Nguyen Sy Tuan was conscious but could barely talk. His wasted frame was tucked beneath a white sheet on a metal hospital cot, arms spindly and useless by his sides. Never a husky man, he had lost more than a third of his weight since the virus set upon him nearly two months earlier. Tuan had withered to eighty-four pounds. His head was propped up slightly on a thin pillow. His face seemed frozen in horror, cheeks sunken and lips agape. His bulging eyes were fixed, staring for hours at the ceiling as if the young man was still haunted by a specter that the doctors had predicted would surely claim him. Never before had the specialists in the intensive care unit of Hanoi’s Bach Mai Hospital seen anyone survive such a massive attack.
“We thought there was no way Mr. Tuan could make it,” confided Dr. Nguyen Hong Ha, head of the ICU, as he stood just outside the doorway. “No patient who we’ve put on a mechanical ventilator has ever survived.”
Yet when I visited Tuan, the twenty-one-year-old had already cheated death. He no longer needed the machine to help him breathe. He could even stomach a little rice on his own.
The small, white-tiled hospital room was silent except for Tuan’s occasional dry cough and the muted sound of distant car horns wafting through the second-floor window. To his right was another cot. Not long ago, his teenage sister lay there beside him, burning with a fever of 105, gasping for air just like her brother. Now the cot was empty. Somehow, she too had eluded death. She had already returned to school in the village, where her classmates, much to her consternation, had nicknamed her Miss H5.
Some doctors on the wards claimed these two cases as a triumph for Vietnamese medicine. But flu specialists nervously monitoring the virus in the spring of 2005 knew better. This unexpected turn of events was no reason to celebrate. The survival of Tuan and that of his sister, ironically, were part of a deeply disturbing trend.
These two siblings, the young seaweed harvester and the mischievous schoolgirl, were at the epicenter of a renewed outbreak in northern Vietnam that signaled to some of the world’s leading virologists and field investigators that the virus had mutated. It wasn’t just the increasing number of cases. It was the pattern. They were coming in larger family clusters, and the overall mortality rate had dropped substantially in a matter of months, suggesting the virus was edging toward pandemic. It may seem counterintuitive, but an astronomically high kill rate can be bad strategy for a prospective epidemic. After all, a virus that swiftly dispatches most everyone it infects gives itself little chance to spread. The 1918 flu virus, by contrast, settled on a far more modest fatality rate, claiming fewer than 5 percent of those infected. Yet it was ultimately able to kill at least 50 million people and perhaps many more.
Over the following months of that spring, new laboratory findings would emerge from northern Vietnam that apparently explained the shifting pattern, confirming that the field observations were no coincidence. Hard science seemed to show that the virus had crossed another threshold. A year earlier, in 2004, this novel strain had demonstrated conclusively that it could pass from one person to another, though widespread transmission had still been elusive. Now, in 2005, that fateful barrier appeared to be falling. Some in the know even concluded that the pandemic had already broken loose. But disease specialists at WHO never publicly disclosed their fears. Instead, they sweated in private, secretly weighing whether to sound a global pandemic alert.
If they did so, the economic fallout could be tremendous. Though the blow would fall hardest on Vietnam, decimating tourism and trade, the whole region could suffer. Multinational companies might suspend their operations. Foreign governments might evacuate their nationals. Airlines might cancel routes, leaving countries isolated and visitors marooned. Stock markets would plunge. These reverberations would be felt worldwide. Yet the danger of waiting to sound the alarm might be catastrophic.
The quandary was compounded by gaps in the evidence. The scientific data were incomplete and contradictory in places. So the flu hunters were forced to make pivotal decisions with only a partial view of the truth. In battling this virus, science has time and again failed to provide the solid answers needed to decipher the pathogen and keep it in the box. Since the last flu pandemic in 1968, the revolutionary field of microbiology has indeed succeeded in breaking the genetic code of the microbes that menace us. But laboratory science has still failed to unlock the secrets of how this mercurial agent evolves and mutates, how it strikes its human prey and when.
This presents a different kind of challenge than those that stem from the Asian landscape. The limits of current science in understanding and disarming the disease are largely independent of the realities on the ground, whether there or elsewhere along the expanding frontier of viral spread.
Nor are scientific constraints the only ones. Both sides of the man-versus-microbes equation pose difficulties. On one side, global efforts to contain flu are hamstrung because WHO and other human health agencies focus on the people afflicted by the disease, at times to the exclusion of the animals that are the source. In addition, money is tight. The resources that frontline states need to identify, contain, and ultimately eradicate the disease among both people and livestock are running short. On the other side of the equation, the essence of the virus itself often eludes disease investigators, whether in the lab or the field.
So on a Friday afternoon in June 2005, WHO’s flu team secretly convened in the agency’s underground command center in Geneva, linked by a dedicated communications network with some of the world’s most elite medical specialists from Atlanta and London to Tokyo, Manila, and Canberra, and prepared to gamble.
Something odd was happening outside of Hanoi. Within a few weeks of one another, three separate clusters of bird flu cases had appeared in a single province southeast of the capital. One of the largest included Tuan and his sister, their grandfather, and a local nurse.
Thai Binh province, where Tuan grew up, is mostly a flat plain of lakes and emerald paddies, part of Vietnam’s rice basket. After Tuan had finished his schooling, he left Thai Binh to look for work in the seaport of Haiphong. Many in the West know Haiphong because of President Richard Nixon’s decision to mine its harbor during the Vietnam War. But today this port city at the mouth of the Red River Delta flourishes as northern Vietnam’s premier industrial center, and there Tuan found a job collecting seaweed for producing agar, a gelatin used in local cuisine.
In early February 2005, all Vietnam took a breather for the Tet holiday. Across the country, Vietnamese bought new clothes, cleaned, repaired, and even repainted their homes, and decorated them with small kumquat trees, pink peach blossoms, and yellow apricot blooms. They stocked up on banh chung, or pork cakes, and on candied fruit and other traditional delicacies. Then they invited the spirits of their ancestors to join them in marking the lunar New Year. Sons and daughters who had moved to the cities crammed trains and buses, streaming home to celebrate this extended festival with their relatives. Tuan joined this mass migration. He headed back to the remote village in Thai Binh he had left more than a year earlier and ambled down the dirt alley to his family home, a one-room brick dwelling with a cement floor built beside a creek. Just outside the front gate, ducks paddled in the murky water as they had since his childhood. On the opposing bank, a verdant field of tobacco stretched into the distance. For the reunion, his family bought a chicken in the local market and butchered it in the yard. Tuan’s fourteen-year-old sister, Nguyen Thi Ngoan, clasped the bird’s wings and legs. Tuan slit its throat. The chicken was likely infected. Soon the siblings were, too.
Tuan broke into a fever about four days later, his wizened father told me over a cup of tea. When I arrived, Nguyen Sy Nham, the family patriarch, was visibly exhausted. For weeks he had been commuting by bus to the Hanoi hospital seventy-five miles away, keeping vigil for hours at a time on a plastic stool at the foot of his son’s cot. Yet Nham offered me a carved wooden chair at his table, turned down the volume on the television, and, between puffs on his traditional dieu bat bowl pipe, softly shared his family’s ordeal.
Tuan’s fever had lasted for about two days and then subsided, his father recounted. Tuan took some aspirin, had a bath, and felt better. But the fever soon returned and spiked at 104 degrees. His head throbbed. His chest ached. He started coughing and had trouble breathing. A village medic was summoned, and Tuan was taken to the local health center, where X-rays showed a white smudge in his left lung. The center’s deputy director suspected it was severe pneumonia. Because bird flu had previously been identified in the area, Tuan was transferred to a larger hospital in the provincial capital after less than a day. There the doctors concluded he had indeed contracted bird flu and immediately rushed him to the tropical disease institute at Bach Mai Hospital.
By the time he made it to Hanoi, the X-rays showed the white smudge had clouded the entire lung. Soon it consumed the other one also. “Just from the morning to the evening and from one day to the next day, it spread very quickly,” recalled Dr. Nguyen Thi Tuong Van, deputy director of the Bach Mai Hospital ICU. The doctors gave him oxygen to ease his breathing, but it continued to grow more labored. After ten days they inserted a tube down Tuan’s throat and hooked him to a mechanical ventilator. The infection marched on, damaging his kidneys and liver. The pain was excruciating. “We thought it was very likely the bird flu would kill him. We were very pessimistic,” Van continued. “Then, when it seemed the situation couldn’t get much worse, it started to get better. Two weeks later, when he didn’t die, I thought maybe we could cure him.”
Tuan’s kid sister, Ngoan, helped care for him during the early days of his sickness. Researchers who later studied the genetic signature of the pathogen concluded that Ngoan may have caught the bug from her brother, noting that some genes in her virus were practically identical to his. By the time I met Ngoan at her home, she was fully recovered. A tall, somewhat gangly teen with a mane of black hair falling to the small of her back, she bubbled over with nervous energy. She told me she loved badminton, chess, and drawing. Her eyes were narrow, but in rascally moments or when feigning surprise, she’d open them wide, big and black. When her father hesitated in retelling the tale, she’d prod him with a playful slap on the leg or she’d interject with details of her own.
Ngoan said she fell ill several days after her brother. “I felt some pain in my legs and some chills,” she recounted. “I started coughing a little.” At the district health center, X-rays revealed her lungs were clear but a subsequent test came back positive for bird flu. She was quickly transferred to the Hanoi hospital, where her fever ascended to searing levels. “I felt so tired because I had so many injections and I couldn’t sleep much,” she recalled. Hospital staff moved her to the same room as her brother and the pair bantered as always to keep up their spirits, until Tuan could no longer speak. Ngoan’s older sister brought her a pad and a pen. Ngoan, who would always draw people when she was feeling down, sketched the doctors and nurses to ease her mind.
After four days, her fever broke. It returned to normal within two weeks. Barely a month after she got sick, she was back in school as something of a local celebrity.
Though the grandfather also contracted the virus, he objected that he had never felt sick and indeed had shown no symptoms. Vietnamese health officials happened across the old man’s infection while testing all the family members. To flu specialists, this was more evidence that the virus was experimenting with new, deceptive paths of infection. Though the man might not feel sick, he could possibly be contagious and, if so, how would anyone know to steer clear of him?
The nurse was the most disquieting case of all. Nguyen Duc Tinh was a tall, skinny twenty-six-year-old with an earnest manner and a whisper of a mustache. He was on duty at the local health center when Tuan was brought in. During the brief, overnight stay, Tinh took Tuan’s blood and temperature, gave him injections, and helped him walk. Within a week, Tinh had developed severe muscle aches, eye pain, and a high fever, symptoms of what he believed was ordinary flu. But when the fever subsided only to return two days later, he grew alarmed.
“Then I suspected I had bird flu,” he recalled, his brown eyes widening. “I was really, really afraid of dying.” But just two weeks after being reunited with Tuan in the Hanoi hospital, Tinh was discharged. “I had lost hope when the fever came a second time. When I returned to my hometown, I felt as if I were born again.”
Vietnamese officials were loath to admit he might have caught the disease by caring for Tuan. This could be an admission that a more dangerous strain was taking hold. They offered a raft of possible explanations for how Tinh got sick: He had sick chickens in his village. There were sick chickens at his girlfriend’s home. He’d eaten a sick chicken. He had eaten it at his girlfriend’s home.
Tinh dismissed them all with a snicker. “I haven’t had any direct contact with poultry or eaten chicken or duck in a long time,” he countered. Nor had he dined at his girlfriend’s house for weeks before he fell ill, and, thank you very much, all her chickens were healthy. “But,” he added, “I was the one in the health center who had the closest contact with Mr. Tuan.”
A rare voice of candor among Vietnamese officials was Dr. Nguyen Tran Hien, the astute and able head of the National Institute of Hygiene and Epidemiology (NIHE), the country’s CDC. He told me in April of that year that his researchers had identified a significant number of mild and even asymptomatic cases, like Tuan’s grandfather. “The symptoms are not as severe as before. Also, the transmission may be faster and easier,” he reported. “We are concerned that if the virus is changing, maybe a new virus is coming in the future.” Hien wanted more data. And he wanted outside expertise.
Keiji Fukuda returned to Hanoi in mid-April 2005 as part of a special WHO mission. Fukuda was still with the CDC in Atlanta and would not officially transfer to WHO for several more months. But his standing and experience in Vietnam made him a natural for the assignment. Joining him was Dr. Aileen Plant, a fellow epidemiologist from Curtin University of Technology in western Australia known for her passion and wicked sense of humor. Plant had headed WHO’s highly successful response to SARS in Vietnam two years earlier. The third member was Dr. Lance Jennings, a virologist from the Canterbury Health Laboratories in New Zealand and his country’s acknowledged authority on flu.
For about a week, they shuttled from the WHO offices on Tran Hung Dao Street in downtown Hanoi to the handsome French colonial edifice that houses NIHE about a mile away. That grand old building, with its warm, mustard-colored facade and gray shuttered windows, is located on a street named for a foreign disease detective, Alexandre Yersin, the French-Swiss bacteriologist who discovered the pathogen causing bubonic plague a century ago and later adopted Vietnam as his home. There, down the elegant, high-ceilinged corridors of NIHE, Fukuda and his team huddled with their Vietnamese counterparts, reviewing their findings.
“We were looking at everything we could look at,” Fukuda recalled. “Was there an increase in cases? Any differences of patterns in cases? Anything different about the people who were getting infected themselves, and so on.” The evidence wasn’t conclusive. “But on the other hand, it began to appear there were some differences from earlier patterns in Vietnam.”
During the previous year, bird flu had killed nearly three-quarters of those Vietnamese it infected. Yet over the first few months of 2005, the mortality rate had dropped by more than half, suggesting that the virus was edging closer to a pandemic strain. The shift was especially conspicuous because it took place only in the north of the country. The cases were also increasingly coming in family clusters, and often the time that elapsed between cases within the clusters was growing, making it ever more likely that relatives were passing the disease to one another rather than all catching it from the same source. Nine cases were from Thai Binh alone, including Tuan’s cluster.
“We thought that it appeared there really could be some changes going on,” Fukuda said. “We were in that sort of gray area of understanding. Even if you have enough data to suggest, you don’t have enough data to tell you really what’s going on, and you need help interpreting.”
Fukuda and his colleagues pressed for a wider review of the evidence, and WHO scheduled a private conference for the first week of May, just ten days after the mission left Hanoi. It was to be held in Manila, the Philippine capital and home of the agency’s regional headquarters. WHO summoned staff from Geneva and across Asia. Senior government health officials from Vietnam, Thailand, and Cambodia were pulled in, as were outside specialists from the United States, Japan, Britain, and Australia. Leading laboratories, in particular the CDC in Atlanta and the National Institute of Infectious Diseases in Tokyo, were also asked to prepare genetic analyses of H5N1 specimens so these could be compared with the pattern of cases in the field.
“We called for the consultation knowing that it was a lot of trouble to bring a lot of people in rather quickly, but on the other hand these weren’t academic questions,” Fukuda recounted. “If there really was a change going on, we really wanted to try to come to grips with that as quickly as possible.”
For two days, the experts cloistered in Manila and sifted the evidence. Afterward the agency issued a report that cited the shifting patterns of infection in northern Vietnam, including a wider age range of victims, more and larger clusters involving cases over a longer period of time, cases without symptoms, and a declining mortality rate. The document said this was all consistent with the possibility of human transmission and greater infectiousness.
It also detailed genetic changes in viruses isolated in northern Vietnam. One mutation involved the place on the virus where it binds to either human or animal cells and could make it easier for the pathogen to infect people. Another change was near a site related to the lethality of the virus. The report also revealed that a sample from Nguyen Thi Ngoan, the mischievous teen from Thai Binh, showed a mutation that could cause resistance to the antiviral drug Tamiflu. If that change became widespread, it could rob doctors of a vital weapon.
“While the implications of these epidemiological and virological findings are not fully clear,” the report concluded, “they demonstrate that the viruses are continuing to evolve and pose a continuing and potentially growing pandemic threat.”
In the United States concern was mounting. Just three days after the Manila conference, the Central Intelligence Agency sponsored an exercise to model the global impact of a pandemic strain erupting out of an unnamed Southeast Asian country. Participants were drawn from five federal departments, including Defense and Commerce. The conclusions were sobering: economic downturns, international tension, and political instability.
On May 26, two weeks after Nguyen Sy Tuan was finally discharged from Bach Mai Hospital, WHO’s senior communicable disease officer in East Asia, Hitoshi Oshitani, got an alarming e-mail. It was from an epidemiologist in the agency’s Hanoi office. Vietnamese researchers at NIHE had been testing specimens taken randomly at health-care facilities in Thai Binh province. The sampling had not specifically targeted suspected bird flu cases. But 10 percent of the 170 specimens had come back positive for the virus, an exceptionally high proportion.
The results seemed to underscore the frightening scenario mooted in Manila. Even worse, the data lent credibility to separate tests conducted by Canadian scientists in Vietnam, which Oshitani had been hearing about.
Without a word to WHO headquarters in Geneva, he flew to Hanoi to see the Canadian microbiologist responsible for the research, Dr. Yan Li. WHO’s flu hunters in Asia were trying to keep the startling information from leaking out prematurely. “We didn’t want a huge panic with unverified information,” explained Peter Horby, the agency’s lead flu investigator in Vietnam.
Based on their briefings in Hanoi, Oshitani and Horby drafted a confidential report and on Tuesday, June 7, shared its contents with Geneva. They reported that Li, a Beijing-born scientist based at the Canadian health department’s National Microbiology Laboratory in Winnipeg, had begun a project earlier in the spring to help train Vietnamese scientists responsible for flu research in testing and laboratory techniques. As part of the work, the Canadians had sent in their own mobile lab. They began testing nearly two hundred samples previously collected by the Vietnamese. These were blood samples, or more accurately serum, the clear liquid that remains in blood once red and white cells and platelets are removed. The Canadians were using a technique called Western blot that could detect the antibodies that the human immune system produces in response to a bird flu infection. Though the Western blot technique was not entirely reliable, it did not require advanced lab safeguards like other antibody tests and could be done under local conditions in Vietnam.
According to the confidential report, the researchers tested 86 specimens from people with suspected cases of bird flu. About two-thirds came back positive for the telltale antibodies, indicating the patients had caught the bug. Another 101 samples were from people who had had contact with confirmed cases or infected birds. Nearly as many of these, about three-fifths, were also positive.
Separately, the Vietnamese had run tests using a different technique on the samples from the Thai Binh health facilities. Scientists at NIHE had established that 10 percent were positive by using a method that looked for genetic evidence of the virus itself rather than for antibodies. This technique, called polymerase chain reaction or PCR for short, uses special strands of highly sensitive genetic material called primers. Scientists would combine these with the sample and, if they matched, the primers would cause the virus’s own genetic material to rapidly reproduce until there was enough of it to identify.
Finally, the Canadians and their Vietnamese counterparts had conducted an analysis of thirty-eight samples and found that many had specific mutations in the surface proteins of the virus, strongly suggesting it was becoming less deadly. These mutations could help explain some of the milder and asymptomatic cases in Thai Binh and elsewhere in northern Vietnam, such as those of Nguyen Sy Tuan’s sister and grandfather.
The report concluded that the disease could be spreading among people more readily than anyone had thought. Moreover, if most cases were mild or lacked symptoms altogether, identifying those who were infected would prove nearly impossible. Even in hospitals, it would be challenging to recognize bird flu patients and segregate them from others. “Extinguishing a pandemic strain by early identification and targeted use of anti-viral [drugs] and public health measures is not going to be successful,” the document warned.
Klaus Stohr, the influenza chief, was taken aback. But at the same time, there was something about the results that struck him as not quite right. If the virus was already racing across Vietnam, shouldn’t the hospitals be flooded with patients? They weren’t. “It should stick out like a sore thumb,” he thought.
Calling his staff into his fourth-floor office at WHO headquarters on the morning of Thursday, June 9, Stohr said he planned to urgently convene an outside panel of experts to evaluate the information. “We’ll never have perfect data,” responded one of his lieutenants, but added, “We have data sufficient to consider raising the pandemic alert level.”
Stohr began drafting a memo to Lee Jong Wook, the agency’s director general, outlining the arguments pro and con for sounding the global alarm. Raising the alert level would immediately activate steps to contain the outbreak. Stockpiles of antiviral drugs could be rushed to Vietnam and the surrounding region. A warning against travel to Vietnam and nearby countries might follow. Every day mattered. Any delay could hand the disease an even larger head start, potentially costing the lives of untold masses of people.
