The Fatal Strain (36 page)

If they did so, the economic fallout could be tremendous. Though
the blow would fall hardest on Vietnam, decimating tourism and trade, the whole region could suffer. Multinational companies might suspend their operations. Foreign governments might evacuate their nationals. Airlines might cancel routes, leaving countries isolated and visitors marooned. Stock markets would plunge. These reverberations would be felt worldwide. Yet the danger of waiting to sound the alarm might be catastrophic.

The quandary was compounded by gaps in the evidence. The scientific data were incomplete and contradictory in places. So the flu hunters were forced to make pivotal decisions with only a partial view of the truth. In battling this virus, science has time and again failed to provide the solid answers needed to decipher the pathogen and keep it in the box. Since the last flu pandemic in 1968, the revolutionary field of microbiology has indeed succeeded in breaking the genetic code of the microbes that menace us. But laboratory science has still failed to unlock the secrets of how this mercurial agent evolves and mutates, how it strikes its human prey and when.

This presents a different kind of challenge than those that stem from the Asian landscape. The limits of current science in understanding and disarming the disease are largely independent of the realities on the ground, whether there or elsewhere along the expanding frontier of viral spread.

Nor are scientific constraints the only ones. Both sides of the man-versus-microbes equation pose difficulties. On one side, global efforts to contain flu are hamstrung because WHO and other human health agencies focus on the people afflicted by the disease, at times to the exclusion of the animals that are the source. In addition, money is tight. The resources that frontline states need to identify, contain, and ultimately eradicate the disease among both people and livestock are running short. On the other side of the equation, the essence of the virus itself often eludes disease investigators, whether in the lab or the field.

So on a Friday afternoon in June 2005, WHO’s flu team secretly convened in the agency’s underground command center in Geneva, linked by a dedicated communications network with some of the
world’s most elite medical specialists from Atlanta and London to Tokyo, Manila, and Canberra, and prepared to gamble.

 

 

 

Something odd was happening outside of Hanoi. Within a few weeks of one another, three separate clusters of bird flu cases had appeared in a single province southeast of the capital. One of the largest included Tuan and his sister, their grandfather, and a local nurse.

Thai Binh province, where Tuan grew up, is mostly a flat plain of lakes and emerald paddies, part of Vietnam’s rice basket. After Tuan had finished his schooling, he left Thai Binh to look for work in the seaport of Haiphong. Many in the West know Haiphong because of President Richard Nixon’s decision to mine its harbor during the Vietnam War. But today this port city at the mouth of the Red River Delta flourishes as northern Vietnam’s premier industrial center, and there Tuan found a job collecting seaweed for producing agar, a gelatin used in local cuisine.

In early February 2005, all Vietnam took a breather for the Tet holiday. Across the country, Vietnamese bought new clothes, cleaned, repaired, and even repainted their homes, and decorated them with small kumquat trees, pink peach blossoms, and yellow apricot blooms. They stocked up on
banh chung,
or pork cakes, and on candied fruit and other traditional delicacies. Then they invited the spirits of their ancestors to join them in marking the lunar New Year. Sons and daughters who had moved to the cities crammed trains and buses, streaming home to celebrate this extended festival with their relatives. Tuan joined this mass migration. He headed back to the remote village in Thai Binh he had left more than a year earlier and ambled down the dirt alley to his family home, a one-room brick dwelling with a cement floor built beside a creek. Just outside the front gate, ducks paddled in the murky water as they had since his childhood. On the opposing bank, a verdant field of tobacco stretched into the distance. For the reunion, his family bought a chicken in the local market and butchered it in the yard. Tuan’s fourteen-year-old sister, Nguyen Thi Ngoan, clasped the bird’s wings and legs. Tuan slit its throat. The chicken was likely infected. Soon the siblings were, too.

Tuan broke into a fever about four days later, his wizened father told me over a cup of tea. When I arrived, Nguyen Sy Nham, the family patriarch, was visibly exhausted. For weeks he had been commuting by bus to the Hanoi hospital seventy-five miles away, keeping vigil for hours at a time on a plastic stool at the foot of his son’s cot. Yet Nham offered me a carved wooden chair at his table, turned down the volume on the television, and, between puffs on his traditional
dieu bat
bowl pipe, softly shared his family’s ordeal.

