The Fatal Strain

by Alan Sipress

  And with the coming of a pandemic, yet another set of limits threatens to exact a tremendous price. These are the bounds of the emergency planning we’ve done, the limitations of our downsized health-care system and outsourced drug industry, even potentially of our power supply and food and water. But that’s a story history will write.

  Now to Asia, where a fatal strain has raised its baleful challenge.

  PART ONE

  CHAPTER ONE

  The Revenge of Begu Ganjang

  Dowes Ginting, the most wanted man in Sumatra, lay dying. He had abandoned the Indonesian hospital, where he had seen his family succumb one after another, and fled deep into the mountains, trying to outrun the black magic, seeking refuge in a small, clapboard home beyond the cloud-shrouded peak of the Sinabung volcano. For four straight nights, a witch doctor hovered above him, resisting the evil spell.

  The medicine man mumbled the unintelligible words of an incantation. He doused Dowes with cooking oil and massaged his tormented muscles. He placed a hefty chunk of betel nut in the corner of his own mouth and chewed, his lips staining red from the juice of the mild stimulant, and then, with the precision of a surgeon, spit the concoction gob by gob over his patient’s head, face, and chest and along his arms and legs. To relieve the surging fever, the witch doctor applied a pasty preparation of pounded rice and ginger called beras kencur to the man’s damp flesh.

  Dowes, a wiry thirty-two-year-old with a mop of dark hair and a whisper of a mustache, seemed at times to improve. His breathing grew less labored and his coughing less wrenching. At these moments, Dowes would hope his affliction was nothing more than the respiratory troubles he sometimes had as a teenager. But other times his condition would suddenly deteriorate. The witch doctor had to repeat the treatment several times in the course of a single night. He even lit some kemenyan, a pungent incense made from the balsamic resin of local trees and burned only when battling the most intractable spirits.

  When the nighttime therapy was finished, Dowes would retire to a house just next door on a rise overlooking the village of Jandi Meriah. While the witch doctor’s home was little more than a shack with a faded white exterior and rickety brown shutters, the neighbors’ was more substantial. It had a jolly pink tile facade with a green tile terrace and even a working toilet. It belonged to relatives of Dowes’s wife, and for the four days he sheltered there, they looked after him, washing him and cooking his meals. Mostly, he slept. But when he felt ambitious, he sat on the terrace and looked down on the rusting, corrugated metal roofs of the village and the tall stands of coconut palms.

  It was to this remote hideaway that Dr. Timothy Uyeki tracked Dowes in May 2006. Uyeki had been dispatched to Indonesia by the World Health Organization after the agency’s office in the capital, Jakarta, had put out an urgent call for reinforcements. Influenza specialists suspected that Dowes was carrying a novel flu strain. And he was on the loose.

  Since bird flu had first jumped the species barrier from animals to humans in Hong Kong nine years earlier, the strain had infected more than two hundred people, yet it had reassuringly shown little aptitude for spreading from one person to another. Now the outbreak ravaging this one Sumatran family suggested the contrary. It was the largest cluster of confirmed bird flu cases in the world to date and the strongest proof yet that the virus could be passed among people. If the virus that Dowes was harboring had mutated into a more transmissible form, tens of millions of people worldwide could die.

  Investigators would ultimately conclude that the Sumatra outbreak was not sparked by an epidemic strain. The toll would be confined to the Gintings. But the outbreak was the closest thing yet to a dry run for an emerging epidemic.

  The experience was sobering. This was more than just a stress test of the world’s emergency response. The episode, more generally, would cast doubts on some of the biggest bets humanity has been placing, raising profound questions about whether the WHO formula of brilliant scientists, courageous investigators, and modern technology was potent enough to break history’s inexorable cycle of pandemics.