But what if it’s a false alarm? “If you raise the level and you’re wrong,” Stohr thought, “you’ll be blamed.” The Vietnamese would be stigmatized. Their economy damaged. The move would spark waves of unnecessary panic worldwide, and WHO’s own credibility would suffer. Future warnings might be ignored.
“You make the decision based on the data you have in a responsible way,” he later explained. “You need to get ready to defend it. You need to get ready to take the blame.”
At that moment in mid-2005, the alert level was at level three, meaning the virus had succeeded in achieving no more than very limited human transmission. Based on the new information, WHO could hike the level to four or five, signifying greater human transmission and alerting the world that a full-blown pandemic, level six, was imminent.
An internal document written that same day suggested the situation might be even graver: “If the results are correct… this could be the signal that an influenza pandemic has begun.”
“Good morning, good afternoon, and good evening to everyone,” Stohr said as he opened the conference call at ten minutes past noon on Friday, June 10. His greeting was familiar to those who had sat in on his previous calls but the setting was not. He had summoned his staff to the WHO bunker, and they gathered around the large, circular conference table in the mezzanine overlooking the main floor of the SHOC. The command center offered a sophisticated communications network that could handle the large call while its secure doors assured that access to the session was kept strictly limited.
On the call were WHO officers from the Hanoi office and Manila regional headquarters. Also invited to participate were Dr. Nancy Cox, chief of CDC Atlanta’s influenza division, Dr. Roy Anderson, a senior epidemiologist at London’s Imperial College and chief science advisor to the British defense ministry, Dr. John Horvath, the Australian government’s chief medical officer, Dr. Masato Tashiro, head of virology at Japan’s National Institute of Infectious Diseases, and Dr. Kiyosu Taniguchi, chief of infectious-disease intelligence at NIID. Dr. Yan Li, the Canadian scientist, was also on the line.
They had all been supplied copies of the report detailing the test results from Vietnam. Now Stohr wanted their feedback. He said they would go in alphabetical order.
Anderson would have started, but he was running late. So Cox, the tough-minded virologist from the CDC, was first out of the box. Wasting no time, she went on the attack, calling the tests into question.
“The results I’m most concerned about,” Cox said, “are the antibody test.”
She and her colleagues at the CDC had previously done extensive work developing various tests for antibodies and had discovered that some of these techniques picked up false positives for H5N1. Some even purported to show evidence of the virus in specimens from U.S. blood donors who had never been within thousands of miles of an actual H5N1 outbreak, whether in people or birds. In particular, Cox was skeptical about the reliability of Western blot testing. To avoid misleading findings, the sensitivity and precision of this kind of analysis had to be calibrated using the results of other tests.
On the call, she grilled Li about his techniques in performing Western blot and interrogated him about whether he had used proper scientific controls to gauge the accuracy of his findings.
“Very limited controls,” Li acknowledged. He was already on his heels. “The number of controls is very low.”
Cox pressed on. She said the CDC had tested similar serum samples from Vietnam, and they’d all come back negative for virus antibodies. She called the rate of positives in Li’s test, or assay, “exceedingly high.”
“I really wonder if your assay is picking up false positives,” she continued. She urged that the samples be retested using a more respected technique for detecting antibodies, called microneutralization. “The serology is very much in doubt and must be repeated with another test in another lab,” she insisted.
“I understand the risks of Western blot,” Li responded defensively. He stressed that his findings were only preliminary. He admitted they might have overestimated the extent of infection in Vietnam.
Cox wanted everyone on the call to take a deep breath and think hard before rushing to conclude there was evidence of an emerging pandemic. So she continued to pound away, questioning the overall reliability of Li’s approach.
“The results are in question because they were obtained with an assay that hasn’t been validated,” she argued.
“I agree,” Li conceded, wishing his results had never been passed to the agency. “I didn’t even want that circulated.”
None of the other experts had yet weighed in, and already they could feel Li squirming on the other end of the line.
For a moment, he seemed to win a respite. The call shifted to a discussion of the genetic changes Li had detected and whether these were making the virus less lethal. He said that the mutations had been found in most of the human samples that his team analyzed. He suggested that either the virus was evolving into a less deadly form, or an entirely new flu virus was now circulating in Vietnam.
But he promptly came under fire again, this time from a new quarter. Anderson, the British epidemiologist, had joined the call and pushed Li on whether those mutations alone would determine the lethality of the virus. Anderson personally didn’t think so. He also noted that the analysis had examined only an “exceedingly small” number of samples.
Cox joined back in, suggesting that a whole series of genetic changes would be needed to alter the lethality, not just one. And even if these changes did make the virus less deadly in animals, as some scientists suspected, she was unconvinced these changes would do the same in people. She wasn’t even sure the mutations had occurred at all.
“The results need to be verified,” she said, repeating her refrain. “It’s quite possible they are true, but they need to be verified.”
Horvath, the Australian chief medical officer, now entered the fray. He wondered whether the researchers had tried to make sense of their highly unusual lab findings by comparing them with the actual experience of patients in the hospital.
“It’s difficult to understand, naturally,” Li offered meekly.
Then, abruptly, the tone changed. Having roughed up Li, the expert panel shifted gears and began to ponder what it would mean if he actually proved to be correct.
“The problem is serious, very urgent,” Anderson conceded. “We need access to information. It’s urgent that an independent lab confirms the changes.” But Vietnam might not share that sense of urgency, and Hanoi’s record of cooperation was poor. “It may be necessary to elevate the pandemic level to get the information,” Anderson suggested.
Stohr pressed the issue of whether to in fact raise the level. “How concerned should we be?” he queried.
“On face value, it’s a very serious report,” Horvath answered. “But it’s not sufficient to take action. I’d be concerned with raising the level of pandemic because it might shut Vietnam down.”
“We’d have to weigh that risk,” Anderson said. The move could be highly unpopular in Southeast Asia. He said the agency would have to weigh “the urgency to understand more versus the danger of upsetting the political balance.”
With time on the call running down, the experts turned to the third and final set of findings. These were the results of the PCR tests on the samples from the Thai Binh health-care facilities, which had revealed a 10 percent rate of infection. They were the most troubling findings. PCR was a more reliable test than Western blot.
“Ten percent is extremely high,” Cox noted. During a seasonal flu outbreak, far fewer than 10 percent of people tested under similar circumstances would have been positive. “But if this is a pandemic beginning, it’s not impossible. It’s urgent that the results be verified.”
Stohr concurred. “There’s an urgent need to verify the accuracies of the findings,” he concluded. WHO would rapidly assemble a new team of experienced virologists and epidemiologists, he decided, and dispatch them to Hanoi. WHO’s chief representative to Vietnam would hope to meet early the following week with senior Vietnamese officials and pressure them to let the team in. The Vietnamese government would be urged to turn over serum and other samples and related material for further testing.
A decision on sounding the pandemic alarm, he said, would be temporarily postponed.
At two o’clock Geneva time, Stohr adjourned the call.
Uncertainty is what often separates public health from laboratory science. Lab researchers select questions they believe they can answer and bypass those they can’t. They design experiments to produce definitive proof. Success means generating results that can be reproduced by other scientists in other labs. Public health, by contrast, rarely gets to choose the questions it must answer. People get sick. Doctors try to diagnose. They prescribe treatment and hope it will work. Symptoms, family history, and even test results are suggestive but often not definitive. The whole purpose of getting a second opinion on medical care is not to reproduce the conclusions of the initial physician but to discover if there are different ones. If the affliction is the common cold, uncertainty can be annoying. If it’s cancer, it can be tragic. If it’s flu, it can be catastrophic.
Medical science as a modern discipline is little more than a century old. Molecular biology goes back barely two generations. In that short period, the field has reshaped human knowledge and answered some of the basic questions about our very essence. Yet in confronting pandemic influenza, the greatest human killer in history, science still comes up short.
The difficulties begin with diagnosing the virus. Scientists have had trouble coming up with a fast way of determining whether someone has H5N1, and this lack of an accurate rapid test has repeatedly fostered confusion and even panic, most notably when the disease came knocking on Europe’s door. In the final days of 2005, villagers in the frigid mountains of eastern Turkey began falling sick with a mysterious respiratory ailment. Flu specialists suspected the novel strain. But initial tests by Turkish health officials came up negative. Days later, they reversed themselves, announcing that further tests had confirmed bird flu in two patients. More would follow. Of eight patients ultimately confirmed with bird flu and treated at a hospital in the regional center of Van, rapid flu tests came back negative every time. So did a separate enzyme-linked immunosorbent assay, or ELISA, test. Even the initial PCR test for four of the cases failed to identify the virus, though they were already very sick. Only after additional samples were taken did they test positive.
Then, as fear spread, Turks from around the country flooded hospitals at the first sniffle or cough. Day after day, hundreds of test samples poured in and overwhelmed the country’s national lab, which was equipped to complete at most a few dozen each day. Soon, instead of missing cases, Turkey was reporting false positives. The crest of the epidemic suddenly seemed to rise far higher than anyone had seen before. The government would eventually announce more than twenty human cases. But follow-up testing by WHO partner labs outside the country could confirm only a dozen.
Researchers in Indonesia reported similar problems with their initial flu tests. So did doctors in Thailand, who said in 2006 that these tests were actually becoming less able to detect the virus over time. Though rapid tests for seasonal influenza are commercially available and widely used, WHO says they are not sensitive enough to be used for bird flu. False negatives are common, and even positive results cannot distinguish between H5N1 and other influenza strains. Both the U.S. government and European Union have funded efforts to come up with a fast diagnostic test for bird flu. In spring 2009, the U.S. Food and Drug Administration approved the initial marketing of a test that can take less than forty minutes to work.
PCR tests that check for genetic evidence of the virus are more accurate but take several hours, longer than some victims can afford. And should the world face an emerging pandemic, even a short delay in detecting the virus could scuttle hopes of slowing its progress. Moreover, these are expensive tests that are frequently ill suited to much of Asia and elsewhere in the developing world. They require precise sampling, highly trained technicians, and the proper primers. As the virus strain mutates, which it does with haste, existing primers may no longer match and the tests will fail. And poorly matched primers can incorrectly detect other genetic material in the sample and yield a false result. Tests for antibodies to the virus can be even more accurate, especially established techniques like microneutralization. But these often demand labs with sophisticated safeguards. And they take much longer. Since antibodies to a virus appear only after the infection, these tests are of little use for responding to the disease in real time. A pandemic could be well on its way before antibody tests confirmed it. The “gold standard” for laboratory science is growing the live virus itself from a sample, traditionally in eggs, and using this to identify the pathogen. But this too is a long process. And for the many countries that lack high-security labs, the risk of the live virus escaping makes this technique far too risky.
The uncertainty goes well beyond testing. Flu specialists have been asking themselves for more than a decade why they know so little about the novel strain. Not long after it first crossed to people in 1997, researchers had already ascertained that the disease could be contracted through exposure to infected birds. But as Fukuda explained, exposure could mean many things. “Do you have to touch it? Do you have to rub your face after you touch it to get the virus near your mouth or your nose? If your face is close enough to infected birds, does that mean you can really breathe it in?” Maybe you don’t have to touch it at all, he suggested. “If you mean proximity, do you mean two feet, five feet, ten feet? Bird feces the same as having contact with birds? Is touching the wall in an area where birds were in the last twenty-four hours, does that count?” These are not idle distinctions. This information would help inform a strategy for stemming the spread of the virus and in turn reduce chances of a sinister mutation.
Research has been slow to offer answers, in large part because it is hard to conduct. Sick people don’t wander into studies. Those who are exposed and infected are often too ill to report how they got that way. Nor are time-consuming field studies involving large numbers of people a priority for countries reeling from these outbreaks. “Most of the countries where the first cases have occurred do not have traditions of analytic field investigation and the high profile of ‘bird flu’ does not encourage immediate openness,” wrote Dr. Angus Nicoll of the European Center for Disease Prevention and Control.
Dr. Michael Perdue, an American microbiologist assigned to WHO’s influenza program for several years, said it is hard to get standardized reporting from countries because each health ministry has its own way of doing things and few are anxious to publicize their disease outbreaks. “When it hits their country, they shut down,” he lamented. “WHO has to walk a fine line between demanding we have to have this information and shutting down the communications with the country, where they say, ‘Whoa, they’re coming after us. WHO is coming after us.’ You don’t get as much information as you like. There’s sort of a fine political dance that you’re doing.”
Perhaps more surprising is the lack of autopsies. Of the first two hundred confirmed deaths from the virus, fewer than a dozen victims underwent these postmortem exams. “This has posed some major problems in understanding the biology of the disease or fully understanding the virus underlying it,” explained influenza researcher Malik Peiris from the University of Hong Kong. Autopsies could examine how the agent wages its assault on the lungs and what other organs might also come under attack. These studies could help explain why some people get infected and not others, why the disease is so severe, and how well antiviral drugs work. “These are all pretty fundamental questions,” Peiris put it to me.
Why so few autopsies? The conventional response from leading researchers and senior officials is that local cultures bar the practice. In Chinese tradition it is said a corpse must be buried intact. Similar strictures are thought to apply in the Buddhist cultures of Thailand and Vietnam and the Muslim culture of Indonesia. “You have to get permission from the family to get that done,” explained Dr. Triono Soendoro, head of laboratory research at Indonesia’s health ministry. “People here are not used to having postmortem procedures.” Had Indonesian officials actually asked families for permission? “No, we haven’t tried,” Soendoro added.
When I broached the subject of autopsies with victims’ relatives, I got surprising responses.
Rini Dina Prasetyaningsih was among the first Indonesians known to succumb to the disease. Months later, I visited her small but comfortable middle-class home in South Jakarta and raised the delicate subject with her husband, Agus Mardeo. “I wouldn’t object to a postmortem as long as it was in the hospital and done by a doctor, as long they didn’t dig up the body after it was buried,” he said. Mardeo’s long, thin face turned somber. “Personally, I really wanted to know what happened to her. I would have been more than happy to have an autopsy.” But he added, “I’m just a common man. I don’t know about these medical procedures. No one suggested the idea to me.”
In a poorer suburb just outside the capital, a woman named Ibu Samida offered the same answer. She received me in her dimly lit living room, where she sat on a tattered couch surrounded by her four children and two grandchildren. The only one missing was her middle daughter, nineteen-year-old Ina, who had died not long before of bird flu. “I would have allowed an autopsy for the benefit of my neighbors and my family and everyone else concerned about the disease,” Ibu Samida said firmly. But again the refrain: “No one asked me. If they had asked, I would have given my permission.”
Yet even with autopsies, field studies, and fast, accurate testing, the answer to the most critical question could remain elusive: What will it take for the novel strain to become a pandemic strain? In other words, what specific genetic changes are required for the disease to become easily passed among people, and what is the sequence of biological events in animals and humans that will foster those changes? Scientists suspect these could involve mutations that make it easier for the virus to bind to human cells. But that’s likely not the whole story. Though modern science has delivered an intimate view of the pathogen’s inner machinery, the world still has little insight into how this fateful transition would work.
David Heymann, who was WHO’s chief of communicable diseases before retiring in 2009, conceded we’re not much further along in that regard than we were in 1918. “We’re handicapped by a lack of knowledge about the risk factors that cause the virus to change,” he said. “There are a lot of things we just don’t know.”
Scientists have little comparative data to go on because there have been only a few flu pandemics in modern times. Despite groundbreak ing work on the genetic makeup of the Spanish flu strain, Fukuda said there’s no way to be sure whether the 1918 experience is relevant to the avian flu virus. And without knowing how a pandemic strain would develop, it is nearly impossible to stop it. What steps should be taken to interrupt the evolution of a pandemic? What practices are speeding it on its way? When do changes in the pathogen represent a real and present danger? When are they a red herring? What to do about them?
“Sometimes the decision is simply ‘Let’s wait.’ We don’t have enough to go on. Let’s see how things evolve,” Fukuda said. “Or, it’s ‘We don’t have as much information as we like but we’re worried enough that if we’re missing something, it’s worth the price of jumping now.’ ”
For five days, WHO had been trying to get a meeting with senior Vietnamese officials. Finally, on the afternoon of Tuesday, June 14, Hans Troedsson’s delegation filed into a conference room at Vietnam’s Ministry of Agriculture and Rural Development, an unremarkable building around the corner from the monumental granite mausoleum, modeled after Lenin’s Tomb, where Ho Chi Minh, father of Communist Vietnam, still lies in repose.
Troedsson was no influenza specialist. He was a Danish doctor who had previously been responsible for children’s health issues at WHO. But as the agency’s chief representative in Vietnam, Troedsson essentially held the rank of ambassador. Flanking him were six other foreigners, including senior figures from the United Nations, World Bank, and European Commission.
The Vietnamese side was led by Deputy Prime Minister Nguyen Tan Dung. Considered a reformer within Communist Party ranks, Dung would be promoted a year later to become his country’s youngest prime minister since Vietnam was reunified. He was joined at the table by the agriculture minister and his deputy, the deputy health minister, and five other top officials. Such audiences with senior dignitaries would often merit a few minutes on Vietnam’s nightly news and a mention in the morning papers. But this one was to be strictly confidential.
After opening formalities, Troedsson explained to Deputy Prime Minister Dung the significance of the recent lab findings. They indicated that bird flu infections in Vietnam were more common than previously thought.
“Vietnam could be on the verge of experiencing a nationwide epidemic, which could spread globally and cause a pandemic,” Troedsson continued. If an epidemic broke out, it could do serious harm to Vietnam’s economy and the health of its people. If went global, it could kill as many as 40 million people. So, he warned, WHO might have to elevate the pandemic alert level to either four or five if the test results were accurate. Several UN agencies stood ready to help Vietnam fight the virus and prepare for a pandemic. But the troubling lab results had to be checked by international experts, he insisted. This was urgent.
Troedsson closed with a veiled threat. If the results could not be checked, WHO might have to raise the alert level as a “precautionary measure.”
Then, one by one, Troedsson’s colleagues tightened the vise. Jordan Ryan, the UN’s ranking official in the country, told the Vietnamese it was no longer question of if a pandemic was coming but when, and he urged Dung to do the right thing. Ryan’s counsel carried weight. A dozen UN agencies were active in Vietnam, engaged on multiple fronts, ranging from agriculture to childhood nutrition.
Next came Klaus Rohland, who ran the World Bank office in Vietnam. Over the years, Vietnam had received more than $5 billion in foreign aid for development, and the World Bank was in charge of coordinating that. Rohland told Dung that his country now faced a situation that could be “disastrous.” He strongly advised him to accept WHO’s offer of assistance.
Finally, Ambassador Markus Cornaro, head of the European Commission’s delegation in Hanoi, warned that foreign donors to Vietnam were counting on the government’s full cooperation. How the government responded to the “offer of international support” would indicate the degree of trust and cooperation between Hanoi and the donors, Cornaro told him.
The words were diplomatic, the threat unmistakable.
Dung listened intently to his visitors. Then he listened to presentations from his own health officials outlining the lab findings in greater detail.
When everyone else had finished, Dung vowed that Vietnam was concerned for the welfare of the whole world, not just itself, and wished to be proactive, neither complacent nor hasty. And so, Dung said, he would propose inviting an international team of experts to work with Vietnamese scientists in checking the recent lab findings and exploring the wider threat. The team could come immediately, but on the condition that the lab findings remained secret until the review was done.
It seemed WHO had gotten its way. But when Troedsson reported back by telephone an hour later, Stohr and his colleagues in Geneva doubted Vietnam’s intentions. Hanoi hadn’t said anything about actually turning over the original lab samples for independent testing, and nothing less would do.
“It’s a trap,” warned one senior official in Geneva.
Troedsson didn’t want to dally. The deputy prime minister had offered full cooperation and Troedsson took him at his word. What Troedsson didn’t say was that some of his staff in Hanoi believed time was already up and the pandemic was under way.
“It’s urgent here,” he pressed. “We want to have a team here next week. Klaus, don’t let us down on this one.”
When the conference call was over, Stohr and his colleagues in Geneva were agitated. “We didn’t get the message across to Vietnam,” Stohr grumbled.
But could they afford to continue bickering with the Vietnamese?
“We have to get a team in there as fast as possible,” urged Tom Grein, the veteran investigator who helped coordinate the global response to Vietnam’s early outbreaks a year before. “Six hours on the ground, ask for the samples.” If Vietnam balks, Grein added, “WHO has to have the guts to pull the team out.”
That week, Yan Li, the Canadian scientist at the center of the storm, sent an e-mail to many of those who had participated in the secret conference call the previous Friday. He said he agreed with their criticisms of his Western blot study and wanted to explain why he had proceeded with this technique.
