by Alan Sipress
Ap Lei Chau was connected to the southern shore of Hong Kong island by a bridge. A decade earlier, the government had erected several dozen brown-and-gray high-rise apartment buildings on the green hillsides of Ap Lei Chau, and about ninety thousand people now lived there, making it one of the most densely populated islands on Earth. Man-kei’s two younger cousins and a third sibling stayed with their parents and grandparents in an apartment barely three hundred square feet in size. This was often where Man-kei spent her days.
When health investigators arrived at the apartment, they were rebuffed. The family patriarch, a sixty-four-year-old watchman, refused to speak with them or provide blood samples to see if he’d been exposed to the virus. Other family members were also reluctant to talk. They were afraid of being stigmatized or shunned by neighbors spooked by this new, mysterious plague. Fukuda arranged to meet one relative secretly at a café, the first of several clandestine interviews health officers conducted over the course of the outbreak. Eventually, they were able to tease out a history of the children’s recent activities, noting what they had done together and what they’d done separately. (Only one of the younger cousins ultimately tested positive for the virus. All three children survived.) But the source of their infection remained elusive.
Chan was frustrated. She couldn’t visit Ap Lei Chau herself because of the media frenzy this would cause. Nor was she getting a good sense of the family and its surroundings from the investigators. She kept sending them back to scare up more details, instructing them to observe the neighborhood at different times of day and different days of the week.
“I want to know exactly what is going on,” she insisted. “What do the children do?”
“They play in the car park,” came the response. “That’s their play-ground.”
Chan wanted to be able to picture the parking lot. She told them to take photographs and draw her a map. They did. Nothing seemed amiss.
But when the team returned to Ap Lei Chau the following Sunday, they spied cages of geese in the parking lot at the base of the apartment tower. There were several stalls near the entrance. Perhaps they’d been there on previous occasions and the children had passed too close. The investigators snapped some photographs and later presented them to Chan. They were all thinking the same thing.
Samples were taken from the grubby cages and tested. “Bingo,” Tsang recalled. “We found a positive swab in one of the stalls.”
They had identified a likely source for the infection. But could it account for both Man-kei and her cousin? Or had Man-kei caught the virus and then passed it to her cousin while they were frolicking on their grandmother’s carpet? Could the virus already be spreading from one person to another? Neither Chan nor Fukuda nor anyone else could ever rule that out.
Hong Kong at Christmas was a city under siege. People were flooding emergency rooms to be tested for the virus. Even medical personnel were calling in sick, fearful they’d been infected. Drug prices had spiked, and panicked calls were overwhelming the health department’s hotlines. Though only a handful of sick chickens had been discovered in the city’s live markets, poultry sales had plummeted, and restaurants were banishing popular Cantonese chicken delicacies from their menus. On Christmas Eve alone, three more suspected human cases had been announced. Now the first of the seasonal flu cases were also surfacing.
There was no holiday break that year for the six members of the CDC team. Fukuda had never before missed a Christmas with his wife and daughters. So the health department arranged a Christmas Day lunch cruise for their CDC guests. But they couldn’t escape the oppressive mood. Word came that four more suspected cases had been identified, the highest one-day total so far.
“I don’t know whether this disease will stop or spread,” Fukuda once again told reporters two days later. He was appearing at a press conference on Saturday, December 27, with Chan and Hong Kong’s agriculture chief, Lessie Wei. There were now about twenty confirmed or suspected cases. The press was demanding to know what more the government would do to stem the crisis. Since poultry were thought to be responsible for most of the outbreaks, would officials have them killed? Chicken hawkers had already been ordered to clean and disinfect their cages. On Christmas Eve, Hong Kong had barred all imports of chicken from mainland China, the primary source of the city’s poultry and a possible origin of the infection. “I feel at this point in time,” Chan responded, “the measures are sufficient.”
The call that changed everything came that night at two in the morning on Sunday, December 28. Chan was at home in bed. It was the agriculture department. There had been a die-off of chickens at Cheung Sha Wan, the city’s main wholesale poultry market. About fifty birds from a batch of three hundred in a single stall had abruptly fallen over dead with swollen chests and necks, internal bleeding, and other symptoms of avian flu. And there was more bad news. A week earlier, a similar outbreak had occurred at a farm in the New Territories. The disease had moved gradually along a row of cages, claiming its victims. The test results had just come back positive for bird flu.
Chan couldn’t fall back asleep. “What is going on?” she wondered. Only days before, city inspectors had toured Hong Kong’s farms and reported that there were no outbreaks. “Margaret,” she told herself, “the size of the problem is bigger than what it appears.”
She didn’t have proof of a widespread poultry outbreak. But if there was one, it could finally explain the unrelenting series of human cases. She thought about the holding pens, nicknamed “chicken hotels,” where Hong Kong’s birds were kept overnight. As demand for poultry had dropped, retailers in the city’s live markets found they couldn’t sell many of their chickens. At the end of each day, birds from various stalls and markets were gathered together before being distributed again for sale in the morning. Chan’s technical advisors had told her this system was perfect for disseminating disease throughout the markets. “Enough is enough,” she thought.