  In the tight-knit world of highland Sumatra, it did not take long for Uyeki and a pair of Indonesian colleagues to trace the fugitive through his extended family, catching up with Dowes three days after he slipped into Jandi Meriah. Uyeki entered the front room of the hilltop refuge and spied Dowes lying by the window. He was sprawled on a thin, pink mattress against the wall, chest bare, his head propped up on a pair of pillows. His eyes were open. They were dark and sunken, and beneath them hung heavy bags left by the long nights of misery and magic. Above him, the curtains were open. Morning sunlight filled the room.

  The patient’s wife and several other family members took seats on a red rug along the far wall and eyed their visitors suspiciously. Uyeki sat down by the door. He started by offering his sympathy for the losses they’d already suffered. He explained he was looking for information. He wanted to help. It was a hard sell. Outsiders, even fellow Indonesians, were a rare sight in the village. They were viewed with distrust, even hostility.

  Uyeki, an American, was an old hand at this kind of fieldwork. During his career as an epidemiologist with the U.S. Centers for Disease Control and Prevention in Atlanta, he had responded to Ebola in Africa, SARS in Asia, and anthrax attacks in Washington.

  But flu was his passion. He had signed on to CDC’s influenza branch in 1998 and was instantly dispatched to investigate an unusual summertime outbreak on cruise ships in Alaska that sickened thousands of tourists and tourism workers. In 2002 he headed off with an international team to the island nation of Madagascar, where thirty thousand villagers had come down with a baffling respiratory infection and hundreds had died. Though it was never publicized, some communicable disease specialists at WHO feared that at that very moment a global flu pandemic was hatching, not somewhere in Asia but in that African country’s remote rural highlands. Uyeki pitched his tent there and camped for five days in continuous rain, collecting samples from the sick. The test results were ultimately reassuring, revealing that the outbreak was caused by an ordinary seasonal flu strain, exacerbated by Madagascar’s crowded conditions, malnutrition, and cold, wet winter.

  Uyeki is evangelical about flu. He calls it the Rodney Dangerfield of diseases. He is outraged that for years the virus was unable to garner much attention from researchers and policy makers despite its proven ability to kill tens of thousands of Americans each winter and potentially millions in a pandemic. He is emphatic about this point, as he is about many things. He is perpetually engaged and chronically restless. He keeps his sleeves rolled up and sneakers on his feet. Even into his late forties, this abundant energy, coupled with his intense brown eyes and dark, uneven bangs, lent him a boyish aspect.

  Uyeki is also a practicing physician, a trained pediatrician, and, as he sat in that doorway in Sumatra, he understood that he was dealing with more than just the devilish twists of microbiology. He also had to attend to stigma and loss. “These were people who had already suffered a great tragedy,” Uyeki later recalled. “This was a family that was trying to grieve. You needed to be empathetic and sympathetic. You feel a little reluctant to keep pushing.”

  As he spoke with the relatives, Uyeki tried to make eye contact, hoping to win their trust. But out of the corner of his eye he also studied Dowes. The ailing man had pulled himself into a sitting position. There was something odd about his breathing. His chest muscles seemed to be working too hard, too fast. Before long, Uyeki fell silent. He looked down at his watch. Then, for a full minute, he observed Dowes, counting each breath. A healthy man would breathe about fourteen or sixteen times in a minute. But Dowes exceeded that in half the time. Uyeki counted up to thirty-six. He knew then that the patient had pneumonia. It was almost certainly bird flu. But he’d need a specimen of virus to be sure.

  Uyeki delicately advised the family that he wanted to take a sample.

  “No blood,” one relative objected.

  “I’m not going to draw
blood,” Uyeki assured them. His aim was to swab the man’s nose and throat.

  “No equipment,” a relative insisted, making clear they’d be horribly offended if Uyeki donned his protective gear.