Li said it would have been difficult to analyze the serum samples using a more reliable test because the Vietnamese didn’t have the proper lab safeguards. “Therefore, it would be better for us to first use the Western blot method for initial testing and provide on-site training to Vietnamese scientists to use this technique in their regular laboratory,” he said. “But the prerequisite was that all, or at least those serum samples initially screened positive by Western blot, be sent back to us so we can further test them.” Li’s own lab in Winnipeg could perform the verifying tests.
After the initial tests came back positive, Li wrote that he had repeatedly told officials from NIHE and WHO that “these were very preliminary results” that could reflect contaminated samples and would have to be retested using a more established method. “It was clear to us,” he said, “that the Western blot method was only for initial screening and training but not for the final decision-making test.”
Dr. Frank Plummer, scientific director general of the National Microbiology Laboratory in Canada where Li worked, later provided me with a similar account of the Canadian collaboration with the Vietnamese, adding that the results of the Western blot tests were supposed to have remained private. “This interim information was neither meant for distribution nor for decision making,” Plummer said. He called it unfortunate that the information was shared with officials, prompting public health concerns.
To some at WHO, Li’s defense rang hollow. They’d heard something similar from the Canadians before, two years earlier, to be precise. That’s when a baffling respiratory outbreak had raced through a nursing home in the suburbs southeast of Vancouver, Canada, and Li’s lab had weighed in with an alarming and ultimately misleading diagnosis.
In the first week of July 2003, scores of elderly residents at the 144-bed Kinsmen Place Lodge in Surrey, British Columbia, started coming down with the sniffles. So did dozens more of the staff. By August about a hundred residents and at least forty-five staff members had developed what looked like a summer cold. Seven residents had died during that period, not an unusually high number for the home. But pneumonia was implicated in three of the deaths, and that was worrisome. Initial tests at several Canadian labs failed to identify the cause of the outbreak. Then, Plummer announced to the media that his scientists had discovered it was SARS.
The revelation rattled Canada. The country was still on edge after the global SARS epidemic earlier in the year. Toronto, Canada’s premier city, had experienced the largest outbreak outside Asia and 250 people had fallen sick. Forty-four had died. Li and his colleagues at the National Microbiology Lab had been deeply involved in researching that epidemic.
The new cases at Kinsmen Place Lodge certainly didn’t look like the same SARS. Most were mild and nearly everyone recovered. But Li’s lab was now reporting that its genetic analysis had revealed an almost perfect match with SARS. Separate tests conducted by the lab on samples from the nursing home had also found antibodies to the SARS Coronavirus. The virus could be returning in a new, unpredictable form. WHO urgently dispatched a SARS expert from Geneva to investigate.
In suburban Surrey, the six-story brick nursing home was placed under quarantine. Ill patients were put into isolation. A sign on the front door greeted visitors: STOP. RESPIRATORY OUTBREAK. STRONGLY RECOMMENDED YOU DO NOT ENTER THE BUILDING. For days, residents could only wave through the windows to relatives on the sidewalk below. At Surrey Memorial Hospital, nineteen health-care workers who had contact with a patient from the nursing home were restricted to home quarantine. Then another nursing home in western Canada reported a similar outbreak.
As time passed, however, tests at other labs, including CDC Atlanta, failed to turn up SARS in the samples. Instead they isolated another Coronavirus called OC43, known to cause common colds. Both WHO and Canadian officials ruled out a new SARS outbreak, and the quarantines were lifted. The misdiagnosis by the National Microbiology Lab was ultimately blamed on a combination of contaminated lab samples and overly sensitive tests that generated false positives. The lab’s reputation took a drubbing.
Li later told the Wall Street Journal that his lab’s results had only been preliminary and were faxed out to the public without his permission.
So as a crack team of investigators secretly set out for Hanoi in June 2005, they suspected that Li’s Western blot results on the samples from northern Vietnam were flawed also. That thought offered a measure of comfort. But there were still those disturbing results from the separate PCR tests conducted by the Vietnamese, and the Vietnamese had a good track record.
Maria Cheng was in China when she took the call asking her to head for Hanoi. Her colleagues in Geneva told her that something was going on in Vietnam but they weren’t sure what. They were more nervous than she’d ever seen them. “They were really scared about what was going on. They thought the pandemic was starting,” she recalled.
Cheng was a bright, young Canadian journalist who had written from Asia for several publications before WHO hired her in the middle of the SARS epidemic to help handle the flood of press calls. She impressed her seniors in Geneva and, after that crisis faded, stayed on, expanding her communications portfolio to include bird flu, polio, and other diseases, splitting her time between headquarters and the field. She was an old hand at flu by the middle of 2005. Yet she didn’t realize how serious the situation might be in Vietnam until Dr. Julie Hall, an influenza expert in WHO’s Beijing office, sat her down.
“If there is a pandemic and you get infected, you’re stuck there,” Hall told her. “Are you really going to do this?”
Cheng said yes.
The Beijing staff showed her how to properly wear a mask fitted to the contours of her face and sent her off.
“It was freaky,” she recounted.
The Vietnamese government had decided, after all, to cooperate with the special mission and provide the required lab samples. By coincidence, Prime Minister Phan Van Khai was due that same week to make the first trip ever to the United States by a top Vietnamese Communist leader, and this was no time to pick a fight. In an interview with the Washington Post on the eve of his trip, Khai signaled his government’s good intentions. “Due to the limited capacity and conditions in scientific research facilities, therefore, we are working closely with the international community,” he said. “A sample has been provided for international experts and foreign countries to carry out joint research.”
In Geneva, Margaret Chan was planning for the worst. Just days earlier, she had been brought in as WHO’s new director of communicable diseases and special representative for pandemic flu. She instructed Stohr to draw up a new list of experts who could advise the director general, Dr. Lee, about whether to sound a pandemic alert once the special team reported back. She recognized this would be as much a political determination as a scientific one.
“They should be from different backgrounds,” she told Stohr. “We need policymakers or advisors to ministries of health, not pure scientists.”
Chan was also concerned that news of the mission would leak. She called Hitoshi Oshitani in the regional office, and they agreed that the agency would say as little as necessary.
In Vietnam, Maria Cheng would have the unenviable task of trying to keep the press in the dark without actually lying to them. It would be hard to miss the foreign scientists that began descending on Hanoi on Monday, June 20. The elite team included Masato Tashiro, the chief virologist from Japan’s NIID; Angus Nicoll, an epidemiologist who was then head of communicable diseases for the British Health Protection Agency; and Oshitani. Also joining the mission was Nancy Cox, the CDC Atlanta’s influenza chief, who would finally get to make sure that the questionable lab findings were properly verified.
The mood in Hanoi was eerie. The team members were on edge. There was a sense, Cheng recalled, that something really bad could be happening.
They dropped their belongings at the Melia Hotel in downtown Hanoi and headed around the corner to the WHO office for a briefing with Hans Troedsson and Peter Horby. “They were convinced this was the beginning of a pandemic outbreak,” Cheng said. “Peter told me it was definitely happening. We just didn’t know how bad it was.” There was no doubt that the alert level would be raised. The only question, Horby told Cheng, was whether it would be hiked to level four, which signifies increased human transmission of the virus, or five, which means widespread transmission.
Horby said he had a high degree of confidence in the Vietnamese lab technicians. They were careful, and their results had always turned out to be right. That’s why he was so worried.
Wilina Lim and her assistant were the last to arrive. Oshitani had turned to Lim for help in retesting Vietnam’s worrisome samples. As the head of Hong Kong’s public health laboratories, she had been intimately familiar with H5N1 longer than nearly anyone else in her field, having identified some of the earliest cases in 1997. She had been reluctant at first to join the mission, asking instead that Vietnam ship the samples to Hong Kong, where she could do the analysis in her own lab. But the Vietnamese refused.
Lim had never been to NIHE. She had no idea what equipment they had or whether they knew how to use it properly. Even the slightest miscue could contaminate the samples, making gibberish of the results. Lim wasn’t taking any chances. She and her assistant started preparing everything they’d need to run the tests, and that meant everything. In one large cardboard box, they packed their own pipettes and pipette tips, their own primers, and even containers of water for testing. They packed their PCR machine, called a thermocycler, into another box. They also crammed a suitcase full with gloves, sanitary wipes, paper towels, and other assorted supplies. If the samples could not come out to Hong Kong, then Lim would recreate a miniature version of her own Hong Kong lab right inside NIHE.
While Lim was packing, the other team members were already in Hanoi at work, scrutinizing the lab techniques the Vietnamese had used, evaluating the test results in light of information from the field. The days started early, not long after dawn, and went until evening. The team members compared notes over late dinners, night after night, and then went to bed so they could begin anew. Everyone was stressed.
Lim caught an early morning flight to Hanoi on Thursday, June 23, and by midmorning was on the ground. She and Cox consulted on how best to run the new test and check the Vietnamese findings. Lim was anxious to set up her equipment and get started. But there was no room at NIHE. The institute was busy with its routine work. She had to wait. Finally, at 7:00 P.M., the lab staff cleared out, and Lim and her assistant began testing the first of thirty samples. They continued until midnight, then returned early the next morning, using their PCR machine to amplify genetic material in the samples. By that afternoon, they were seeing a clear pattern emerge.
Several colleagues were waiting anxiously in the WHO office when Lim returned with her findings.
Lim reported that her tests were coming back negative, every last one. There was no trace of genetic material from the virus. The patients sampled in Thai Binh had not been infected after all.
The earlier results had been flawed. The positives had all been false positives. The Vietnamese, it turns out, had been using a set of primers they’d been given by the Canadians, and these were detecting rogue bits of genetic material. The new tests using Lim’s primers had all come back clean.
In the office, the relief was tremendous, the swing of mood extreme.
Nicoll had been studying the field results when the pair reported back that there was no evidence the virus was becoming more infectious. He immediately put aside his papers. “What problem?” he suddenly thought. “It all goes away. It’s like water disappearing into sand. You think you have a cluster and you don’t.”
Horby, hugely comforted, packed up his belongings and left. Twenty minutes later he was bound for a previously scheduled vacation in Britain.
“We dodged a bullet there,” Cox said.
And with that, she and Nicoll decided to go shopping. Nicoll loaded up on souvenirs in the markets of Hanoi’s old city near St. Joseph’s, the city’s neo-Gothic cathedral. Cox bought an ao dai, the traditional, form-fitting Vietnamese gown with a high collar and slits up both sides. A day later, the pair headed north to the haunting waters of Halong Bay, one of Vietnam’s most popular tourist destinations, for a cruise amid its sculpted limestone islets.
When officials from Geneva called Hanoi for an update, they were informed that Cox and Nicoll were on a boat and unavailable.
The scare would remain secret. The world would never be told how close WHO had come to putting it on a war footing. Just about the only hint provided by the agency came one day after the team departed Vietnam. Citing WHO, the French press agency reported that an international team of virologists and epidemiologists had left the country after assessing that the threat posed by the bird flu virus was less than they’d suspected. Few other details were offered. “The most important thing,” Troedsson was quoted as saying, “is that we could rule out that there was an immediate, imminent pandemic.” It was meant to be reassuring. But his comments acknowledged more about the agency’s fears than officials ever had before.
Her maroon minivan had just edged into Friday morning traffic and already Gina Samaan was troubled. The case just didn’t make sense.
Seated in the backseat, Samaan flipped through the file yet again. This much was for sure. A twenty-nine-year-old Indonesian woman from the east side of Jakarta had died two days earlier. She had suffered from acute pneumonia. She had been ill for at least a week. The victim’s doctors suspected it was bird flu, and indeed her samples tested positive for the virus at a government laboratory.
The specimens also came back positive from another, secretive lab run by the U.S. Navy in downtown Jakarta. This was one of three overseas labs established by the navy to specialize in infectious diseases confronting U.S. forces on foreign terrain. Recently it had been forced to lower its public profile in Indonesia because of rising anti-Americanism fueled by the wars in Afghanistan and Iraq. Still, the lab continued to operate, perhaps ironically, right across from the city’s main prison, where Indonesia had jailed some of its most notorious terrorism suspects. The navy facility was more sophisticated than anything the Indonesians could muster, quietly supporting the government’s efforts to contain the spreading bird flu outbreak. If the lab confirmed the victim had died from the virus, it was sure to be so. But that scientific fact by itself revealed precious little about the case at hand.
Samaan’s van inched through the traffic. Outside, another equatorial morning had settled on the Indonesian capital, air so thick and languorous that breathing was a chore, the sky depressingly gray from the smog hugging Java’s swampy coast. Commuter buses muscled through some of the third world’s worst gridlock while motorbikes swarmed like mosquitoes. Though the van’s front and rear windows were emblazoned with the shield of the United Nations, few took notice of the vehicle or the young WHO investigator inside. Even fewer made way.
At twenty-nine, Samaan was the same age as the victim. Dark eyes earnest and intent behind rimless glasses, brown hair tied back with a pink hair band in a practical ponytail, Samaan pursed her lips as she continued to review the case. The local media were reporting that chickens in the victim’s neighborhood had recently fallen sick and died. But Samaan had access to test results on samples collected by the city’s veterinary department. These seemed to show that the local poultry were healthy. “That makes me a bit worried,” she admitted to me in a broad Australian accent. “Is there anything different here?” she wondered. “If so, what’s different?” If the source of infection wasn’t chickens, could it be another person? If so, it might mean the virus had mutated into a form more easily passed among humans.
That prospect seemed to grow over the following days as this influenza gumshoe followed a trail of clues leading unexpectedly into a neighboring province and then back again. In its own way, the stakes of her investigation were every bit as high as that of the special WHO mission dispatched to Hanoi seven months earlier to verify whether the virus was perilously mutating. Northern Vietnam had been a source of intense anxiety because of flawed test results that appeared to show that the novel strain had broken the pandemic code. But in the months before Samaan set out on this morning in January 2006, more people had died of the disease in Indonesia than anywhere else. And if a global epidemic were to erupt, there was no place more likely for it to start.
Samaan and the Indonesian health ministry had both agreed to let me accompany her on her investigation as long I respected the victim’s medical privacy by keeping her identity confidential. This afforded me an intimate view, not only of the hunt but of the challenges and frustrations epidemiologists face as they try to run this killer to ground.
Samaan wasn’t taking any chances. She had stashed a bag with masks and plastic shoe coverings in the back of the van. In her bulky brown satchel of a handbag, buried beneath a cell phone, digital camera, and BlackBerry, she kept a small bottle of pink antiseptic hand lotion and a cheap thermometer. She had been taking her temperature twice a day since she had arrived in Jakarta eight months earlier, dispatched by WHO from the Australian health ministry. “It’s important to know your baseline,” she explained, adding that hers was a cool 97.5 degrees. She had also carefully considered her footwear, donning simple shoes with covered tops so her feet would be protected against any contamination on the ground. They had flat bottoms so they were less likely to get cruddy with dirt, chicken droppings, and other possible sources of infection. And because she was constantly removing her shoes according to Indonesian etiquette before entering someone’s home, she settled on a pair that was easy to slip on and off, so she didn’t have to bend down near the ground. After each outing, she washed them in the sink and, as a result, was going through a pair every few months.
Yet for all her preparations, Samaan wasn’t expecting what awaited her when we finally pulled up in the victim’s neighborhood. It was as if the whole community had turned out and was now sitting in rows of folding chairs on the block captain’s grassy front yard, anxiously anticipating an explanation for their tragedy. Samaan waded through the crowd along with her translator, a stocky Indonesian with thick sideburns, wispy beard, and crisp American accent acquired during a childhood in Pittsburgh, and a middle-aged woman in batik named Ibu Eni from the health ministry’s national lab. When they announced that blood samples were to be taken, dozens crowded around, offering their arms.
This was not the way things were done back home in Australia, where Samaan had recently graduated from an elite program in epidemiology at the Australian National University in Canberra. She would have preferred to proceed calmly, methodically. She would have wanted to interview the victim’s relatives and neighbors in their own homes, carefully taking stock and observing them, noting their answers, calibrating their responses, piecing together the timeline, then drawing samples only from those who had immediate contact with the dead woman. Instead this was verging on chaos.
Ibu Eni took a seat behind a wooden school desk set out in the yard. She snapped on a pair of rubber gloves and began accepting one thrusting arm after another. After the first man had given blood, Samaan buttonholed the graying old-timer and tried to clarify the conflicting reports about sick poultry.
“Have there been any bird deaths in the kampung, or neighborhood?” she asked.
“Nothing,” he demurred. “Everything’s been ordinary.”
A second man in a black Mercedes cap interjected, correcting him, “Yes, there were two chicken deaths, about thirty meters away from the victim’s home.”
“How many were dead?” Samaan asked, confirming the number.
“There were two,” the second man repeated.
Then a third man, with a bushy mustache, stepped forward, weighing in, “Yes, there were two dead chickens a month ago.”
Samaan listened intently, producing a large, spiral notebook from her handbag and jotting down the details. “What were the symptoms?”
“It was all of a sudden. We didn’t see any symptoms,” answered the mustachioed neighbor.
“What made you think the birds were sick?” she pressed.
“My wife found them,” he answered. “My mother-in-law poured kerosene on them and burned them. I just cleaned up the remains.”
The three men started buzzing among themselves. The translator fell silent, trying to follow the conversation. Samaan waited. Perhaps the neighbors were trying to recall the details. Or perhaps, like many other Indonesians, they were reluctant to disclose them, fearing that local veterinary officers would raid the kampung and cull the remainder of their birds.
“How’s it going?” Samaan prodded after a few minutes.
“We didn’t see any chickens with symptoms,” insisted the man with the mustache. “They were just kind of dead. We still don’t know whose chickens they were.”
Samaan rolled his remarks over in her mind, examining them for any elusive clue. Two dead birds, no symptoms, no samples. It was hard to conclude they were responsible for the death. She excused herself. Then she went to locate the victim’s relatives in the crowd.
The victim’s mother was a handsome woman in a coarse, orange dress with thick brown hair pulled back in a bun. Samaan ushered her to the shade of a stately jackfruit tree in a corner of the yard. The great green fruit dangled from the canopy. Another neighbor dragged over two folding chairs so the pair could sit down.
“When did your daughter become sick?” Samaan asked, this time pulling a large calendar out of her handbag.
“Nine days ago.” That made it the first week of January. The timing could eventually prove crucial to cracking the case.
“Did she have a temperature?”
The mother furrowed her brow trying to summon the specifics. “She was very hot. She had a terrible cough. She had a bad infection in the lungs.”
Samaan inquired about the rest of the family, where they lived, and whether the other members were healthy. Everyone else was fine. She asked about the family’s recent travels. She asked who did the shopping and the cooking in the family.
“Do you own chickens?”
“No, but sometimes the neighbors’ chickens come around,” the mother responded, squinting as she thought about the answer.
“Did any of those chickens die?”
“We didn’t see any sick chickens. But most of the time we weren’t home. We’re a working family,” she said, lines deepening across her dark brow. Then she added, “My daughter’s a nurse at a hospital.”
This last disclosure landed like a bombshell. Though Samaan’s expression remained placid, her heart fell. If the victim had been a nurse, she might have been infected by another flu patient, signaling that the novel strain had mastered the ability to jump from person to person. Or she might have passed the disease to one of the many people whom she treated on the wards. Was the hospital itself breeding an epidemic? Had it already burst beyond the walls into the teeming quarters of Jakarta? The possibilities were frightening. The prospect of pandemic instantly seemed closer. But Samaan refused to let her anxieties betray her. She pressed on.
“Which hospital did she work in? Where is it located?” Samaan probed.
“West Java.”
“Which department did she work in? ICU? Pediatrics?”
“I don’t know,” the mother said. “She’s a regular nurse.”
As Samaan wandered down the narrow concrete alley to the victim’s home, her mind was humming with questions. First, what was the culprit? She wanted to uncover the precise source of her victim’s infection to determine how the sickness spread and whether others were at risk. Had the mercurial virus changed its modus operandi? If so, this might reflect a fateful mutation, and the world would want to know. Samaan also needed to find anyone who’d been in contact with the deceased to see if they required medical care. Most urgent of all, was this extraordinarily lethal disease now being relayed from person to person? Was it time to sound the alarm?
The answers lay in the quotidian details of kampung life. Samaan intended to sift through the family’s habits, peering under their prosaic routines for the tracks of a killer.