After a long wait for sunrise, she contacted researchers at Hong Kong University. They had begun sampling poultry in the city’s markets just before Christmas. Most of the test results had yet to come back. Chan urged them to take as many specimens as possible and to hurry up. She was about to recommend drastic action but didn’t yet have the scientific evidence to support it. “When you are ahead of the curve in dealing with new and emerging infections, science is always lagging behind,” she later explained. But despite the uncertainty, she wouldn’t wait. “Don’t be afraid to make major decisions,” she told herself. “Don’t be afraid to be wrong.”
Chan spoke that morning with her boss, Chief Secretary Anson Chan, who ran the Hong Kong administration. They scheduled an emergency meeting for later in the day. As health director, Chan would tell her that all the chickens in Hong Kong had to go. But there was no guarantee the city’s political leaders would sanction such a costly measure. “I am prepared, if they don’t accept that, to resign,” she thought. “I will resign, because if the environment does not allow me to do my job to protect the people, then that is the proper action to take.”
Chan’s driver ferried her up to the Peak, the highest point on Hong Kong island and home to a white colonial villa called Victoria House. Once a taipan’s summer retreat, it was now the official residence of the chief secretary.
Chan and agriculture director Lessie Wei briefed the chief secretary on the latest poultry outbreaks. Hong Kong had already closed its borders to imports from China, yet the poultry infections persisted. If the disease continued to circulate among birds, Chan explained, the public health threat would mount, especially if the virus mutated or reassorted. That’s why all 1.2 million chickens in Hong Kong had to be culled. About three hundred thousand ducks and geese that were kept in close contact with the chickens would also have to go.
The chief secretary cautioned that the economic implications were huge. A mass slaughter could severely harm the livelihoods of countless chicken farmers and traders.
“People will not l
ike it,” Chan admitted, “especially when it affects their vested interests.”
The chief secretary continued to press. The poultry sector would demand the government pay compensation. The bill could be tremendous.
“Yes, it’s going to cost money,” Chan agreed.
“What if we don’t solve the problem after killing all of the chickens?” the chief secretary asked.
“Then we need to go after all the ducks and geese,” Chan said.
“And what if we still don’t solve the problem again?”
“I’ll be accountable,” Chan answered. If she needlessly put Hong Kong through the trauma of a mass slaughter, she’d accept the consequences. “I’ll deliver my head on a platter. I’ll resign.”
Finally, the chief secretary accepted Chan’s recommendation. She agreed to take it to Hong Kong’s leader, Chief Executive Tung Chee-hwa.
Within hours, Chan announced that Hong Kong would kill every last chicken. The slaughter would start the following afternoon. They were all to be gone within a day.
From the start, it was clear the slaughter would not go as planned. The government pressed 2,200 public employees into the operation, giving them masks, canisters of carbon dioxide, and orders to gas the birds to death. But these were dogcatchers, park rangers, and other civil servants with no experience in killing birds and unsure even where to find all of Hong Kong’s farms. Day laborers were hired as reinforcements, and even some market traders joined the effort, slitting the throats and snapping the necks of their birds. The result was literally bloody chaos. The chickens clawed and scratched and scampered for safety. Flies swarmed. Farmers resisted. By the end of the first day, less than a fifth of the chickens targeted had been slaughtered, and many of those remained unburied. Television showed plastic garbage bags of carcasses heaped high while stray animals and vermin scavenged through the carnage, spreading fear of contagion. Nearly a week into the slaughter, fugitive chickens still roamed the streets.
Many traders and laborers in the city’s nearly one thousand poultry markets were incensed. On the third day of the slaughter, New Year’s Eve, Chan accompanied Chief Executive Tung to the Cheung Sha Wan wholesale market, an expanse of weathered stalls with rusting corrugated metal roofs in an old industrial quarter of Kowloon. They walked through the parking lot, crowded most other mornings with small trucks heavy with poultry, and toured sheds crammed with wood and bamboo cages, now empty but still caked with droppings. The chickens had gone silent. Instead about two hundred market employees confronted the officials, shouting objections and waving placards with slogans scrawled in red paint.
The South China Morning Post, Hong Kong’s leading English newspaper, captured the prevailing public skepticism. In a front-page editorial, the paper asked whether the mass slaughter would eradicate the bird flu virus and allow poultry sales to recover. “There must be serious doubts whether either of these aims will be quickly achieved, if only because the central question surrounding the spread of bird flu has still not been answered: where does it come from? Until we know the answer, the killing of a million birds cannot hope to quell the public’s understandable fears. And, more importantly, nor can it be certain to stop any more cases of bird-to-human transmission of the deadly H5N1 virus.” A week later, this skepticism turned to harsh criticism over what the Post labeled the “botched” operation. “What is amazing is that the Government should have embarked on this task without any accurate estimate of its scale or duration,” the newspaper editorialized. “Equally astonishing is that it should have bungled matters so badly as to raise the possibility that other animals may have become infected.”
Yet even as the Post published those words, the final chickens were meeting their fate, and Chan was starting to find her vindication. The researchers at Hong Kong University had finished sampling nearly 350 chickens at markets around the city. They discovered the disease was even more widespread than expected. One of every five chickens had been infected.
