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NEW THIS WEDNESDAY: THREE ON DR. CARLO URBANI, PIONEER IN SARS CONTROL

Tuesday, 13th of August 2013

• THREE ON CARLO URBANI

 

• DISEASES PIONEER IS MOURNED AS A VICTIM

By DONALD G. McNEIL Jr
Published: New York Times, April 08, 2003

When the microbe that causes severe acute respiratory syndrome is finally isolated, some people will know what to call it. They want a Latin variation on the name of Carlo Urbani.

If SARS was an infectious cloud blowing out of southern China, Dr. Urbani was the canary in its path. Working in a hospital in Hanoi, Vietnam, as a mysterious pneumonia felled one nurse after another, he sang out the first warning of the danger, saw the world awaken to his call -- and then died.

If not for the intuition of Dr. Urbani, director of infectious diseases for the Western Pacific Region of the World Health Organization, the disease would have spread farther and faster than it has, public health officials around the world say.

It was a tricky call. There is nothing as telltale about the disease as the bleeding of a hemorrhagic fever or the bumps of a pox, and its symptoms mimic other respiratory conditions.

Dr. Urbani, 46, died on March 29, a month after seeing his first case and 18 days after realizing he was coming down with the symptoms himself. 

  

His death was the most coherent and eloquent epilogue his life could produce, said Nicoletta Dentico, a friend from the Italian chapter of Médecins Sans Frontières, or Doctors Without Borders, which Dr. Urbani once headed. His death was as a giver of new life.

And it was in keeping with his medical philosophy. When Dr. Urbani spoke in 1999 at the ceremony in which Doctors Without Borders accepted the Nobel Peace Prize, he described the duty of doctors to stay close to the victims.

Its possible to study an epidemic with a computer or to go to patients and see how it is in them, said Dr. William Claus, the MSF emergency coordinator for Asia. Carlo was in the second category.

In Italy, he had pushed the organization into working with the poorest of the poor, with Gypsies in Rome and with African and Albanian boat people who were landing in Sicily and Calabria.

Even as a student, said Fabio Badiali, a childhood friend who is now mayor of Castelplanio, their hometown on the Adriatic Coast, he had been a volunteer, organizing groups to take the handicapped on countryside picnics. As a family doctor, he had taken vacations in Africa, traveling with a backpack full of medicine.

He had accepted the W.H.O. post, friends said, because he wanted to be back in the third world and working with patients. It was that instinct that took him to the bedside of Johnny Chen, an American businessman who entered Vietnam-France Hospital in Hanoi on Feb. 26 with flulike symptoms.

Dr. Urbani might not have been an obvious choice as a consultant in Mr. Chens case. In his heart, friends said, he was a worm guy, a specialist in parasites.

Other people did not think worms were sexy, said Dr. Kevin L. Palmer, W.H.O.s regional specialist in parasitic diseases and a friend. But it is a really basic problem for every child in the tropics.

Dr. Urbani was an expert in Schistosoma mekongi in Vietnam, in the food-borne nematodes and trematodes of Laos and Cambodia and the hookworms of the Maldives.

Dr. Lorenzo Savioli, who worked with Dr. Urbani in the Maldives, said they worked from sunup to sundown, ignoring the famous beaches and reefs, tracking hookworm epidemiology and training workers at a malaria control laboratory, who were used to working with blood, in testing for worms. Over rice and fish in the evenings, Dr. Savioli said, they had joked, Nobody at headquarters was going to believe we were spending our days in the Maldives over fecal samples.

Dr. Urbani was a worm zealot, Dr. Palmer said, because they did so much damage but could be so easily treated. For example, he said, a 3-cent pill administered to schoolchildren twice a year could rid them of most intestinal worms. Dr. Urbani was working to have school systems in southeastern Asia cooperate.

He also attacked a worm that lived on fish farms. He could not get Cambodians and Laotians to give up eating undercooked fish, Dr. Palmer said, but he hoped to solve the problem by teaching fish farmers to divert sewage from their ponds.

He was also testing the use of a veterinary drug to kill worm larvae that can reach human brains and cause seizures.