That meant delving into the family’s medical history, whom they worked with and lived with, how they prepared their meals, and where they slept. She would need to know if they raised animals and how they kept them. She would learn where the family shopped and who butchered the poultry, whether they took traditional medicine or had a taste for liver, eggs, or raw meat, whether they were hunters, farmers, or regulars at the city zoo. To solve this whodunit, Samaan would also reconstruct the victim’s final weeks and days. She would weave together the account in the hospital records with the recollections of relatives and coworkers whose memories were now buffeted by fear, confusion, and grief.
Epidemiology is often likened to detective work. But the metaphor is misleading. In reality, disease investigators all too rarely enjoy the satisfaction of collaring their suspect. Clues are few and easily overlooked: a smudge of bird feces on an eggshell, mucus on a feather. Trails go cold quickly. Infected birds may have flown away; victims may have been diagnosed too late and died before investigators could question them. Witnesses forget innocuous but crucial details: a friend’s songbird, fertilizer in the garden, or a quick stop at the market. Even when a death coincides with an obvious outbreak in a neighbor’s flock, the evidence of infection is often circumstantial. When several family members contract the virus, it’s often impossible to conclude whether they all got it from the same sick chicken or shared it among themselves.
If a nascent pandemic strain were circulating in an Indonesian hospital, Samaan would find this out. If it wasn’t, she would offer the world a measure of reassurance. But she also realized she might never be able to stamp “Case Solved” on her file. A study of Indonesia’s first 127 confirmed cases found that that investigators had failed to come up with any possible explanation for one-fifth of them. At best, Samaan might only be able to suggest a plausible hypothesis for her victim’s death. Yet this would leave much of the flu’s mystery unrevealed and possible strategies for defeating it obscured.
“Sometimes you can only go so far and stop,” she told me. “Sometimes you have to draw the line.”
The victim’s neighborhood was not as poor as Samaan had expected. Small, tidy dwellings lined the alley with laundry hanging limply out front. Sewage trickled down a ditch beside the alley.
After two minutes, Samaan reached the family home, a simple, middle-class house at the top of the alley. The victim had lived there with her parents, husband, and four-year-old son. Samaan crossed the porch and removed her shoes at the doorway. She joined half a dozen Indonesian officials inside. The air was close, tangy with sweat. They sat cross-legged on a woven mat in the front room, unfurnished except for a large wooden cabinet with glass doors, the walls unadorned but for family portraits. The mother reached up, took down a photograph in a carved wood frame, and passed it around. It was a formal portrait of the deceased and her young boy. The woman was fleshy but attractive with wavy brown hair and thick red lipstick. For the photograph, she had donned a green tunic over a red batik sarong. She was standing with her hands folded before her. At her side was the boy, smart in a traditional Javanese sarong and black pece cap.
From outside on the porch came the staccato of a youngster coughing. Samaan looked quizzically at her Indonesian colleagues. None of them were wearing any protection, no mask, no gloves. Samaan asked whether the boy might be infected. Unlikely, the Indonesians assured her. He had been coughing for weeks, long before the victim fell ill, and otherwise seemed healthy. As if to prove the point, the youngster suddenly appeared in the doorway on a bicycle. Besides, the Indonesians explained, he had already tested negative for the virus.
Samaan scribbled a few notes. Then she returned her attention to the victim’s mother.
“In the ten days before she became ill, did she go to any parks? Any farms?”
“Nothing,” the mother answered.
“A traditional market?”
“Yes, she went to a traditional market. A couple days beforehand, she bought us chicken.”
Samaan jotted down the details.
“Did she kill it herself?” Samaan continued, wondering whether the victim had been infected while butchering a sick or contaminated bird.
“It was already killed.”
“Feathers or no feathers?”
“It was already cut up and ready to cook.”
“When did she go to the market?”
The mother shrugged and turned toward a bushy-haired man sitting quietly in the far corner. It was the victim’s husband.
“I don’t know,” he said softly.
“Before New Year’s?”
“Yes, before New Year’s,” he confirmed.
Rising to her feet, Samaan asked to see the rest of the house. She entered a long room in the rear of the house. There was a refrigerator. She opened the door and peered inside. It was mostly empty. Next she went into the cluttered kitchen, where she instantly spotted a metal wire basket suspended about six feet off the ground. She pulled a pair of rubber gloves from her handbag and tugged them on. Then she craned her neck back, reached up, and gingerly unhooked the basket, placing it on a table. Inside were about a dozen brown eggs. She plucked them out one by one and scrutinized them, looking for traces of chicken droppings that could have contained the fatal dose. Nothing.
“Very clean,” she acknowledged. “No sign of feces.”
Samaan replaced the basket and snapped a picture of it with her digital camera.
The general lack of filth was becoming ever more disturbing, the absence of livestock unnerving. None of the neighbors seemed to have the wooden cages common in most Indonesian yards for raising chickens. In fact, except for a pair of black chickens lingering in a bush near the block captain’s home, there was practically no trace of poultry anywhere in the neighborhood.
“It’s perplexing and it makes me a bit worried,” Samaan confided to me. “She was a health-care worker. If there’s no sign of infection here…” Her voice trailed away.
Inside WHO, Tom Grein is a legend. His exploits as an epidemiologist are unsurpassed in his generation. He has ventured to some of the world’s most remote corners and confronted some of its most horrifying diseases. When bird flu initially exploded in Vietnam, he was among the first from WHO on the ground in January 2004. When the virus recorded its single largest cluster in the highlands of Sumatra in May 2006, again he was there. Yet Grein readily admits the limits of his calling. “Epidemiology never proves. It only highly suggests,” he put it to me. “As frustrating as that might be, not having a smoking gun itself is not failure.”
A lanky German with still, blue eyes, a strong chin, and closely cropped brown hair tinged with gray, Grein has a reserved, methodical manner. His colleagues say he can be dour when he’s stuck in Geneva and this demeanor has earned him the moniker Gray Cloud. Nothing makes him happier than when he gets to leave the office.
In 2005 he left and headed for southern Africa, responding to the deadliest outbreak of Marburg hemorrhagic fever ever recorded. He drove for ten hours from the Angolan capital, Luanda, into the country’s hilly interior, where he discovered villagers dying by the scores. Victims would develop a high fever, crippling headache, diarrhea, and vomiting. Then, as one of the most lethal pathogens of all turned its fury on the liver, spleen, and other organs, blood would often gush into the body’s cavities before emptying out through the nose, mouth, eyes, rectum, and other orifices. Barely one in ten survived. As if that weren’t daunting enough, Angola was just coming out of a twenty-seven-year civil war and remained unstable and violent. The landscape was still littered with land mines, the few concrete buildings scarred by gunfire. “There was a lot of hands-on work to do in a very difficult climate and very difficult environment,” Grein told me. “It took a long time to contain the outbreak.”
For nearly a month he and his team remained in the Angolan province of Uige. They went hut to hut carrying out inspections, working inside low, dark dwellings, the air thick with death. They disinfected bodies and buried those who had perished. Their protective suits, double gloves, and face shields were all that separated them from a similar fate. “There’s a perception that you’re putting yourself quite at risk. Though you take appropriate measures, the brain plays its games,” he admitted. All the time, he feared the disease would spin out of control. The international team would contain it in one place, believing they had broken the chain of transmission, and it would erupt somewhere else. They were never able to identify the original source.
Twice before, he had been dispatched to face down Marburg in Africa. He had investigated and ultimately helped control outbreaks in the Democratic Republic of Congo, formerly known as Zaire. In 1998 he had responded to a flare-up in southern Sudan of what health officials suspected was also hemorrhagic fever. Ebola, an equally cruel and contagious cousin of Marburg, had first been identified a decade earlier in an equatorial province of Sudan. Now that same pathogen was believed to have struck a quarter of the people in four isolated farming villages high in the savannah. Two Sudanese medical investigators who first reached the area had gotten ill, and one died. To get there, Grein and his entourage hiked from dawn until the middle of the night, fording four rivers along the way. “It was like Dr. Livingston with high grass left and right,” he recounted. “It was something out of an old movie with people in single file carrying things on the top of their heads.” The affliction turned out to be a particularly nasty respiratory tract infection. But not long after, he would confront Ebola itself in the Republic of Congo.
Then there was the time he was airlifted into the mountains of Afghanistan. Once again, hemorrhagic fever was suspected. An outbreak had pervaded three-quarters of the homes in a remote hamlet of northern Afghanistan, which was then controlled by the forces of the storied Tajik militia leader Ahmed Shah Masood. During the summer, it would take a week by mule to reach the village. But the disease broke out during the height of winter and the outpost was cut off by snow. Grein and a WHO colleague flew in by helicopter from the neighboring country of Tajikistan. They treated about twenty patients with antibiotics and collected specimens for further testing. The outbreak was ultimately blamed on an “influenza-like” respiratory infection.
I had known of Grein’s reputation long before I met him. When I finally caught up with him in Yogyakarta, a historic royal city on Indonesia’s Java island, he was exhausted. Six days earlier, a powerful earthquake had struck just south of the city, killing nearly six thousand people and displacing 1.5 million others. Now the neighboring Mount Merapi volcano was threatening to blow. Grein, who had coincidentally been in Indonesia for several weeks investigating the Sumatra bird flu cluster, was asked by WHO to extend his stay and set up a system for monitoring possible outbreaks of cholera and other disease in the quake’s aftermath. He had done the same a year earlier in the Indonesian province of Aceh after it was struck by the massive South Asian tsunami.
“Epidemiology is a different world than lab work,” he explained to me over strong coffee. “Most field epidemiologists only understand the basics of what happens in the lab. Laboratory science has advanced so much that it’s impossible for field epidemiologists to keep up. But laboratory results without epidemiological information are limited. If you send in lab samples from the field without epidemiological background, they throw a fit.”
We were sitting in the restaurant of the Santika Hotel, one of the few hotels in town still functioning and a base for humanitarian operations. Around us, relief workers in blue-and-white vests mingled at the buffet with Japanese soldiers in camouflage. Grein was clad informally in a short-sleeve blue shirt open at the collar, brown jeans, and heavy black shoes. The fine lines across his forehead deepened as he tried to regain his train of thought.
“You can’t go by the first piece of information you have,” he resumed. “You have to be able to listen and understand, look for the small details, be a little obsessive, and not give up. You have to keep trying to track down the disease.” He paused to let the point sink in, then continued. “You also have to understand the cultural sensitivities. You are dealing with a lot of people who are grieving, who have lost family members. You have to strike a balance between pushing your agenda and not upsetting the local population.”
During the Marburg investigation in Angola, villagers had stoned his team’s vehicles, forcing WHO to temporarily suspend its efforts. The foreigners had initially descended on the community in the back of pickup trucks wearing what appeared to be strange “astronaut suits” and carried off the victims’ bodies. The locals were prevented from showing their ritual respect to the dead by washing and embracing the corpses. They suspected the foreigners of stealing their loved ones. Grein said the WHO team ultimately defused the confrontation by putting on their protective gear in front of the villagers and taking the time to explain what they were doing. “It takes trust, transparency, and openness. Without it, it’s an uphill battle.”
Despite the potential for cultural miscues, Grein said he found the third world an easier place to work. Developed countries often keep WHO epidemiologists at a bureaucratic distance, preferring to run their own investigations. In developing countries short on resources, he added, “we get to work on the ground.”
In Asia he stalked bird flu through the tropical jungles of Indonesia, the rice paddies and river deltas of Vietnam, and the deep mountain snows of southeastern Turkey. Other WHO epidemiologists had picked up death’s trail elsewhere. Yet for all the months and miles, even the most seasoned investigators had failed to crack the mysteries of the novel strain. “Since it began in Vietnam in 2004, every case was followed up on one way or another but very little is known,” he admitted. The precise incubation period remained unclear because investigators were rarely able to determine the source of exposure and thus the exact moment the victim was infected. But that knowledge would be vital for crafting public health policies to contain an emerging epidemic. Nor had they been able to detail how the virus infected people and why some were susceptible while others were not. These elusive specifics could be crucial for limiting human exposure to the disease and developing drugs to combat it.
Though Grein is the best at what he does, even his own flu investigations have often yielded partial success at most. Frequently victims take their personal histories with them to the grave. It’s simple to blame poultry for the infection since they’re everywhere in Asia, he noted. What’s harder is ruling out the possibility that the source was actually another person. “That’s always going to be a question. You can’t really prove it,” he explained.
When investigators manage to break open a case, the novelty makes it striking. Late in the winter of 2006, they’d hit a wall after the virus had suddenly erupted in Azerbaijan, a former Soviet republic situated on the cusp between eastern Europe and western Asia. Of the eight confirmed cases, seven were from one remote farming settlement so poor that it lacked electricity. All but one of these cases were from the same extended family, mostly girls and all between ages ten and twenty. They’d fallen sick within two weeks of one another. It was the largest family cluster of cases yet recorded, and the intriguing pattern promised new insights into the disease if only it could be deciphered. WHO investigators and their Azeri counterparts trekked to the village over and over, yet the family refused to cooperate, even denying the sickness was bird flu. “They wouldn’t give us any information about how the patients got infected,” recounted Dr. Caroline Brown, a WHO virologist who led the team. “There was no way they were going to talk to us. That’s for sure. Even the young children wouldn’t talk to us.”
The family kept some chickens, but they looked healthy. Other poultry had died in the community, but veterinary officials were claiming it was not bird flu. Brown and her colleagues, however, had heard of a large die-off of wild birds in Azerbaijan a month earlier that was attributed to the flu virus. Next they learned from villagers that dead swans had been found at a lake on a nature reserve near the settlement. At least one member of the stricken family was a hunter, and his neighbors confided that he’d brought home some of the swans. It was an open secret that locals could earn good money by plucking the feathers for making pillows. That was usually the job of teenage girls and young women. But hunting swans was a crime, and the penalty for poaching could run into hundreds of dollars. The family adamantly denied any contact with wild birds, much less infected ones.
As Brown was leaving the family’s house after another frustrating interview, she looked around the garden and spied at least three large, white pillows hanging from a clothesline. “You couldn’t miss them,” she said. “You could see the feathers sticking out.” It was the smoking gun. Later, the mother of one victim later confirmed that, yes, all those afflicted had been plucking contraband swan feathers. This marked the first time that investigators anywhere had proven a link between wild birds and human cases of the virus. Yet the breakthrough, like the Azeri outbreak itself, remains exceptional.
“We don’t know much,” Grein told me with heightened urgency. “All of us, we really need to get our act together to enhance our knowledge and get better tools to fight this disease.”
The clock was ticking on Samaan’s investigation. Somewhere on the wards of a private hospital in neighboring West Java province, the novel strain could be incubating, amplifying, provisioning for an inexorable march toward the capital, toward the international airport only a ninety-minute drive away, toward the regional hub of Singapore another ninety minutes by air. By the time Samaan made arrangements with Indonesian officials to visit the hospital, it was already Saturday morning, and she hadn’t had a chance to line up the minivan. She flagged down a white city taxi on the street near her downtown apartment building. Her translator was off, so she called an Indonesian colleague from WHO and rousted her with a playful, early-morning plea, “C’mon, let’s go save the world.”
Samaan’s career had been building toward this moment. Born to Iraqi parents, she was raised in Kuwait until the political upheaval wrought by Saddam Hussein’s 1990 invasion sent her fleeing as a teenager to Australia. There she went on to study clinical psychology. For a year she worked with refugees detained on the remote South Pacific island of Nauru, a tiny outpost of little more than eight square miles. Many of the migrants, held in camps while applying for amnesty in Australia, were suffering from depression and other maladies. The experience piqued Samaan’s interest in broader issues of public health and led her back to the university to take up epidemiology. During her first stint with WHO, she was assigned to Manila just as bird flu was sweeping East Asia. But she was kept primarily in the office. At her desk by 6:30 A.M. each morning, she was tasked to troll the Internet, international media, and the agency’s own network of informants for rumors and emerging reports of flu outbreaks. A year later she rejoined WHO and headed into the field.
Now, as the taxi finally escaped the congested streets and pulled up beside the pink walls of the five-story hospital, Samaan was hoping to do better. This was a new facility with a clean, white-tiled lobby that contrasted with the filth and disorder just beyond the gates. No sign of panic or plague, just a few parents waiting to have a doctor examine their children.
The hospital’s personnel director, a woman in a pink blazer, led Samaan through the breezy corridors to a conference room. The hospital’s vice president, a woman in a Muslim headscarf and brown batik dress, and three other officials joined them around an oblong table. Samaan briefed them on her investigation. She shared the reports of poultry deaths in the victim’s neighborhood but noted they remained unconfirmed. “So we cannot discount other possible sources of infection,” she told them without revealing her suspicions about the hospital. Then she asked about the victim’s recent work history. The personnel director recounted that the victim had reported for the afternoon shift on New Year’s Day complaining of fever and chills. She had been initially diagnosed with dengue fever or possible typhoid. “We let her go home early,” the director said. The ailing woman had never returned. Her disappearance, the director said, had left the maternity ward short staffed.
So the victim, it turns out, had been a midwife. That was a welcome detail. Because the maternity department tended to see healthy patients, this reduced the chances that the woman had contracted the illness in the hospital. It would also be easier to spot anyone else in the ward she might have infected. But Samaan was not yet sanguine.
“Can you look at the hospital records?” she asked. “If you concentrate on the ten days before she felt sick, would she have had contact with anyone who had an influenza-like virus?”
The hospital’s vice president said that was an easy one to answer. She referred to a report in front of her. The victim hadn’t come to work at all in the week before she became ill. She had been on vacation.
“That’s not what the family told us,” Samaan objected politely. “They said she was working.”
“We’ll double-check our records. But maybe she was working in another hospital?” the vice president responded, suggesting a new, disquieting possibility.
The personnel director produced a stack of schedules and time sheets. Samaan and several others huddled around. The documents showed, in fact, that the family was right: The woman had indeed reported for work four times during the final week of December. Two dates in particular drew Samaan’s interest. The woman had worked the overnight shifts on December 27 and 28, just when she would have likely contracted the virus. Samaan made a mental note.
Glancing up from the time reports, she asked whether any of the women who had given birth in the maternity ward had gotten sick. Nothing unusual, she was told. She inquired after the other midwives. All healthy. She requested to meet a few.
The maternity department was spotless. It had twenty-three beds in a series of rooms, mostly vacant at the moment. Four newborns slumbered in small, glass-sided cribs. The private waiting room was large, with padded chairs, a sofa, and a television on the counter. An air conditioner hummed in the wall.
The personnel director showed in a pair of midwives dressed in pink uniforms. The younger one, a slight woman with short brown hair and lively eyes, named Swarni, was the chattier of the pair. Samaan asked about the last time she saw her dead colleague.
“I wasn’t working the same shift as her that day,” Swarni began. “I was leaving after the morning shift, and she was arriving for the afternoon shift.”
Samaan nodded.
“I asked her why she was wearing a jacket,” Swarni continued. “She said she wasn’t feeling well. The next time I saw her, she was in the intensive care unit.”
Samaan asked the midwives how they were feeling. They reported their health was good, further allaying Samaan’s concern that the hospital was the source of infection. She shifted her line of questioning, asking about the woman’s final days.
“Did she do anything before she got sick that comes to mind? Any activities?”
“She mentioned she had been coughing for a while. That’s all.”
“Did she talk about going to a poultry market?” Samaan pressed, following up on the tip from the previous day.
“Sometimes she would go after work,” Swarni recalled. The young midwife mentioned a particular market in East Jakarta and then giggled softly, covering her mouth. Samaan waited for the rest of the answer, puzzled. “She would go buy chicken feet,” Swarni added. “That was one of her favorite foods.”
Epidemiologists are often faced with two complementary questions. The first is like the one that was stumping Samaan: Why does someone fall sick? The second question is less obvious, though the answer can be even more revealing: Why doesn’t someone fall sick?
For each victim laid low by bird flu, there are hundreds, perhaps thousands, who should have been. These are the cullers, the armies of peasants, soldiers, veterinary officers, and day laborers who have slaughtered several hundred million birds across Asia, Africa, and Europe since 2003 in an orgy of bloodletting aimed at exterminating infected flocks and stemming the spread of the virus. They often did so with minimal protection, lacking masks, goggles, and even gloves. Yet a full decade passed after H5N1 claimed its first confirmed victim in 1997 before a single culler ever got seriously sick—a Pakistani man who died shortly after helping carry out a two-day poultry slaughter in October 2007. In Vietnam alone, more than ten thousand people participated in the great massacre without a reported case. This mystery has defied explanation, posing one of the great riddles confronting flu investigators.
