by Alan Sipress
75 The government pressed: Robin Ajello and Catherine Shepherd, “The Flu Fighters,” Asiaweek, Jan. 2008.
75 bloody chaos: Billy Wong Wai-Yuk, “Tears of Anger, Rivers of Blood,” South China Morning Post, Dec. 30, 1997; Stella Lee, “Slaughter Held Up by Inexperience,” South China Morning Post, Dec. 31, 1997; Keith B. Richburg, “Chicken Sightings Frighten Hong Kong, Washington Post, Jan. 3, 1998; and Keith B. Richburg, “Hong Kong Faulted on Handling of ‘Bird Flu’ Crisis, Washington Post, Jan. 4, 1998.
76 On the third day of the slaughter: “Tung Handling of Flu Crisis Attacked,” South China Morning Post, Jan. 1, 1998.
76 In a front-page editorial: “Only Time Will Prove Wisdom of Dramatic Move,” South China Morning Post, Dec. 29, 1997.
76 the “botched” operation: “Taking Charge,” South China Morning Post, Jan. 3, 1998.
76 nearly 350 chickens: Kennedy F. Shortridge, “Poultry and the Influenza H5N1 Outbreak in Hong Kong, 1997: Abridged Chronology and Virus Isolation,” Vaccine 17 (1999): s26-s29.
76 more widespread than expected: Kennedy F. Shortridge et al., “Characterization of Avian H5N1 Influenza Viruses from Poultry in Hong Kong,” Virology 252, no. 2 (Dec. 20, 1998): 331-42.
77 a pandemic had been averted: Kennedy F. Shortridge, J. S. Malik Peiris, and Yi Guan, “The Next Influenza Pandemic: Lessons from Hong Kong,” Journal of Applied Microbiology 94 (2003): 70S-79S.
77 its most successful: Several researchers have held up Hong Kong as the model. See, for example, Robert Webster and Diane Hulse, “Controlling Avian Flu at the Source,” Nature 435 (May 26, 2005): 415-16. Yet the model may be hard to apply elsewhere. See Les Sims, “Achievements, Issues and Options on Strategies for HPAI Control and Prevention,” Background Paper at the Technical Meeting on Highly Pathogenic Avian Influenza and Human H5N1 Infection, June 27-29, 2007, Rome.
78 Their main exposure: Anthony W. Mounts et al., “Case-Control Study of Risk Factors for Avian Influenza A (H5N1) Disease, Hong Kong, 1997,” Journal of Infectious Diseases 180 (1999): 505-8.
78 would resurface in 2001: On this outbreak and Hong Kong’s response, see Yi Guan et al., “Emergence of Multiple Genotypes of H5N1 Avian Influenza Viruses in Hong Kong SAR,” PNAS 99, no. 13 (June 25, 2002): 8950-55; and N. Y. Kung et al., “The Impact of a Monthly Rest Day on Avian Influenza Virus Isolation Rates in Retail Live Poultry Markets in Hong Kong,” Avian Diseases 47 (2003): 1037-41.
78 the virus struck yet again: For an overview of the poultry outbreaks in 2001- 2002, see L. D. Sims et al., “Avian Influenza in Hong Kong 1997-2002,” Avian Diseases 47, no. s3: 832-38; L. D. Sims et al., “An Update on Avian Influenza in Hong Kong 2002,” Avian Diseases 47 (2003): 1083-86; and Kennedy F. Shortridge, J. S. Malik Peiris, and Yi Guan, “The Next Influenza Pandemic: Lessons from Hong Kong,” Journal of Applied Microbiology 94 (2003): 70S-79S.
Chapter Three: The Elephant and the Lotus Leaf
This chapter draws on interviews with WHO infectious disease specialists and other officials in both Geneva and Asia, public health officials and medical professionals in Thailand, and internal documents from WHO.
81 “Influenza has been an epidemic illness”: Prasert Thongcharoen, Influenza (Bangkok: Mahidol University, 1998).
