The Fatal Strain

by Alan Sipress

  The agency’s critics fault it for becoming a prisoner of its politics. They accuse it of too often bowing before the dictates and deceits of its member countries, of placing a higher price on diplomatic nicety than on truth. But senior WHO officials, including some who have personally braved the world’s most horrible pathogens, scoff at the contention that they’re weak or cowardly. They counter that WHO is a creation of international politics and thus, by definition, a creature of one. Otherwise, they say, WHO and its mission could not exist at all.

  Nor is WHO some kind of global health department with an army of doctors, nurses, ambulance drivers, and inspectors. It has no labs or hospitals of its own. The oldest disease-control program at WHO, even older than the agency itself, is its global monitoring effort for flu. The perils of pandemic combined with the economic and health impact of seasonal flu made this initiative an early priority. Yet even this program depends entirely on a network of outside labs—at latest count more than a hundred in eighty-plus countries—to track the evolution of flu viruses and help develop suitable tests, drugs, and vaccines.

  Mostly, WHO supplements the efforts of individual governments, offering specialized expertise and scarce materiel like stockpiled vaccines for meningitis and yellow fever. To accomplish this, the agency relies on an extensive network of consultants from around the world, both public and private, to help investigate outbreaks, treat the sick, test samples, train local health staff, and deliver medicine, vaccines, and equipment.

  These outside allies are people like Prasert, whose career was devoted to forging the institutions and disciplines of modern medical learning in Thailand that now make his country among the most advanced in the region. Yet there was always time for WHO. On a curriculum vitae stretching for several pages of publications and affiliations, Prasert prominently highlights his position as consultant to the World Health Organization. For over three decades, he served on various advisory committees for the agency, most notably the expert panel on viral diseases. He has run a WHO collaborating laboratory for AIDS research and edited an agency monograph on dengue fever.

  In Geneva, senior agency officials describe their role in coordinating all this outside expertise by using words like secretariat, catalyst, and platform. What they mean is that they’re like the salaried fire chief of a vast volunteer brigade.

  WHO was born of the optimism that followed the Second World War, when international cooperation in the shape of the freshly minted United Nations and its agencies promised a new chapter in human history. Founded in 1948, WHO set its objective as nothing less than the “attainment by all peoples of the highest possible level of health.” This was an ambitious goal. Yet advances in medical science at the time seemed to be bringing down the curtain on epidemic diseases that long plagued mankind, notably polio and smallpox. By the 1960s, however, WHO suffered a colossal setback with the failure of global efforts to eradicate malaria. It was emblematic of a broader resurgence of infectious disease as microbes mutated, outsmarting new medicines and vaccines, exploiting environmental degradation, poverty, population growth, and humanity’s lapses in vigilance.

  As a young American physician, Dr. David Heymann had played a starring role in the eradication of smallpox. He and his WHO team had tracked it to its final havens in India. But soon after, as a new recruit to the CDC, he confronted a pair of entirely new threats. In the summer of 1976, he was dispatched to help investigate a mystery pneumonia spreading through an American Legion convention in Philadelphia. The outbreak, which sickened more than two hundred people and killed nearly three dozen, was ultimately blamed on a previously unknown illness dubbed Legionnaires’ disease. By the end of that same year, Heymann was in Zaire, responding to the first recognized outbreak of a horrible hemorrhagic fever called Ebola. He would end up spending thirteen years in Africa and, during that time, track the Ebola virus deep into the rain forests of Cameroon.

  Heymann would later point to 1976—with its outbreaks of Legionnaires’ disease, Ebola, and also swine flu in the United States—as an inflection point in public health history. Man’s conceit was that modern medicine and potent drugs had given him mastery over emerging diseases. But the events of 1976 started to rekindle the world’s concern about these threats, Heymann told me, and the appearance of the AIDS pandemic dashed any remaining illusion of invincibility. “HIV-AIDS really caught the world off guard,” he said. “This really changed the thinking. The world realized the vulnerabilities.”