Field sampling has revealed that some cullers were in fact exposed to the pathogen. Five South Koreans who helped stamp out infected flocks eventually tested positive for antibodies though none ever became ill, and a lone culler in Indonesia also showed elevated antibodies without any outward sign of illness. So, too, nine workers who helped carry out Hong Kong’s mass slaughter in 1997 tested positive, with only one displaying mild symptoms. These findings suggested that bird flu may have spread farther than the flu hunters suspected but that many human cases were asymptomatic. If so, this would not be welcome news. It would mean a greater chance for the strain to stumble across the genetic mutations required to unlock a pandemic. Field investigators turned up other worrisome evidence. Blood taken from two elderly but otherwise healthy relatives of Vietnamese victims in 2005 had antibodies to the virus. A year later, a pair of young brothers in Turkey were also positive despite showing no symptoms.
But these instances proved to be rare exceptions. Efforts to uncover a rash of asymptomatic cases have found none. In one telling study, researchers canvassed nearly a hundred homes in a Cambodian village where a man had contracted the virus days earlier. Poultry outbreaks were widespread. If the virus were adept at causing cryptic cases, certainly some would turn up here. But not a single one of the 351 villagers tested had antibodies. A subsequent study of 674 people in two Cambodian villages where there had been both human and poultry outbreaks revealed that 7 of the villagers, or about 1 percent, had antibodies to the virus, indicating they’d been exposed even if they hadn’t had symptoms. For some reason, they were all younger than eighteen. Though this last study suggested some mild cases were being overlooked by health officials, the results hardly signaled a silent epidemic. The enigma of the cullers endured.
At times, epidemiologists have also been stumped by the converse scenario: sick humans without sick birds. Indonesia detected its first human case in mid-2005 and over the following year confirmed that fifty-four Indonesians had the virus. Yet Samaan and her fellow investigators were unable to identify a possible source of infection in a quarter of those cases. During 2007 nearly one-third of the Indonesian cases were ruled inconclusive because there’d been no direct contact between the victims and poultry of any sort. Tjahjani Widjas tuti, head of the agriculture ministry’s bird-control unit, called the behavior of the virus in Indonesia “mysterious.”
One morning in July 2005, just days after the country’s first human case was announced, I drove west out of Jakarta and two hours later found myself unexpectedly in a California-style subdivision of palm-lined streets and middle-class bungalows. Health officials had reported earlier in the week that three residents of the town had succumbed to bird flu. The deaths of Iwan Siswara Rafei, a government auditor, and his daughters marked Indonesia’s first confirmed fatalities from the virus. I had expected to find a typical Javanese village, with serpentine alleys, ramshackle homes fashioned partly from bamboo, and scrawny hens scavenging in the mud. Instead Villa Melati Mas was a gated bedroom community of bankers, businessmen, and doctors. Neighbors were anxiously trading rumors across the metal fences separating their neatly landscaped yards. Mothers were keeping their children off the quiet streets, and some families were considering whether to pack up their belongings in their SUVs and abandon their homes.
“We’ve really got a panic attack,” said Kresentia Widyanto, a mother of three in a floral housedress. “People have been asking, ‘Do we need to evacuate and go somewhere else, to vacate this place?’ ” For fifteen years, Wiydanto and her husband, a physician, had lived around the corner from Rafei’s brown cottage with its pitched terra-cotta roof and sweet purple flowers out front. Widyanto’s son was eight years old, the same age as Rafei’s older daughter, Sabrina. When the girl was hospitalized a month earlier with a high fever, diarrhea, and cough, word spread quickly. Rafei’s second daughter, one-year-old Thalita, developed symptoms days later, followed by Rafei. “I’m wondering why this happened,” Widyanto told me while she finished her business with a street peddler selling broccoli and cauliflower. “Can we get it? We’re trying to be calm.”
But despite a six-week investigation by Samaan and her colleagues from WHO, the Indonesian health ministry, and the U.S. Navy lab, they remained utterly stumped. Even Grein was called in to help. Around the subdivision, a few parrots and other pet birds twittered from cages hanging on porches and balconies. But neighbors did not raise their own poultry, instead shopping at a Western-style supermarket. A solitary pet bird in the neighborhood tested positive for the virus, but Rafei’s home was free of contagion. Tests conducted on him and his daughter, coupled with the timing of their deaths, suggested that the virus might have been passed among family members. Yet this was never confirmed, and the original source of infection was never discovered.
Rafei’s wife and mother both told me they had no idea how he and the daughters got sick. Rafei was a busy professional who set out early every morning on his long commute to Jakarta’s downtown financial district and returned late in the evening, leaving little time for side trips to farms or chicken markets. His wife, Lin Rosalina, eyes red from crying, said she was also certain her children had not come into contact with live poultry. “I’m very sure,” she added, switching from Indonesian to English to make the point.
Her family’s tragedy also highlighted yet another mystery. In clusters of cases, the virus has targeted blood relatives almost without exception. The disease that struck down Rafei passed over the remaining members of his household: his wife, two housekeepers, and his son. All but the last were unrelated to him by blood. By 2008 there were already more than three dozen family clusters across Asia and beyond, representing about a quarter of all confirmed cases, and in the overwhelming majority these involved blood relations like siblings, parent and child, children and grandfather, or niece and aunt. Rarely did both husband and wife test positive.
One of the largest clusters occurred in January 2006 in Cipedung, a destitute, hard-bitten village along Java’s north coast. Unlike in the case of Rafei, there was little question where this family caught the bug. They had two dozen chickens, which regularly straggled into their flimsy bamboo shack, sleeping on the dirt floor beneath the platform beds. In the previous weeks, the virus had raced through this small flock. One by one, the chickens got drowsy and died. When the last six birds developed symptoms, the father, a meatball peddler, helped his brother slit their throats beside a large palm in their front yard. The chickens were plucked and cooked in coconut milk for a family feast. By the time I caught up with the family at a hospital in the provincial capital, Bandung, the father was huddled on a cot wrapped in a gray blanket, haggard and unshaven, under treatment for the virus. In an adjacent room, a teenage daughter with a fever lay sprawled on a bed under observation. Two other children had died before they ever got to the hospital.
The question was why the mother had been spared. Just beyond the doors, in a quarantined waiting room, she kept vigil. “I don’t know why I’m healthy,” the woman, Buenah, whispered to me. She was a short, frizzy-haired peasant with tired brown eyes, wearing only a surgical mask for protection. For my part, the hospital staff had outfitted me in a white hooded jumpsuit with goggles and a respirator and sent me in alone to speak with Buenah. The rubber gloves were making it difficult to take notes. “I don’t have a fever, cough, or symptoms,” she related. “I really don’t know why not.”
Outside the isolation ward in Hasan Sadikin Hospital, her relatives were camped on the lobby floor, spending nights on thin, woven mats, wondering how she had escaped the curse. “It’s really incomprehensible to us,” said Surip, her husband’s cousin.
Could the rest of Buenah’s immediate family have had more contact with sick chickens than she did? That’s doubtful. Relatives and local agriculture officials explained to me that as a rural homemaker, she was in daily contact with livestock. Could the three children have caught the virus by playing with chickens and then passed it on to their father but not their mother? Relatives and fellow villagers reported that it was Buenah who usually looked after the children and that for days she had carried her ailing son in a sling across her chest. Could Buenah, who complained of high blood pressure, have skipped the repast of chicken and coconut milk? No, she and the rest of the extended family all took part.
During the coming months, as epidemiologists turned up this intriguing pattern of clusters over and over, flu specialists came to suspect some kind of coding in the genes that made some people susceptible to infection and others not. If understood, this could help design ways to slow or even stop an emerging epidemic. But the genetic mechanism has remained unclear. And some researchers even countered that statistical chance alone could account for what appears to be genetic susceptibility.
Markets still made Samaan uneasy. When she first started investigating flu cases in Indonesia, she was always fretting about catching the virus. “I counted the sneezes I’d make,” she recalled. As she got better acquainted with the behavior of bird flu, she worried less about catching it at victims’ homes or from their families. But traditional Asian poultry markets remained scary places where butchers, birds, and buyers all converged, swapping their microbes among splattering blood and flying feathers. It took courage for Samaan to brave a live market even when she wore a mask. But the trail of her victim’s killer now led back to one of the capital’s largest, a vast covered complex encompassing several city blocks in East Jakarta known as the Kramat Jati Market.
Samaan had done the math. The victim had started feeling sick on New Year’s Day or perhaps a day earlier. The typical incubation period for the virus was believed to be three to five days. During that time, she had worked two shifts at the hospital, December 27 and 28. They were both overnighters. Samaan deduced that the woman would have been hungry when she came off duty at 7:00 A.M. and likely stopped at Kramat Jati, which was on the way home. In the hours just after dawn, the market would have been brimming with fresh produce and live poultry.
“She probably got a big dose of something and got sick,” Samaan surmised. She was back in the rear seat of the maroon minivan, and the van was again crawling through Jakarta streets, fighting Monday morning traffic. Samaan sensed she was getting close to her prey. The van passed pickup trucks stacked with plastic chicken cages, loose feathers stuck to the cruddy exterior, then pulled into a parking spot beside titanic sacks of chili peppers. Samaan got out, stepping carefully around the mud puddles, and plunged into the dim aisles of the market. Escorted by two colleagues from the Indonesian health ministry, she marched past the cassette stalls blaring the Indo-Arabic strains of working-class dangdut music, past jewelry shops heavy with gold bangles and necklaces, past stalls overflowing with dry goods, and then up the stairs to the second floor, where the thud! thud! of a meat cleaver welcomed her.
Samaan sloshed along tile floors slick with water, mud, and rivulets of blood. The footing was treacherous. On the chipped tile counters lay butchered chickens in a row. Their claws extended upward into the twilight of several naked lightbulbs. Toward the back, a few survivors clucked in dissent, their legs bound to makeshift wooden cages. Samaan kept her arms folded tightly in front of her, avoiding any contact.
“If she came here, could she buy the chicken here?” Samaan asked.
One of the health officials nodded.
“Her friends at the hospital said she really liked chicken feet,” Samaan continued. “Like that?” She pointed toward a small pile on the counter amid other odd bits and pieces of chicken. Several men were hacking plucked birds into pieces.
Samaan and her colleagues approached another butcher, a husky man in a skullcap. His feet were bare and his pants legs were rolled up to the knees. He was busy grasping birds with his bare hands and slitting their throats. The investigators asked whether the market had been checked for flu.
Swoosh went the knife. Blood freckled the man’s forearms.
He glanced up and assured them that local veterinary authorities tested the market once or twice a week.
“What did they find?” Samaan asked.
Swoosh went the knife.
“It’s disease-free,” he said curtly.
Samaan wasn’t convinced. Local food and health inspectors were notoriously lax when they weren’t outrightly corrupt. But she wasn’t going to linger any longer. She was reasonably confident she had stalked the infection to its source. She retreated through the maze and emerged into the sunlight.
There, she spied something that instantly made her amend her conclusions. Four peasant women were seated on the blacktop hawking chicken off wooden crates. Stacked behind them were round bamboo chicken cages, all empty. The birds had obviously been butchered right on the crowded sidewalk. Even if the market inside was free of infection, this informal commerce was less likely to be. She paused to look.
“She didn’t have to go all the way in there,” Samaan speculated, retracing the victim’s steps in her mind. “She could have bought the chicken right here. That might be more risky.”
Samaan reflected on the fateful morning, reasoning that the woman would have been weary after coming off her shift. She would have been eager to get home quickly. “That’s it,” Samaan thought. “She probably didn’t go inside. She would have bought it right here. There was plenty of potential for exposure.”
Samaan climbed back into the van.
“That’s my hypothesis,” she reported. “Can I prove it? It’s impossible.”
When I met the man who might save the world, he was making thirty-eight dollars a month. Ly Sovann was a physician in the Cambodian capital, Phnom Penh. He was full-faced with dark, playful eyes and sloping shoulders. He had a tendency to lecture, and when he did, he would stretch out his arms and gesture with open hands. But he was also quick to laugh, often at his own straits.
The first time I encountered him, Ly Sovann was planted behind an aging metal desk in a tiny room that passed for the headquarters of Cambodia’s disease surveillance bureau.
He was the director, responsible for spotting the stirrings of an epidemic in a country where the public health and veterinary systems were so impoverished that experts acknowledged at the time they were probably failing to detect most of the human cases and had no idea how rampant the virus was among poultry. He shared the twelve-by-ten-foot office with the rest of his ten-member team. The room was crammed with four other metal desks and tables, filing cabinets, shelves heavy with bound reports, and five boxes stuffed with the health ministry’s stockpile of protective gear, including gloves, goggles, masks, and aprons. There was only enough space for three people at a time, so his staff rotated through. They all shared one Internet line, which was just about the sole way they could follow the inexorable progress of the virus in neighboring countries, and Ly Sovann had secured that connection only after prevailing on the health minister to seek help from the prime minister’s office. Even at times of crisis, they could work only until 7:00 P.M. each night. That was when the power in the health ministry was shut off and Ly Sovann had to find his way down the stairs from the third floor and out of the darkened building by the faint glow of his mobile phone.
“We’ve had over thirty years of war,” Ly Sovann said as a small air conditioner sputtered and whined in the window behind him. “We need time to build up our system of public health. We try our best to build up the system for detecting avian flu in Cambodia. Five years ago, it was nothing. Now I have computers, paper, and stationery. It’s better.”
Still struggling to recover from decades of conflict and political instability, Cambodia’s government had only three dollars per person to spend on health care each year despite high rates of HIV/AIDS, tuberculosis, and infant and maternal mortality. The country lacked trained doctors, clinicians, laboratory facilities, referral wards, epidemiologists, and an overall health system tying them together. For a time, the government couldn’t even afford to produce radio spots warning about the risks of bird flu.
Out in the provinces, the health system was even more primitive than Ly Sovann’s operation. Local clinics couldn’t recognize cases of bird flu when the sick came in for treatment, raising the prospect that the virus would evolve into a more pernicious form and spread before anything could be done to stop it. This posed a danger not just for Cambodians but for those well beyond the country’s borders. “The chain is as strong as the weakest link,” warned Klaus Stohr when I first asked him in 2005 about his concerns over Cambodia and its destitute neighbor Laos. As the virus raced westward during the following year, WHO began raising a similar alarm over the threat posed by sub-Saharan Africa.
The situation would be less dire in some countries confronting the virus, but only by degree. Along the breadth of the battlefront, from Vietnam and Indonesia to Bangladesh, Egypt, and Nigeria, public-health and veterinary services have remained precariously short of the money needed to corner the disease in birds, detect and treat those people who contract the virus, and stem its onward spread.
For the wealthy of the world, geographic distance affords little protection from an emerging flu epidemic. There is no strategic depth, as war planners say. But the danger posed by limited resources goes beyond the shared vulnerability of all countries.
Inequality itself has a corrosive effect on efforts to confront this disease. WHO and its wealthier member states have urged developing countries to battle the novel strain on everyone’s behalf. Yet these countries have been told they must do so without any solid assurance they’ll get a fair share of antiviral drugs, vaccines, or other medical aid if an epidemic erupts. This despite some projections that a pandemic would take a disproportionate toll on developing countries.
Some Asian countries have done what they’ve been asked, even as they appeal for more money to do it. Others, at times, have resentfully rebuffed instructions from abroad, vowing to pursue their own national interest even if that puts the wider world at risk. Vietnam, for instance, was so sure it would be neglected in the event of a pandemic that local scientists pursued a homegrown vaccine using unorthodox techniques, though WHO warned that this effort could lead to tragic consequences. In Indonesia an aggrieved government went even further, turning the tables on the developed world. Indonesian health officials discovered that they controlled some of the most precious resources of all—actual virus samples urgently required by WHO’s labs to monitor mutations in the strain—and stopped supplying these specimens. Indonesia demanded that its claim to these virus samples be recognized and any benefits, for instance vaccines produced from them, be more equitably shared.
At the very bottom of the heap, Cambodia has been in no position to insist on anything. Beaten down by history, it was already heavily dependent on foreign assistance just to keep from closing down. A full half of the central government’s budget was financed by aid.
Ly Sovann was born in Phnom Penh in 1969, the year that the United States began its secret bombing of eastern Cambodia during the Vietnam War. This withering aerial campaign was aimed at eliminating the base camps of the Vietnamese Communists. But the upheaval caused by the four-year bombardment fueled the insurgency of Cambodia’s own Communists, the Khmer Rouge, who were fighting to topple the Phnom Penh government allied with the United States. When the Khmer Rouge captured Phnom Penh in 1975 and established their genocidal rule there, the capital was emptied. Ly Sovann’s family, like most others, was banished to the countryside.
After the Vietnamese army ousted the Khmer Rouge from Phnom Penh four years later, he returned to the capital, where he went on to study medicine at a local college. This was a break with tradition. Like many Cambodians of Chinese ancestry, his was a family of merchants and traders. So was that of his future wife, and her relatives would later help support him as he pursued his medical passion. With few options for advanced study in Cambodia, he left for Bangkok, where he received a master’s degree in clinical tropical medicine. Once he returned, he joined the health ministry. He was promoted to director of disease surveillance after distinguishing himself during the SARS outbreak by crafting an aggressive national response.
That was when he began devising an epidemic alert system tailored for austerity. Ly Sovann told me he realized the one thing Cambodia had going for it was cell phones. They were in wide use because landlines were so rare, and cellular coverage had already reached two-thirds of the country. He’d taken advantage of this rare asset, he told me. Reaching backward to a bulletin board, he pulled down the roster of names and phone numbers he’d been compiling since SARS. The stapled sheets, worn and smudged with fingerprints, listed contacts for scores of health-care workers in Cambodia’s cities and all twenty-four provinces. He had cobbled this network together with little more than charisma and extensive personal contacts. “He just knows everybody,” a doctor in the local WHO office said to me. But calls cost money. He didn’t have enough even to buy gas for his investigators’ motorbikes, much less pay their salaries on time. So Cambodia applied for ten thousand dollars from foreign donors to purchase prepaid phone cards to allow local health workers to report suspicious respiratory cases that could be flu.
The effort stumbled at the start. Local doctors missed what would be Cambodia’s first confirmed case of avian flu. It would have been overlooked altogether if the victim’s family had not brought the twenty-four-year-old woman across the border for treatment in Vietnam, where the health system was more advanced. Though Vietnamese doctors could not save her, they did identify the virus. This first reported case in January 2005 drew intense international concern and several weeks later brought me to Cambodia’s southern Kampot province.
When I arrived, I discovered that the woman was not the only one in her family who’d been stricken. I tracked down her father squatting in a sandy lot by the side of the road. With a homemade sledgehammer, he was pounding into place the wooden foundation of a new house. He was barefoot, and his narrow eyes squinted in the sun. He wasn’t sure what was cursing his home in the parched rice fields across the road, but cursed it was. He had also lost a teenage son, he told me, and two others in his family had fallen ill.
The man, Uy Ngoy, related that his fourteen-year-old son was the first to get sick, complaining of a fever, diarrhea, and trouble breathing. The boy was brought to a storefront clinic with peeling paint and muddy tile floors in the local town. The clinician took the boy’s temperature and blood pressure. His condition continued to deteriorate. Two days later, suspecting that the disease was somehow caused by an affront to the spirits, the clinician sent the boy home so his family could pray to their ancestors. The boy died soon after.
At the funeral, the boy’s older sister had embraced his body. Soon she came down with the same symptoms. The family took her to a slightly better clinic, where an ultrasound scan revealed lung damage, and then across the nearby border for medical care in Vietnam. It was too late. By the time the next two fell sick, Uy Ngoy had lost faith in modern medicine. “I decided to try another way,” he recounted. He dispatched them first to a Buddhist priest and then to a witch doctor in the mountains. These family members later recovered.
There was no public education about the virus, and local public health was hardly any better. The health workers at the two local clinics told me in separate interviews that they had believed the siblings had routine pneumonia, common among villagers. The clinicians never thought to report the cases to Ly Sovann’s bureau or any other official. After Ly Sovann learned about the woman’s death from media reports, he rushed to Kampot with his team and stayed for a week. Blood samples were taken from family members, villagers were canvassed, and health warnings were broadcast from loudspeakers mounted on motorbikes. Ly Sovann’s mobile phone rang relentlessly.
Several weeks later, he returned to the province, setting out from Phnom Penh before dawn on the three-hour drive. He had put on a white dress shirt with sleeves buttoned to the wrists and a dark striped tie fastened with a clip. His black hair was slicked to the side. He wanted to look as authoritative as possible. He had to convince the villagers to start reporting suspicious illnesses. Too many lives could be at stake. When he arrived at a community hall in Kampot town, he set up his laptop computer for a slide presentation and fished his PDA from the breast pocket. Then, over the hum of the ceiling fans, he made his pitch. The farmers, provincial officials, and community activists in the audience were skeptical. Some approached the microphone to question whether bird flu was even real.