Tuan’s fever had lasted for about two days and then subsided, his father recounted. Tuan took some aspirin, had a bath, and felt better. But the fever soon returned and spiked at 104 degrees. His head throbbed. His chest ached. He started coughing and had trouble breathing. A village medic was summoned, and Tuan was taken to the local health center, where X-rays showed a white smudge in his left lung. The center’s deputy director suspected it was severe pneumonia. Because bird flu had previously been identified in the area, Tuan was transferred to a larger hospital in the provincial capital after less than a day. There the doctors concluded he had indeed contracted bird flu and immediately rushed him to the tropical disease institute at Bach Mai Hospital.

By the time he made it to Hanoi, the X-rays showed the white smudge had clouded the entire lung. Soon it consumed the other one also. “Just from the morning to the evening and from one day to the next day, it spread very quickly,” recalled Dr. Nguyen Thi Tuong Van, deputy director of the Bach Mai Hospital ICU. The doctors gave him oxygen to ease his breathing, but it continued to grow more labored. After ten days they inserted a tube down Tuan’s throat and hooked him to a mechanical ventilator. The infection marched on, damaging his kidneys and liver. The pain was excruciating. “We thought it was very likely the bird flu would kill him. We were very pessimistic,” Van continued. “Then, when it seemed the situation couldn’t get much worse, it started to get better. Two weeks later, when he didn’t die, I thought maybe we could cure him.”

Tuan’s kid sister, Ngoan, helped care for him during the early days of his sickness. Researchers who later studied the genetic signature of the pathogen concluded that Ngoan may have caught the bug from her
brother, noting that some genes in her virus were practically identical to his. By the time I met Ngoan at her home, she was fully recovered. A tall, somewhat gangly teen with a mane of black hair falling to the small of her back, she bubbled over with nervous energy. She told me she loved badminton, chess, and drawing. Her eyes were narrow, but in rascally moments or when feigning surprise, she’d open them wide, big and black. When her father hesitated in retelling the tale, she’d prod him with a playful slap on the leg or she’d interject with details of her own.

Ngoan said she fell ill several days after her brother. “I felt some pain in my legs and some chills,” she recounted. “I started coughing a little.” At the district health center, X-rays revealed her lungs were clear but a subsequent test came back positive for bird flu. She was quickly transferred to the Hanoi hospital, where her fever ascended to searing levels. “I felt so tired because I had so many injections and I couldn’t sleep much,” she recalled. Hospital staff moved her to the same room as her brother and the pair bantered as always to keep up their spirits, until Tuan could no longer speak. Ngoan’s older sister brought her a pad and a pen. Ngoan, who would always draw people when she was feeling down, sketched the doctors and nurses to ease her mind.

After four days, her fever broke. It returned to normal within two weeks. Barely a month after she got sick, she was back in school as something of a local celebrity.

Though the grandfather also contracted the virus, he objected that he had never felt sick and indeed had shown no symptoms. Vietnamese health officials happened across the old man’s infection while testing all the family members. To flu specialists, this was more evidence that the virus was experimenting with new, deceptive paths of infection. Though the man might not feel sick, he could possibly be contagious and, if so, how would anyone know to steer clear of him?

The nurse was the most disquieting case of all. Nguyen Duc Tinh was a tall, skinny twenty-six-year-old with an earnest manner and a whisper of a mustache. He was on duty at the local health center when Tuan was brought in. During the brief, overnight stay, Tinh took
Tuan’s blood and temperature, gave him injections, and helped him walk. Within a week, Tinh had developed severe muscle aches, eye pain, and a high fever, symptoms of what he believed was ordinary flu. But when the fever subsided only to return two days later, he grew alarmed.

“Then I suspected I had bird flu,” he recalled, his brown eyes widening. “I was really, really afraid of dying.” But just two weeks after being reunited with Tuan in the Hanoi hospital, Tinh was discharged. “I had lost hope when the fever came a second time. When I returned to my hometown, I felt as if I were born again.”

