The Fatal Strain

by Alan Sipress

  Rafei’s wife and mother both told me they had no idea how he and the daughters got sick. Rafei was a busy professional who set out early every morning on his long commute to Jakarta’s downtown financial district and returned late in the evening, leaving little time for side trips to farms or chicken markets. His wife, Lin Rosalina, eyes red from crying, said she was also certain her children had not come into contact with live poultry. “I’m very sure,” she added, switching from Indonesian to English to make the point.

  Her family’s tragedy also highlighted yet another mystery. In clusters of cases, the virus has targeted blood relatives almost without exception. The disease that struck down Rafei passed over the remaining members of his household: his wife, two housekeepers, and his son. All but the last were unrelated to him by blood. By 2008 there were already more than three dozen family clusters across Asia and beyond, representing about a quarter of all confirmed cases, and in the overwhelming majority these involved blood relations like siblings, parent and child, children and grandfather, or niece and aunt. Rarely did both husband and wife test positive.

  One of the largest clusters occurred in January 2006 in Cipedung, a destitute, hard-bitten village along Java’s north coast. Unlike in the case of Rafei, there was little question where this family caught the bug. They had two dozen chickens, which regularly straggled into their flimsy bamboo shack, sleeping on the dirt floor beneath the platform beds. In the previous weeks, the virus had raced through this small flock. One by one, the chickens got drowsy and died. When the last six birds developed symptoms, the father, a meatball peddler, helped his brother slit their throats beside a large palm in their front yard. The chickens were plucked and cooked in coconut milk for a family feast. By the time I caught up with the family at a hospital in the provincial capital, Bandung, the father was huddled on a cot wrapped in a gray blanket, haggard and unshaven, under treatment for the virus. In an adjacent room, a teenage daughter with a fever lay sprawled on a bed under observation. Two other children had died before they ever got to the hospital.

  The question was why the mother had been spared. Just beyond the doors, in a quarantined waiting room, she kept vigil. “I don’t know why I’m healthy,” the woman, Buenah, whispered to me. She was a short, frizzy-haired peasant with tired brown eyes, wearing only a surgical mask for protection. For my part, the hospital staff had outfitted me in a white hooded jumpsuit with goggles and a respirator and sent me in alone to speak with Buenah. The rubber gloves were making it difficult to take notes. “I don’t have a fever, cough, or symptoms,” she related. “I really don’t know why not.”

  Outside the isolation ward in Hasan Sadikin Hospital, her relatives were camped on the lobby floor, spending nights on thin, woven mats, wondering how she had escaped the curse. “It’s really incomprehensible to us,” said Surip, her husband’s cousin.

  Could the rest of Buenah’s immediate family have had more contact with sick chickens than she did? That’s doubtful. Relatives and local agriculture officials explained to me that as a rural homemaker, she was in daily contact with livestock. Could the three children have caught the virus by playing with chickens and then passed it on to their father but not their mother? Relatives and fellow villagers reported that it was Buenah who usually looked after the children and that for days she had carried her ailing son in a sling across her chest. Could Buenah, who complained of high blood pressure, have skipped the repast of chicken and coconut milk? No, she and the rest of the extended family all took part.

  During the coming months, as epidemiologists turned up this intriguing pattern of clusters over and over, flu specialists came to suspect some kind of coding in the genes that made some people susceptible to infection and others not. If understood, this could help design ways to slow or even stop an emerging epidemic. But the genetic mechanism has remained unclear. And some researchers even countered that statistical chance alone could account for what appears to be genetic susceptibility.

  Markets still made Samaan uneasy. When she first started investigating flu cases in Indonesia, she was always fretting about catching the virus. “I counted the sneezes I’d make,” she recalled. As she got better acquainted with the behavior of bird flu, she worried less about catching it at victims’ homes or from their families. But traditional Asian poultry markets remained scary places where butchers, birds, and buyers all converged, swapping their microbes among splattering blood and flying feathers. It took courage for Samaan to brave a live market even when she wore a mask. But the trail of her victim’s killer now led back to one of the capital’s largest, a vast covered complex encompassing several city blocks in East Jakarta known as the Kramat Jati Market.

