To confirm that Lam Hoi-ka had died of bird flu, and that the sample had not become contaminated, all the tests were run again. The laboratory in Hong Kong still had samples of Lam Hoi-ka’s throat wash, and these were tested. The result was the same: bird flu.
Now that two different teams, de Jong’s in Utrecht and Cox’s in Atlanta, had confirmed that Lam Hoi-ka died of bird flu, it was vital to find out how he had become infected. Dr Keiji Fukuda, a colleague of Cox’s, maintained that according to his research, a human being had never been infected with bird flu before.7 This was regardless of the research being conducted by Taubenberger in the United States. If this was bird flu, he asked, was it unique, ‘or was there a new epidemic brewing?’8 It was impossible to think of an influenza pandemic without invoking the spectre of Spanish flu.
In order to determine how Lam Hoi-ka had become infected, or whether his specimens had become contaminated in Hong Kong, a team of scientists from the World Health Organization arrived in Hong Kong, including Fukuda and pre-eminent bird flu expert Robert Webster.
Fukuda and his colleagues carried out a meticulous examination of conditions at the Queen Elizabeth Hospital in Kowloon, inspecting the health of the staff who had cared for Lam Hoi-ka, the equipment used to treat him and the health status of any fellow patients. Next, Wilina Lim’s government laboratories were investigated, but once again, Fukuda and his colleagues found nothing amiss, concluding that ‘the government labs were very clean, very well organized’.9 Lim and her team had clearly done everything to minimize contamination. Fukuda spoke to Lam Hoi-ka’s doctor, who confirmed that Lam had been a normal healthy little boy with nothing in his medical history to suggest such a tragedy. The next step was to discover how and when Lam had been exposed to the H5 virus. Had he visited a farm, or mixed with a schoolmate whose family were poultry workers? Again, the investigation drew a blank until it was discovered that his school had played host to a clutch of baby chickens a few days before Lam’s death. The chicks had been placed in a pen under a lamp in a corner of the classroom, and the children were encouraged to hold them and even give them names. But the chicks had died within hours. Could these chicks have been the cause of Lam’s death from H5?10 Extensive tests failed to confirm the presence of H5N1, and yet those doomed chicks seemed to suggest the source of Lam’s fatal infection.11
Lam Hoi-ka’s death from the H5 virus was a medical mystery. But there appeared to be one grain of comfort in all this. Despite fears of a pandemic, the infection had not spread, and no other deaths from bird flu were reported. By September, Nancy Cox at the Center for Disease Control in Atlanta, Georgia, had concluded that Lam Hoi-ka’s death was an isolated incident. However, just before Thanksgiving, Cox received a phone call from Hong Kong telling her that additional cases of bird flu had been confirmed.12 The first of these was a two-year-old boy from Kennedy Town, in the north-west of Hong Kong Island, on 8 November. The boy was admitted to the Queen Mary hospital on 7 November, as he had a weak heart, but he recovered within two days and was discharged. A specimen from the boy’s nose and throat tested positive for H5.13 On 24 November, a thirty-seven-year-old man from Kowloon was admitted to Queen Elizabeth hospital with the new strain of influenza, and on 26 November a thirteen-year-old girl from Ma On Shan in the New Territories was admitted to the Prince of Wales Hospital with headaches, a cough and a fever.14 On 21 December, she died there. In Kowloon, a fifty-four-year-old man fell ill on 21 November and died of pneumonia at the Queen Elizabeth Hospital on 6 December.15
