The Fatal Strain

by Alan Sipress

  But when WHO subsequently pressed Chinese officials for more details, they offered a terse, dismissive reply. It was indeed flu, they reported, but just routine flu and everything was under control. In essence, “Now buzz off.”

  By the waning days of 2002, with wildfowl in Hong Kong starting to drop, Guan and his fellow researchers suspected that whatever was killing the birds was also afflicting the patients in Guangdong’s hospitals. So on Christmas morning he came to Kowloon Park, an exquisitely maintained expanse of manicured greenery, flower beds, and faux waterfalls at the heart of central Kowloon, just off a stretch of Nathan Road known as the Golden Mile for the bountiful commerce of its shops and boutiques. Toward the center of the park, fringed by palms and shade trees, was the man-made lake where several dozen species, including flamingos, ducks, geese, and teal, frolicked in the water and sunbathed on the banks. Guan laid out his gear. Meticulously, he clasped a small vial in his curled pinky, leaving the rest of his fingers free. As a colleague restrained the first bird, Guan slowly inserted a Q-tip-like swab into its cloaca and withdrew a specimen. Guan sampled at least a dozen birds this way. Most later tested positive in the lab for avian flu.

  He and fellow researcher Malik Peiris also continued to stalk the strain into the Mai Po Marshes of the New Territories. There the mudflats and mangroves offered a refuge unique in Hong Kong for hundreds of species of wild birds. The scientists drove up before dawn. It was a cold, damp morning. Though they were wrapped in heavy coats, the chill penetrated Guan’s bones. He pushed a small boat into the dark water, mud soaking his sneakers, and then rowed across the narrow inlet. He came ashore on Duck Island, a sliver of land that fittingly boasted more than twenty species of ducks. It was too hard to catch these birds. So for an hour and a half, Guan scoured the ground for their droppings. Live virus would be lurking inside.

  The specimens collected from scores of birds in Hong Kong suggested that the mystery outbreak in Guangong’s hospitals was H5N1. But by February 2004, Guan and his fellow microbiologists realized there was no substitute for actual human samples. Someone would have to go to Guangzhou to get them.

  “Why not Yi?” Webster asked. “It’s not everyone who’s going to want to go into that room and risk his life.” Guan was impetuous and courageous, and it was obvious to him that this was his moment.

  When Guan arrived at the Guangzhou Institute of Respiratory Diseases, he told the director, Nanshan Zhong, that the pathogen was most probably influenza. “It is possible this is the early stage of a pandemic. If we don’t deal with it carefully, this will be a disaster,” Guan warned.

  To contain it, medical experts had to determine precisely what it was. Guangzhou didn’t have the necessary lab facilities, Guan concluded, but Hong Kong did. Zhong concurred.

  With the vials stashed in his satchel, Guan hailed a taxi outside the institute gate on the afternoon of February 11 and set off into rush-hour traffic. He wanted to make the 6:30 P.M. express train to Hong Kong. If he did, he could turn over the cache of vials to his lab staff in time for them to begin the process of culturing the virus samples that very night. Guangzhou East Railway Station was teeming with travelers. The cavernous hall echoed with the announcement of trains departing for destinations in the Chinese hinterland. Guan headed toward the terminal for the Kowloon-Canton Railway, which would whisk him to Hong Kong. Police officers, some alone, some in pairs, meandered through the crowd. Guan avoided eye contact.

  He ascended the escalator. At the top were the immigration counters. Guan liked to tell himself it was all one country, Hong Kong and the mainland. That was, after all, the official Chinese government line. And by that logic, he wasn’t smuggling the samples abroad. But in many practical ways, China still treated its border with Hong Kong as an international frontier. Guan showed his passport to the blue-uniformed immigration officer, who waved him through. When he reached customs and saw the X-ray machine, he momentarily considered looking for another way around. Then he thought better. “If you try to avoid that,” he told himself, “there will be more trouble.” He placed his satchel on the belt. Seconds passed before it reappeared on the far side. The white-uniformed customs officer didn’t say a word. Guan retrieved his bag and continued toward the waiting room.

