia. The Tufts team has trained 30 so-called master trainers who have, in turn, gone on to train and support 2,100 surveillance and response officers on the islands of Java, Bali, Sumatra, Kalimantan and Sulawesi.

About 25 percent of the response officers are women—good news, considering that women and children are the primary caretakers of backyard poultry. These community-based animal health officers have diagnosed and responded to more than 6,000 avian influenza outbreaks and have worked with more than two million community members.

There is no cure for H5N1, so prevention is key, says Lawson, who earned a master’s in public health from Tufts along with her veterinary degree.

“The vaccination is done by the community for a disease of importance to the community,” Lawson says. “A good vaccinator is someone respected in the community, an experienced village farmer who sees the economic benefits both personally and in the community,” she says. “Community mobilization is the most important thing. Without widespread participation, you can’t get flock immunity.”

Global Work, Local Outreach

As with Tufts’ involvement in eradicating a deadly cattle plague in sub-Saharan Africa, education is a critical ingredient in controlling avian influenza in Indonesia, and the involvement of local communities is paramount.

Before the quarterly vaccines are administered, the Cummings team and district livestock officials hold meetings in the Indonesian villages to discuss the benefits of vaccination and encourage poultry owners to participate. Once villages are free of disease, response teams hold regular meetings to prepare prevention plans.

As the Participatory Disease Surveillance and Response program evolves and expands, the goal is to establish community-based programs to prevent and control not only avian flu, but other emerging infectious diseases that originate in animals.

Some of that effort will need to include more educational opportunities for Indonesian veterinarians. Lindenmayer was principal investigator on a 2008 Rockefeller Foundation-funded project to assess veterinary health services in Indonesia and develop recommendations for strengthening the country’s capacity to respond to infectious disease threats.

The study, which involved the deans of Indonesia’s five veterinary schools, identified a need for the country’s veterinarians to receive advanced public health training as well as education in team-building, negotiation and conflict resolution to create a pipeline of Indonesian veterinarians prepared for leadership roles in public health.

A central recommendation of the study is to develop an in-country veterinary public health program, something that does not now exist.

The study “captured the real veterinary public health education need in Indonesia,” says I. Made Damriyasa, the dean of the veterinary school at Udayana University in Bali, who plans to send some of his faculty outside the country to pursue master’s degree work in veterinary public health.

In addition, Damriyasa says, the Indonesian veterinary schools need to collaborate more closely on curriculum development, teaching and research. “This will produce a graduate with better capabilities to diagnose, prevent and control disease,” he says.

Colored pins dot a world map hanging in the Bernice Barbour Wildlife Medicine Building on the Cummings School campus. They denote countries where Tufts veterinarians and students are studying animal diseases—including those that can be transmitted to people—and helping to develop strategies to manage outbreaks when they occur.

In addition to the avian influenza program in Indonesia, they’re investigating tick-borne livestock disease in Mozambique, rabies prevention in Nepal and Sierra Leone and swine production in Chiapas, the southernmost state in Mexico, among others.

The public health role of the veterinarian is something that Lindenmayer has thought about since her four-year stint training biology teachers as a Peace Corps volunteer in East Malaysia. She saw firsthand the challenge of caring for sick animals in a country with limited veterinary services and decided she wanted to become a vet.

A member of the third graduating class at Tufts’ veterinary school, Lindenmayer went on to earn a master’s in public health from Harvard. She served as founding director of the master’s in public health program at Brown University Medical School before joining the Cummings faculty in 2006.

“Diseases emerging from animals tend to appear in countries that have the poorest surveillance and the worst ability to respond,” says Lindenmayer. “We need to set up surveillance among wildlife and domestic animals to research new and reemerging diseases that could potentially affect the health of human populations—and we don’t know what diseases they may be.”

While the challenges loom large, Lindenmayer says it’s the right place and right time to be a veterinarian with a global health agenda. “I think there has been a change in culture,” she says. “Veterinarians more and more recognize that public health is part of what we do. I want our students to have the confidence to know that they can be there, that they know how to speak public health and that they can join in the conversation and be confident that they belong there.”

This story first appeared in the Fall 2009 Tufts Veterinary Medicine magazine.

Catherine O’Neill Grace can be reached at

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