  Samaan had done the math. The victim had started feeling sick on New Year’s Day or perhaps a day earlier. The typical incubation period for the virus was believed to be three to five days. During that time, she had worked two shifts at the hospital, December 27 and 28. They were both overnighters. Samaan deduced that the woman would have been hungry when she came off duty at 7:00 A.M. and likely stopped at Kramat Jati, which was on the way home. In the hours just after dawn, the market would have been brimming with fresh produce and live poultry.

  “She probably got a big dose of something and got sick,” Samaan surmised. She was back in the rear seat of the maroon minivan, and the van was again crawling through Jakarta streets, fighting Monday morning traffic. Samaan sensed she was getting close to her prey. The van passed pickup trucks stacked with plastic chicken cages, loose feathers stuck to the cruddy exterior, then pulled into a parking spot beside titanic sacks of chili peppers. Samaan got out, stepping carefully around the mud puddles, and plunged into the dim aisles of the market. Escorted by two colleagues from the Indonesian health ministry, she marched past the cassette stalls blaring the Indo-Arabic strains of working-class dangdut music, past jewelry shops heavy with gold bangles and necklaces, past stalls overflowing with dry goods, and then up the stairs to the second floor, where the thud! thud! of a meat cleaver welcomed her.

  Samaan sloshed along tile floors slick with water, mud, and rivulets of blood. The footing was treacherous. On the chipped tile counters lay butchered chickens in a row. Their claws extended upward into the twilight of several naked lightbulbs. Toward the back, a few survivors clucked in dissent, their legs bound to makeshift wooden cages. Samaan kept her arms folded tightly in front of her, avoiding any contact.

  “If she came here, could she buy the chicken here?” Samaan asked.

  One of the health officials nodded.

  “Her friends at the hospital said she really liked chicken feet,” Samaan continued. “Like that?” She pointed toward a small pile on the counter amid other odd bits and pieces of chicken. Several men were hacking plucked birds into pieces.

  Samaan and her colleagues approached another butcher, a husky man in a skullcap. His feet were bare and his pants legs were rolled up to the knees. He was busy grasping birds with his bare hands and slitting their throats. The investigators asked whether the market had been checked for flu.

  Swoosh went the knife. Blood freckled the man’s forearms.

  He glanced up and assured them that local veterinary authorities tested the market once or twice a week.

  “What did they find?” Samaan asked.

  Swoosh went the knife.

  “It’s disease-free,” he said curtly.

  Samaan wasn’t convinced. Local food and health inspectors were notoriously lax when they weren’t outrightly corrupt. But she wasn’t going to linger any longer. She was reasonably confident she had stalked the infection to its source. She retreated through the maze and emerged into the sunlight.

  There, she spied something that instantly made her amend her conclusions. Four peasant women were seated on the blacktop hawking chicken off wooden crates. Stacked behind them were round bamboo chicken cages, all empty. The birds had obviously been butchered right on the crowded sidewalk. Even if the market inside was free of infection, this informal com
merce was less likely to be. She paused to look.

  “She didn’t have to go all the way in there,” Samaan speculated, retracing the victim’s steps in her mind. “She could have bought the chicken right here. That might be more risky.”

  Samaan reflected on the fateful morning, reasoning that the woman would have been weary after coming off her shift. She would have been eager to get home quickly. “That’s it,” Samaan thought. “She probably didn’t go inside. She would have bought it right here. There was plenty of potential for exposure.”

  Samaan climbed back into the van.

  “That’s my hypothesis,” she reported. “Can I prove it? It’s impossible.”

