by Alan Sipress
Yet for all her preparations, Samaan wasn’t expecting what awaited her when we finally pulled up in the victim’s neighborhood. It was as if the whole community had turned out and was now sitting in rows of folding chairs on the block captain’s grassy front yard, anxiously anticipating an explanation for their tragedy. Samaan waded through the crowd along with her translator, a stocky Indonesian with thick sideburns, wispy beard, and crisp American accent acquired during a childhood in Pittsburgh, and a middle-aged woman in batik named Ibu Eni from the health ministry’s national lab. When they announced that blood samples were to be taken, dozens crowded around, offering their arms.
This was not the way things were done back home in Australia, where Samaan had recently graduated from an elite program in epidemiology at the Australian National University in Canberra. She would have preferred to proceed calmly, methodically. She would have wanted to interview the victim’s relatives and neighbors in their own homes, carefully taking stock and observing them, noting their answers, calibrating their responses, piecing together the timeline, then drawing samples only from those who had immediate contact with the dead woman. Instead this was verging on chaos.
Ibu Eni took a seat behind a wooden school desk set out in the yard. She snapped on a pair of rubber gloves and began accepting one thrusting arm after another. After the first man had given blood, Samaan buttonholed the graying old-timer and tried to clarify the conflicting reports about sick poultry.
“Have there been any bird deaths in the kampung, or neighborhood?” she asked.
“Nothing,” he demurred. “Everything’s been ordinary.”
A second man in a black Mercedes cap interjected, correcting him, “Yes, there were two chicken deaths, about thirty meters away from the victim’s home.”
“How many were dead?” Samaan asked, confirming the number.
“There were two,” the second man repeated.
Then a third man, with a bushy mustache, stepped forward, weighing in, “Yes, there were two dead chickens a month ago.”
Samaan listened intently, producing a large, spiral notebook from her handbag and jotting down the details. “What were the symptoms?”
“It was all of a sudden. We didn’t see any symptoms,” answered the mustachioed neighbor.
“What made you think the birds were sick?” she pressed.
“My wife found them,” he answered. “My mother-in-law poured kerosene on them and burned them. I just cleaned up the remains.”
The three men started buzzing among themselves. The translator fell silent, trying to follow the conversation. Samaan waited. Perhaps the neighbors were trying to recall the details. Or perhaps, like many other Indonesians, they were reluctant to disclose them, fearing that local veterinary officers would raid the kampung and cull the remainder of their birds.
“How’s it going?” Samaan prodded after a few minutes.
“We didn’t see any chickens with symptoms,” insisted the man with the mustache. “They were just kind of dead. We still don’t know whose chickens they were.”
Samaan rolled his remarks over in her mind, examining them for any elusive clue. Two dead birds, no symptoms, no samples. It was hard to conclude they were responsible for the death. She excused herself. Then she went to locate the victim’s relatives in the crowd.
The victim’s mother was a handsome woman in a coarse, orange dress with thick brown hair pulled back in a bun. Samaan ushered her to the shade of a stately jackfruit tree in a corner of the yard. The great green fruit dangled from the canopy. Another neighbor dragged over two folding chairs so the pair could sit down.
“When did your daughter become sick?” Samaan asked, this time pulling a large calendar out of her handbag.
“Nine days ago.” That made it the first week of January. The timing could eventually prove crucial to cracking the case.
“Did she have a temperature?”
The mother furrowed her brow trying to summon the specifics. “She was very hot. She had a terrible cough. She had a bad infection in the lungs.”
Samaan inquired about the rest of the family, where they lived, and whether the other members were healthy. Everyone else was fine. She asked about the family’s recent travels. She asked who did the shopping and the cooking in the family.
“Do you own chickens?”
“No, but sometimes the neighbors’ chickens come around,” the mother responded, squinting as she thought about the answer.
“Did any of those chickens die?”
“We didn’t see any sick chickens. But most of the time we weren’t home. We’re a working family,” she said, lines deepening across her dark brow. Then she added, “My daughter’s a nurse at a hospital.”
This last disclosure landed like a bombshell. Though Samaan’s expression remained placid, her heart fell. If the victim had been a nurse, she might have been infected by another flu patient, signaling that the novel strain had mastered the ability to jump from person to person. Or she might have passed the disease to one of the many people whom she treated on the wards. Was the hospital itself breeding an epidemic? Had it already burst beyond the walls into the teeming quarters of Jakarta? The possibilities were frightening. The prospect of pandemic instantly seemed closer. But Samaan refused to let her anxieties betray her. She pressed on.
“Which hospital did she work in? Where is it located?” Samaan probed.
“West Java.”
“Which department did she work in? ICU? Pediatrics?”
“I don’t know,” the mother said. “She’s a regular nurse.”
As Samaan wandered down the narrow concrete alley to the victim’s home, her mind was humming with questions. First, what was the culprit? She wanted to uncover the precise source of her victim’s infection to determine how the sickness spread and whether others were at risk. Had the mercurial virus changed its modus operandi? If so, this might reflect a fateful mutation, and the world would want to know. Samaan also needed to find anyone who’d been in contact with the deceased to see if they required medical care. Most urgent of all, was this extraordinarily lethal disease now being relayed from person to person? Was it time to sound the alarm?