82 blame the spiraling death toll on the weather: Newin Chidchob, deputy agriculture minister, is quoted in “Thailand Declared Free of Bird Flu,” Nation (Thailand), Jan. 15, 2004. Yukol Limlamthong, director-general of the Livestock Department, is quoted in “Bird Flu: Govt to Sue over ‘False Report,’” Nation (Thailand), Jan. 17, 2004.
85 researchers had confirmed: Arthit Khwankhom and Sirinart Sirisunthorn, “Govt Ignored Chula Warning,” Nation (Thailand), Jan. 30, 2004.
86 “We were fighting”: “What Happened When the H5N1 Virus Visited Thailand,” lecture at the Asia Medical Forum, Lancet 2006, Singapore, May 4, 2006.
87 “Irresponsible media”: Tini Tran, “WHO Says SARS Helped Asia Prepare for Bird Flu; Poultry Culls Continue,” Associated Press, Jan. 16, 2004.
87 “There’s absolutely no evidence”: Alisa Tang, “Thai Cabinet Seeks to Boost Confidence of Chicken-Wary Public,” Associated Press, Jan. 19, 2004.
88 a confidential tip: Internal WHO report, Jan. 20, 2004.
90 broader resurgence of infectious disease: For an excellent exploration of what was optimistically called the Health Transition and subsequent setbacks, see Laurie Garrett, The Coming Plague (Penguin: New York, 1995).
91 Storm clouds were gathering: See, for example, David L. Heymann and Guenael R. Rodier, “Hot Spots in a Wired World: WHO Surveillance of Emerging and Re-emerging Infectious Diseases.”
91 WHO’s rapid response: David L. Heymann and Guenael Rodier, “Global Surveillance, National Surveillance and SARS: Commentary,” Emerging Infectious Diseases 10, No. 2 (Feb. 1, 2004); and David L. Heymann, Mary Kay Kindhauser, and Guenael Rodier, “Coordinating the Global Response,” in SARS: How a Global Epidemic Was Stopped (Manila: WHO Western Pacific Regional Office, 2006).
93 Subsequent study: Kulkanya Chokephaibulkit et al., “A Child with Avian Influenza A (H5N1) Infection,” Pediatric Infectious Disease Journal 24, no. 2 (Feb. 2005): 162-66; and Mongkol Uipprasertkul et al., “Influenza A H5N1 Replication Sites in Humans,” Emerging Infectious Diseases 11, no. 7 (July 2005): 1036-41.
94 followed right behind: For a synopsis of Thailand’s experience with avian flu in 2004, see Thanawat Tiensin, et al., “Highly Pathogenic Avian Influenza H5N1, Thailand, 2004,” Emerging Infectious Diseases 11, no. 11 (Nov. 2005): 1664-72.
95 “It’s not a big deal”: Sutin Wannabovorn, “Thailand Confirms Two Human Cases of Bird Flu as Infection spreads Through Asia,” Associated Press, Jan 23, 2004.
97 teams were running short: Tipawayan Kwankhauw, “Anger and Tears as Thailand’s Farmers Cull Millions of Chickens,” Agence France Presse, Jan. 25, 2004.
100 mixing vessel: See, for instance, S. Scholtissek et al., “The Nucleoprotein as a Possible Major Factor in Determining Host Specificity of Influenza H3N2 Viruses,” Virology 147 (1985) 287-94; H. Kida et al., “Potential for Transmission of Avian Influenza Viruses to Pigs,” Journal of General Virology 75, no. 9 (Sept. 1994): 2183-88; and Ian H. Brown, “The Epidemiology and Evolution of Influenza Viruses in Pigs,” Veterinary Microbiology 74, nos. 1-2 (May 22, 2000): 29-46.
101 “Are the doctor and the media”: “PM Derides Doctor over Pig Comments,” Nation (Thailand), Jan. 28, 2004.
Chapter Four: Into the Volcano
This chapter draws on interviews with current and former infectious-disease specialists, investigators, and other officials at WHO and CDC in the United States, Geneva, and Asia, with Vietnamese, Thai, and Hong Kong disease specialists, and on documents from WHO and CDC and personal notes kept by participants in the events described.