  CHAPTER ELEVEN

  The Lights Go Out at Seven

  When I met the man who might save the world, he was making thirty-eight dollars a month. Ly Sovann was a physician in the Cambodian capital, Phnom Penh. He was full-faced with dark, playful eyes and sloping shoulders. He had a tendency to lecture, and when he did, he would stretch out his arms and gesture with open hands. But he was also quick to laugh, often at his own straits.

  The first time I encountered him, Ly Sovann was planted behind an aging metal desk in a tiny room that passed for the headquarters of Cambodia’s disease surveillance bureau.

  He was the director, responsible for spotting the stirrings of an epidemic in a country where the public health and veterinary systems were so impoverished that experts acknowledged at the time they were probably failing to detect most of the human cases and had no idea how rampant the virus was among poultry. He shared the twelve-by-ten-foot office with the rest of his ten-member team. The room was crammed with four other metal desks and tables, filing cabinets, shelves heavy with bound reports, and five boxes stuffed with the health ministry’s stockpile of protective gear, including gloves, goggles, masks, and aprons. There was only enough space for three people at a time, so his staff rotated through. They all shared one Internet line, which was just about the sole way they could follow the inexorable progress of the virus in neighboring countries, and Ly Sovann had secured that connection only after prevailing on the health minister to seek help from the prime minister’s office. Even at times of crisis, they could work only until 7:00 P.M. each night. That was when the power in the health ministry was shut off and Ly Sovann had to find his way down the stairs from the third floor and out of the darkened building by the faint glow of his mobile phone.

  “We’ve had over thirty years of war,” Ly Sovann said as a small air conditioner sputtered and whined in the window behind him. “We need time to build up our system of public health. We try our best to build up the system for detecting avian flu in Cambodia. Five years ago, it was nothing. Now I have computers, paper, and stationery. It’s better.”

  Still struggling to recover from decades of conflict and political instability, Cambodia’s government had only three dollars per person to spend on health care each year despite high rates of HIV/AIDS, tuberculosis, and infant and maternal mortality. The country lacked trained doctors, clinicians, laboratory facilities, referral wards, epidemiologists, and an overall health system tying them together. For a time, the government couldn’t even afford to produce radio spots warning about the risks of bird flu.

  Out in the provinces, the health system was even more primitive than Ly Sovann’s operation. Local clinics couldn’t recognize cases of bird flu when the sick came in for treatment, raising the prospect that the virus would evolve into a more pernicious form and spread before anything could be done to stop it. This posed a danger not just for Cambodians but for those well beyond the country’s borders. “The chain is as strong as the weakest link,” warned Klaus Stohr when I first asked him in 2005 about his concerns over Cambodia and its destitute neighbor Laos. As the virus raced westward during the following year, WHO began raising a similar alarm over the threat posed by sub-Saharan Africa.

  The situation would be less dire in some countries confronting the virus, but only by degree. Along the breadth of the battlefront, from Vietnam and Indonesia to Bangladesh, Egypt, and Nigeria, public-health and veterinary services have remained precariously short of the money needed to corner the disease in birds, detect and treat those people who contract the virus, and stem its onward spread.

  For the wealthy of the world, geographic distance affords little protection from an emerging flu epidemic. There is no strategic depth, as war planners say. But the danger posed by limited resources goes beyond the shared vulnerability of all countries.

  Inequality itself has a corrosive effect on efforts to confront this disease. WHO and its wealthier member states have urged developing countries to battle the novel strain on everyone’s behalf. Yet these countries have been told they must do so without any solid assurance they’ll get a fair share of antiviral drugs, vaccines, or other medical aid if an epidemic erupts. This despite some projections that a pandemic would take a disproportionate toll on developing countries.

  Some Asian countries have done what they’ve been asked, even as they appeal for more money to do it. Others, at times, have resentfully rebuffed instructions from abroad, vowing to pursue their own national interest even if that puts the wider world at risk. Vietnam, for instance, was so sure it would be neglected in the event of a pandemic that local scientists pursued a homegrown vaccine using unorthodox techniques, though WHO warned that this effort could lead to tragic consequences. In Indonesia an aggrieved government went even further, turning the tables on the developed world. Indonesian health officials discovered that they controlled some of the most precious resources of all—actual virus samples urgently required by WHO’s labs to monitor mutations in the strain—and stopped supplying these specimens. Indonesia demanded that its claim to these virus samples be recognized and any benefits, for instance vaccines produced from them, be more equitably shared.