The answers lay in the quotidian details of kampung life. Samaan intended to sift through the family’s habits, peering under their prosaic routines for the tracks of a killer.
That meant delving into the family’s medical history, whom they worked with and lived with, how they prepared their meals, and where they slept. She would need to know if they raised animals and how they kept them. She would learn where the family shopped and who butchered the poultry, whether they took traditional medicine or had a taste for liver, eggs, or raw meat, whether they were hunters, farmers, or regulars at the city zoo. To solve this whodunit, Samaan would also reconstruct the victim’s final weeks and days. She would weave together the account in the hospital records with the recollections of relatives and coworkers whose memories were now buffeted by fear, confusion, and grief.
Epidemiology is often likened to detective work. But the metaphor is misleading. In reality, disease investigators all too rarely enjoy the satisfaction of collaring their suspect. Clues are few and easily overlooked: a smudge of bird feces on an eggshell, mucus on a feather. Trails go cold quickly. Infected birds may have flown away; victims may have been diagnosed too late and died before investigators could question them. Witnesses forget innocuous but crucial details: a friend’s songbird, fertilizer in the garden, or a quick stop at the market. Even when a death coincides with an obvious outbreak in a neighbor’s flock, the evidence of infection is often circumstantial. When several family members contract the virus, it’s often impossible to conclude whether they all got it from the same sick chicken or shared it among themselves.
If a nascent pandemic strain were circulating in an Indonesian hospital, Samaan would find this out. If it wasn’t, she would offer the world a measure of reassurance. But she also realized she might never be able to stamp “Case So
lved” on her file. A study of Indonesia’s first 127 confirmed cases found that that investigators had failed to come up with any possible explanation for one-fifth of them. At best, Samaan might only be able to suggest a plausible hypothesis for her victim’s death. Yet this would leave much of the flu’s mystery unrevealed and possible strategies for defeating it obscured.
“Sometimes you can only go so far and stop,” she told me. “Sometimes you have to draw the line.”
The victim’s neighborhood was not as poor as Samaan had expected. Small, tidy dwellings lined the alley with laundry hanging limply out front. Sewage trickled down a ditch beside the alley.
After two minutes, Samaan reached the family home, a simple, middle-class house at the top of the alley. The victim had lived there with her parents, husband, and four-year-old son. Samaan crossed the porch and removed her shoes at the doorway. She joined half a dozen Indonesian officials inside. The air was close, tangy with sweat. They sat cross-legged on a woven mat in the front room, unfurnished except for a large wooden cabinet with glass doors, the walls unadorned but for family portraits. The mother reached up, took down a photograph in a carved wood frame, and passed it around. It was a formal portrait of the deceased and her young boy. The woman was fleshy but attractive with wavy brown hair and thick red lipstick. For the photograph, she had donned a green tunic over a red batik sarong. She was standing with her hands folded before her. At her side was the boy, smart in a traditional Javanese sarong and black pece cap.
From outside on the porch came the staccato of a youngster coughing. Samaan looked quizzically at her Indonesian colleagues. None of them were wearing any protection, no mask, no gloves. Samaan asked whether the boy might be infected. Unlikely, the Indonesians assured her. He had been coughing for weeks, long before the victim fell ill, and otherwise seemed healthy. As if to prove the point, the youngster suddenly appeared in the doorway on a bicycle. Besides, the Indonesians explained, he had already tested negative for the virus.
Samaan scribbled a few notes. Then she returned her attention to the victim’s mother.
“In the ten days before she became ill, did she go to any parks? Any farms?”
“Nothing,” the mother answered.
“A traditional market?”
“Yes, she went to a traditional market. A couple days beforehand, she bought us chicken.”
Samaan jotted down the details.
“Did she kill it herself?” Samaan continued, wondering whether the victim had been infected while butchering a sick or contaminated bird.
“It was already killed.”
“Feathers or no feathers?”
“It was already cut up and ready to cook.”
“When did she go to the market?”
The mother shrugged and turned toward a bushy-haired man sitting quietly in the far corner. It was the victim’s husband.
“I don’t know,” he said softly.
“Before New Year’s?”
“Yes, before New Year’s,” he confirmed.
Rising to her feet, Samaan asked to see the rest of the house. She entered a long room in the rear of the house. There was a refrigerator. She opened the door and peered inside. It was mostly empty. Next she went into the cluttered kitchen, where she instantly spotted a metal wire basket suspended about six feet off the ground. She pulled a pair of rubber gloves from her handbag and tugged them on. Then she craned her neck back, reached up, and gingerly unhooked the basket, placing it on a table. Inside were about a dozen brown eggs. She plucked them out one by one and scrutinized them, looking for traces of chicken droppings that could have contained the fatal dose. Nothing.
“Very clean,” she acknowledged. “No sign of feces.”
Samaan replaced the basket and snapped a picture of it with her digital camera.