The sixth case was a twenty-four-year-old woman from Tsuen Wan, in the New Territories. She was admitted to hospital on 4 December after falling ill with dizziness and fever, and became so sick that she spent months on a respirator before being discharged the following April.16 Two other victims fell ill on 4 December, a five-year-old girl from Ap Lei Chau, just off the south side of Hong Kong Island, and a six-year-old girl from Kowloon.17 Both girls spent December in hospital, along with a ten-year-old boy from Tsuen Wan who came down with the symptoms on 10 December and a two-year-old boy from Ap Lei Chau.18 On 15 December, a nineteen-year-old girl from Tsuen Wan fell ill and started coughing up sputum; she was to spend almost six months in hospital.19
On 16 December, three people developed influenza: a baby boy from Kowloon and a baby girl from the New Territories both became unwell but survived; a woman of sixty did not, dying two days before Christmas.20 On 17 December, a twenty-five-year-old girl from Yuen Long fell ill, and died in January with acute respiratory distress and pneumonia; on the same day in Kowloon, a thirty-four-year-old woman suffered kidney failure and her lungs filled with fluid; she too died in January.21
The seventeenth victim was a girl of fourteen, who fell sick in Kowloon with influenza symptoms as well as histiocytosis, a disease of the bone marrow cells, on 23 December.22 Five days later a three-year-old boy presented with the same symptoms.23 By 28 December, eighteen people, including the first victim, Lam Hoi-Ka, had fallen victim to the mysterious new strain of influenza and six were dead or dying. A mortality rate of one in three was a terrifying prospect.24 An outbreak of bird flu was apparently under way, much to the horror of Dr Wilina Lim and her colleagues. ‘That month was terrible,’ she said. ‘It wasn’t clear where these viruses were coming from, but these people were getting sick, there were new cases day by day and we were really under a lot of stress.’25 In a state of panic, even those with the mildest symptoms laid siege to their doctors; Dr Lim’s laboratory was inundated with samples. And then the unthinkable happened. Dr Lim’s sixteen-year-old daughter fell ill with a sore throat. At first, Dr Lim suggested that her daughter was merely ‘swinging the lead’ in order to avoid her piano lesson. In normal circumstances, the doctor would have encouraged her daughter to get up and attend the lesson anyway. Instead, she told her daughter to stay in bed. ‘Because there was that worry. I was frightened. A lot of people were.’26 Mercifully, Dr Lim’s teenage daughter survived her attack of suspected bird flu.
Dr John LaMontagne, Mexican-born deputy director of the National Institute of Allergy and Infectious Diseases, learned about the outbreak during an official visit to India. ‘I had remembered that there was a case in May, but this was a six-month interval. The fact that it had come back after six months was very worrisome to me.’27 Was the outbreak about to replicate the chilling first and second waves of the 1918 Spanish flu pandemic? If so, medical scientists had no time to lose in coming up with a vaccine.
LaMontagne’s immediate response was to try to develop a vaccine in sufficient quantities to protect the entire world, if necessary – a massive logistical operation. Meanwhile, in Hong Kong, the number of cases increased. Eighteen people were hospitalized between November and the end of December. Eight patients had to be placed on respirators, and six died.28 Just as in 1918, it was mainly young adults who perished, a pattern chillingly reminiscent of Spanish flu. As LaMontagne negotiated with the drug companies to prepare a vaccine, and found them reluctant to do so in case their laboratories became infected with H5N1, the Australian virologist Kennedy Shortridge took a walk through the ‘wet markets’ of Hong Kong.
Every day, crates of live chickens arrived in Hong Kong from the Chinese countryside. They were sold in ‘wet markets’ in the centre of the city, and slaughtered in front of their buyers; the Hong Kong Chinese liked their birds fresh. Hygiene consisted of a brief wash down with cold water, and given that the virus grows in the chicken’s intestines, this was sufficient to cause an infection.29 While raw chicken is a notorious source of food poisoning such as salmonella, campylobacter and E. coli, the concept that humans could die of chicken influenza was another matter entirely.