104 When SARS broke out: The results of the outbreak investigation in Vietnam are discussed in Hoang Thu Vu et al., “Clinical Description of a Completed Outbreak of SARS in Vietnam, February-May 2003,” Emerging Infectious Diseases 10, no. 2 (Feb. 2004): 334-38; and Mary G. Reynolds et al., “Factors Associated with Nosocomial SARS-CoV Transmission Among Healthcare Workers in Vietnam, 2003,” BMC Public Health 6 (2006): 207.
109 The flu outbreak that began that fall: For more discussion, see Niranjan Bhat et al., “Influenza-Associated Deaths Among Children in the United States, 2003-2004,” NEJM 353, no. 24 (Dec. 15, 2005): 2559-67; and Laura Jean Podewils et al., “A National Survey of Severe Influenza-Associated Complications Among Children and Adults, 2003-2004,” Clinical Infectious Diseases 40 (June 1, 2005):1693-96.
109 flooded with the infirm: See, for example, Rob Stein, “Shortage of Flu Shots Prompts Rationing,” Washington Post, Dec. 9, 2003; Rob Stein, “24 States Hit Hard by Flu Outbreak,” Washington Post, Dec. 12, 2003; and Anita Manning and Tom Kenworthy, “Flu and Fear Run Rampant,” USA Today, Dec. 10, 2003.
109 give up their beds: “Influenza: Last Bad Flu Season Killed Nearly 65,000; Will This Season
Be Worse?” Drug Week, Jan. 2, 2004.
109 made its first recorded appearance: Alfred W. Crosby, America’s Forgotten Pandemic: The Influenza of 1918, 2nd ed. (New York: Cambridge University Press, 2003), 71.
109 sailors transferred days earlier: John M. Barry, The Great Influenza: The Epic Story of the Deadliest Plague in History (Viking Penguin: New York, 2004), 192.
110 Fourth Annual Liberty Loan parade: Philadelphia Inquirer, Sept. 29, 1918.
110 an old photograph: www.history.navy.mil/photos/images/h41000/h41730.jpg.
110 every hospital bed: Barry, Great Influenza, 220.
110 “When they got there”: Selma Epp, transcript of unaired interview for “Influenza 1918,” American Experience, Feb. 28, 1997, quoted in Barry.
110-11 “historic records of the plague”: Ellen C. Potter, letter to Miss M. Carey Thomas, Oct. 3, 1918, M. Carey Thomas Papers, Special Collections Department, Bryn Mawr College.
111 254 deaths in a single day: Barry, Great Influenza, 221.
111 daily toll was 759: Ibid., 329.
111 “none to replace them in the wards”: Francis Edward Tourscher, Work of the Sisters During the Epidemic of Influenza, October, 1918 (Philadelphia: American Catholic Historical Society, 1919), p. 18, accessed through Villanova University Digital Library Browser, reprinted from the Records of the American Catholic Historical Society of Philadelphia 30s, nos. 1-3 (Mar.-Sept. 1919).
111 Almost half the doctors and nurses: Barry, Great Influenza, 226.
111 “had no attention for over 18 hours”: Tourscher, Work of the Sisters, 18.
111 “After gasping for several hours”: Ira Starr, “Influenza in 1918: Recollections of the Epidemic in 1918,” Annals of Internal Medicine 145, no. 2 (July 18, 2006).
111 at the poorhouse: Tourscher, Work of the Sisters, 50.
112 the residence of a wealthy family: Ibid., 62.
112 cars bearing medical insignia: Starr, “Influenza in 1918.”
112 so they could help fill prescriptions: Eileen A. Lynch, “The Flu of 1918: It Started with a Cough in the Summer of 1918,” Pennsylvania Gazette, Nov. 1998.
112 Nearly 500 police officers: Philadelphia Inquirer, Oct. 20, 1918.
112 About 1,800 telephone employees: Barry, Great Influenza, 328.
112 “no other than absolutely necessary calls”: Philadelphia Inquirer, Oct. 18, 1918.
112 one Fishtown home: Tourscher, Work of the Sisters, 74.
112 During the second week: Great Britain Ministry of Health, Report on the Pandemic of Influenza 1918-1919, Reports on Public Health and Medical Subjects no. 4 (London: His Majesty’s Stationery Office, 1920), 319-20, quoted in Crosby, America’s Forgotten Pandemic.