  In 1995, WHO tapped Heymann to establish a program on emerging and communicable diseases. Storm clouds were gathering at all points of the compass: pneumonic plague in India, cholera in Latin America, resurging tuberculosis in Russia and Ukraine, Ebola in central Africa, meningitis across the whole of that continent, and an unprecedented epidemic of dengue fever in nearly sixty countries. Under Heymann, the agency overhauled its intelligence gathering, integrating a system developed by the Canadian health department that mines the Internet for reports and rumors of disease outbreaks. Next Heymann and his colleague Guenael Rodier set up what they called a global strike force, tapping disease investigators from more than a hundred universities, hospitals, and ministries who could get their boots on the ground within two days of any reported outbreak.

  Then came SARS. In a matter of weeks in 2003, this novel respiratory disease spread to four continents, striking the economic heart of Asia, putting global air travel in jeopardy, and raising the specter of a worldwide epidemic. WHO’s rapid response contained the epidemic before it became entrenched. This success consolidated the agency’s role in managing outbreaks around the world. That largely explains why WHO, and not the CDC, took the lead in responding to the human cases of bird flu when they erupted in 2004.

  SARS was a close call. It underscored the need to rewrite the global code of conduct called the International Health Regulations. The new rules, which took effect in the middle of 2007, require countries to notify WHO within twenty-four hours of any outbreak posing a global threat. Previously, the requirement applied only to yellow fever, plague, and cholera, a legacy of the nineteenth century, when European governments sought to forestall pestilence from the East. Now it was flu, again rising from the East, which posed the greatest menace.

  The adoption of the regulations emboldened WHO. “When we come to an assessment that our assistance is needed, we have to push our agenda,” said Dr. Michael Ryan, the burly Irishman who runs the agency’s alert and response operations. But WHO is still ultimately constrained. Governments like the one in Bangkok can continue to tell it to buzz off. “At the end of the day, you are dealing with sovereign states,” Ryan added. “That has to be respected.”

  One day before WHO was tipped off to the spreading epidemic in Thailand, a six-year-old boy with symptoms of pneumonia was rushed to Prasert’s hospital. He had a fever of 104 degrees and was desperately short of breath. Within twelve hours, his breathing had grown so labored that the doctors placed him on a ventilator. It seemed at first to do little good, so they kept cranking up the pressure on the device until they could finally achieve an adequate flow of oxygen. An X-ray revealed that the boy’s lower right lung had gone cloudy white, indicating that fluid was flooding the airspaces. The cloud spread a day later to the upper right lung. The next day, it progressed to the left one. The boy, Captan Boonmanut, had been brought to Siriraj Hospital from his home province of Kanchanaburi, located eighty miles from Bangkok near the western border with Burma. Outside Thailand, Kanchanaburi is best known for the Death Railway, built during World War II by Japanese occupying forces to supply its front lines, using Allied prisoners of war and Asian forced labor. At least sixteen thousand POWs perished from disease, hunger, and exhaustion, as did many more of the locals. This brutal chapter was captured in the Oscar-winning film The Bridge on the River Kwai, and the infamous steel-and-concrete bridge still stands, very much in use. But inside Thailand, Kanchanaburi today means rice paddies and chicken sheds.

  Captan was a healthy youngst
er who had a country boy’s love of farm animals. He would often play with the chickens that roamed his backyard. So when he had been handed a rooster during a fateful visit to his uncle’s nearby farm, the boy had hugged it tight. Like many in rural Thailand, the uncle had raised fighting cocks and at first had high hopes for this particular rooster. But when it got sick, the uncle decided to do what most Southeast Asian farmers do with an ailing bird: eat it. Captan’s parents told me how the boy had cradled the bird in his arms and kissed it during the final moments before it was slaughtered and converted to curry.