The general lack of filth was becoming ever more disturbing, the absence of livestock unnerving. None of the neighbors seemed to have the wooden cages common in most Indonesian yards for raising chickens. In fact, except for a pair of black chickens lingering in a bush near the block captain’s home, there was practically no trace of poultry anywhere in the neighborhood.
“It’s perplexing and it makes me a bit worried,” Samaan confided to me. “She was a health-care worker. If there’s no sign of infection here . . .” Her voice trailed away.
Inside WHO, Tom Grein is a legend. His exploits as an epidemiologist are unsurpassed in his generation. He has ventured to some of the world’s most remote corners and confronted some of its most horrifying diseases. When bird flu initially exploded in Vietnam, he was among the first from WHO on the ground in January 2004. When the virus recorded its single largest cluster in the highlands of Sumatra in May 2006, again he was there. Yet Grein readily admits the limits of his calling. “Epidemiology never proves. It only highly suggests,” he put it to me. “As frustrating as that might be, not having a smoking gun itself is not failure.”
A lanky German with still, blue eyes, a strong chin, and closely cropped brown hair tinged with gray, Grein has a reserved, methodical manner. His colleagues say he can be dour when he’s stuck in Geneva and this demeanor has earned him the moniker Gray Cloud. Nothing makes him happier than when he gets to leave the office.
In 2005 he left and headed for southern Africa, responding to the deadliest outbreak of Marburg hemorrhagic fever ever recorded. He drove for ten hours from the Angolan capital, Luanda, into the country’s hilly interior, where he discovered villagers dying by the scores. Victims would develop a high fever, crippling headache, diarrhea, and vomiting. Then, as one of the most lethal pathogens of all turned its fury on the liver, spleen, and other organs, blood would often gush into the body’s cavities before emptying out through the nose, mouth, eyes, rectum, and other orifices. Barely one in ten survived. As if that weren’t daunting enough, Angola was just coming out of a twenty-seven-year civil war and remained unstable and violent. The landscape was still littered with land mines, the few concrete buildings scarred by gunfire. “There was a lot of hands-on work to do in a very difficult climate and very difficult environment,” Grein told me. “It took a long time to contain the outbreak.”
For nearly a month he and his team remained in the Angolan province of Uige. They went hut to hut carrying out inspections, working inside low, dark dwellings, the air thick with death. They disinfected bodies and buried those who had perished. Their protective suits, double gloves, and face shields were all that separated them from a similar fate. “There’s a perception that you’re putting yourself quite at risk. Though you take appropriate measures, the brain plays its games,” he admitted. All the time, he feared the disease would spin out of control. The international team would contain it in one place, believing they had broken the chain of transmission, and it would erupt somewhere else. They were never able to identify the original source.
Twice before, he had been dispatched to face down Marburg in Africa. He had investigated and ultimately helped control outbreaks in the Democratic Republic of Congo, formerly known as Zaire. In 1998 he had responded to a flare-up in southern Sudan of what health officials suspected was also hemorrhagic fever. Ebola, an equally cruel and contagious cousin of Marburg, had first been identified a decade earlier in an equatorial province of Sudan. Now that same pathogen was believed to have struck a quarter of the people in four isolated farming villages high in the savannah. Two Sudanese medical investigators who first reached the area had gotten ill, and one died. To get there, Grein and his entourage hiked from dawn until the middle of the night, fording four rivers along the way. “It was like Dr. Livingston with high grass left and right,” he recounted. “It was something out of an old movie with people in single file carrying things on the top of their heads.” The affliction turned out to be a particularly nasty respiratory tract infection. But not long after, he would confront Ebola itself in the Republic of Congo.
Then there was the time he was airlifted into the mountains of Afghanistan. Once again, hemorrhagic fever
was suspected. An outbreak had pervaded three-quarters of the homes in a remote hamlet of northern Afghanistan, which was then controlled by the forces of the storied Tajik militia leader Ahmed Shah Masood. During the summer, it would take a week by mule to reach the village. But the disease broke out during the height of winter and the outpost was cut off by snow. Grein and a WHO colleague flew in by helicopter from the neighboring country of Tajikistan. They treated about twenty patients with antibiotics and collected specimens for further testing. The outbreak was ultimately blamed on an “influenza-like” respiratory infection.
I had known of Grein’s reputation long before I met him. When I finally caught up with him in Yogyakarta, a historic royal city on Indonesia’s Java island, he was exhausted. Six days earlier, a powerful earthquake had struck just south of the city, killing nearly six thousand people and displacing 1.5 million others. Now the neighboring Mount Merapi volcano was threatening to blow. Grein, who had coincidentally been in Indonesia for several weeks investigating the Sumatra bird flu cluster, was asked by WHO to extend his stay and set up a system for monitoring possible outbreaks of cholera and other disease in the quake’s aftermath. He had done the same a year earlier in the Indonesian province of Aceh after it was struck by the massive South Asian tsunami.
“Epidemiology is a different world than lab work,” he explained to me over strong coffee. “Most field epidemiologists only understand the basics of what happens in the lab. Laboratory science has advanced so much that it’s impossible for field epidemiologists to keep up. But laboratory results without epidemiological information are limited. If you send in lab samples from the field without epidemiological background, they throw a fit.”