And, said Daniel Berman, a director of the Doctors Without Borders campaign for cheaper lifesaving drugs, Dr. Urbani was pushing Vietnamese farmers to grow more sweet wormwood, a plant that can produce artemisinin, a new malaria cure.

Still, when a troublesome case turned up in Hanoi, Dr. Palmer said, the W.H.O. staff usually said, Call Carlo, because he was also known as an expert clinical diagnostician.

Mr. Chen was such a case, suffering with pneumonia and fever, as well as a dry cough. The hospital suspected that he had the Asian bird flu that killed six people in 1997 and was stopped by rigid quarantines and the slaughter of millions of chickens and ducks.

Rumors of a mysterious pneumonia had been coming out of the Guangdong region of southern China, but the Chinese authorities had been close lipped, even instructing local reporters to ignore it.

Although no one then realized the significance, Mr. Chen, 48, had also stayed in the Metropole Hotel in Hong Kong. He may have picked up the disease from a 64-year-old Guangdong doctor in town for a wedding, staying in Room 911. Investigators theorize that the doctor infected 12 other guests, several from the same floor, who carried the disease to Singapore, Toronto and elsewhere.

By the time Dr. Urbani arrived at Vietnam-France Hospital, the microbe that Mr. Chen carried was spreading. Before he died, he infected 80 people, including more than half of the health workers who cared for him. The virulence of his case alarmed world health officials, helping lead to the extraordinary health alert that W.H.O. issued on March 15.

But Dr. Urbani, who first saw Mr. Chen in late February, quickly recognized that the disease was highly contagious and began instituting anti-infection procedures like high-filter masks and double-gowning, which are not routine in impoverished Vietnam. Then he called public health authorities.

Dr. Palmer recalled his conversation: I have a hospital full of crying nurses. People are running and screaming and totally scared. We do not know what it is, but it is not flu.

On March 9, Dr. Urbani and Dr. Pascale Brudon, the W.H.O. director in Hanoi, met for four hours with officials at the Vietnam Health Ministry, trying to explain the danger and the need to isolate patients and screen travelers, despite the possible damage to its economy and image.

That took a lot of guts, Dr. Palmer said. He is a foreigner telling the Vietnamese that it looks bad. But he had a lot of credibility with the government people, and he was a pretty gregarious kind of character.

With dozens of workers at the hospital sick, it was quarantined on March 11. Infection-control practices were instituted at other hospitals, including the large Bach Mai state hospital, where Dr. Claus of Doctors Without Borders oversaw them.

His quick action was later credited with shutting down the first Vietnamese outbreak.

In the middle of it, Dr. Savioli said, Dr. Urbani had an argument with his wife, Giuliani Chiorrini. She questioned the wisdom of the father of three children ages 4 to 17 treating such sick patients.

Dr. Savioli said Dr. Urbani replied: If I cannot work in such situations, what am I here for? Answering e-mails, going to cocktail parties and pushing paper?

In an interview with an Italian newspaper, Ms. Chiorrini said her husband knew the risks. He said he had done it other times, she recalled, that there was no need to be selfish, that we must think of others.

But on March 11, as he headed to Bangkok for a conference on deworming schoolchildren, he started feeling feverish and called Dr. Brudon.

He was exhausted, and I was sure it was because he had had a lot of stress, Dr. Brudon said later. I said, Just go.

But she had second thoughts. I called my colleagues in Bangkok and said, Carlo doesnt feel well, and we should be careful.

Dr. Scott Dowell, a disease tracker for the federal Centers for Disease Control and Prevention, who is based in Thailand, met him at the Bangkok airport near midnight. Dr. Urbani, looking grim, waved him back. They sat in chairs eight feet apart until an ambulance arrived 90 minutes later, its frightened attendants having stopped for protective gear.

For the first week in a Bangkok hospital, his fever receded, and he felt a bit better. But he knew the signs. I talked to him twice, Dr. Palmer said. He said, I am scared.

That was uncharacteristic for a man who was known as big, charming and full of ironic wit. In Italy, he staved off boredom by hang gliding. In Hanoi, he negotiated the insane traffic on a motorcycle and took his children on overnight car jaunts to rural villages. He carried Bach sheet music and stopped at churches, asking if he could play.