  Captan fell ill within days. A nearby clinic diagnosed the illness as a common cold. When it got worse, his father brought him to the local hospital, where he was given injections of antibiotics. Then, as his fever climbed and his breathing began to race, he was rushed by ambulance to Siriraj Hospital, eventually admitted into the pediatric intensive care unit. His white-blood-cell count was plummeting. So was the level of platelets in his bloodstream. Doctors prescribed broad-spectrum antibiotics on the assumption that his pneumonia was caused by a bacterial infection—but to no effect. The disease was unrelenting. So the doctors shifted their diagnosis to a possible viral infection and began treating Captan with antiviral drugs. They notified Prasert, the hospital’s most respected virologist.

  The doctors had learned from Captan’s parents about his history of close contact with poultry. His father had related the tale of the rooster. Family members further reported that all three hundred chickens on the uncle’s farm had eventually died or been culled and that all but one of the chickens at Captan’s home had also succumbed.

  Prasert was afraid he knew what this meant, that he was seeing his worst fears materialize in his own hospital. But without definitive test results, he was reluctant to go public. “We had suspicions already but couldn’t say anything. At that time, nobody could reveal information to anyone. The information the government was releasing was that we didn’t have any avian flu,” he said with narrowing eyes and an ironic smile. For all his credentials and earlier bluster, Prasert was wary of tangling with Thaksin and his ministers, at least for now. That very week, the agriculture ministry had threatened to sue another research institute and the media for allegedly damaging Thai national interests by exaggerating the number of chickens that had died nationwide. “What could I do?” Prasert asked. “I’m only a small, old man. Who would believe me?”

  Subsequent study would reveal the viciousness with which the virus was assaulting the little boy’s body. The disease was decimating his respiratory system, destroying the air sacs and capillaries in his lungs and inundating them with blood. The virus also invaded his intestines, where it established a beachhead and began to reproduce further. The pressure on the ventilator helping him breathe had to be turned up so high that even this was starting to take a toll.

  Shortly after he arrived at Siriraj Hospital, initial tests confirmed that Captan had influenza A. A week later, on Thursday, January 22, another set of results came back and showed conclusively that it was the novel strain. Prasert now had proof that the second condition for a pandemic had been met. The virus was again infecting people.

  Time was up. Prasert placed three calls in the following hours to officials at the public health ministry, including the minister and the director general of the Thai center for disease control. He rebuked them: “Bird flu has reached humans already.” He also went public with his laboratory evidence of a flu outbreak in chickens, telling reporters that the H5N1 strain was widespread and the “cover-up” had to stop. His efforts were seconded by a top Thai lawmaker, a physician-turned-politician named Nirun Phitakwatchara. Nirun, a member of the Thai Senate, announced he’d learned from health officials about a second boy, this one from Suphan Buri province, who had also tested positive for bird flu. He accused the government of hushing up the outbreak for the sake of poultry exports. “I think it’s very late but very late is better than not telling the truth,” Nirun told me at the time.

  The next morning, Thailand’s Public Health Minister, Sudarat Keyuraphun, hastily summoned the Bangkok press corps. “There are two cases of bird flu, in a seven-year-old boy from Suphan Buri and a six-year-old boy from Kanchanaburi,” she announced, adding that they were in stable condition. She said that everyone who had contact with the boys would be quarantined for ten days. She blamed the delay in disclosing the cases on the time required to finish testing samples.

  The agriculture ministry followed right behind by issuing a statement confirming that chickens on a farm in Suphan Buri province had tested positive for the H5N1 strain. Samples from elsewhere in the country were still being analyzed. Newin, the deputy agriculture minister, announced that a mass slaughter of birds in central Thailand was already under way and that Thailand’s poultry exports were to be suspended.

  “It’s not a big deal,” Thaksin reassured the Thai public. “If it’s bird flu, it’s bird flu. We can handle it.”

  Tamiflu was urgently flown into the country and immediately administered to the sick boys.

  Three days later, Thailand confirmed its first fatality from bird flu. In the early hours of Sunday, January 26, after taking an abrupt turn for the worse, Captan died.

  Krisana Hoonsin could not sleep the night he paid eight laborers to slaughter all his chickens. He took a pill to help. When he awoke, he discovered that the silence blanketing the flat, lush province of Suphan Buri had enveloped his farm. Morning broke without the cackling and cooing he had known since he was a teenager. “It reminds me I’m not a chicken farmer anymore,” he told me plaintively. “In a week, all the chickens in our district will be gone.”