  There were families with large suitcases, and businessmen returning home after a day trip to their factories and suppliers. They were already queuing up when the train was announced. Guan joined the line. An immigration officer was conducting a final passport inspection. “The quieter you are, the safer you are,” Guan reminded himself. Usually he was a dervish of activity, a fast-walking, fast-talking impresario of scientific notions who pressed his theories, passions, and grievances on listeners in a shotgun spray of sentences, a chronically restless soul who found it nearly impossible to remain seated or stand still unless, of course, he was smoking a cigarette out an open window. Yet in his plain gray suit, inexpensive haircut, and large, silver-framed aviator glasses, he could melt into the undifferentiated mass of commuters if he could just feign the right air of indifference.

  “The more you keep quiet,” he repeated to himself, “the safer you are.” The immigration officer asked for Guan’s passport. He flicked his cigarette to the floor and produced the document from his jacket with an affected look of weary annoyance. The officer returned the passport and moved on.

  Finally the line moved. The passengers filed downstairs to the red tile railway platform and onto the train. Guan claimed his seat. He placed the satchel carefully on the overhead rack. Then he took out his cell phone and called his lab. “Are you ready?” he asked. “The samples are on their way.”

  But as they were analyzed over the coming days, the samples stumped Guan and his fellow researchers. The virus wasn’t H5N1. It wasn’t flu at all. It would later be identified as SARS, and that was fortunate. Because in the age of globalization, flu would have been much worse.

  Half a year after the SARS epidemic had subsided and life had returned to Hong Kong’s deserted streets, the city’s legislative council would conduct an inquiry in January 2004 into the government’s handling of the crisis. The outbreak had killed 299 people in Hong Kong alone. Nearly six times that number had been infected. Amid stinging criticism, Hong Kong’s secretary of health, welfare, and food and the chairman of the hospital authority would lose their jobs.

  Margaret Chan, the city’s health director who had so ably steered Hong Kong through the bird flu outbreaks of 1997, had also skippered its emergency response to SARS. As she testified before the legislative council, she broke into tears. “We tried to do our best,” she assured the members before being overcome by emotion, forcing them to briefly suspend the hearing. During her testimony, Chan told the council she had tried several times in early 2003 to confirm the press reports of an epidemic brewing in neighboring Guangdong province. On February 11, 2003, the very day that Guan was making his clandestine run to the Guangzhou institute, Chan and one of her departmental consultants had repeatedly phoned health officials in Guangdong about the rumors. No one answered their calls. “Usually, with other infectious diseases, there was no problem with communication,” she testified. She added that a Guangdong official later told her “there was a legal requirement for infectious diseases at that time, that infectious diseases were classified as state secrets. That is why they cannot share the information.”

  The council went on to censure Chan, who by that time had resigned from the health department for a post at WHO in Geneva. She was faulted in part for leaving Hong Kong vulnerable “in that she did not attach sufficient importance to ‘soft intelligence’ on the [acute pneumonia] epidemic in Guangdong.” The report suggested she could have dispatched a team to the mainland to investigate.

  Ultimately, it was a doctor named Liu Jianlun who had brought the disease to Hong Kong’s attention. Liu was a retired kidney specialist from southern China. At age sixty-four, he still worked part-time in an outpatient clinic at a hospital in Guangzhou. It was this hospital
that first treated one of the earliest victims, a forty-four-year-old seafood seller from the suburbs who came in January 30, 2003, with a severe cough and fever. This patient stayed only two days before being transferred to another hospital. But in that remarkably brief time, he infected at least ninety-six other people, including ninety health-care workers.

  Liu himself started feeling sick two weeks later. He worried that he had contracted whatever horrible illness was besieging his hospital. But his chest X-rays looked clear. So he dosed himself with antibiotics and set out with his wife on a three-hour bus ride for a nephew’s wedding in Hong Kong. When they arrived, he felt well enough to go shopping and enjoy a long lunch with relatives. Late that afternoon, on February 21, Liu and his wife checked in to their room on the ninth floor of the Metropole, a three-star hotel in Kowloon with a large swimming pool on the roof and a karaoke bar in the basement. Their room was what marketers call cozy, with two single beds and a pale olive carpet. From the window of room 911, they could see a Shell service station, an Esso service station, a YMCA guesthouse, and beyond, one of the most congested quarters in all Hong Kong.