On a walk through a wet market one morning, Shortridge, who had isolated the H5N1 virus in Asia, witnessed something that made his blood run cold. ‘We saw a bird standing up there, pecking away at its food, and then very gently lean over, slowly fall over, to lie on its side, looking dead. Blood was trickling from the cloaca. It was a very unreal,
bizarre situation. I had never seen anything like it.’30 After seeing the same thing happen to another chicken, and another, Shortridge concluded: ‘We were looking at chicken Ebola … When I saw those birds dying like that, it really hit home what might have happened in the 1918 pandemic. My God. What if this virus were to get out of this market and spread elsewhere?’31
It emerged that Hong King’s bird population had been blighted by bird flu for months. The first chickens died on a farm near the rural town of Yuen Long. The infection quickly spread to a second and then a third farm, each time with grisly results. One farmer recalled seeing his birds beginning to shake as thick saliva dripped from their mouths. The wattles on other birds turned green or black, giving the chickens the appearance of feathered zombies. Some hens started laying eggs that had no shells. Others fell dead on the spot, asphyxiated from blood clots lodged in their windpipes. By the time of Lam Hoi-ka’s death, nearly 7,000 birds had succumbed.32 It had, as Fukuda put it, happened not in the lab, but out in the wild.33
If the nightmare prospect of a bird flu epidemic was to be avoided, there could be only one solution. After learning that, despite previous measures, chickens at a farm in Yuen Long in the New Territories had tested positive for the virus and that a large number of chickens had died at the Cheung Sha Wan poultry wholesale market in Kowloon, possibly from the virus, Margaret Chan, Hong Kong’s then director of public health, closed the territory’s wet markets and initiated a mass poultry cull.34
Hong Kong’s Agriculture Department suspended the city’s daily import of 75,000 live chickens from mainland China and on 29 December 1997, Steven Ip, Secretary for Economic Services, announced that ‘we will start destroying all the chickens in Hong Kong Island, Kowloon Island, and the New Territories’.35
According to Elisabeth Rosenthal of the New York Times, this was a grisly operation, extreme, but necessary. An army of government clerks was mobilized across the territory to collect all the birds from 160 chicken farms as well as from more than 1,000 chicken wholesalers and retail chicken stalls. The birds were killed by market owners, or carted away by local authorities and euthanized with poison gas. Their corpses were disinfected, wrapped in plastic and taken to landfill sites. Geese and ducks that had been in close contact with the chickens were also killed.36
The slaughter of the innocents presented a biblical sight:
At 8 a.m. today, after receiving brief instructions from a blue-uniformed poultry inspector, the four workers at the outdoor store called Fai Chai Lam Cheung Kai set out to complete the morning’s grim task. Working with skilled bare hands, the workers lifted dozens of chickens, ducks, pigeons and quail out of stacked metal cages, arched back each bird’s neck, and deftly pulled a sharp knife over the veins and arteries. As blood oozed forth, they tossed the birds – a few with wings still flapping – into several large plastic garbage bins. The inspector said he would return later with disinfectant and plastic bags.
The store’s owner, Mr. Tam, who refused to give reporters his full name, remained surprisingly upbeat despite this horrific event.
‘We knew this would happen sooner or later and there’s good and bad to it,’ said Mr. Tam, as he slit a bird’s neck. ‘Hopefully it will calm people’s fears so business will pick up. But it will take three months to replace all my chickens, and how will I pay rent until then?’
Mr. Tam said his business had fallen by 90 percent in the last month and the government had promised him $3.87 for each chicken, but he normally sold them for twice as much.37
Hong Kong’s draconian response to the threat of bird flu appeared to have been successful, at least at the time. Subsequently, the World Health Organization has recorded 598 cases since 2003, with 352 deaths. Most deaths from bird flu are in Egypt, Indonesia, Vietnam and China. So far, the virus has not adapted to spread easily between humans.38 However, the resurgence of human infections in Thailand and Vietnam in 2003, followed by outbreaks on chicken farms across Asia, the Middle East and Eastern Europe in 2005, made H5N1 a household name and even inspired a blockbuster movie, Steven Soderbergh’s ‘bio-thriller’, Contagion.39
Tragic as it was, the Hong Kong bird flu outbreak of 1997 constituted a wake-up call for epidemiologists and public health authorities, allowing pandemic civil contingency plans to be put in place. In Great Britain, for instance, anyone who arrived at Heathrow Airport from Hong Kong with a respiratory infection during the 1997 outbreak was immediately quarantined. The Hong Kong outbreak also focused attention on the terrifying prospect of another pandemic on the scale of 1918.
‘This was the first time that there was evidence that a bird virus could actually infect a human and cause disease,’ commented Jeffery Taubenberger. ‘The two stories – the 1918 and the H5N1 bird flu story – have kind of intertwined with each other and so there was this enormous upsurge of interest in influenza. People were worried that what the H5N1 virus was doing was paralleling what 1918 did – causing high mortality in young people.’40
Meanwhile, virologist Professor John Oxford, a world expert on Spanish flu, saw the Hong Kong outbreak as ‘a dress rehearsal for the real thing’.41 While the Hong Kong H5N1 virus had been hitting the headlines worldwide, and Taubenberger’s team were attempting to sequence the genome behind the 1918 flu pandemic, Professor Oxford had been involved in another investigation. His task was to seek out the origins of the Spanish Lady in Spitzbergen, Norway.