112 abandoned corpses were stacked: “Emergency Service of the Pennsylvania Council of National Defense in the Influenza Crisis,” 35, quoted in Crosby, America’s Forgotten Pandemic.
113 piling up on the porches: Harriet Ferrell, transcript of unaired interview for “Influenza 1918,” American Experience, Feb. 28, 1997, quoted in Barry, Great Influenza.
113 “The smell would just knock you”: Interview by Charles Handy for WHYY-FM program “The Influenza Pandemic of 1918: Philadelphia, 1918.”
113 “They were taking people out”: Ibid.
113 “They had so many died”: Ibid.
113 dispatched a steam shovel: “Emergency Service of the Pennsylvania Council of National Defense in the Influenza Crisis,” 35, quoted in Crosby, America’s Forgotten Pandemic; and the Philadelphia Inquirer, Oct. 12, 1918.
113 people were stealing them: Michael Donohue, transcript of unaired interview for “Influenza 1918,” American Experience, Feb. 28, 1997, quoted in Barry, Great Influenza.
113 under armed guard: Barry, Great Influenza, 327.
113 12,897 Philadelphians: Great Britain Ministry of Health, Report on the Pandemic , 319-320, quoted in Crosby, America’s Forgotten Pandemic.
113 “It was the fear and dread”: Tourscher, Work of the Sisters, 105.
114 tremendous financial pressure: One-third of hospitals were reported to be operating at a deficit. See John G. Bartlett and Luciano Borio, “The Current Status of Planning for Pandemic Influenza and Implications for Health Care Planning in the United States,” Clinical Infectious Diseases 46 (Mar. 15, 2008): 919-25.
114 Hospitals have been closing: Neil A. Halpern, Stephen M. Pastores, and Robert J. Greenstein, “Critical Care Medicine in the United States 1985-2000: An Analysis of Bed Numbers, Use, and Costs,” Critical Care Medicine 32, no. 6 (June 2004): 1254-59. Between 1993 and 2003, the United States saw a net loss of 703 hospitals, or 11 percent, and a decline in inpatient beds of 198,000 or 17 percent. See American Hospital Association figures cited in Institute of Medicine, Hospital-Based Emergency Care: At the Breaking Point (Washington: National Academies Press, 2007), 38. Sixty percent of U.S. hospitals reported in 2001 that they were operating at or over capacity. See the Lewin Group, Emergency Department Overload: A Growing Crisis, the results of the AHA Survey of Emergency Department (ED) and Hospital Capacity.
114 vacant ICU beds were rare: Lewis Rubinson et al., “Augmentation of Hospital Critical Care Capacity After Bioterrorist Attacks or Epidemics: Recommendations of the Working Group on Emergency Mass Critical Care,” Critical Care Medicine 33, no. 10 (2005): 2392-2403. In a severe pandemic, the demand for these ICU beds could outstrip capacity by nearly five times. See Eric Toner et al., “Hospital Preparedness for Pandemic Influenza,” Biosecurity and Bioterrorism 4, no. 2 (2006): 207-14. Even in a moderately severe outbreak, half the states would run out of hospital beds within two weeks. See Trust for America’s Health, Ready or Not? Protecting the Public’s Health from Diseases, Disasters and Bioterrorism, Dec. 2006.
114 a severe nursing shortage: See Elizabeth Daugherty, Richard Branson, and Lewis Rubinson, “Mass Casualty Respiratory Failure,” Current Opinion in Critical Care 13, no. 1 (Feb. 2007): 51-56; Derek C. Angus et al., “Current and Projected Workforce Requirements for Care of the Critically Ill and Patients with Pulmonary Disease,” Journal of the American Medical Association 284, no. 21 (Dec. 6, 2000): 2762-70; Mark A. Kelley et al., “The Critical Care Crisis in the United States: A Report from the Profession,” Chest 125 (2004): 1514-17; Gary W. Ewart et al., “The Critical Care Medicine Crisis: A Call for Federal Action,” white paper from the Critical Care Professional Societies, Chest 125 (2004): 1518-21; and J. K. Stechmiller, “The Nursing Shortage in Acute and Critical Settings,” AACN Clinical Issues 13, no. 4 (Nov. 2002): 577-84. The nationwide shortage of nurses has been estimated at between 100,000 and 291,000. All but ten states had a shortage of registered nurses in 2006. See John G. Bartlett and Luciano Borio, “The Current Status of Planning for Pandemic Influenza and Implications for Health Care Planning in the United States,” Clinical Infectious Diseases 46 (Mar. 15, 2008): 919-25; and Trust for America’s Health, Ready or Not? Protecting the Public’s Health from Diseases, Disasters and Bioterrorism, Dec. 2006.