Chan had accurately identified the source of the crisis. But had she found the solution?
Reporters asked Chan shortly after she announced the slaughter how she would know if it was a success. Chan told them it would have to put a complete stop to human cases. The normal incubation period for flu was a week. To be confident, Hong Kong would wait twice as long. If there were no more cases by the end of the second week of January, she would declare victory.
Just two days into the waiting period, Chan received a report of a new case, a three-year-old boy. “Son of a gun,” she thought. “What is going on?” Chan was scared. But when she reviewed the boy’s history with her staff, they concluded he had likely been infected just before the mass cull began. For two weeks the newspapers counted down the days and the population held its breath. On the final day, two new cases were announced. But these victims, too, had fallen ill before the slaughter.
There were to be no more. The final count stood at eighteen. Of those, six had died. Hong Kong would be the source of no new human infections, not that year and not for the next decade. The city had banished a killer.
Researchers later concluded a pandemic had been averted. This took an unprecedented effort that marshaled some of the world’s leading disease specialists and courageous investigators. It required exhausting lab work in Hong Kong and Atlanta, tapping some of the most sophisticated techniques then available to medical science.
Yet that alone was not enough. Hong Kong had aggressively pursued the pathogen from the instant city health officials learned of it. They took radical action to eradicate the virus though it was a gamble that carried a huge economic cost. The government acted with openness, even when hammered with criticism. As a result, humanity’s first brush with this novel strain would be its most successful. Over the following years, no other government would match this achievement, and the standard set by Chan and her colleagues would too often be honored in the breach.
Hong Kong’s success also lay partly in its nature, rare in Asia. As a small, mostly urban outpost, there were few agricultural interests to contest the imperatives of public health. Nor did most residents of Hong Kong live among livestock. Their main exposure to the virus, researchers later concluded, was at live markets. And though an age-old preference for fresh meat made these markets an integral part of Cantonese culture, the government overcame the inertia of tradition by restructuring them. When they reopened, Hong Kong barred the sale of live ducks and geese, believed to be the original source of the infection in chickens. Live chicken sales resumed, but all imported birds were screened for the virus before entering the markets.
But the virus would prove implacable. Even in Hong Kong, it would resurface in 2001, killing chickens in market after market. As a pre emptive strike, the government ordered a second mass slaughter of all poultry in the markets and imposed a mandatory rest day each month when they would be emptied, unsold poultry killed, and the stalls cleaned before restocking with new flocks. Undeterred, the virus struck yet again the following year. But over that period, it never again jumped to people.
Fukuda eventually would go on to become WHO’s global influenza chief. Yet he always remembered the Hong Kong investigation as the most rewarding in his life. He lauded Chan’s leadership as heroic. He had no way of knowing that nearly a decade later he would be reunited with her in fighting the virus as it spread to much more difficult terrain far beyond the horizon.
CHAPTER THREE
The Elephant and the Lotus Leaf
The operation, as Dr. Prasert Thongcharoen called his lonely campaign against a killer, started on a hungry stomach. After seventy years of life, he had developed an abiding fondness for farm-fresh eggs and looked forward to those occasions every few weeks when a pair of young friends would present him with dozens of the finest from their family homestead outside of Bangkok. So when they returned to the Thai capital empty-handed one warm December day in 2003, Prasert was disappointed. He also suspected something was terribly amiss.
A disting
uished man with silver-and-black hair combed back off a high forehead and eyes keen behind thick aviator glasses, Prasert had accumulated countless honors and accolades during his pioneering career. He had been dean of the medical school at Bangkok’s Mahidol University, chief editor of the Thailand Medical Association’s journal, and a fellow of the Thai Royal Institute. He had also earned a reputation as something of a gourmet. He often cooked for the staff at Siriraj Hospital, where he continued to do research as an emeritus professor, preparing chicken-leg curry and other favorites in the small departmental kitchen. He experimented at home with new recipes, trying them out on his children. He was so passionate about fresh food that he once flew home from Hong Kong with a newly butchered goose in his hand luggage.
The doctor was partial to eggs sunny-side up for his breakfast and had been expecting a fresh batch as usual. Two of his longtime friends, the chief reporter at one of Thailand’s leading newspapers and his wife, had taken advantage of a national holiday marking the birthday of Thailand’s revered monarch, King Bhumibol Adulyadej, to escape Bangkok’s suffocating traffic and hectic pace. They had decamped to their farm about fifty miles to the east amid the mango orchards of Chachoengsao province. After a brief vacation, the couple returned to the capital and came to Prasert with apologies. “What happened?” he asked. The response astonished him: “There are no chickens, so there are no eggs. The farm is usually full of chickens. But the chickens all died. We don’t know why.”
The couple traditionally visited their farm twice a month and for years had been furnishing Prasert with six or seven dozen eggs on their return. This time they brought him only a riddle. It was a grim and disquieting puzzle that would become the focus of a personal crusade. Almost alone, he would press his kingdom’s leaders to admit that a plague was raging in the Thai countryside and threatening to leap beyond the borders. “I had no eggs to eat,” he later told me. “And so the operation began.”