Vietnamese officials were loath to admit he might have caught the disease by caring for Tuan. This could be an admission that a more dangerous strain was taking hold. They offered a raft of possible explanations for how Tinh got sick: He had sick chickens in his village. There were sick chickens at his girlfriend’s home. He’d eaten a sick chicken. He had eaten it at his girlfriend’s home.

Tinh dismissed them all with a snicker. “I haven’t had any direct contact with poultry or eaten chicken or duck in a long time,” he countered. Nor had he dined at his girlfriend’s house for weeks before he fell ill, and, thank you very much, all her chickens were healthy. “But,” he added, “I was the one in the health center who had the closest contact with Mr. Tuan.”

 

 

 

A rare voice of candor among Vietnamese officials was Dr. Nguyen Tran Hien, the astute and able head of the National Institute of Hygiene and Epidemiology (NIHE), the country’s CDC. He told me in April of that year that his researchers had identified a significant number of mild and even asymptomatic cases, like Tuan’s grandfather. “The symptoms are not as severe as before. Also, the transmission may be faster and easier,” he reported. “We are concerned that if the virus is changing, maybe a new virus is coming in the future.” Hien wanted more data. And he wanted outside expertise.

Keiji Fukuda returned to Hanoi in mid-April 2005 as part of a special WHO mission. Fukuda was still with the CDC in Atlanta and
would not officially transfer to WHO for several more months. But his standing and experience in Vietnam made him a natural for the assignment. Joining him was Dr. Aileen Plant, a fellow epidemiologist from Curtin University of Technology in western Australia known for her passion and wicked sense of humor. Plant had headed WHO’s highly successful response to SARS in Vietnam two years earlier. The third member was Dr. Lance Jennings, a virologist from the Canterbury Health Laboratories in New Zealand and his country’s acknowledged authority on flu.

For about a week, they shuttled from the WHO offices on Tran Hung Dao Street in downtown Hanoi to the handsome French colonial edifice that houses NIHE about a mile away. That grand old building, with its warm, mustard-colored facade and gray shuttered windows, is located on a street named for a foreign disease detective, Alexandre Yersin, the French-Swiss bacteriologist who discovered the pathogen causing bubonic plague a century ago and later adopted Vietnam as his home. There, down the elegant, high-ceilinged corridors of NIHE, Fukuda and his team huddled with their Vietnamese counterparts, reviewing their findings.

“We were looking at everything we could look at,” Fukuda recalled. “Was there an increase in cases? Any differences of patterns in cases? Anything different about the people who were getting infected themselves, and so on.” The evidence wasn’t conclusive. “But on the other hand, it began to appear there were some differences from earlier patterns in Vietnam.”

During the previous year, bird flu had killed nearly three-quarters of those Vietnamese it infected. Yet over the first few months of 2005, the mortality rate had dropped by more than half, suggesting that the virus was edging closer to a pandemic strain. The shift was especially conspicuous because it took place only in the north of the country. The cases were also increasingly coming in family clusters, and often the time that elapsed between cases within the clusters was growing, making it ever more likely that relatives were passing the disease to one another rather than all catching it from the same source. Nine cases were from Thai Binh alone, including Tuan’s cluster.

“We thought that it appeared there really could be some changes going on,” Fukuda said. “We were in that sort of gray area of understanding. Even if you have enough data to suggest, you don’t have enough data to tell you really what’s going on, and you need help interpreting.”

Fukuda and his colleagues pressed for a wider review of the evidence, and WHO scheduled a private conference for the first week of May, just ten days after the mission left Hanoi. It was to be held in Manila, the Philippine capital and home of the agency’s regional headquarters. WHO summoned staff from Geneva and across Asia. Senior government health officials from Vietnam, Thailand, and Cambodia were pulled in, as were outside specialists from the United States, Japan, Britain, and Australia. Leading laboratories, in particular the CDC in Atlanta and the National Institute of Infectious Diseases in Tokyo, were also asked to prepare genetic analyses of H5N1 specimens so these could be compared with the pattern of cases in the field.

“We called for the consultation knowing that it was a lot of trouble to bring a lot of people in rather quickly, but on the other hand these weren’t academic questions,” Fukuda recounted. “If there really was a change going on, we really wanted to try to come to grips with that as quickly as possible.”