The Fatal Strain

by Alan Sipress

  Krisana’s family had been raising hens in Suphan Buri for twenty-two years in a village called Baanmai. At first, their aim was to produce just enough eggs for income between rice harvests. But when Krisana took over the farm from his father in 1994, the ambitious young man decided paddy was the past and poultry the future. He immediately quadrupled the number of hens to four thousand, adding more in the following years. It proved a lucrative business. He built an airy, two-story house with a solid brick facade. An upstairs veranda with a cheerful blue-and-purple balustrade looked out over the emerald fields. He bought a new Toyota pickup, parked it out front, and hired a farmhand. He never imagined that one day his livelihood would be buried along with his birds in a hole in the side yard.

  Over the years, he had grown accustomed to a few chickens dying suddenly and mysteriously. But he had never witnessed the kind of epidemic that had been stalking his province for the last two months. “It got bigger and bigger and spread from one farm to another before it reached our farm,” he recalled. “Every night, three or four chickens would die.” He consulted a veterinarian, who prescribed antibiotics. They had no effect. Local livestock officers could offer no explanation. The provincial livestock chief reprised the official line that the affliction was fowl cholera. But Krisana was starting to suspect something else. When Vietnam confirmed its poultry had been infected by influenza, Thai television carried reports with footage showing the symptoms. The birds suffered from stiff muscles, reddening skin, and chills, then died. “I saw it on the news and saw the same symptoms here, and I was sure it was bird flu,” he said.

  Krisana and his neighbors had alerted officials to their suspicions but were ignored. Now the farmers were livid. They were convinced their flocks could have been salvaged by a swifter government effort to quarantine contaminated farms. “They kept denying and denying and denying it was bird flu. If the government had admitted it earlier, they could have contained it,” he said. A thin smile passed across his sullen face. “Instead, farmers kept transporting chickens and eggs from one place to another.”

  Slipping on his sandals, Krisana roused himself from his bench inside the kiosk. He led the way around the side of the house to give me a closer look at one of his chicken sheds, empty and deadly quiet. He shuffled along the wooden planks that served as a short causeway. Though the shed had been disinfected, I was still wary of following. I had the surgical mask and rubber gloves with me but Krisana had neither. I didn’t want to be rude. So with some trepidation, I left them in my bag and poked my head ever so briefly inside the entrance. I tried not to breathe.

  When we returned to the kiosk, Krisana’s father came out of the house to join us. At seventy-six, Sompao Hoonsin was still vigorous, with thinning gray hair, and age spots on his broad face. He wore a jolly T-shirt with pictures of Winnie the Pooh and Tigger, but his manner was decidedly downcast. In his hand, he carried a small, handwritten note listing the family’s liabilities in blue ink. They totaled nearly $40,000. The family, he explained, netted about $2,500 a month from selling eggs to small-time retailers in Bangkok, and this had long been enough for Krisana to support his wife, three children, and his father, who had raised him alone since he was a boy. But the debts mounted over the previous two years as the price for eggs weakened. They had to put up the house and land as collateral. “Finally,” Sompao said, “things began to brighten.” Prices had picked up since summer, and the weather had at long last turned favorable for laying: not too warm, with a gentle breeze. “We thought we’d be able to get out of debt and buy all our chicken feed without borrowing money,” the elderly farmer continued. “Then suddenly, we had to bury all our chickens. We can’t even earn one penny. All the children in the family, before they go to school, they’re asking, ‘Will we have enough to eat today?’ ”

  Often overlooked in discussions about bird flu, amid all the anxiety over a possible human pandemic, are the staggering economic costs already incurred by Asia’s farmers. For the poorest peasants, their few chickens were an insurance policy against hunger in bad times. For those who have proven more successful, like Krisana, the flu plague has jeopardized the investments and aspirations of a generation. Some of the farmers in Baanmai village, seduced by the riches that poultry promised, had gone so far as to ask their children to quit or forgo good jobs in Bangkok to help with the business back home. Now they faced bankruptcy.