CHAPTER TWENTY-THREE
SECRETS OF THE GRAVE
IN AUGUST 1998, while Hong Kong came to terms with the aftermath of the bird flu outbreak, and Jeffery Taubenberger’s team deciphered the origins of the 1918 pandemic from its victims, another group of ‘viral archaeologists’ set off for Spitsbergen Island in Norway’s Svalbard archipelago. Their mission was to recover tissue samples from the preserved bodies of miners buried in the permafrost of the Norwegian Arctic. Professor John Oxford, virologist at the Royal London Hospital Medical School, aimed to solve the riddle of the original Spanish flu epidemic in order to avoid such outbreaks in the future. In other words, how did the avian strain of flu leap the species barrier to mutate into the virus of 1918? The Hong Kong H5N1 outbreak of 1997 had lent the issue a new urgency.
Professor Oxford had become involved with the project after being approached by Dr Kirsty Duncan, a Canadian geologist who developed a fascination with the Spanish flu pandemic after reading Alfred Crosby’s book on the subject at the age of twenty-six in 1993. ‘I said to my family, “I’m going to find out what caused this.”’1 Following five years of painstaking research, Duncan had pinpointed a graveyard in Longyearbyen, a small coal-mining town on Spitsbergen Island. It was here, in 1918, that the bodies of seven miners had been buried in the Arctic permafrost, and Duncan believed their remains might provide clues to the origins of the Spanish Lady. Having been introduced to Jeffery Taubenberger, Duncan hoped he would lend his expertise to the Spitsbergen expedition. However, just as the Spitsbergen expedition was about to leave, the breakthrough in Taubenberger and Hultin’s research occurred, and he decided to withdraw from the project, much to Duncan’s dismay.2
The Spitsbergen expedition included Professor Oxford, bird flu expert Dr Robert Webster, and Dr Rod Daniels of the National Institute for Medical Research at Mill Hill, an influenza expert with experience of working with highly contagious viruses in Category Four laboratories.3 Professor Oxford’s wife Gillian and their daughter Esther also joined the team, and Esther Oxford provided a vivid account of subsequent events for the Independent newspaper.
Daniels and Oxford had been working together to analyse lung tissue samples from victims of the 1918 influenza epidemic stored at the Royal London Hospital. Unfortunately, according to Esther Oxford, ‘the samples were preserved in formalin which made it impossible to extract an accurate “footprint” of the genetic structure of the 1918 virus. The point of the Svalbard project was to find fresh tissue samples which had not been affected by chemical treatment.’4
‘If we identify t
he “deadly motif”, we will be able to target that gene in the development of new anti-viral drugs,’ said Professor Oxford.5 This meant that any future outbreak of a similarly lethal virus could be effectively controlled:
Once we know which part of the virus causes morbidity, then when a new influenza virus arises unexpectedly, like the one in Hong Kong, the first thing you do is look at the genes in that new virus and say to yourself, ‘How do those genes compare to the 1918 genes?’ If you see they are exactly the same, you are in trouble. That would be the moment to pour resources into preventing a pandemic. If on the other hand, you find that the genetic structure is not related, you can relax a little bit.6
Excavating the miners’ bodies would be the task of the London Necropolis Company, a professional exhumation team originally founded in 1852,7 and now empowered to exhume and rebury human remains at sites where new roads, housing or commercial developments were planned.8
When Dr Kirsty Duncan had set out to find remains of Spanish flu victims in the Norwegian permafrost, she had not undertaken an easy task. There were no medical records dating back to 1918, the hospital having been destroyed. Neither were there parish records, as the first pastor did not arrive until 1920, and there were no government records, as Svalbard only became part of Norway in 1925. But, through research, Duncan discovered that there were diaries, written by the chief engineer of a coal-mining company. These diaries were in the custody of a local schoolteacher, and he agreed to translate them. From the diaries, the graves of seven miners were identified with ground-penetrating radar. Their remains were buried at the foot of the mountains in the ‘freezing, windy valley of Longyearbyen’.9
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