It is an unconscious assumption of many public health officials, experts and most health educators that The Truth Shall Make you Free. We know it won’t, not even in something as simple as understanding what to do and not do about bird flu. A paper this month in CDC’s scientific journal, Emerging Infectious Diseases, is a case in point. Public health workers at the Pasteur Institute in Cambodia, the London School of Hygiene, the Cambodian Ministry of Agriculture and the UN’s FAO undertook a survey about the knowledge, attitudes and practices among rural villagers in Cambodia, a southeast asian country that has suffered periodic poultry outbreaks with influenza A/H5N1 (bird flu) since 2003. There have been 6 human cases, as well, all fatal. Cambodian public health authorities maintain that human infections are the result of close contact with infected poultry and they began a vigorous public education campaign. It has been half successful. The results of the survey show the message has been received and understood. It also shows that there continues to be widespread risky interactions between people and poultry in rural Cambodia (“AI,” below, is avian influenza):

Twenty-three villages were included in Kampong Cham and Prey Veng Provinces. Four hundred sixty respondents from 269 households completed the questionnaire. Most were women (60%), farmers (88%), and persons who had completed less than primary schooling (57%). The median number of household members was 5 (range 1-16), and 77% of all households included children <15 years of age.

Many households owned chickens (97%) and ducks (39%), although the size of most poultry flocks was small. Almost all poultry were free ranging (100% of chicken flocks; 96% of duck flocks), and mixing of the poultry with pigs and other domestic animals was common. Respondents reported that they use poultry feces for manure (77%), touch sick/dead poultry with bare hands (75%), eat poultry that died from illness (45%), eat wild birds (33%), let children touch sick/dead poultry with bare hands (20%), and gather dead wild birds for consumption (8%).

During the previous 6 months, of the 260 households that owned poultry, 162 (62%) experienced poultry deaths; however, only 18 (7%) reported these deaths to local authorities. Half of the respondents (n = 231) believed that it was important to report any poultry deaths because the death may be due to AI (61%) or because the poultry owners may receive management advice from the village veterinarians (39%). Among these 231 respondents, many did not report poultry deaths because they did not know how (41%), were in the habit of not reporting poultry deaths (31%), believed they would have a problem selling poultry if they reported deaths (18%), did not know the risks of AI (7%), or feared poultry culling (5%). Among those respondents who did not believe reporting deaths was important, the reasons provided included the following: "the number of poultry deaths were too few" (62%), "poultry are not as important as cattle" (18%), "no help would be provided from veterinary staff or authorities" (13%), or "because mortality was similar to previous years" (7%). Of respondents that experienced poultry deaths, 62% buried or burned dead poultry, 53% prepared them for food, 22% threw away the dead poultry, 3% used them to feed other animals, and 2% prepared them for sale or gave them to their neighbors. (Soarth Ly et al., Emerging Infectious Diseases, cites omitted)

Very few (7%) of the respondents gave ignorance of the dangers as reason. Indeed 81% had learned about bird fu from TV and 78% from radio, one in three could even describe the symptoms of bird flu and more than 7 in 10 knew that it was a fatal disease of birds that could infect humans.

Most respondents believed it is unsafe to touch sick or dead poultry with bare hands (67%), eat wild birds (70%), let children touch sick or dead birds with bare hands (83%), and eat meat or eggs that are not fully cooked (86%). Sixty-one percent of respondents mentioned at least 1 of the recommended behavioral practices that protect against AI infection.

This is both a stunning success and an equally stunning failure. People knew, understood and still practiced risky behavior. Why?

Anecdotally, we also reported that family members of H5N1-infected patients, who knew about AI risks, still prepared dead or sick poultry for household consumption during massive die-offs, because they observed that neighbors with the same behavior did not become sick (Institute Pasteur in Cambodia, unpub. data). These findings provide evidence that high awareness does not necessary lead to behavior change. Behavior change involves comprehensive and multidisciplinary intervention, which combines risk perception communication and feasible and practical recommendations, including economic considerations. We speculate that it is hardly feasible to sustain good poultry-handling practices if access to personal protective equipment is cost prohibitive, particularly when disease occurrence poultry die-offs are common.

Clearly the lack of a compensation policy has a major effect on willingness to report. This paper points to Vietnam’s apparent success as an indication that poultry vaccination should be seriously considered. But persistent concerns that vaccination leaves birds still infectious yet apparently healthy, if true would not solve the problem of risky poultry handling practices but perhaps even exacerbate it.

Knowledge and understanding are important, but as this paper indicates once again, not sufficient. But we know that. Many readers of this site are acutely aware of the dangers of climate change but haven’t sold their big cars for hybrids or bicycles, haven’t insulated their houses, stamp the earth with unconscionably large carbon footprints and much more. We understand but fail to act.

Just thought I’d mention it.