  A day before I stopped by the farm, Sompao had visited the bank to talk about the family’s debts. He had hoped to defer the interest payments of about $250 a month. Nothing was resolved. Government officials had floated the idea that they might pay some degree of compensation for culled flocks. But even if they did, Krisana vowed he was through with chicken farming. “Once they announced the results of the lab tests, I got worried about my health and the health of my kids. We don’t know if this flu would come back,” he said.

  His voice trailed off. A white government van pulled up at the edge of the front yard. Krisana watched as officers from the animal disease control department got out to examine the pit where his birds were buried. Satisfied that they were properly interred, the inspectors got back in and drove off.

  Krisana resumed his thought. Perhaps it was time to go back to rice farming. He certainly had abandoned his ambition to keep expanding. Maybe self-sufficiency was the answer, he suggested dejectedly. “You can’t imagine how it feels to sit and stay quiet when you see all you have suddenly disappear,” he went on mournfully. “Everyone around here is in shock. We’ve lost hope in life.”

  Earlier in the day, Krisana had heard Thaksin might visit the province with his agriculture minister to inspect the culling operation and reassure local farmers. Krisana hoped they would. He said he had something for them—a lotus leaf. “If an elephant dies, you can’t cover it with a lotus leaf,” he quipped, reciting a Thai proverb. Don’t try to hide a large mistake once it’s in the open. “If a million chickens die, you can’t cover it with a lotus leaf,” he continued, embroidering on the original. He paused and reflected for a moment. Then he added, “I’d give them the leaf. But I’m not sure they would understand.”

  Hours after Captan Boonmanut died on January 26 in a nearby ward, Siriraj Hospital convened a seminar to discuss the gathering storm. Prasert was to brief his medical colleagues and review what it would take for H5N1 to spark a human epidemic. The first two conditions had been met. He wanted to discuss the third and fateful one.

  Many of those at the seminar were relative newcomers to flu. Prasert reminded them there were two ways a bird flu virus could become transmissible among people. The virus could gradually undergo a series of discrete mutations making it progressively better suited to the human body. This first process was called antigenic drift. The other way, Prasert continued, was antigenic shift, in which the bird flu virus experiences genetic reassortment, swapping genes with an existing human influenza virus and creating an entirely new strain that is both highly lethal and as easy to catch as an ordinary flu bug. This latter transformation could happen overnight, he warned.

  It had taken a whole lot of pushing and prodding to get the government to acknowledge that Thailand’s birds were spreading the disease. But now, Prasert told his audience, an equally acute threat could be posed by the country’s pigs. That was because swine could be what researchers called the mixing vessel, in which two flu strains exchange genetic material. Sick pigs in Asia, Europe, and Africa had repeatedly been found infected with a human strain of influenza. Prasert said he was also hearing reports, later confirmed by Chinese researchers, that pigs in China had come down with bird flu. If a pig caught both strains at the same time, the results could be catastrophic.

  Over the coming months, as the scourge spread to a third of Thailand’s provinces and across a half-dozen Southeast Asian countries, flu hunters would grow haunted by the prospect that the strain had cracked the code for human transmission. Yet even as the world was reawakening to this threat, Prasert was already probing how the virus might cr
oss this final hurdle.

  The next morning, his admonitions made headlines in Thai newspapers. But the reaction was not as he’d hoped. Swine farmers were enraged, fearing for their sales, and some threatened him.

  The prime minister was asked by reporters about Prasert’s warnings and brushed them off as the ranting of a mad old man, calling them overly imaginative and without basis in science. “Are the doctor and the media going take any responsibility if the virus does not spread to pigs?” Thaksin asked pointedly.

  Dismissing the elderly virologist with a disparaging Thai word, ai, that can best be translated imprecisely as “goddamn,” the prime minister accused the elderly virologist of going too far this time. “It was that goddamn doctor,” he snapped, “saying it all by himself.”