Foreign governments were far more unnerved than these locals. Flu specialists worried that cases were being missed and warned of a stealth outbreak in an utterly unprepared land. Over the following two years, foreign donors provided $13 million in emergency assistance. It wasn’t a lot, but in a small country it went a long way. Cambodia established rapid-response squads in every province. Composed mostly of doctors, these two-member teams were trained to investigate any suspected human case. Twenty-nine thousand village volunteers were mobilized to report rumors of unusual illnesses. Antiviral drugs and protective gear for health-care workers were purchased and pre-positioned in each province. Building on Ly Sovann’s cell-phone network, Cambodia pioneered a program in which local health officials could report a variety of diseases, including unusual respiratory outbreaks, by text message directly to a central computer.
Cambodia soon had more foreign aid for the flu fight than its tiny cadre of medical professionals could handle. Yet the funding was short-term, good only for about three or four years. Cambodian health officials and their WHO colleagues remained anxious. After the emergency funding for bird flu was exhausted, who would pay to keep the rapid-response teams trained and send them to the field? Who would pay to replenish the antiviral drugs as they expired and conduct lab tests on samples? Who would pay to print the flyers and brochures distributed to villagers warning of the virus? Who would pay for the cell-phone calls?
Nearly a year after I wrote about Ly Sovann for the Washington Post, I happened across a surprising item in Vanity Fair magazine. It was a long piece about bird flu that mentioned this Cambodian hero. Turns out, the magazine reported, the Post article had done Ly Sovann some good. The publicity had gotten him a raise. Two dollars more a month.
David Nabarro was an effusive speaker. Yet when it came to money for fighting flu, the world’s wealthiest countries got him to bite his tongue. Nabarro was an Oxford-trained physician, a veteran of development efforts in Asia and Africa, and, as a senior United Nations official, he had worked some of the world’s most horrifying disasters, including the Indian Ocean tsunami and the genocidal conflict in Sudan’s Darfur region. He had been in the UN’s Baghdad headquarters in 2003 when it was devastated by a car bombing that killed twenty-two of his colleagues. After all that, he had become the global flu czar. As United Nations System Senior Coordinator for Avian and Human Influenza, he was responsible for coordinating the alphabet soup of UN agencies involved with flu.
He was also the money guy. By 2007, donor countries and international institutions like the World Bank had pledged $2.3 billion toward fighting bird flu and preparing for pandemic. That was a significant sum, equivalent to what I later learned was being spent in the Washington area to replace an aging interstate highway bridge over the Potomac River. About $1 billion of the promised funding had already been delivered by the end of 2007, mostly to poorer countries. But as Nabarro reviewed the figures in advance of an avian-flu conference in New Delhi in December of that year, he realized that even if all the pledges were met, the needs would still far outstrip the available funds. He calculated the deficit would run into billions of dollars.
Some donor countries didn’t want to hear it. They had already ponied up at a pair of similar conferences the previous year. They didn’t want to want to get tapped for more. “The donors convinced me not to come out with a strong statement about funding gaps,” Nabarro told me soon after.
So in a briefing for reporters in New York before flying to New Delhi, he pulled his punches. He told the press that the world’s response to the pandemic threat was on the upswing but that “much more remains to be done.” He gave no dollar figure. That was the same equivocal message offered by a ninety-one-page progress report jointly released at the time by Nabarro’s office and the World Bank.
Less than two weeks after the conference was over, Nabarro sent out a new version of the report. It was practically identical except for two extra pages inserted toward the beginning. They said what Nabarro had not. “There are signs of declining donor interest,” the updated edition warned. It disclosed that pledges were tumbling while the shortfall in emergency funding was on the rise. (The number of donors and amount of new money pledged would decline even further in 2008 as a senior U.S. diplomat warned of growing “flu fatigue.”) The updated document warned that the immediate fight against bird flu was now short about $1.3 billion. Most of that was money required by countries on the front line. In late 2006, the World Bank had helped estimate the funding these countries would need through the end of 2008. The document reported that nearly half of this was still unmet. Most notably, countries in sub-Saharan Africa still needed $462 million and those in East Asia were short $341 million. Those figures did not even address the longer-term needs that Ly Sovann in Cambodia and his counterparts across the developing world would soon face.
To careful readers of the original ninety-one pages, this staggering deficit should have been no surprise. The report detailed sector after sector where frontline countries were outgunned by the virus. More than one-third of Asian and African countries surveyed said they had no lab capacity to confirm human flu infections. About half of these countries said they didn’t have enough antiviral drugs to cover even 1 percent of their population. The situation was equally grim on the livestock side, where many countries said they lacked basic veterinary services and lab facilities. On average, these countries required more than a week to identify poultry outbreaks and notify international authorities, a potentially catastrophic time lag. About a quarter of African and Asian countries reported they had no lab capacity to detect bird flu viruses in poultry. Only a small percentage paid farmers enough compensation to get them to report infected flocks rather than cover them up.
Looking five to ten years ahead, the report concluded, “Adequate financial support for long term technical assistance and for integrated country programs is essential.” How much would it all run? Nabarro declined to name a figure. He said an honest number would scare donor governments.
With outside assistance uncertain, some in the developing world have sought their own solutions, their initiatives driven by pride and pragmatism. Professor Nguyen Thu Van was one. Behind the high gray double doors of her Hanoi laboratory, Van was on a quest for the Holy Grail: a vaccine against the novel flu strain. Her team of young Vietnamese researchers scurried around the small, second-floor lab, some nights breaking only long enough to steal a few hours of a sleep in some corner of the elegant French colonial building that houses her institute. They were attempting a new, unorthodox approach to accelerate their effort. It involved developing a vaccine strain with fast-growing cancer cells despite the risk of deadly contamination. Two months before I met her in April 2005, the team had successfully tested the prototype on monkeys. The researchers were now preparing to try it on themselves.
At age fifty, Van was a veteran vaccine scientist with a proven record that had won her the top post at Vabiotech, a pharmaceutical company affiliated with Vietnam’s National Institute of Hygiene and Epidemiology. There was little about her appearance to suggest Van’s august place in her country’s emerging drug industry. She dressed simply in a plaid sweater over black slacks, with her plain, straight hair held back by a barrette. She had a quiet confidence to match. But her brown eyes gleamed when she predicted that Vietnam would soon outpace more advanced countries by developing the world’s first effective vaccine against the virus. She offered a warm smile that tempered the audacity of her boast.
Flu specialists outside Vietnam did not share her enthusiasm. To outsiders, her unconventional methods looked like reckless endanger ment. Yet to Vietnam, already facing recurring bird flu outbreaks, it was necessity, a clear case of national security. “We cannot wait,” Van told me.
Few pharmaceutical endeavors could save as many lives as the development of a pandemic flu vaccine. Yet the obstacles are many. For years, international research into any kind of flu vaccine languished, in large part because government investment was directed toward AIDS and other diseases considered more pressing. The drug industry had no incentive to put its own money into influenza at a time when anemic public demand even for seasonal flu shots often fell short of existing supply. As a result, the technique for making flu vaccines, an unwieldy process that uses fertilized chicken eggs, remained largely unchanged since the 1950s. Since bird flu began proliferating in Asia, researchers have been chipping away at the challenge. But without significant scientific advances, vaccines against a pandemic strain will only become available long after it has circled the globe because of delays inherent in the technology. An analysis in 2007 found it would take more than half a year after the pandemic strain emerged for the first doses to be delivered. This reflects a timeline that includes about a month for WHO to isolate and distribute the seed strain, a month and a half to ramp up manufacturing, and another four months to produce the vaccine and release it for use. And even after the initial doses debut, most people will still have a long wait because of the world’s modest production capacity.
The H5N1 strain has been particularly nettlesome. The virus has continued to rapidly evolve, spinning off various subtypes that confound efforts to develop a single vaccine in anticipation of an epidemic. The strain has also proven unusually resistant to experimental vaccines. This means higher doses are required to produce immunity, and the higher the dose, the less vaccine there is to go around.
Scientists have been experimenting with new ways to get over these hurdles. One has centered on using cells, rather than chicken eggs, to incubate vaccines. This could cut the production time for a pandemic vaccine in half while increasing available doses. Initial clinical trials of a bird flu vaccine made by Baxter Bioscience using this technology showed promising results, according to a 2008 report.
Another approach has centered on the use of chemicals called adjuvants, which enhance the effectiveness of a given dose by stimulating a person’s immune response. In 2007 the Belgian drug company GlaxoSmithKline reported the results of a study showing that an experimental vaccine against bird flu containing an adjuvant worked at lower doses than even seasonal flu shots. Later that year, WHO announced that these boosters could radically increase the global supply of pandemic vaccines. The agency predicted that by 2010, the world might be able to produce enough to immunize 4.5 billion people per year. But as WHO acknowledged, this would still fall short of what would be required to protect everyone on Earth.
Even with these scientific advances, Vietnam has long suspected it would be at the back of the line if it waited for someone else to come up with a vaccine. Health officials in Hanoi—as well as those in Bangkok, Jakarta, and other Asian capitals—often told me they were sure industrialized countries would look after their own people first. And even if there were enough to go around, who could afford it? The drug industry “can’t provide vaccines to the world free of charge,” stressed Wayne Pisano, chief executive of French vaccine-maker Sanofi Pasteur.
Van had no illusions. “If another country develops this vaccine, the cost will be very, very high,” she explained. “Vietnam is still very poor and could not afford a vaccine with a high cost. We need to provide this essential vaccine through local production at an affordable cost.”
She had been down this road before. In 1997 she had been involved in developing a local vaccine against hepatitis B, which at the time infected at least 15 percent of all Vietnamese. The availability of this low-cost alternative to imported vaccines allowed Vietnam to immunize millions of children against the potentially fatal disease. Five years later, using genetic engineering, Van’s company produced a new generation of vaccines against both hepatitis A and B. She crowed at the time that Vietnam was one of only three countries able to make them. The potential savings were tremendous. At sixty cents per dose, the locally produced hepatitis A vaccine cost less than one-fifteenth the price of those on the international market.
In the 1970s, Van had studied biochemistry in the Soviet Union before returning to get her doctorate in Vietnam. She had done subsequent training in Japan, Russia, and twice at the CDC in Atlanta. For most of her three decades at the institute, hepatitis had been her specialty. But after bird flu erupted in 2003, one of her mentors, a senior Vietnamese virologist who had earlier developed the vaccine that helped eradicate polio in their country, suggested that Van tackle influenza. He told her to hurry. “It was difficult at the beginning, because we did not have the experience,” she recounted, smiling and laughing softly. “But it isn’t really new for me. Any vaccine has similar steps and similar techniques.”
With Japanese assistance, Van’s researchers obtained samples of the flu virus and then engineered a prototype vaccine strain by reverse genetics. The team began growing vaccine in monkey kidney cells, the same method the institute had used in making hepatitis A and polio vaccines. But before clinical trials could begin, WHO asked Vietnam in February 2005 to apply the brakes.
A special WHO delegation, which included officials from agency headquarters in Geneva and the U.S. Department of Health and Human Services in Washington, was sympathetic to Vietnam’s predicament. “No licensed H5N1 vaccine for human use is available from vaccine manufacturers and future availability to Vietnam is doubtful,” the mission wrote.
But the visiting officials objected that Van’s approach was too hazardous. Her team had flouted international guidelines by using monkey kidney cells, which were unapproved for making flu vaccines and might allow the virus to mutate into epidemic form. The use of cancer cells to accelerate the growth of the vaccine strain could introduce another fatal ingredient. Moreover, her lab lacked strong enough safety measures to ensure that the new, genetically engineered strain would not escape. The WHO mission also raised “serious ethical reservations” about the institute’s plan to ask its own scientists to volunteer as guinea pigs. The issue was coercion. “There are concerns that the volunteer ‘spirit’ may not be universally shared and some volunteers may feel uncomfortable and unable to state that for various reasons,” WHO wrote.
Members of the delegation later told me they had received official guarantees from Vietnam that it would abandon the program. But Van had been in those two days of meetings and came away with a different impression. “I believe in our procedures and all the laboratory testing,” she said. “I’m sure our vaccine is safe. So I’m not concerned.”
Clinical trials would go ahead in five months, Van told me. The first phase would involve about twenty volunteers. She would be one of the first. If production stayed on schedule, her company could deliver a half-million doses by the end of the year.
When senior health officials in Geneva and Washington read Van’s comments on the front page of the Washington Post several weeks later, they were taken aback. The United States dispatched the health attaché at its Hanoi embassy to privately confront NIHE’s director and insist that Vietnam make good on its pledge to suspend the program. WHO officials made the same demand in public. Under duress, senior Vietnamese health officials sidetracked the vaccine program, and for a time Van’s drive for national self-sufficiency ran aground on the conflicting anxieties of rich and poor.
Finally, in early 2008, clinical trials began. It was the same vaccine, developed in monkey kidney cells. And it was initially tested, as long planned, on researchers at the institute, ten in all. Then the vaccine was tested on what Vietnamese officials described as thirty student volunteers at the country’s Military Medical Institute, with larger trials planned. “Good results,” Van reported. Her institute planned to start mass production by late 2009. Each dose would cost 30,000 Vietnamese dong, or a mere $1.80.
If Van confronted global inequities with determination and forbearance, Indonesia’s Siti Fadilah Supari was far less patient. And on a crisp Geneva morning on a climactic day in 2007, Dr. Supari was already running late. Her scheduled flight on a British airliner had been grounded. But she had been lucky enough to find a later flight to Geneva, this one on Lufthansa. She had flown through the night and, once on the ground, had to wait again, this time for nearly everyone else on board to file out. There had only been room for her at the very back of the plane, even though she was a cabinet member from the world’s fourth-largest country.
Supari, Indonesia’s health minister, was scheduled to give her speech in half an hour, and she was still on the plane. “Dear God, help me!” she thought. As she descended a stairway from the jetliner and headed finally for the VIP lounge, she was welcomed by a delegation of fellow Indonesians, including her country’s ambassador at the UN mission in Geneva. They exchanged pleasantries. Then her colleagues handed the minister a draft of the address she would give at the meeting. When Supari read what they had written, she felt wounded. “I was thoroughly shocked,” she recalled. “They had no idea of the core of the problem.”
By that time, in November 2007, Indonesia had long since become the epicenter of the bird flu outbreak. More people were dying of the virus there than anywhere else on Earth, and many flu specialists feared Indonesia would ultimately be the source of a pandemic. Yet for more than a year, Indonesia had refused to provide virus samples from the overwhelming majority of its cases to WHO-affiliated labs, leaving the world blind to the evolution of the virus. The danger was grave. If the pathogen was mutating into a pandemic strain, no one might know. This could preclude the world from launching an effort at rapid containment before the virus spread or making emergency preparations in case it did. Without current samples, scientists would be hampered in developing vaccines against the pandemic strain, monitoring the effectiveness of antiviral drugs, or producing updated diagnostic tests to identify the virus elsewhere.
WHO had convened a special meeting of representatives from more than a hundred countries to address complaints raised specifically by Supari over how the developing world shared virus samples and what health benefits it received in return. The speech penned by her colleagues explained that Indonesia’s objective was to safeguard the lives of those in poor countries by winning them better access to pandemic vaccines. But Supari’s fight had gone beyond that by now. It was no longer a technical dispute over the distribution of vaccines. It was a wider struggle over fundamental inequities in the global health system embodied by WHO. In short, she told her colleagues, she was taking aim at the “oppression between nations.” Supari chided them, informing them she had her own draft and that was the one she would deliver.
Supari stopped at her hotel only long enough to change clothes. Then she dashed for the Palais des Nations. Initially erected as the headquarters of the League of Nations in 1919, the monumental building now served as the European seat of the United Nations. The meeting itself was running late, and Supari was allowed to proceed with her speech.
For ten minutes she skewered the long-standing system under which countries like Indonesia freely provided virus specimens to WHO labs and they in turn supplied them to commercial drug makers. The countries of origin were rarely told what purpose their samples were put to. “We do not really know whether they are used for research and publication or they are shared with vaccine manufacturers for vaccine production. Or maybe they are utilized for the development of biological weapons,” Supari told the audience. Her hyperbole was startling for those accustomed to the diplomatic palaver of Geneva. She pressed on, lambasting the arrangement in which developing countries were forced to pay market prices for vaccines, even if these countries were the original source of the vaccine strain. “If these oppression practices continue, poor countries will become poorer and rich countries will become richer,” she warned. “This is more dangerous than an avian influenza pandemic itself—and even a nuclear explosion.”
The gap between rich and poor that had provoked resentment elsewhere was here begetting full rebellion. Nor was this resistance at the margins of global efforts to stem a pandemic. Now it struck at the heart.
Barely three years earlier, few even in Indonesian public health circles had heard of Supari. She had been an obscure cardiologist and medical researcher at a Jakarta hospital. Then, one evening in October 2004, her cell phone rang. She never did find out who the caller was. But he told her that Indonesia’s incoming president, retired general Susilo Bambang Yudhoyono, urgently had to meet her. He wanted her to be his health minister. She would be sworn in the following day. “Why me?” she asked. “I am just a woman. The president needs someone who is tough. Am I that?”
What she had were the right credentials. One day before his inauguration, Yudhoyono was still struggling to assemble his cabinet. He’d won a decisive electoral victory, but his own political party was tiny. His government would be stillborn unless he could line up backing from larger political forces. Supari’s family had long been active in Muhammadiyah, a Muslim civic organization that claimed about 30 million members nationwide, and its support would be a boon to any politician. So when the group’s chairman suggested Supari, Yudhoyono agreed. Besides, she was indeed a woman. The cabinet was short on those.
Supari had graduated with a medical degree from Indonesia’s elite Gajah Mada University but, unlike many in the cabinet, had never studied abroad. She was a stout woman with large, round, rimless eyeglasses. She had jet-black hair and, though a devout Muslim, often appeared in public without concealing her bouffant beneath a traditional headscarf. She favored batik dresses and suit jackets, acces sorizing generously with gold and pearls. At first she had difficulty being taken seriously as a minister. Jakarta’s chattering classes dismissed her as giggly and prone to public gaffes. But she proved shrewd. She honed her public relations, even launching her own Sunday evening television talk show. She also tapped into Indonesia’s profound sense of national grievance.
Every way Indonesians looked, life seemed to be getting harder. That was particularly true for their health. The public health system Supari inherited as minister was sorely underfunded and had eroded sharply since the 1997 Asian financial crisis. In one typical clinic in southeastern Sumatra, the director explained to me that he could no longer offer routine immunization against childhood diseases. “For us, it’s hard to answer the parents when they ask why the vaccines have run out,” he complained. Apologizing for the rat droppings that littered the clinic floor, he shuffled into his tiny, tiled office and opened the rusty clasps on the fifteen-year-old freezer once stocked with vaccines. It was almost empty. He told me that health workers were forced to scavenge for unused syringes in other medical offices or scrape together money to buy their own. The refrigerator used for making ice to transport vaccines into the field was broken. “Money is our unending problem,” he said. Already unable to provide basic care across much of the archipelago, Indonesia’s health system then suffered a series of staggering calamities within months of Supari taking office: the tsunami that killed at least 150,000 in Sumatra, earthquakes, and a resurgence of polio. Finally, bird flu struck.
Indonesia was fortunate that it started with an isolated outbreak. At the premier hospital in Jakarta for treating infectious diseases, there were enough doses of Tamiflu on hand to treat no more than eight people. “When we have an epidemic, we cry for help,” said Santoso Soeroso, a physician at Sulianti Saroso Infectious Disease Hospital, as he gave me a tour of his facility’s spartan isolation wing. He acknowledged that he worried there was not enough of the drugs for preventive use by doctors and nurses who would care for flu patients. The balance of the national supply had already been divvied up among thirty-three other hospitals, with each receiving enough for just two patients. Soeroso said he had no budget for any more.
WHO eventually shipped over more supplies of Tamiflu. But these were just limited emergency stockpiles. Indonesia had no money to follow the lead of wealthier nations that were already ordering sufficient quantities of the drug to treat as much as half their population should the disease spread beyond Asia. Supari learned that Indonesia would have to wait months to buy more Tamiflu if it wanted any, and even then would have to pay up to forty dollars per treatment. She was flabbergasted.