  It was a terrible demand. This was a monster of a virus that had killed most of those it infected. Flipping a coin would give better odds of survival. It was so deadly that scientists studying the virus were required to wear protective suits and work in special limited-access laboratories behind double doors with reverse ventilation to siphon off contaminated air. In the field, investigators were instructed to wear full outfits, including respirator masks, goggles, surgical caps and gowns, shoe coverings, and gloves. Uyeki usually snapped on three layers of gloves just to be sure. He always carried the complete gear in his backpack. This was going to be a tough negotiation.

  “OK,” Uyeki offered, “I won’t wear a gown and I won’t wear goggles.” He would compromise. “But I’m going to wear a respirator and gloves.” He figured the main hazard would be breathing in the virus or getting it on his bare flesh.

  “Nothing,” the relative repeated.

  “No, this is what I’m going to wear,” Uyeki responded, motioning to his face and hands.

  They went back and forth. Eventually the family relented. Uyeki slipped on what he considered the minimum protection, a mask and gloves.

  Uyeki had wanted one of the Indonesian doctors to help him take samples. But his colleague was petrified, rightfully so. He was just a local country doctor who had never confronted such a cruel and exotic killer. Uyeki tried to reassure him. Uyeki produced another mask and pair of gloves from his backpack and passed them to his reluctant partner, then explained step-by-step what they were about to do.

  On Uyeki’s instruction, the Indonesian physician lifted a Q-tip-like swab to Dowes’s left nostril and gingerly inserted it. Then he handed it back to Uyeki, who carefully snapped off the top, placed it into a tube containing sterile media for transporting virus samples, and screwed on the cap.

  Next Uyeki sampled the right nostril himself, repeating the procedure.

  Finally Uyeki prepared to take the throat specimen. This would be tougher. He would have to reach into the windpipe with the swab and fish out a glob of mucus. It would be absolutely loaded with virus. The pathogen had already been replicating inside its host for a week, and Dowes would be teeming with infection.

  Uyeki squatted beside him and leaned right in. The doctor’s eyes were just inches from those of his patient. Uyeki lifted the swab. Then, he carefully inserted it through the open mouth and down Dowes’s throat.

  The sensation must have tickled. For at that very moment, Dowes coughed. And when he did, it was right in Uyeki’s face.

  Uyeki didn’t blanch. But inside, his stomach dropped. “Oh, this is not good,” Uyeki fretted to himself. Despite the mask, most of his face was exposed. His mind raced. He instantly thought about his unprotected eyes. He knew other types of avian flu viruses had been contracted through the eyes. Could the same be true for this strain?

  He tried to stay focused. He had long since learned to remain calm no matter what. Countless times in his career he had resuscitated children when one slight miscue or false start might mean their death. This time he stared past his own mortality. Later, after leaving the village, he would urgently dose himself with antiviral drugs, taking four times the usual amount prescribed for prophylaxis, and acknowledge he’d made a mistake. He would promise himself never to forgo goggles again.

  But now he had to rein in his rising anxiety. Slowly, he withdrew the swab from the Dowes’s mouth and backed away.

  Uyeki placed the final, hard-won sample in a tube. With a Magic Marker, he labeled all the specimens. Next, he removed his gloves, then those of his Indonesian partner. He stuffed them in a bag he had brought specifically for disposing of dirty material. He sealed it tight.

  Then he turned back to the row of family members seated along the wall with another request. He told them he now wanted to briefly examine Dowes and asked for permission.

  “All I want to do is listen,” Uyeki appealed, showing them his stethoscope. “I just want to listen to him. No blood. I’m not going to do a full exam.” They agreed.

  Squatting next to the mattress, he listened to Dowes’s chest. He listened with the patient sitting up and with the patient lying down. Uyeki heard an odd crackling sound, a kind of coarse gurgling each time Dowes inhaled and each time he exhaled. Uyeki had heard this in other patients, but never this loud. It was the sound of fluid, of a man drowning.

  “He has pneumonia and he has it in both lungs,” he reported to the relatives. “I strongly recommend he go to a hospital.”