  CHAPTER FOUR

  Into the Volcano

  The flu hit America early that year and it hit hard. It was shaping up to be the worst season in twenty-five years. That fall, in October 2003, Tim Uyeki had been summoned back to Atlanta while at an international influenza conference on the Japanese island of Okinawa. His CDC colleagues had urgently notified him about an unusual spike in severe flu cases among children. Texas and Colorado were being struck particularly hard. The culprit was a traditional strain of human flu but a new, unexpected subtype. As autumn turned to winter, the epidemic spread eastward until outbreaks were being reported in most states. The disease was taking an unusual turn in some children, resulting in neurological complications. Even worse, scores of children were dying. Uyeki, as both a pediatrician and influenza specialist, was tapped by the CDC to help run a national effort to identify and detail these fatal cases.

  Now, in the waning days of December 2003, Uyeki found himself at his desk. The hallways of the CDC were depressingly empty except for a few other souls on flu duty.

  He had been forced to cancel his Christmas vacation. He could have used the downtime. It had been a grueling year, much of it spent on the road. But the mounting pile of pediatric files beckoned. He had to sift them, study them, and try to divine why children were falling victim while the flu’s typical casualties, the elderly, had this time been spared.

  When he logged on to his computer on Monday, December 29, he came across an e-mail from Vietnam titled “Urgent.” It was a copy of a request sent to one of Uyeki’s colleagues by a virologist at Hanoi’s National Institute of Hygiene and Epidemiology (NIHE). The Vietnamese scientist, Dr. Le Thi Quynh Mai, reported that Hanoi Hospital was treating a number of children with respiratory symptoms and doctors there were stumped. “We need to know what’s causative of it,” she appealed.

  This entreaty was the first hint outside East Asia of a nascent outbreak that would soon transfix the world’s flu specialists. In nearby Thailand, Prasert Thongcharoen had already concluded earlier in the month that bird flu was sweeping his country’s poultry flocks. But he still had no inkling that it had spread to people. That would come three weeks later.

  By then, global flu hunters would be streaming into Vietnam on the trail of the novel strain. Their pursuit would widen over the coming months to ever more provinces of Vietnam and then Thailand, the two countries to confirm human infections in 2004. (More countries, including Indonesia, would begin to report them in 2005.) And with each case, investigators would confront that terrible question: Had the virus been passed from one person to another? As the cases persisted and the deaths in Vietnam and Thailand mounted, it became increasingly clear there were indeed likely instances of human transmission. Yet the region’s leaders and the senior brass of WHO itself remained loath to acknowledge publicly that the virus was flirting with the third and final condition for a pandemic.

  As Uyeki reviewed the e-mail, he immediately thought of two possibilities, one worrisome and the other worse. “Could the situation be similar to what we are experiencing in the U.S.?” he wondered, thinking about the unusual uptick in seasonal flu. It would hardly be unprecedented for such a strain of human flu to circle the world. “Or,” he pondered, “could these be highly pathogenic H5N1 virus infections?”

  He had reason to suspect the latter. Though there was yet no public report of unusual poultry deaths in Southeast Asia, South Korea had officially disclosed a die-off two weeks earlier on a chicken farm outside the capital, Seoul. But Uyeki had little other information to go on. So he replied to the e-mail best as he could, laying out possible diagnoses, suggesting more than a half-dozen different viral infections. Topping the list were influenza of some stripe and an ailment called respiratory syncytial virus infection, or RSV, common among infants. He urged his Vietnamese counterpart to collect samples from the patients and test for those two possibilities.

  Uyeki was already acquainted with the Vietnamese doctor and her colleagues in Hanoi. He had first gone to Vietnam three years earlier to collaborate with them on a study looking for evidence of bird flu in live poultry markets. He had stayed in touch, cultivating the relationship as he had with scientists across much of Asia. When SARS broke out in Hanoi in early March 2003, Uyeki returned to help contain the epidemic. He arrived just days after Vietnam’s first case was identified and stayed for a month. Later in the year, he was back yet again, advising the Vietnamese on how to monitor for flu.

  When Uyeki first joined the CDC’s influenza branch in 1998, Keiji Fukuda had been on board for two years and had already helped run the investigation into Hong Kong’s H5N1 outbreak. Now the two of them would return together to Asia yet again, trying to decipher whether the new threat was also a passing scare or a harbinger of something far worse.