In November 2006, David Heymann and Keiji Fukuda came calling in Jakarta. Heymann, who had helped stand up WHO’s global strike force, was the agency’s new assistant director general for communicable diseases. Fukuda, who had helped quarterback the world’s response to the Hong Kong bird flu outbreak in 1997 and the Vietnam outbreak just over six years later, had been tapped to become WHO’s new influenza chief. The agency was planning to spell out in an official resolution what had long been the informal process for sharing virus samples with WHO, and the pair wanted to run it by Supari.
What she told them in response brought them up short. Indonesia would no longer share, not at all.
Behind the scenes, Indonesia had already been locked in a running dispute with foreign scientists over access to flu virus samples. For a year, researchers from the U.S. Navy lab in Jakarta had been engaged in what an Indonesian health officer called a “cat-and-mouse game,” trying to collect specimens in hospitals and stricken villages despite government efforts to stop this. “It was so difficult to get the damn virus out of Indonesia and analyzed,” recalled the navy lab’s influenza chief at the time. “You had to go around the system.” Neither side ever publicly disclosed this subterranean contest, but the competing claims to local virus samples silently poisoned relations between Indonesian and foreign scientists.
The U.S. Naval Medical Research Unit 2, or NAMRU-2, was established in Jakarta in 1970 to help U.S. military forces research diseases they might encounter in the tropics. Along the way, the lab worked on maladies that also afflicted the local population, including malaria and dengue fever, and eventually set up a system to monitor for seasonal flu viruses in collaboration with six Indonesian hospitals. NAMRU was the most sophisticated infectious-disease lab in Indonesia, the only one with safeguards required to fully analyze pathogens like bird flu, and its staff, largely Indonesian, was the most technically proficient in the country.
In 2000 the agreement between the United States and Indonesia authorizing the lab to operate ended. But for several years, the lab continued its activities with the approval of Indonesian officials and even expanded its flu surveillance network to cover twenty hospitals on most of the country’s main islands, stretching from Papua in the east to Sumatra in the west. In return for supplying virus samples from patients, Indonesian doctors were paid a monthly stipend by the lab. It also gave them money to come to training sessions, with daily allowances that often exceeded the actual expenses. The payments to each doctor could come to several hundred dollars a year, a generous sum in Indonesia. Plus, NAMRU helped the doctors pay for equipment, such as microscopes and refrigerators for storing specimens. As long as the navy lab was focused on seasonal flu, few Indonesian officials objected.
In July 2005 that relationship changed with the country’s first recorded case of bird flu. NAMRU had dispatched Andrew Jeremijenko, the leader of its influenza surveillance project, to investigate the outbreak along with Gina Samaan of WHO. Jeremijenko already had a relationship with the pathologist at the local suburban hospital through the flu network and was able to secure samples of this new, mysterious virus taken from the victims. It was NAMRU scientists who initially identified H5N1 in Indonesia. But Indonesian officials barred Jeremijenko and his colleagues from disclosing these results. Moreover, the government insisted bird flu was different from seasonal flu and thus not covered by the protocol allowing the lab to conduct research. To the navy lab, the distinction was preposterous.
“We were doing human influenza surveillance in the hospital and that’s all influenza. It doesn’t matter what sort of influenza it is. The problem with H5N1 is that it is a political disease,” recalled Jeremijenko, an Australian doctor who worked on contract at the lab between 2004 and 2006. “We were walking on eggshells. The whole time, I was afraid I was going to get thrown out of the country.”
Indonesian officials were determined to keep control over both the samples and any findings about the disease’s evolution, which were potentially staggering for the country’s economy. The government tried to block NAMRU staff from investigating subsequent outbreaks. Then, in late October 2005, a senior health ministry official informed health agencies and more than two dozen hospitals around the country that the navy lab would have to cease all activities at the end of the year. No longer was any agency or hospital permitted to collaborate with the lab.
But the lab persevered. It continued to offer payments to doctors in the hospital network, and they continued to send samples. The lab also continued to dispatch staff to various hospitals, where they collected even more virus specimens and related material such as copies of X-rays, often beating government health officials to the site. “We had to push these things,” Jeremijenko said. “We couldn’t do anything in Indonesia if we didn’t break the rules sometimes.” On several occasions he and his colleagues even eluded government restrictions to visit the scene of outbreaks, arriving under the radar in a private van. It was always on a Sunday, when Indonesian officials were scarce. “We weren’t officially anywhere,” he put it to me. “We didn’t have the right to go sample and investigate anything. We did it surreptitiously.”
Indonesian health officials weren’t completely in the dark. After one outbreak in Sumatra, a stricken man resisted giving mucus and blood samples to government disease investigators. “Some of you already took my blood,” the patient told them, one official recounted. “Why would I give two times?” NAMRU had already been there. And when a girl on the eastern island of Sulawesi fell sick, her family refused to give samples to government health investigators, another official recalled. NAMRU staff, accompanied by a team from the provincial hospital, had already been through the village gathering specimens.
“They manipulated our agreement,” a senior Indonesian health official later fumed. “They think they can just go to the field without proper procedure and violate the protocol.”
Three months after their initial visit with Supari, Heymann and Fukuda were back at Indonesia’s health ministry, a large, modern structure on a downtown boulevard lined with bank towers, embassies, and hotels. The meeting was off to a late start. That day in February 2007 was a Friday, the Muslim Sabbath, when everything in Jakarta runs even slower than usual. Supari and her staff had temporarily disappeared to make their midday prayers while the visitors kept their eyes on the clock. They were scheduled to fly out of Jakarta later that same day. When they were finally ushered into the minister’s spacious second-floor office, there were far more people gathered around the large wooden coffee table than three months before. The dispute over virus sharing had escalated.
Supari had been stunned weeks earlier to learn that an Australian drug maker, CSL Limited, had used an Indonesian virus strain provided by WHO to manufacture an experimental human bird flu vaccine. “I never gave permission to any Australian company to produce a vaccine based on the Indonesia strain of the virus,” she protested.
Even before that, she had opened talks with U.S. drug maker Baxter International over acquiring 2 million doses of bird flu vaccine for Indonesians. Baxter had offered to sell the vaccine, which was based on a separate H5N1 strain from Vietnam, but at the steep market price. That was when Supari gained her first glimpse of what she called the “neocolonialism” of WHO. “The situation is ironic,” Supari later told me. “The virus obtained by vaccine manufacturers came from dead Vietnamese people who had been grieved by their brothers and sisters and parents, and then it is commercialized by other nations without compensating Vietnam.” Supari had made Baxter a counter-offer. Indonesia would give permission to Baxter to develop a vaccine from the Indonesian subtype in return for 2 million vaccine doses and help in establishing a vaccine plant in Indonesia itself. Indonesia and Baxter signed a memorandum of agreement just days before Heymann and Fukuda returned to see the minister. The suggestion from Jakarta was that no one else would get access to the Indonesian strain, now the deadliest on Earth, unless they met Supari’s demands.
For half a century, countries had freely provided samples of circulating flu viruses to WHO’s collaborating labs under a system called the Global Influenza Surveillance Network. These routine viruses were analyzed by WHO each year to predict which would cause the next round of seasonal flu. Then the seed viruses were turned over to drug companies to make annual flu vaccines. The developed world has been home to both the labs and the drug makers. But since most of those getting flu shots were in Temperate Zone industrialized countries anyhow, poorer nations had paid the process little mind. Now, facing a possible pandemic, Supari was challenging not only this traditional system but the integrity of WHO itself. Her attack was unprecedented in the agency’s history. Further, she was making the claim that viruses were biological resources owned by the countries where they circulate, not public health information that must be shared freely with the world. She insisted that WHO acknowledge Indonesia’s sovereignty over its viruses and sign a material transfer agreement, which would limit what could be done with Indonesia’s virus samples and potentially entitle it to compensation if they were used commercially.
But senior WHO officials feared that such conditions could wreck the global surveillance system. Flu specialists depended on unencumbered access to virus specimens to watch for menacing twists in viral mutation, keep the tests for the virus updated, and ensure that vaccine research remained current.
“WHO has become a target for Indonesia,” Fukuda later lamented. “That’s not us. We support Indonesia.”
There were already signs the Indonesian rebellion might spread. Thailand, for one, had recently signaled its sympathy in remarks at a WHO executive board meeting. Heymann and Fukuda aimed to keep the disagreement from escalating any further. They wanted to frame the debate around proposals for reform, like making the virus-sharing system more transparent and enhancing the access of poorer countries to vaccines and vaccine production technology. Heymann balked at Indonesia’s more radical demands. The meeting was deadlocked, and yet they kept talking and arguing for five hours, right until the last minute when the visitors had to leave for the airport.
As Supari escorted them from her office, they were unexpectedly confronted by a pack of reporters. She hadn’t bothered to tell her guests she’d invited the media. It felt like an ambush, and two things immediately became clear: They would miss their flight. And there was now little hope of keeping the dispute from boiling over into a heavily publicized political row that could sabotage global cooperation between rich and poor.
Heymann struck a diplomatic note for reporters, telling them, “Indonesia’s leadership alerted the international community to the needs of developing countries to benefit from sharing virus samples, including access to quality pandemic vaccines at affordable prices.” He said he hoped Indonesia would soon resume sending its specimens to WHO.
Supari turned and glared at him. “Without the new regulations,” she said, “until our last drop of blood, the answer is still no, no, no!”
It was time for Margaret Chan as director general to weigh in. She could speak with unquestioned authority for WHO and, by virtue of her position, demonstrate to Supari that she was being accorded all due respect. Chan, moreover, could connect with Supari as an Asian woman. But if Supari wanted to rumble, Chan was an adroit inside fighter well seasoned by Hong Kong’s contentious politics.
At the end of February 2007, the women spoke by telephone. The conversation seemed to end in agreement, with Supari pledging to begin sharing samples. But within hours, they were disputing what they’d agreed to. Supari told the press that Chan had acceded to demands that specimens be used only to monitor the evolution of the virus and not for making commercial vaccines. WHO officials adamantly denied the account. No samples were sent.
A month later, Chan made an unscheduled detour from Singapore to pursue the issue with President Yudhoyono himself at the Istana Negara palace in Jakarta. The Indonesian leader stressed that international drug companies had to make affordable, high-quality vaccines available to developing countries. Chan agreed, vowing to do what she could. Afterward, Supari, who had attended the talks, came out and announced the disagreement was essentially resolved. “We will resume the sending of virus samples for the sake of global interests,” she told reporters. “The delivery will take place this year, within two months from now at the latest.” Again, it didn’t happen.
And so it continued over the months, with each side accusing the other of bad faith. One grueling negotiating session followed the next, often grinding far into the night and deep into the fine print of international law. In public Chan would at times express sympathy for Indonesia. “I believe the developing countries are right to ask us to address the issue of equitable access now,” she told a meeting of drug industry executives and laboratory directors. “To date, developing countries have suffered the most from this virus.” But in private, she was increasingly exasperated. Sometimes she let it show. “If you do not share the virus with us, I want to be absolutely honest with you, I will fail you,” Chan warned ominously during a speech at the annual meeting of WHO member states in May 2007. She didn’t name Indonesia, but she didn’t have to. “I will fail you because you are tying my hands. You are muffling my ears. You are blinding my eyes.”
The prospect of a flu pandemic had deepened the fissure between rich and poor, which in turn was subverting international efforts to head off the coming plague. Poverty had always hamstrung the fight against disease, leaving humanity vulnerable to epidemics that arise in the developing world. The emergence of AIDS from Africa was but one tragic example. But now the world was also at risk because Indonesia had realized that viruses were a resource potentially more prized than oil and could be used to press its claims against the wealthy. The challenge represented such a threat to global health that some veteran observers suggested the UN Security Council might ultimately be asked to break the impasse.
When the two women met next, in November 2007, the Indonesian minister was coming off her impassioned speech in Geneva’s Palais des Nations. The jet lag and drama were taking their toll. “I was exhausted,” she recounted. But at the moment, it was Chan she pitied. “I knew I made her feel uneasy,” Supari later said. “My move had made her tremendously busy.”
Supari steeled herself for their private encounter, telling herself to be strong. The two women hugged tightly. Then they started in, speaking in little more than whispers.
Chan urged the minister to trust her.
She did, Supari answered. “But I don’t trust the WHO system.”
Chan appealed for understanding, explaining that she and Heymann were trying to transform the antiquated system they’d inherited. She needed Supari’s help to do it.
Supari was struck by Chan’s apparent good will. But the minister refused to bow. “I tell you once again, Madame Chan, my trust in the WHO will resume only if they materialize a new mechanism which is equitable and transparent. We, the Third World, have long been suffering from the inequity, Madame Chan. It is time to change.” Supari felt compassion for Chan, an Asian sister who she believed had been forced to do the bidding of rich, powerful countries like the United States. “She was a brave warrior, like me, actually,” Supari thought. “But she had to give up her principles, her conscience, to keep her position in the WHO.”
The minister apologized, repeating that Indonesia would not compromise on its demands.
“I need a total and fundamental transformation, Madame Chan. And I will continue to speak about this all over the world,” she continued. “I am your friend and I do not deliberately put you into this difficult position. However, the bigger concern of humanity made me do this. I am very sorry, Madame Chan.”
The dispute metastasized much as senior WHO officials had feared. The distrust engendered by the clash over virus sample sharing and associated benefits infected other facets of the effort to contain bird flu. Moreover, during 2008 and on into 2009, Indonesia’s grievance grew into a crippling distraction. Jakarta continued to press its campaign on behalf of the world’s underprivileged while largely ignoring a virus that was assiduously putting down ever deeper roots across the Indonesian archipelago. Other governments were entangled in the diplomatic quarrel with Indonesia while frittering away years crucial for their own pandemic preparations.
As the negotiations dragged on, the United States became Indonesia’s main interlocutor. In their respective capitals, the thinking was that if two governments that were so far apart on the issue could find a resolution, everyone else would agree. But other countries, such as Brazil, India, and Thailand, were now starting to agitate for sovereign control over their viruses, suggesting that a deal with Indonesia alone would no longer settle the matter. At the same time, the disagreement between Washington and Jakarta was becoming ever more shrill. Then Supari released her book.
In early 2008 she published It’s Time for the World to Change: In the Spirit of Dignity, Equity, and Transparency, Divine Hand Behind Avian Influenza. Drawn from her diary, the book was a blistering critique of the industrialized world and WHO’s global system for virus sharing. The most sensational attack was saved for the United States: her claim in the first chapter that the U.S. government could use bird flu samples to fashion weapons of mass destruction. Her evidence was that genetic data from some virus samples was stored in a database at Los Alamos National Laboratory, a U.S. government lab that conducts advanced research on such diverse subjects as national security, climate change, traffic management, and disease dynamics.
“It was the same laboratory that designed the atomic bomb to destroy Hiroshima in 1945,” Supari wrote. “It is likely that they utilize the same facility to research and develop chemical weapons. What a terrifying fact! The DNA sequence data had been the privilege for the scientists in Los Alamos. Whether they used it to make vaccine or develop chemical weapon would depend on the need and the interest of the U.S. government.”
The notion that the United States would weaponize bird flu is ludicrous to most Americans. “I think it’s the nuttiest idea I ever heard,” quipped U.S. Defense Secretary Robert Gates. But in developing countries, some were inclined to believe the worst, and in some quarters of Jakarta, Supari’s book got a rapturous reception.
The dispute over virus sharing also spilled over into negotiations over the status of the NAMRU lab. The U.S. and Indonesian governments, which were quietly discussing a new agreement to authorize its activities, had been hung up over the finite question of how many U.S. personnel at the lab would be accorded diplomatic immunity. Full of fury, Supari abruptly announced in 2008 that it was time to expel the lab altogether. “NAMRU-2’s presence is of no use to us,” she averred in June of that year. “In fact, its operations are an encroachment on our country’s sovereignty.” She urged the Indonesian parliament to close it down. One lawmaker called for a probe into reports circulating among Indonesians that the navy lab was a front for spying. The fate of the most advanced disease lab in Indonesia grew even more uncertain.
Next Supari disclosed that the government would no longer announce human cases of bird flu on a routine basis as before. Days after she made that declaration in June 2008, she assured me Indonesia would still report the cases to WHO. But no more would the government release details to the public with each new infection. “The families of victims of avian flu have very, very fresh wounds,” she explained, and the practice of announcing cases had been “very insensitive to them.”
Maybe so. But yet another source of vital intelligence had been choked off. Indonesia had severed the supply of virus samples to the world’s labs. It had shut down the one lab inside the country capable of fully analyzing specimens. And now the government had deprived flu hunters, and Indonesians themselves, of information needed to confront a budding epidemic. Supari promised that all details would be released in time. But time is the most precious commodity when it comes to flu.
The fracture between haves and have-nots now yawned wide. Even as the novel strain increasingly marked its territory in Indonesia, the world became ever less able to chart its progress.
The figures first appeared on the ridgeline. They emerged one after another from behind a bluff in the middle distance, more than a dozen of them. Then, like ants, they started down a dirt track hewn from the lush, sculpted mountains separating Vietnam from China. The descent was steep, the footing treacherous. The slopes above were densely forested. But the trail itself was broad and exposed, the deep brown earth well trampled. As the smugglers drew closer, their stooped forms became visible in the afternoon light. Their backs heaved under the weight of their freight. Soon the cargo came into view. They were hauling bamboo cages crammed with live, bootleg chickens.
On the paved road below, two young men waited, mounted on a pair of red dirt bikes. They were lookouts. My Vietnamese driver had pulled our car to the side so I could check out the foot traffic coming over the border. Now, as I stood beside the guardrail, staring past a cornfield up into the craggy cliffs, I was the one being checked out. The two sentinels revved their engines and brazenly approached, slowing briefly as they buzzed by. Several dozen yards away, they stopped their bikes. One man produced a two-way radio and barked into it. Though his words were inaudible to my translator and me, within moments the figures on the slopes above began to shift to the edge of the track and melt into the surrounding brush. Yet almost instantly, more traffickers appeared over the ridge from China. Even more were bounding down a second path about a hundred yards to the left. This trail was narrower, largely concealed by banana palms and other trees. These smugglers apparently figured I couldn’t see them and continued their progress undeterred by the alarm.
I had come to the village of Dong Dang escorted by two provincial officials. Now, with some urgency, they were inviting me to get back in the car. The smugglers were a violent lot, known to set upon outsiders with stones, even guns. In recent weeks, the traffickers had bat tled soldiers dispatched to intercept them. In one case, five troops had been injured and their car destroyed. I quickly understood who had the upper hand. “You can put helicopters up there, really mobilize the army and put all kinds of resources in, and it would still go on,” Jeffrey Gilbert of the UN Food and Agriculture Organization told me after I returned to Hanoi. “It’s like the Ho Chi Minh trail.”
Every day, despite an import ban, the smugglers were hauling more than a thousand contraband chickens into Lang Son, one of six Vietnamese provinces along the untamed Chinese frontier. In Lang Son alone, the jagged border runs for 150 miles through angular, misty mountains that seem drawn from a stylized Oriental painting. The highest peak, Mau Son, rises nearly 4,500 feet. It also lends its name to the local rice wine, widely sold in unmarked, five-hundred-milliliter plastic bottles for about sixty cents each. My government escorts had knocked back enough shots over lunch that it had taken some of the edge off their anxiety.
For centuries, extended tribal families straddling the border have navigated highland footpaths to run goods from one side to the other. In recent years these had come to include electronics, DVDs, exotic wildlife, and all sorts of clothes and shoes. The illicit poultry business had turned lucrative in 2004 after Vietnam began slaughtering about 50 million chickens to contain its bird flu epidemic. The resulting shortage of chicken meat, a favorite protein source for the Vietnamese, sent prices soaring on their side of the border. But with the increase in the illegal poultry trade, the traffickers had also unknowingly—and repeatedly—smuggled the virus from its source in southern China into Vietnam, at times introducing altered strains that bedeviled efforts to contain the outbreaks.
Two months before my visit to Lang Son in July 2006, Vietnamese veterinary officials had disclosed they’d identified the virus in a sample taken there from smuggled chickens during a bust on the border. Two years later, provincial health authorities reported they were discovering H5N1 in nearly a quarter of all the illegally trafficked chickens they were confiscating. Researchers had already uncovered lab evidence implicating cross-border commerce in spreading the disease. In mid-2005 they had isolated a strain of the H5N1 virus in Vietnam that was entirely new to the country—different from the subtype that had burned through farms starting in 2003 and killed dozens of people—but similar to one found months earlier in China’s Guangxi region, just over the mountains from Lang Son. Another study published in 2008 found genetic evidence that the virus may have been introduced from Guangxi to northern Vietnam on “multiple occasions,” most likely by poultry trade.