  From beneath his straight black bangs, Uyeki’s detective eyes watched them, trying to gauge their reaction. But he knew what the answer would be. The relatives refused. They insisted that Dowes had to complete two more days of traditional treatment. Uyeki had no choice but to defer to their wishes. He didn’t want to make a scene. Nor did he have any way of forcing them to comply. Though he had come to the village with a security officer, the escort’s charge was limited to keeping Uyeki safe should the locals turn unruly. So after only two hours in the village, the medical team was back on the road in their four-wheel-drive vehicle, skirting the volcano, bound for the district capital of Kabanjahe twenty-five miles away.

  But before they left, Uyeki urged the relatives to get Dowes to a hospital if his condition worsened. Uyeki suspected it would. It was clear Dowes was going to die. Uyeki did not realize how quickly.

  It had been nearly a year since Indonesia had confirmed its first human cases of bird flu. A government auditor in the suburbs of Jakarta and his two young daughters had died abruptly in July 2005. The outbreak was unnerving on several counts. Not only were disease specialists unable to determine the original source of infection despite weeks of investigation, but the sequence of the three cases strongly suggested that the virus had been passed from at least one victim to another. Perhaps most worrisome was that the virus was now striking people in Indonesia at all. The strain had already been exacting a toll elsewhere in Southeast Asia, but Indonesia, a country of vast size, sprawl, and poverty, was the most daunting front so far.

  Then, less than a month later, the world got some surprisingly good news from a pair of international research teams. By applying cold, hard numbers and sophisticated computer models to the outbreak in Southeast Asia, the two teams had each determined that the world could nip a human flu epidemic in the bud given the right mix of antiviral drugs, quarantines, and social controls. This would be unprecedented. Mankind had never before been able to stem an emerging influenza pandemic but throughout history always had to ride out the storm, waiting for the plague to burn itself out. Now, armed with high-speed computers, advanced statistics, and modern medical science, humanity might be able to bend nature to its will.

  At Imperial College London, computational biologist Neil M. Ferguson led a group of researchers in simulating an emerging epidemic in rural Thailand. They chose Thailand because detailed demographic data was available. But the researchers said the conclusions could equally apply to similar low-density communities in Southeast Asia. Starting with a single human infection, Ferguson and his colleagues found that the virus remained limited to the local area for about thirty days before shooting like buckshot across the rest of the country over the following two months. They said this created an opportunity to contain a nascent pandemic at its source if about 2 million courses of the antiviral drug oseltamivir were rushed to the scene and dispensed to those within three miles of the initial outbreak. Oseltamivir is marketed by the Swiss drug company F. Hoffmann-La Roche Ltd. under the brand name Tamiflu. Officials would also have to shutter schools and workplaces to limit human contact and would have to place the entire area under quarantine.

  A separate team led by Ira M. Longini Jr., a biostatistician at Emory University in Atlanta, ran a slightly different model that also simulated an outbreak in a theo
retical population based on data from northeast ern Thailand. These researchers likewise examined the impact of antiviral medicine, limits on human contact, and quarantine and came essentially to the same encouraging conclusions. Their analysis was even more optimistic, finding that no more than 1 million courses of Tamiflu might be needed.

  Together, these two studies, published almost simultaneously in the rival journals Nature and Science, offered the WHO a strategy for confronting a pandemic. It was perhaps the only hope, and WHO was quick to integrate the findings into its emergency planning. “No attempt has ever been made to alter the natural course of a pandemic at its start and the behavior of influenza viruses is hard to predict. Nevertheless, the rapid containment approach is considered one of the key elements of pandemic influenza preparedness,” WHO wrote in describing its new strategy.

  But the researchers made clear that success rested on some very perilous assumptions. The nature of the virus itself was a crucial variable. If the epidemic flu strain were good at reproducing itself, say for instance if each sick person on average infected at least two others, containment would be unlikely. If, however, the strain were less contagious, with each sick person infecting fewer than two others, chances of checking the disease would be better.