by Alan Sipress
Success depended equally on the speed and effectiveness of the response. Ferguson’s team stressed that health authorities would have to almost instantly recognize the initial case of an epidemic strain and detect most of the subsequent ones. They would also have to identify nearly everyone who may have had contact with the victims, including relatives, schoolmates, work colleagues, and anyone else who had ridden in the same bus, shopped together in same market, eaten in the same restaurant, or prayed in the same mosque, temple, or church, and then get Tamiflu into their hands. The drugs would have to reach an overwhelming majority, preferably more than 90 percent. Longini’s group concluded that containment could only work if “the stockpile were deployed at the source of the emerging strain within two to three weeks of detection.” Any longer and the highly infectious virus would breach the containment zone, confronting the world with an unstoppable epidemic.
WHO’s emergency containment plan incorporated this narrow window, stressing that success depended on mass administration of antiviral drugs within three weeks of the “timely detection” of the first case of this new epidemic strain. A twenty-day supply of Tamiflu would have to reach 80 percent of the targeted population, defined as everyone within at least three to six miles of every detected case, or between ten thousand and fifty thousand people in each area at risk. This would require a massive global undertaking to tap international stockpiles of Tamiflu, airlift the drug into the country, ship it to the hinterlands, and distribute it among the locals. (If the outbreak occurred in a city, such efforts would be pointless. The population density would offer so much dry tinder to the virus that a global conflagration would be unavoidable.)
WHO would rely heavily on the government of the stricken country to quickly detect and honestly report any suspicious outbreaks, initiate the containment effort, and then efficiently transport antiviral drugs to the affected area, no matter how remote. Movement in and out of the containment zone would be sharply restricted. Cooperation from the community would be essential. People would have to stay put, stay home, and take their medicine as prescribed. The sick would be isolated, those exposed to them quarantined. Lab testing of their samples would be crucial for tracking the evolution of the outbreak and calibrating the response. To succeed, this highly disciplined operation would have to last a month or more. “It will require excellent surveillance and logistics mechanisms as well as an ability to ensure compliance with policy directives,” WHO acknowledged.
The power of the computer simulations was awesome, and the chances they promised humanity to dodge a pandemic were previously unimaginable. But what would happen when they collided with the realities of Asia?
In the weeks before Dowes was tracked to his mountain hideaway in May 2006, he had watched sickness burn through his family. It had taken his older sister, his younger sister, and three of their children. His own ten-year-old son had held on longer than most. Dowes and his wife barely moved from the boy’s bedside, but eventually, after suffering eleven days of fever and ever-greater difficulty breathing, he, too, succumbed.
The members of this Sumatran family had perished despite the efforts of the best hospitals in the island’s main city of Medan, the third-largest in Indonesia. Though overseas laboratory analysis in Hong Kong had confirmed the cause was bird flu, Dowes did not believe it. When his relatives took antiviral drugs as prescribed for bird flu, they only got worse. When they gave blood to be tested for the virus, they only grew weaker. Nearly everyone who entered the hospital was fated to die, not to survive. So when Dowes fell sick two days after his son’s death, he decided to make himself scarce.
The outbreak in his family had already attracted international attention because of the cluster’s size. The WHO had sent Uyeki to Indonesia along with the agency’s premier epidemiologist, Dr. Tom Grein. An intrepid German investigator, Grein had repeatedly responded to some of the world’s most terrifying outbreaks, including Ebola and Marburg epidemics in Africa and mysterious clusters of respiratory disease in remote areas of northern Afghanistan and southern Sudan. He and Uyeki had worked together before and were familiar with each other’s routines.
When Dowes fell ill, WHO’s flu specialists surmised he was another link in an unprecedented chain of human transmission. Now his disappearance was setting off warning lights well beyond the islands of Indonesia. He was on the move and potentially contagious with what seemed to be the most transmissible strain of the virus yet. This was the way epidemics started. Indonesian authorities put out a bulletin to local health officers: Find Dowes. Uyeki and Grein had reached Sumatra the very day he went to ground. They joined the hunt.