  At the very bottom of the heap, Cambodia has been in no position to insist on anything. Beaten down by history, it was already heavily dependent on foreign assistance just to keep from closing down. A full half of the central government’s budget was financed by aid.

  Ly Sovann was born in Phnom Penh in 1969, the year that the United States began its secret bombing of eastern Cambodia during the Vietnam War. This withering aerial campaign was aimed at eliminating the base camps of the Vietnamese Communists. But the upheaval caused by the four-year bombardment fueled the insurgency of Cambodia’s own Communists, the Khmer Rouge, who were fighting to topple the Phnom Penh government allied with the United States. When the Khmer Rouge captured Phnom Penh in 1975 and established their genocidal rule there, the capital was emptied. Ly Sovann’s family, like most others, was banished to the countryside.

  After the Vietnamese army ousted the Khmer Rouge from Phnom Penh four years later, he returned to the capital, where he went on to study medicine at a local college. This was a break with tradition. Like many Cambodians of Chinese ancestry, his was a family of merchants and traders. So was that of his future wife, and her relatives would later help support him as he pursued his medical passion. With few options for advanced study in Cambodia, he left for Bangkok, where he received a master’s degree in clinical tropical medicine. Once he returned, he joined the health ministry. He was promoted to director of disease surveillance after distinguishing himself during the SARS outbreak by crafting an aggressive national response.

  That was when he began devising an epidemic alert system tailored for austerity. Ly Sovann told me he realized the one thing Cambodia had going for it was cell phones. They were in wide use because landlines were so rare, and cellular coverage had already reached two-thirds of the country. He’d taken advantage of this rare asset, he told me. Reaching backward to a bulletin board, he pulled down the roster of names and phone numbers he’d been compiling since SARS. The stapled sheets, worn and smudged with fingerprints, listed contacts for scores of health-care workers in Cambodia’s cities and all twenty-four provinces. He had cobbled this network together with little more than charisma and
extensive personal contacts. “He just knows everybody,” a doctor in the local WHO office said to me. But calls cost money. He didn’t have enough even to buy gas for his investigators’ motorbikes, much less pay their salaries on time. So Cambodia applied for ten thousand dollars from foreign donors to purchase prepaid phone cards to allow local health workers to report suspicious respiratory cases that could be flu.

  The effort stumbled at the start. Local doctors missed what would be Cambodia’s first confirmed case of avian flu. It would have been overlooked altogether if the victim’s family had not brought the twenty-four-year-old woman across the border for treatment in Vietnam, where the health system was more advanced. Though Vietnamese doctors could not save her, they did identify the virus. This first reported case in January 2005 drew intense international concern and several weeks later brought me to Cambodia’s southern Kampot province.

  When I arrived, I discovered that the woman was not the only one in her family who’d been stricken. I tracked down her father squatting in a sandy lot by the side of the road. With a homemade sledgehammer, he was pounding into place the wooden foundation of a new house. He was barefoot, and his narrow eyes squinted in the sun. He wasn’t sure what was cursing his home in the parched rice fields across the road, but cursed it was. He had also lost a teenage son, he told me, and two others in his family had fallen ill.

  The man, Uy Ngoy, related that his fourteen-year-old son was the first to get sick, complaining of a fever, diarrhea, and trouble breathing. The boy was brought to a storefront clinic with peeling paint and muddy tile floors in the local town. The clinician took the boy’s temperature and blood pressure. His condition continued to deteriorate. Two days later, suspecting that the disease was somehow caused by an affront to the spirits, the clinician sent the boy home so his family could pray to their ancestors. The boy died soon after.