W.H.O. experts flew in from Australia and Germany to help. One scoured Australian drug companies for ribavirin, a toxic antiviral drug that was said to have helped some cases. It did not help Dr. Urbani, though, and was withdrawn.

Then patches showed up on a lung X-ray, and he told his wife to take the children and return to Castelplanio. Instead, she sent them ahead and flew to Bangkok.

By the time she arrived, his room had been jury-rigged as an isolation ward. Carpenters had put up double walls of glass, and fans had been placed in the window to force air outside.

The couple could talk only by intercom, and Ms. Chiorrini saw him conscious just once. As his lungs weakened, Dr. Palmer said, he was put on a respirator.

In a conscious moment, Dr. Urbani asked for a priest to give him the last rites and, according to the Italian Embassy in Bangkok, said he wanted his lung tissue saved for science.

As fluid filled his lungs, he was put on a powerful ventilator, sedated with morphine.

The end came at 11:45 on a Saturday morning. Doctors and nurses heavily shrouded in anti-infection gear pounded on his chest as his heart stopped four times, Dr. Dowell said, but it was useless.

Most of those who had died of SARS were old or had some underlying condition that weakened them, but he worked with patients for weeks, and we suspect he got such a massive dose that he did not have a chance, Dr. Palmer said.

It is very sad, Dr. Claus said, that to raise awareness as he did, you have to pay such a price.

 

• ALISTAIR COOKE ON CARLO URBANI

BBC Radio 4

Letter from America by Alistair Cooke, 11 April 2013

Saint Carlo

Carlo Urbani. Carlo Urbani. A name to remember, to mourn and forever to honour.

Dr Carlo Urbani, an Italian doctor we grievously remember now, gave his life for us and died at the age of 46.

We know him as Dr Urbani, but it would seem proper and inevitable that future generations will come to know him as Saint Carlo. For if ever a saint was alive and practising in my time, Dr Urbani was it.

On 26 February this year a Chinese-American businessman, a Mr Chen, was in a hospital in Hanoi suffering from what was first taken to be a special kind of flu picked up from birds.

Then it was thought to be a pneumonia.

But there were some odd atypical symptoms that baffled the doctors.

Somebody said: Send for Carlo!

Dr Urbani was a world-ranking expert on parasites but also was thought by his associates to be an uncannily good diagnostician.

He was also the Asian expert on several tropical diseases, especially ones induced by food.

While Dr Urbani sat by Mr Chens bedside he heard that a nurse in the same hospital appeared to have the same infection.

And then another nurse and another.

Dr Urbani immediately suspected something very rare in the world - a new and highly contagious disease.

He instituted masks, double gowning and then quarantining of a floor and in time of the whole hospital.

He called the public health official closest to the World Health Organisation and told him to alert them at once of a new disease.

By that time it turned out Mr Chen had stayed in a Hong Kong hotel, in a room just vacated by an old doctor visiting from Guangdong, which turned out to be the Asian Silicon Valley, the capital of wireless chips.

Dr Urbani was ready to confirm a rumour that the disease had started so far back as last November but the Chinese, with their normal distaste for citing unfavourable Chinese statistics, had not reported to the World Health Organisation.

When Dr Urbani had taken the drastic step of practically quarantining Hanoi, his wife begged him over the phone from Italy: he must leave Vietnam at once.

They argued. He said: If I cannot work in such a situation what am I here for?

Here, we now discover, meant on earth.

Throughout his whole professional life, from the time of his being a student, hed devoted his energies and his skill from dawn to dusk, or midnight, to the afflictions of the poor in many countries.

He chose to holiday in the poorest parts of Africa, always carrying a pack of medicines.

Shortly after his wifes call Dr Urbani felt a little chilly and then he had flu symptoms and sure enough he had the mysterious disease and called for a priest and the last rites.

He died on 29 March.

We also discover he had pioneered the splendid world body known as Doctors Without Borders and last year he accepted on its behalf the Nobel Peace Prize.

I do not know if the Nobel Institute has a rule against making a posthumous award.

If so, they had better break it. The next Nobel Prize for Medicine surely belongs to Dr Carlo Urbani.

• WIKIPEDIA ENTRY ON CARLO URBANI

http://en.wikipedia.org/wiki/Carlo_Urbani