Dowes and his family had rented a public minibus to smuggle him even deeper into the wilderness. They drove along a rough country road that cut through orange orchards, fields of high corn, and glistening terraces of rice. They passed the occasional brick church, onion-domed mosque, and villagers drying tobacco on wood frames set out in their yards. In places, tall brush brimming with wildflowers pressed up against the roadside. The green slopes of Mt. Sinabung beckoned in the distance, its upper reaches in shadow, the lower ones in crisp sunshine. After several hours they reached their destination.
Jandi Meriah is built on the opposing slopes of a slender valley bisected by the Loborus River, which courses through a deep, lush ravine. A bridge connects the two halves, and a dirt and gravel road ascends each side, meandering through the hamlet to the fields and orchards above. The villagers grow oranges, durian fruit, corn, chili peppers, and chocolate. But Jandi Meriah is particularly famed in North Sumatra province for its witch doctors.
When Dowes arrived at the small, clapboard dwelling three days after falling ill, he could still walk and talk. He was feverish and coughing badly, but he seemed relieved to be there. The reclusive witch doctor, or dukun in Indonesian, agreed to treat him and said there would be no charge. It is believed that demanding payment is the surest way for a sorcerer to lose his mystical gift, though gratuities like cigarettes are always welcome.
The witch doctor’s formal name was Suherman Bangun. The villagers, with a mixture of affection and awe, called him Pak Dirman. Bangun had been born forty-three years earlier in Medan before retreating into the mountains to farm corn and exercise his mystical talents. Though Bangun was a Muslim, many of those who sought his help, including Dowes, were Christian. “His reputation is very famous,” Bangun’s wife, Rintang Boru Ginting, boasted to me when I later caught up with her in the village. “His patients come from many faraway places.” Rintang herself had been his first patient, she recalled. Not long after the birth of their second child, he had removed a tumor from her neck, carving it out with a razor blade, then sealing the flesh by spitting betel nut juice on it and reciting a spell.
Dowes proved to be a more trying case. The nighttime treatments failed to dispel the affliction. Each new dawn found Dowes fighting harder for his breath. Late on his fourth night at the witch doctor’s home, hours after Uyeki had made his futile appeal to the family, Dowes got up to use the bathroom. Since there was no toilet there, his uncle wrapped his arm around him and helped him walk next door. Dowes could hardly breathe. He was staggering, on the brink of collapse. His condition had taken an abrupt turn for the worse since the previous day. “He was almost unconscious,” one relative later recalled.
Bangun advised the family there was nothing more he could do. So the uncle wrestled Dowes to the Suzuki jeep parked out front. Together with an aunt and two cousins, they drove out of the valley and began racing through the dusky daybreak back toward Kabanjahe and the district hospital. Before they made it, Dowes died.
In the highland village of Kubu Sembilang where Dowes and his family had lived, the Suzuki jeep was a rare luxury. The vehicle had originally belonged to Dowes’s father, the patriarch of the Ginting clan, until he died in 2001. Though most everyone in Kubu Sembilang came from generations of hardscrabble peasants, Dowes’s father, Ponten, had also been a gangster. In fact, in that corner of Sumatra,
he had been the godfather, running protection and extortion rackets throughout the environs. It was said he had won his power by conjuring evil spirits. His criminal pursuits had earned the family a measure of respect and riches. But the Gintings remained essentially farmers, spending their days in orange and lime orchards and fields heavy with red chili peppers.
Ponten had five children, three boys and two girls, with Dowes in the middle. The eldest sister, thirty-seven-year-old Puji, peddled the family produce at a traditional market in the neighboring town. Villagers from the surrounding area of Karo district came to buy clothes, shoes, and other dry goods from stalls in the heart of the market. Puji’s stand was near the edge with the other fruit, vegetable, and meat mongers, about twenty yards from a kiosk hawking live chickens. After she fell fatally ill, WHO investigators hypothesized she had contracted the flu virus at that nearby poultry stall, though samples later taken in the market all came back negative. Investigators also suggested she could have been infected by contaminated chicken droppings that she used as fertilizer in her garden.