114 Emergency rooms are being shuttered: Eric W. Nawar, Richard W. Niska, and Jianmin Xu, “National Hospital Ambulatory Medical Care Survey: 2005 Emergency Department Summary,” advance data from Vital and Health Statistics, no. 386, June 29, 2007. For a comprehensive overview of the crisis facing U.S. emergency departments, see Institute of Medicine, Hospital-Based Emergency Care: At the Breaking Point (Washington: National Academies Press, 2007). According to figures from the American Hospital Association cited in the IOM report, the number of hospitals with emergency departments declined by 425 over the decade ending in 2003.
114 departments were routinely overcrowded: “State of Emergency Medicine: Emergency Physician Survey,” American College of Emergency Physicians, October 2003. Sixty-two percent of U.S. hospitals surveyed in 2001 said their emergency departments were operating at or over capacity. For large hospitals and those offering the most advanced trauma care, the percentage increased to about 90 percent. See the Lewin Group, Emergency Department Overload: A Growing Crisis, results of the AHA Surv
ey of Emergency Department (ED) and Hospital Capacity, Apr. 2002. As the IOM writes, “In many cities, hospitals and trauma centers have problems dealing with a multiple-car highway crash, much less the volume of patients likely to result from a large-scale disaster.” Institute of Medicine, Hospital-Based Emergency Care, 265.
114 once every single minute: Catharine W. Burt, Linda F. McCaig, and Roberto H. Valverde, “Analysis of Ambulance Transports and Diversions Among U.S. Emergency Departments,” Annals of Emergency Medicine 47, no. 4 (2006): 317-26. See also Sally Phillips, “Current Status of Surge Research,” Academic Emergency Medicine 13 (2006): 1103-8.
114 hospital executives were too preoccupied: “Emergency Preparedness: States are Planning for Medical Surge, but Could Benefit from Shared Guidance for Allocating Scarce Medical Resources,” U.S. Government Accountability Office, June 2008.
114 decreased 18 percent: Ibid.
114 producers of medical oxygen: Michael D. Christian et al., “Definitive Care for the Critically Ill During a Disaster: Current Capabilities and Limitations,” Chest 133, no. 5 (May 2008): 8S-17S.
114 tremendous shortage of ventilators: Ibid.; and Isaac Weisfuse, “Summary Background on Hospital Pandemic Preparedness in NYC,” in Beth Maldin-Morgenthau et al., “Roundtable Discussion: Corporate Pandemic Preparedness,” Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 5, no. 2 (2007): 171.
115 about 740,000 people would require ventilation: “States are Planning for Medical Surge,” U.S. Government Accountability Office, June 2008.
115 between 53,000 and 105,000: Michael T. Osterholm, “Preparing for the Next Pandemic,” NEJM 352, no. 18 (May 5, 2005): 1839-42; and Elizabeth Daugherty, Richard Branson, and Lewis Rubinson, “Mass Casualty Respiratory Failure,” Current Opinion in Critical Care 13, no. 1 (Feb. 2007): 51-56. A study by New York State found that even in a moderate pandemic, there would be a state-wide shortfall of 1,256 ventilators. In a severe pandemic, the total demand for ventilators in peak weeks would run to 17,844, almost three times the existing capacity. See NYS Working Group on Ventilator Allocation in an Influenza Pandemic, NYS DOH/NYS Task Force on Life and the Law, “Allocation of Ventilators in an Influenza Pandemic: Planning Document,” Mar. 15, 2007.