  Long before the term globalization was coined, Hong Kong was the definition. As a colonial entrepôt, it evolved into a bridge between Occident and Orient, a global financial center, and one of the world’s busiest ports. The ninth floor of the Metropole was true to form. Staying on the floor that same evening were also three women from Singapore, including a former flight attendant on a shopping excursion, four Canadians, among them an elderly woman from Toronto visiting her son, a British couple on the way to their native Philippines, a young German tourist headed for a two-week vacation in Australia, and three Americans, including, right across from 911, a Chinese-American garment merchandiser bound for Hanoi to meet his denim suppliers. Sometime in the course of that evening or early the next morning, before Liu checked out of the hotel with a searing headache and dragged himself five blocks to a hospital, he managed to infect all thirteen of those neighbors. Three others at the Metropole also caught the virus. Based on intensive sampling, health investigators later theorized that Liu, upon returning to the ninth floor from dinner, had thrown up on the teal-colored carpet outside the polished, wood-trimmed doors of the elevator. Someone, perhaps his wife, cleaned up the mess. An invisible mist of infectious particles wafted along the corridor.

  Liu would become Hong Kong’s first case. Before he died, he told the doctors and nurses caring for him about the disease raging in his own hospital.

  The Singaporean hotel guests returned home, where they were all hospitalized, and one, the woman on the shopping spree, in turn sparked an outbreak that sickened at least 195 people in her own country. The doctor who treated the initial Singaporean case later flew to New York for a medical conference and on the way infected a Singapore Airlines flight attendant.

  The Chinese American merchandiser continued to Hanoi, where, before succumbing to his sickness, he seeded a Vietnamese outbreak that infected sixty-three others. A French physician in Hanoi who cared for a stricken colleague later carried the virus home to Paris, along the way infecting three others on the Air France flight.

  Just four days after Dr. Liu had boarded the bus in Guangzhou, the elderly Canadian woman from the Metropole was back in Toronto, halfway around the globe, and feeling ill. Before she died, this grandmother passed the virus to four family members, ultimately igniting a cluster of 136 cases in Canada. One of those stricken in Toronto was a nurse from the Philippines, who later flew home to help find a faith healer for her cancer-stricken father and instead infected her family with the killer virus, volleying the illness right back to Southeast Asia.

  This is how an epidemic becomes a pandemic. This was the first great wave of a still-unnamed virus washing over the world. More would follow.

  Of all those sickened at the Metropole, the one who went on to infect the most people directly wasn’t a guest at all. He was a twenty-six-year-old airport freight handler from Hong Kong itself who visited a friend staying on the ninth floor. About two days after this young worker started feeling lousy, he went to the emergency room, where he was diagnosed with a respiratory infection and sent home. Almost a week later, as his condition worsened, he was admitted to Prince of Wales Hospital. As the main referral hospital in the New Territories, this modern medical complex has the feeling of a bus terminal at rush hour, with crowded corridors and long lines at the reception windows. The young man was placed in Ward 8A. He went on to infect at least 143 others, all at the hospital.

  From here, the virus again exploded into the world. Nearby in Ward 8A was an elderly Chinese man being treated for an unrelated salmonella infection. His seventy-two-year-old kid brother visited him often. On March 11, the younger brother developed a fever and three days later came down with a cough and chills. Though a physician urged him to get hospital care himself, the man insisted on flying back home to Beijing as planned. On March 15 he did so.

  “It was like seeds thrown into the wind,” a doctor in Beijing later remarked. “Who knows where they will land?”