Puji started feeling unwell on April 24, 2006, less than a week before the people of her village were to celebrate their annual harvest festival, Merdang Merdem. She began to cough and her temperature climbed. Her sister massaged Puji’s throbbing muscles and tried unsuccessfully to nurse her to health. Her family decided to proceed with their thanksgiving anyway.
Tradition is an essential ingredient of daily life in the district. The Karo people are Bataks, a distinct ethnic group within Indonesia known for a stubborn streak and a fierce adherence to their own culture and beliefs. In the past, the Bataks were storied as ferocious warriors. Today they are leading officers in the Indonesian military and some of the most formidable lawyers in Jakarta. Inevitably the fearless bus drivers who career through the capital’s tortured traffic are also Bataks. While the Javanese of Indonesia’s main island are refined, aloof, and at times duplicitous, the Bataks can be coarse but also refreshingly candid.
The festival brought together all five Ginting siblings, their spouses, and their children. They gathered at the small house, facing the village soccer field, where Puji lived with her husband and three sons. It was a wooden dwelling with a sun-bleached blue facade and pitched corrugated metal roof crowned by a satellite dish. Chickens rooted around in the dirt out back. Directly next door, her sister lived with her husband, two daughters, and son in a larger, more robust, cream-colored home built from concrete and tile, also capped by a satellite dish. Just beyond that was where her brother Dowes resided with his wife and two sons. His home was the most modest of the three, a small, unpainted clapboard structure.
The celebration began just after sunrise and continued until nightfall, the family feasting on curried chicken and roasted pork served in a spicy sauce prepared from pig’s blood, while the children played in the dirt road out front. In olden times, the harvest festival would last seven days, culminating with a communal feast and folk dancing that doubled as matchmaking for the girls and boys of the village. The holiday had in recent years been condensed to one day. But as they always had, relatives who’d moved away from the village came back to celebrate. So the youngest of the Ginting siblings, a twenty-five-year-old kid brother named Jones, who had left the village to start his own family in the district capital, returned with his wife and two sons.
Once the party finished, it was too late for Jones and his family to go home. They stayed over at Puji’s house, sleeping in the same confined quarters with her and her children and two other relatives. It was a rough night, nine people crammed into one small space with Puji coughing uncontrollably.
Three days after the festival, the family brought Puji to the emergency room at the district hospital. She could hardly breathe, and her skin was turning blue from a lack of oxygen in the blood. The doctors gave her medicine and advised the family to take her to Santa Elisabeth Hospital in Medan, about fifty miles away along the coast, where she was admitted into the intensive care unit. Santa Elisabeth was one of the best medical facilities in Sumatra, a seventy-five-year-old Catholic hospital opened by Indonesia’s former rulers, the Dutch. Inside the colonial structure, the black-and-white marble corridors were spotless. The interior courtyards were meticulously maintained with manicured lawns, sculpted shrubbery, and flowering bushes. Patients and their families waiting in the main lobby, with its high stained-glass windows, spoke only in hushed tones. By contrast with the crowds and chaos at Indonesia’s public hospitals, everything about Santa Elisabeth was orderly and organized. But that wasn’t enough. On May 4, after only twelve hours in intensive care, Puji died. The precise cause of death was never determined. No samples were taken, and no one suggested at the time it could be bird flu.
But by the time Puji was buried a day later, six other family members were already sick. Most had gone to their village’s rudimentary health post complaining of fever and breathing difficulties, but found no relief. As they continued to grow weaker, even talking became a chore.
“The doctors were shocked,” recalled the district health chief, Dr. Diana E. Ginting, who was no relation to Puji and her family. “The chest X-rays were all white.” Their lungs had filled with fluid. The clinic doctor was the first to suspect they had caught a novel flu strain and sent them to Adam Malik General Hospital in Medan, which had been designated by the Indonesian government as the referral facility for all bird flu cases in the region.