An average of 1,500 birds came over the mountains into Long San each day, provincial officials reported. Along the entire Vietnam-China border, the total could run well into the thousands. The syndicates running the smuggling rings were paying local villagers about thirty cents a bird to haul the contraband along mountain trails that could snake for more than ten miles. Some smugglers, especially women and children, could carry only a few birds. But hardy highland men lugged as many as twenty at a time. Their earnings could far outstrip the salaries of animal-health officers, inspectors, and others charged with stemming the commerce.
Once the smugglers came down from the slopes, they often transferred their haul to motorbikes, which ferried it to local farms serving as transit depots. From there, the chickens were loaded onto trucks for transport, in many cases to the markets of Hanoi, five hours away, and points even farther south. The smugglers were repeatedly seeding new outbreaks, and each outbreak was affording the virus a new chance to ensnare human victims and, even more ominously, mutate. This was how the novel strain continued to press its offensive.
Do Van Duoc was the director of animal health in Lang Son, a friendly man with full cheeks and silver hair that sat atop his head like a mushroom cap. He explained it would be nearly impossible to stem the smuggling as long as prices on either side of the border were so different. On average, chicken that sold for thirty cents a pound in China was fetching a dollar or more in his country. But that wasn’t the whole explanation. He accused Chinese farmers of unloading chickens from areas struck by bird flu at bargain-basement prices.
China’s agriculture ministry confirmed for me that poultry was being illegally transported into Vietnam. An investigation by Guangxi animal-health investigators had discovered three clandestine routes originating in different areas adjacent to Lang Son. But Chinese officials, true to form, denied that any birds coming from their side of the border were infected. Duoc wasn’t buying that. “We have evidence,” he told me. “We’ve tested and we can prove there’s H5N1.”
The farther influenza goes, the closer it comes to hitting the microbial jackpot. Extent means opportunity, more chances to mutate or swap genes. By 2009 the virus had stricken birds in at least sixty countries and spread to people in fifteen of them.
The strain made its debut in Europe in October 2004 when customs officers at Brussels airport discovered two infected eagles in a passenger’s hand luggage. A Thai traveler had smuggled them from Bangkok, wrapping the creatures in cotton cloth and shoving them headfirst into a pair of two-foot-long woven bamboo tubes. Then he had tucked these into an athletic bag, left unzipped slightly so the birds could breathe. His delivery had been destined for a Belgian falconer who had paid nearly $1,900 for the pair. They would have arrived unnoticed but for the passenger’s bad luck. He was stopped and searched as part of a random drug check. “We were very, very lucky,” Rene Snacken, the flu chief at Belgium’s Scientific Institute of Public Health, said at the time. “It could have been a bomb for Europe.”
But before long the virus indeed exploded out of East Asia. The startling outbreak among migratory birds at China’s Qinghai Lake in April 2005 had left Hong Kong’s Yi Guan and other scientists wondering where the virus might next wing. Over the following year, the disease struck birds in more than forty countries in Europe, Africa, South Asia, and the Middle East, and each time researchers checked, they found the distinctive genetic signature of the Qinghai subtype. By that winter, a dozen people had fallen sick in Turkey, four fatally, bringing human casualties to Europe’s doorstep for the first time. Wild birds and domestic poultry were succumbing in more than two dozen European countries. Panic spread. In Paris, the famed bird market on the Île de la Cité removed all live fowl, and France’s annual livestock festival took the unprecedented step of banning poultry. In Britain, where legend claims that the monarchy will survive only as long as the ravens at the Tower of London, these celebrated birds were locked up for their own protection for the first time in history.
The virus struck in the Middle East amid the conflicts in Iraq and the Palestinian territories, where health officials were hard-pressed to respond. The disease also turned its wrath on Egypt, where denizens of Cairo, terrified to learn that chicken carcasses were being dumped in the Nile River, initially stopped drinking tap water. Soon Egypt would record more human cases and deaths than anywhere but Indonesia and Vietnam.
Then the disease crossed the desert to sub-Saharan Africa, infecting commercial farms in Nigeria and stoking fears that this indigent, ill-governed continent could become an entirely new breeding ground for a pandemic strain. Nigeria’s information minister told reporters, “While it was originally suspected that migratory birds may have been the purveyor of this disease, preliminary reports recently obtained from relevant security agencies indicate that there is a strong basis to believe that avian flu may have been introduced into Nigeria through illegally imported day-old chicks.” Scientists who later decoded the genetics of Nigerian samples concluded the virus had been introduced to the country three separate times along routes coinciding with the flight paths of wild birds. But the study also said imports could not be ruled out as the cause.
Once the virus was established in Nigeria, the epidemic spread, most likely along internal trade routes, and put neighboring countries in jeopardy because of widespread cross-border commerce. By the close of 2007, eleven African governments had reported outbreaks in birds, some in countries no better able than the poorest in Asia to confront the disease.
A rancorous debate has erupted over exactly how avian flu spreads.
Are wild birds the culprit, conveying the virus on their seasonal migrations? Or is it trade in poultry, legal or not, that inadvertently extends the global reach? Some wildlife conservation groups have said that migratory patterns aren’t a good match for the distribution of outbreaks, suggesting instead that the virus spread from Asia to Europe by commerce along the route of the Trans-Siberian Railroad. But other researchers have noted outbreaks near wintering sites for migratory birds and far from any farms or markets that could account for contamination. After more than a decade, there is now enough evidence to conclude that the novel strain has taken ample advantage of both these opportunities to advance across the Eastern Hemisphere.
Some countries have been able at times to roll back the tide of infection, notably those in Europe and more developed Asian states like Japan and South Korea. But elsewhere, the disease refused to surrender its foothold.
No one is better positioned to evaluate the viral storm gathering in the animal kingdom than Joseph Domenech, chief veterinarian of the UN Food and Agriculture Organization. In a series of public warnings starting in the fall of 2007 and running into 2008, Domenech offered a disturbing, though not universally bleak prognosis. “Surveillance and early detection and immediate response have improved and many newly infected countries have managed to eliminate the virus from poultry,” he reported. “But,” he continued, “the H5N1 avian influenza crisis is far from over.”
He singled out Indonesia as the place where bird flu had become most stubbornly entrenched. “I am deeply concerned that the high level of virus circulation in birds in the country could create conditions for the virus to mutate and to finally cause a human influenza pandemic,” Domenech said in another assessment in March 2008. “The avian influenza situation in Indonesia is grave—all international partners and national authorities need to step up their efforts for halting the spread of the disease in animals and making the fight against the virus a top priority.” He faulted a lack of money, poor coordination among different levels of government in Indonesia’s decentralized political system, and insufficient commitment. With the strain in Indonesia actively undergoing genetic changes, Domenech warned that the virus was spinning off new subtypes that could elude the poultry vaccines meant to contain it.
Even when outbreaks ebb, it doesn’t mean flu has been beaten. It goes to ground, smolders, waits for an opening. Vietnam adopted a raft of eradication measures in late 2005, including a drive to vaccinate tens of millions of chickens and ducks. Officials also imposed a ban on live markets and poultry farming in cities, tightened regulations on transporting birds, and restricted the raising of ducks and quail, which were thought to be spreading the disease without getting sick themselves. The virus went silent for a time. Vietnam boasted it had cornered the virus. But then it resurfaced, establishing a new beachhead in ducks that had not been properly vaccinated. In 2008 and then again in 2009, poultry outbreaks were reported from the north of the country to the south. After more than two dozen provinces were struck in 2008, Vietnam’s agriculture minister acknowledged that only a few localities were completely capable of controlling the disease and blamed their slow response for the recurring epidemic. His deputy said the country’s poultry vaccination program was flagging. While both poultry outbreaks and human cases were still few relative to 2004 and 2005, FAO officials cautioned that the Vietnamese government would be unable to keep paying for the vaccination drive. Researchers, meantime, noted the separate strains circulating in northern and southern Vietnam were both becoming more lethal.
In China, human infections spiked in early 2009, striking provinces across the breadth of the country. As in earlier years, these cases were occurring without corresponding accounts of poultry outbreaks. WHO officials again concluded that the epidemic among birds was worse than China was reporting and promised, along with FAO, to press their concerns with the Beijing government. “We still have a very serious situation in the agriculture sector,” said Hans Troedsson, who had become WHO’s senior representative in Beijing after leaving Hanoi. “The virus is well-entrenched and circulating in the environment.”
Thailand appeared to fare better. After repeatedly claiming it had banished the bug only to see it return, the Thai government launched an ambitious campaign to crush it in 2005. About seven hundred thousand village health volunteers were mobilized to watch for any hint of emerging infection. Twice a year, the government conducted nationwide door-to-door inspections, dubbed X-ray surveys, searching for infected poultry. Stricken flocks were culled, their owners compensated. Duck grazing was barred. Reported outbreaks tailed off. But researchers continued to detect the virus in bird samples, and suspicions lingered. Were Thai farmers secretly doping their chickens to look healthy? “Some commercial producers in Thailand are apparently using unauthorized vaccines to protect their flocks and vaccinating without proper oversight from health authorities,” FAO’s infectious disease chief wrote in August 2006.
Elsewhere, the virus kept coming back. The disease reappeared in 2008 and 2009 among the birds of Hong Kong, India, Pakistan, and the West African countries of Benin and Togo. In mid-2008, Nigeria reported its first new H5N1 outbreaks in almost a year, in a pair of poultry markets. When scientists tested the virus, they were dismayed to find it was different from those previously circulating in sub-Saharan Africa, a baffling transplant from either Europe or the Middle East. And after nearly a year, a new case surfaced in ducks in Germany. “Somewhat surprising,” German authorities admitted.
The virus was already entrenched in a few places outside East Asia. Egypt officially acknowledged in July 2008 that H5N1 was endemic in its flocks, primarily in the Nile Delta. Bangladesh was equally unable to root out the disease. Domenech called the crises in those two countries “particularly worrying.”
He also offered a chilling admonition for Europe. Tens of millions of apparently healthy ducks and geese that graze along the Danube River and in the wetlands surrounding the Black Sea could be spreading the infection. “It seems,” he said, “a new chapter in the evolution of avian influenza may be unfolding silently in the heart of Europe.”
Even more chilling was the prospect raised by the debut of H1N1 swine flu in early 2009. What would happen when this new arrival spread from its apparent source in North America to countries like Indonesia, China, Vietnam, and Egypt, where bird flu was already endemic? What new virus might emerge from the encounter of these two novel strains? “We must never forget that the H5N1 avian influenza is now firmly established in poultry in several countries,” Margaret Chan told an assembly of the world’s top health officials in May 2009. “No one can say how this avian virus will behave when pressured by large numbers of people infected with the new H1N1 virus.” The swine flu virus had already demonstrated an uncanny ability to swap genes and shift shape. Might this highly contagious strain now acquire the attributes that make avian flu so deadly? Or might swine flu finally provide its avian cousin with the keys required to break loose among people? “Do not drop the ball on monitoring H5N1,” Chan urged Asian health ministers at a separate session in Bangkok called to address swine flu. “We have no idea how H5N1 will behave under the pressure of a pandemic.”
In the five years after the virus reemerged in mid-2003, it tallied nearly 390 confirmed human cases and 245 confirmed deaths. For each one of those fatalities, almost precisely one million birds either succumbed to the disease or were slaughtered to contain it. That tremendous disparity between human and avian deaths underscores where the action has been. The bulk of the battle has consisted of culling, vaccinating, testing, and protecting poultry with the soldiers drawn from the ranks of the agricultural and veterinary services. The spread of disease among animals has long been beyond the mandate of public health, receiving little of the attention that a menace of such magnitude deserves.
Yet if there is any possibility of postponing future human flu pandemics, whether born of H5N1 or another strain, it means reducing the circulation of these viruses in animals. The less the microbe spreads and replicates, the fewer times the dice are rolled. And the less often the dice are rolled, the longer it will likely take for the virus to mutate or reassort into an epidemic strain.
By contrast, once a pandemic strain emerges and begins passing easily from one person to another, the only hope will be to retard its ineluctable progress by using antiviral drugs, quarantines, and other measures to keep people from mixing. A delay of even a few days would be no mean achievement. This could provide more time to start producing and distributing vaccines. Though they wouldn’t come soon enough for those infected at the beginning of the pandemic, millions of lives could be spared if vaccines arrive in time for those sickened toward the tail end. Yet ultimately, this is a rear-guard action. “You accept a victory as slowing the virus down,” offered Michael Ryan, WHO’s head of epidemic alert and response.
For much of their history, the fields of human and animal health have been divorced and introspective. When bird flu outbreaks were reported across Southeast Asia in early 2004, relations were strained between WHO and its sister agency, the FAO. Though officials on the ground tried at times to craft ad hoc alliances, tensions simmered over turf and money. Since then, these two UN agencies and the independent World Organization for Animal Health have taken steps to enhance cooperation, convening joint strategy sessions and setting up a common early-warning system to share information about bird flu and other diseases. But for many in public health, the fight in the animal kingdom has remained an afterthought.
“I don’t think the medical community has paid enough attention to the veterinary community in terms of the risks for humans,” said veteran scientist Dr. Michael Perdue. “It is the responsibility for human health, for the medical community, to reach out.” Perdue told me that means, for instance, pressing to get money for cash-strapped veterinary counterparts and helping set up more labs for testing animal diseases.
In 2006 Perdue joined the U.S. Department of Health and Human Services, where he took a leading role in preparing the United States for the coming epidemic. By the end of 2008, the department had spent about $1 billion toward creating a stockpile of antiviral drugs sufficient to treat about a quarter of the U.S. population. Another $1.5 billion went toward the development of advanced technologies for making pandemic vaccines, while nearly $1 billion more was invested in setting up a stockpile of prepandemic vaccines, which are based on current H5N1 subtypes and might afford limited protection to medical staff and other vital personnel in the early days of an epidemic. These measures, too, could save millions of lives, though they are powerless to preclude the inevitable.
Perdue, a genial Mississippi native, has a rare perspective on flu. He has hunted it on both sides of the species divide. As a microbiologist, he long probed the mysteries of avian influenza at the U.S. Department of Agriculture’s elite poultry research lab in Athens, Georgia. Once the disease launched its unprecedented attack on Southeast Asia, WHO called for reinforcements, and Perdue crossed to the human health side, signing on to the agency’s global influenza program in Geneva. From there, he was repeatedly dispatched to investigate human outbreaks. WHO is in a bind, he told me. As long as the virus remains primarily an animal disease, the agency must often defer to agriculture officials, who have priorities beyond fighting infectious disease—for instance, promoting livestock development. “It’s sort of animal health versus human health. It’s challenging,” Perdue said. “The problem is, once it becomes a human virus and WHO is clearly engaged, then maybe it is too late, because then it’s off and running.”
The trail of the fatal strain led me from one end of Southeast Asia to the other. I tracked the virus across nine countries, through hospitals and laboratories, into chicken coops, rice paddies, wet markets, and cockfighting rings. Yet few places were as remote and none as awesome as the floodplain of the Tonle Sap.
For much of the year, this lake in northwestern Cambodia is modest, covering slightly more than a thousand square miles at depths of about a yard. But each June, monsoon rains swell the Mekong River and its tributaries, forcing the water to back up into the lake and transforming it into the largest freshwater body in all of Southeast Asia. The lake’s waters overflow the banks and inundate another five thousand square miles, covering nearly a tenth of Cambodia’s area. Fields and forests are submerged. Then, with the coming of the dry season each October, the waters drain away.
Over the generations, Cambodians have adapted to the furious but predictable mood swings of their habitat. Many have built their homes on stilts to stay clear of the rising waters. Some inhabitants migrate with the shoreline, dismantling their dwellings as the water advances and reassembling them farther out. Others live on houseboats or floating homes of thatch, palm fronds, and clapboard mounted on bamboo rafts. This ecosystem has also made the shores of the lake and the surrounding floodplain a unique wintering ground for Asia’s wild birds.
It was the birds that brought me to the Tonle Sap. The monsoon was only weeks away, and soon they would migrate to summer breeding grounds in China, Japan, Siberian Russia, and even across the Bering Sea to North America. What if the birds were infected? Would the virus follow the multitude of flyways that radiate out from the Tonle Sap?
Few outside of Cambodia had heard of this wilderness. Yet here, in utter silence but for the occasional ruffle of wings, with no other sign of human life on this vast, flat expanse, I wondered whether a plague could be taking shape. If so, no place on Earth would be left untouched.
I came to the Tonle Sap floodplain looking for the virus. I found an insight. I realized we’re all living on a floodplain.
Several times each century, a novel flu strain emerges, often from the fountainhead of Southeast Asia. Death and disorder wash across the face of the planet. Sometimes they just skim the surface; other times they deluge all that lies before them. Then they recede. This cruel cycle isn’t as predictable as that of the Tonle Sap waters. But it is equally inevitable.
Those who live around the Tonle Sap have adapted with forethought and creativity to nature’s challenge. They have learned to ride out the flood. We have yet to do so.
For much of the last generation, the silence has been deceiving. Not since 1968 had a new flu virus menaced humanity and circled the world. But the outbreaks of avian flu that multiplied over the early years of this new century made it hard to continue mistaking luck for a change in the laws of nature. “The present situation is unique,” Margaret Chan has admonished from her bully pulpit in Geneva. “In the past, pandemics have always announced themselves with a sudden explosion of cases, and taken the world by surprise. For the first time in history, we have been given an advance warning.” She calls this an “unprecedented opportunity” for countries and communities to get ready.
Then swine flu broke out. Researchers initially concluded it was spreading as vigorously as each of the three last pandemic strains. But soon it seemed the attack rate was no greater than that for ordinary flu bugs. Still, the epidemic’s ultimate course remained uncharted. Public health officials once more were making fateful decisions, whether, for instance, to embark on a crash vaccine program amid scientific uncertainty. Like all flu viruses, especially those so new to us, swine flu remained unpredictable. Its message, however, was unmistakable. Again, get ready.
Though governments have recently taken steps to gird the world for a pandemic, too little has been done. As I write, epidemic planning for hospitals and public health systems remains wanting. Preparations in other essential sectors, in particular those to ensure supplies of food, water, electricity, and fuel and to maintain public order, are even more deficient.
It’s surprising how few people know the horrors of 1918. Perhaps that cataclysm is overshadowed in memory by the final months of World War I, a conflict that recast the geopolitics of the world and defined a generation. Perhaps epidemics exist outside of history, ideology, and meaning, and their imprint vanishes like footsteps on the beach, especially when people have no one to blame for their tragedy, no grievance to harbor. It could be that people simply want to forget suffering. Or maybe we believe, as an advanced civilization, we’ve moved beyond plagues. By that reasoning, 1918 belongs to another, remote era of little relevance to today.
After I started this book, I told friends and colleagues what I was writing. The response wasn’t what I expected. Time after time, they would mention relatives who had died during the Spanish flu, a grandfather’s brother, a distant cousin. My architect told me his uncle and two other kin are buried in Jamaica after perishing in 1918. Then, several months before I finished the first draft, I discovered evidence of another visitation.
Growing up, I’d heard the story about how my grandmother’s mother, Yetta, had died as a young woman back in Poland. No one seemed to know precisely when, and no one ever mentioned the word influenza. We never connected it to anything else going on in the world at the time. All we knew was that she had been killed by some respiratory disease, maybe tuberculosis, maybe what they called grippe back then.
My grandmother, we heard, was eight at the time. It turned her life upside down. Soon after, Grandma’s father abandoned the family, leaving her to care for her younger sister and brother. They drifted from place to place, sleeping one night here, another there. Grandma found odd jobs to feed them, even working for a time picking fruit in orchards around Warsaw. Ultimately, her two maternal uncles sent for the children. The pair had earlier immigrated to New York, where one became a political pamphleteer and the other, according to family lore, hosted the longest continuously running pinochle game in the Bronx. Grandma left her homeland and crossed the ocean.
We’d never done the math to determine what year great-grandmother Yetta died. We couldn’t, because we didn’t know when Grandma was born. Grandma had lied on her American immigration papers to pass for a few years older so she could line up work. Over the rest of her life, the birth date on her government papers was fiction. When she finally passed away in 2006, she herself wasn’t sure how old she was. But my mother later came across Grandma’s marriage contract in an old file. On the back of this crumbling religious document, the date of the wedding was noted in pencil. With that clue, we could calculate Grandma’s birth date. She had been born in 1910. It meant Yetta had died, and our history pivoted, eight years later in 1918.
The timing wasn’t absolute proof that flu had been the killer. But the odds were overwhelming. The last great epidemic suddenly felt much closer. So did the next.