  One day after Thai officials publicly confessed that bird flu had struck, Krisana sat heartbroken in a small, clapboard kiosk erected inches above a fishpond in front of his farmhouse. He wore a loose, black-checked work shirt and had a slight scar on his left cheek. His eyes were bloodshot, his dark brow deeply furrowed, like some of the nearby plots. Between the fingers of his rough right hand, the thirty-eight-year-old farmer clutched a lit cigarette, but he barely puffed. It would burn to a stub. Then, noticing just in time, he would rub it out and light another. This was still January, one of the coolest months in Thailand, but the midday sun was intense, so Krisana had taken refuge beneath the pitched, corrugated metal roof of the simple shelter. It was here that he had often come at dusk, when his chores were finished, and fondly gaze at one of his poultry sheds on the other side of the narrow country road. “My chickens would recognize me,” he recounted. “They would stick their heads up and see me. Now it’s empty.” His voice cracked. “I still think of all my chickens.”

  His birds started getting sick two weeks earlier. He reported it to local livestock officers. Though they assured him it was only a minor case of fowl cholera, he was ordered to take draconian measures and put all seven thousand to death. Too upset to execute the sentence himself, Krisana hired a few locals. They marched down the tight aisles of the poultry sheds, wrestled the birds from the raised metal cages, and stuffed them alive into plastic feed and fertilizer sacks. The chickens were left to suffocate, then buried in a pit coated with lime at the edge of his property. “How can I express the feeling to see all our chickens die that way?” he asked. He let his sandals slip from his feet and rubbed his soles against the rough wood planks. “When you do chicken farming, it’s like you’re taking care of your own children. You love them. They love you back.”

  I had come to Suphan Buri early that morning with an energetic Thai journalist, Somporn Panyastianpong, who often worked as my translator. Before we left Bangkok, she had stopped to buy us surgical masks and rubber gloves, though the two health officials I had consulted were unsure whether these would adequately protect us. The disease was still so new, its precise lines of attack still uncharted. We drove north along the modern divided highway that connects the sprawling suburbs of the capital with Thailand’s central wetlands. After an hour, shimmering green rice paddies opened up before us, many fr
inged with coconut palms. Storks, herons, egrets, and cormorants swooped and scavenged amid the neon fields. Peasants in straw hats meandered along the earthen dikes, hoes slung over their shoulders. A few ragged duck herders, barely teenagers, squatted at the edge of flooded paddies while their flocks waded into the murky waters, shaking their dark brown tail feathers and rooting around in the muck, hunting snails.

  As we turned off the main road, we began see the scores of metal-roofed chicken sheds that Suphan Buri’s farmers had raised in making their region one of Thailand’s most prodigious poultry producers. These were long, open-sided structures on wooden stilts that all seemed to jut out over ponds and reservoirs. Under an ingenious system, chicken droppings are not cleared away but allowed to fall between the wooden floorboards into the water, which are stocked with carp, tilapia, and barb. The droppings serve as nourishment and save on fish food. The fish themselves often command better prices at market than the birds. But when the chickens die, the fish go hungry.

  Now, as we ventured deeper down the rural roads, we drove past one eerily vacant shed after another. A legion of cullers had swept across the countryside ahead of us, killing an estimated 7 million birds over previous days in Suphan Buri and two other provinces. More than five hundred workers from the agriculture ministry were again fanning out across Suphan Buri to continue the mass slaughter. Teams clad in masks, rubber gloves, and high boots were storming through the sheds, cramming squawking birds into sacks and spraying disinfectant from tanks. Hundreds of Thai soldiers and several dozen prisoners were also being pressed into service, many with brightly colored shower caps to protect their heads. Though the government was targeting four hundred more farms on this day, Newin had warned that teams were running short of sacks and burial space. He told reporters that the cullers were now being forced to use the grounds of Buddhist temples.