As soon as they arrived, it was clear they desperately did not want to be there. “They didn’t accept that it was avian influenza,” recounted Dr. Nur Rasyid Lubis, the hospital’s deputy director and head of its outbreak response team. “They tried to refuse all treatment. We could treat them only because their condition made it impossible for them to resist. But if they had been healthy enough to walk, they all would have run away.”
The family members balked at giving blood for testing. Several initially refused to go to the isolation ward set up for suspected bird flu cases. “None of us believed it was bird flu,” Puji’s sister-in-law later recounted. “We thought it was black magic. Everyone in the family was getting sick and no one else was. Someone had put a spell on our family.”
That account was offered to me by the wife of Puji’s younger brother Jones. I must have given her an inquisitive look because she added, “Black magic is very common in our place.”
True to local practice, relatives and in-laws had streamed out of the mountains to keep vigil at the hospital. They crowded into the large room where their kin were lined up in two facing rows of metal cots and scoffed at the insistent advice of hospital staff that they put on masks and gloves to protect themselves.
Puji’s oldest son died just one day after being admitted to the hospital. One of Puji’s sisters succumbed next.
As Jones watched his kin perish in the beds around him, he confided to his wife, “If I stay here, I’ll be dead.” Jones’s fever had topped 102 degrees and showed no sign of breaking. Fresh X-rays revealed that his left lung had entirely clouded over and his right lung was nearly as bad. He told his wife it was time to leave.
“I was losing hope,” Jones later recounted in a raspy voice, almost a whisper. His stare was blank beneath thick eyebrows, and his cheeks were sunken. He had been a young tough. Now his arms and legs, covered with elaborate swirling tattoos of red and green, had grown emaciated. He had dropped twenty pounds during his struggle for survival, and his tank top hung off his shrunken frame. “I was afraid of the hospital,” he continued. “I thought I was going to die. I can’t remember much, but I remember running away.”
At that moment in the retelling, Jones fell silent. His wife, a chatty twenty-three-year-old with long hair parted in the middle and tied in the back, picked up the thread. “We were watching our family die one by one,” she recalled. “We thought the hospital could not cure him.”
Jones had slipped out of the hospital with his wife and two young sons and hailed a taxi on the street. They told the driver to take th
em to a congested, working-class quarter of Medan jammed against the edge of the city airport. The houses were jumbled together along narrow alleys. Young men lingered on cramped front porches. Drainage ditches ran past the doorsteps and chickens pecked in the fetid black water. Every few minutes, an airplane would pass overhead with a tremendous roar. A year earlier, an Indonesian jetliner had crashed into the neighborhood moments after taking off, killing at least 149 people, including dozens on the ground, yet the incident was soon all but forgotten outside the quarter. This was the kind of place where Jones could disappear.
Jones also had relatives there to take him in. One, a distant relation, was a doctor with a practice on the main boulevard. Jones went to see him. The doctor examined Jones, prescribed some medicine, and offered an unwelcome diagnosis. “You have bird flu,” the doctor said, urging the feverish fugitive to return to Adam Malik Hospital. Jones balked.
If Jones could not find the answer in the city, he reasoned, he should go home to the mountains. He and his family hired another taxi and fled Medan. They drove deeper and deeper into the jungle, following the steep winding road and treacherous switchbacks up and up and up to the highlands of Karo, where cool breezes offered relief and promise of a cure.
By the time health officials in Sumatra realized they had a problem, it had already been two weeks since the eldest Ginting sister, Puji, fell sick, and six others were already desperately ill.
District health and veterinary officials drove to Kubu Sembilang and summoned the villagers. “Bird flu is here, now, among you,” an animal-health officer told the hundreds of people who gathered at the village hall. “To break the chain of infection, we have to depopulate your livestock.”