  Uyeki talks about his colleague as he would about an older brother. Both are Japanese American, graduates of Oberlin College in Ohio, and dedicated to a virus that others in Atlanta call “their bug.” They are both among the best at what they do. But while Fukuda is reserved, precise, and methodical, Uyeki is exuberant. Fukuda speaks in carefully crafted arguments, commanding attention with an economy of words. Uyeki’s discourses cascade from topic to topic, detouring through colorful details and intriguing distractions. Fukuda is the kind of man who organizes his day so he can drive his daughter to evening soccer practice. When I last met Uyeki, he was still regretfully a bachelor. His work habits are legend at the CDC. It is not unusual to find him at his desk until one in the morning or later.

  So it was no surprise that Uyeki was still in the office when, shortly before midnight on December 29, Dr. Mai’s e-mail reply arrived. “Dear Tim,” she wrote, “these childrens . . . have fever, cough, difficult breath.” But other symptoms didn’t look at all like flu, she reported. Some of the patients developed diarrhea a few days after the onset of illness and, she added, “died quickly.”

  “Died?” Uyeki thought. She hadn’t mentioned that earlier.

  Exactly a week later, Dr. Peter Horby got an urgent call on his cell phone. He had driven out of Hanoi that Monday morning to train Vietnamese medical personnel in a nearby province. Horby, a British epidemiologist, had joined WHO’s Hanoi office only a few months earlier after working for several years at the Public Health Laboratory Systems in London, specializing in communicable diseases. He was still learning his way around his new home.

  The call was from the director of Vietnam’s National Pediatric Hospital back in Hanoi. He had a mystifying outbreak of respiratory cases. A week earlier, he’d brought these to the attention of senior officials at Vietnam’s health ministry, but they’d brushed him off. So now he was turning to Horby. There was something about the call that told Horby he shouldn’t wait. He broke away from the training session and directed his WHO driver to take him back to Hanoi, directly to the hospital.

  The car pulled past the gate and onto the campus of the pediatric hospital, an oasis of soothing greenery and tropical decay in the middle of one of the capital’s most crowded quarters. The institution’s sun-bleached buildings with their ancient wooden doors and paint-chipped balconies were arrayed amid overgrown lawns. Stands of bamboo rose here and there. The grounds were still but for the
chirping of birds in the generous shade trees and the occasional sound of a wailing infant. Uniformed nurses walked briskly along the scarred tile walkways. Orderlies in traditional conical hats shuffled past.

  Professor Nguyen Thanh Liem, the hospital director, met Horby on his arrival. Three other doctors, including the heads of intensive care and infectious disease, were asked to join them. The doctors told Horby they feared that SARS might again be breeding within their walls. During the previous three months, they had admitted eleven children with unusual respiratory ailments, and seven had died. The other four remained hospitalized. Yet another child, the sibling of one of their cases, had succumbed a week earlier from a similar illness in a provincial hospital.

  Horby inquired about the background of the children. There didn’t seem to be an obvious pattern. They ranged in age from nine months to twelve years. They came from a variety of places outside Hanoi, mostly from the countryside but in a pair of cases from town. There were no reported outbreaks in their communities or in their schools.

  The doctors escorted Horby to the intensive care unit to see the four surviving children. They had all been healthy just weeks earlier. At first it was just a runny nose, dry cough, and fever. Then the infection grew violent and spread to their lungs. When Horby reviewed the chest X-rays, they were desperately clouded. Their white blood count was low, suggesting the infection was not bacterial but viral. It was likely, Horby concluded, they would die.

  “How unusual is this?” he asked the doctors.

  “It’s unusual,” Liem replied. “They’re not responding to treatment and we don’t have a diagnosis.”

  Horby quickly surmised it wasn’t SARS. That disease had largely bypassed children. It was more likely a pathogen called adenovirus, or perhaps flu. They agreed to conduct more tests on the patients and to press the health ministry about similar cases at other hospitals. WHO would supply masks, gloves, goggles, and face shields to the staff at the pediatric hospital.