Management of Bali’s Rabies Crisis Is Just Barking Mad

By Richard Laidlaw

Just what is going on with rabies in Bali? It’s an interesting question – quite literally a vital one – and yet no one can give a clear answer. The national and provincial governments still cannot organise consistent supplies of anti-rabies vaccine in the quantities demanded by dog-bite victims. Not all such bites are by rabid animals, but in our present situation you cannot take the chance that it wasn’t.

The regencies are focused – although that hardly seems the word – on culling so-called wild dogs, a natural enough reaction but, on all the evidence, hardly a sensible one. Whatever is actually happening at the banjar level – local community organisations – is, as always, a complete mystery.

And last week the new national health minister, Dr Endang Rahayu Sedyaningsih, said when she attended a medical conference in Jimbaran that she didn’t know Bali was a rabies area.

It’s not as if it’s a new problem. Rabies broke out among dogs in the Ungasan area of the Bukit in the extreme south of Bali some time before September 2008. It is thought it was reintroduced by a rabid dog that came ashore from a boat from Java. There were rabies-like deaths of people in the Ungasan area from September last year, although it took the authorities until November to confirm rabies in human patients.

So far, 15 people are known to have died of the disease. Earlier deaths that most probably were from rabies cannot be defined as such because no one was alert enough to order the required tissue sampling from victims.    The disease is now a declared presence in Badung, Tabanan, Bangli and Karangasem regencies and in Denpasar, a city authority. It has recently re-emerged at Jimbaran (in Badung, in the heart of the tourist south) after an absence – one quantified only by the non-reporting of any human cases resulting from local dog bites – of some months. Rabies has been identified in dogs in two other regencies (Gianyar and Buleleng); allegedly this was in animals brought into those areas from Badung. But as yet the authorities have failed to declare either regency as a rabies area.

Belatedly, the World Health Organisation has taken action to help combat an outbreak – an “extraordinary event” – that threatens to get out of control. WHO’s chief regional focus is on swine flu and avian influenza, and that’s understandable (though not everyone who contracts influenza dies: the fatality rate from rabies is 100 percent). But it poses a question: If the Indonesian authorities had been more aware of the rabies situation in Bali, and acted (sensibly and according to a better plan than “run in circles, scream and shout”), would WHO and other international agencies have been better placed to render assistance early?

Here at home, the usual rules of bureaucratic engagement have swung into gear. Critics of culling as a prophylactic against rabies risk falling into disfavour with the governments with whom they must work. Similarly, those who might note publicly that, for potential epidemic control, you’d be better off equipping yourself with a posy of lavender and singing Ring-a-Ring-of-Roses than betting on workable preventive medicine policies emerging from the conflicted bureaucracies allegedly in charge, are unwelcome in the debate. “Shoot the messenger” has a long political pedigree.

Public education on rabies is haphazard at best. Most Balinese people you speak to have no knowledge of the disease – beyond the fact that it will assuredly kill you – and scant details of what can (and should) be done to prevent its occurrence in humans and eradicate it among domestic animals.

Post-exposure vaccine is free for local people (rightly) but is administered on a cut-rate plan – two vaccinations instead of the required three in most cases – and is available only if there are stocks in hand at the time.

At the crucial preventive end of the equation, little evidence exists of any understanding at official level of what needs to be done. There is a wealth of literature available to assist, including field reports from countries with comparable living standards and income levels. These measures all centre on vaccination, which effectively keeps the risk of rabies away from your doorstep.

Reducing feral dog populations is sensible public policy too – if it can be done by bait-sterilisation or humane destruction – but it is complicated in Bali by the fact that many so-called “wild” dogs are actually informal pets left to wander unfed. And it must be done (as with revaccination of dogs) on a continuing basis. Doing it once and then forgetting about it won’t work.

It is complicated, also, by the lackadaisical approach to management of communities. If something costs money – say a licence for your dog or a requirement that it be vaccinated against rabies – it will be avoided. And if such a breach is detected, payment of a smaller sum (under the table, to an official with his hand out) will usually eliminate the risk of legal penalty.

Bali is constantly in the world’s focus. It is a premier tourist destination. Already, the American Centres for Disease Control has issued an official warning that Bali is a rabies area. The destruction of human lives by rabies, even if relatively few, is appalling. But in terms of tourism and investment, allowing rabies to become endemic in Bali and to be viewed as a growing threat to visitors is a time-bomb.

Perhaps the governor, the provincial legislature, the regencies, the banjars – and even (if she can ever get round to reading her briefing papers) the minister for health and the tourism minister – should ponder the possible financial cost of continued failure to address the issue. That might focus their minds on the stark imperative they face.

Richard Laidlaw is a former Australian journalist and political advisor now living in Bali.

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