  Air China flight 112 was nearly full that Saturday. The Boeing 737 had 112 passengers and 8 crew members. The ailing seventy-two-year-old was slumped in seat 14E. He looked pale, his brow was drenched. He couldn’t quiet his coughing and kept hacking until his handkerchief was soaked. He went to the galley to ask a flight attendant for water to take some pills. In the three hours it took to reach Beijing, he infected 22 passengers between rows 7 and 19 and 2 flight attendants. The first victim would spike a fever within days. By the middle of the next week, three-quarters would develop what initially felt like a bad head cold. Five would later die, as would the elderly traveler himself.

  The two flight attendants were from Inner Mongolia, a region of northern China. When they returned home, they sparked an outbreak that accounted for most of its 290 subsequent cases. From there, the virus leapfrogged across the border to the independent country of Mongolia.

  Ten of those infected on CA-112 were members of a Hong Kong tour group.

  Four were employees of a Taiwanese engineering firm, who eventually carried the virus home with them.

  Another was a young woman from Singapore, who later flew home and was hospitalized there.

  Yet another was a Chinese official who journeyed to Bangkok. As he headed back to Beijing from that subsequent trip, on a Thai Airways flight, he in turn infected a Finnish official of the International Labor Organization, who had been seated next to him.

  It had only been five weeks since Dr. Liu got on the bus. Of the 8,098 cases of SARS ultimately detected, more than 4,000 could be traced back to his overnight stay in the Metropole.

  When the Spanish Lady came calling in 1918, no place was too remote to elude her entreaties. She even found the islanders of the Pacific. In prior centuries, when seafaring ships were driven solely by the wind, an epidemic disease brought on board would have time to burn itself out before coming ashore on these distant islands. They were beyond reach. Maritime technology changed that. In October 1918, a U.S. Navy transport called the Logan sailed from Manila with an infected crew and put in at Guam. Nearly everyone on the island fell sick with flu. About 800 died. Another vessel, the Navua, set out from the stricken port of San Francisco and in mid-November docked in Tahiti. Three thousand Tahitians caught the disease, and more than a tenth of the population perished. From the ailing port of Auckland in New Zealand, a steamer named the Talune set sail, scattering death at each stop along its tropical itinerary. In Fiji, 5,000 died. In Tonga, as many 1,600, about a tenth of its inhabitants, died. The Talune fatefully docked at Apia, the capital of Western Samoa, in early November. By the time the suffering subsided early the next year, an estimated 8,500 natives had succumbed, more than a fifth of the population.

  For many Eskimo villages of Alaska, the plague was even less forgiving. As winter was closing in, the final ship of the season, a vessel from Seattle called the Victoria, moored in the port of Nome on Alaska’s Se
ward Peninsula and deposited its lethal cargo. From there, sped by the wanderings of white missionaries, influenza advanced along the frozen tundra, penetrating the coast to the north. It killed every last Eskimo in the village of York, about 150 miles from Nome by dogsled. The inhabitants of nearby Wales, the westernmost point on the North American continent, joined in a funeral for a boy from York. Soon more than half those from Wales were also dead. At another outpost, Teller Lutheran Mission, disease erupted after a pair of visitors from Nome had joined a local church service. The first native fell sick two days later. Soon corpses stacked up inside the igloos. All but eight of the village’s eighty residents perished and were buried beneath the permafrost. One was a woman who ultimately helped crack the genetic code of the Spanish flu after researchers excavated her grave seventy-nine years later and retrieved a sample of infected lung tissue from her well-preserved body.

  The global reach of pandemic flu is thus nothing new. But globalization is. And over the last generation, it has fundamentally recast the threat of infectious disease. As with SARS, the next flu pandemic will spread at the speed of jet aircraft, coursing along an ever-thickening web of international travel, each new thread reducing the time the virus must wait before breaching another frontier.

  “As the first severe contagious disease of the twenty-first century, SARS exemplifies the ever-present threat of new emerging infectious diseases and the real potential for rapid dissemination made possible by the current volume and speed of air travel,” said Mark A. Gendreau, a senior attending physician at the Tufts School of Medicine, in testimony before the U.S. Congress. Margaret Chan was even blunter: “SARS was a wake-up call for all of us. It spread faster than we had predicted.” Within six months, it reached more than thirty countries on six continents.