The Fatal Strain (7 page)

Before leaving the man’s bedside, Uyeki had taken the tubes and wrapped them with a cold pack in double plastic bags, which he then put in his backpack for the return trip to Kabanjahe. There, on a cement landing just outside the district office, he repackaged the samples. He made sure the vials were closed tightly and relabeled them so it was clear for the laboratory what they contained. He placed them, along with new cold packs, into a plastic bag, which he put inside another bag and then inside another. A provincial health officer drove this hazardous delivery out of the mountains, back to Medan, where a waiting WHO official carried them on to an evening flight to Jakarta. It was about 11:00 P.M. when this official arrived by taxi at Indonesia’s national health laboratory. The samples were split up, half to be tested by Indonesians and half at a U.S. Navy lab in the capital. The scientists worked through the night.

That evening, a senior WHO official in Jakarta e-mailed the agency’s regional headquarters in New Delhi reporting on Uyeki’s success in finding the fugitive, Dowes, and obtaining the samples. The outcome of the tests would be crucial. “If he turns out to be positive, then we will have to consider going in for rapid containment measures,” the official wrote. These would involve an intensified investigation, widespread distribution of Tamiflu, and possibly, for the first time, a mandatory quarantine of the affected villages.

His missive received an urgent rebuttal. It came not from the regional office but from the top, from the chief of the global influenza program at WHO’s main headquarters in Geneva. “In response to the possibility of a rapid response raised in the e-mail, my sense from various communications is that the level of suspicion and hostility in the area is high. Trying to mount a rapid response, especially one involving many outsiders and oseltamivir coupled with quarantine and isolation, seems most likely to lead to a very bad outcome, especially
in terms of more suspicion and hostility and rumors,” wrote Dr. Keiji Fukuda, the global influenza chief. Only if the virus spread beyond the Ginting family should a rapid response be considered, he said. Fukuda was not optimistic about its prospects even then. “If intense social mobilization doesn’t quickly reverse the population’s suspicion,” he added, “we would probably have to contemplate a heavy security force/military backed operation which is, I suspect, very unappealing to us all.”

 

 

Uyeki had come down for breakfast at his modest hotel in the Sumatran highlands when, at 7:00 A.M., he got a call on his cell phone. Both labs had results. The specimens had indeed tested positive for the virus.

Fifteen minutes later came a second call. Dowes was dead. His body had just arrived at Kabanjahe Hospital, and people there were reportedly in panic. Uyeki was worried they’d blame him for the death since he’d worked on Dowes only hours earlier. “OK,” Uyeki responded, “we’re on our way.”

When he arrived, he found the relatives were actually quite calm, even relieved. They’d been advised by the witch doctor, Purba, that seven people would succumb and Dowes was number seven. That meant the dying was over.

Tom Grein, as a seasoned veteran of Ebola and other hemorrhagic fever outbreaks in Africa, knew what to do next. He and Uyeki asked the local health staff for supplies: large-gauge needles, formaldehyde, rubber boots, chlorine bleach, and a backpack sprayer, the kind used for insecticide. They suited up in their gowns and other protective gear. They used the needles to take additional lung tissue specimens, blood, and other samples from the body. Then they donned the boots and filled the sprayer with bleach. They sprayed the corpse to disinfect it, setting aside the man’s wristwatch to give to his family, placed the body in a black plastic bag, and hauled it over to a waiting coffin. They closed the coffin, sealed it, and disinfected it. They disinfected the hospital room. They disinfected each other. And when they
were almost done, they disinfected the Suzuki jeep that had had transported Dowes to the hospital all too late.

In Jandi Meriah, Uyeki and his Indonesian colleagues had left behind boxes of Tamiflu with instructions that relatives, the witch doctor and his wife, and anyone else who’d been exposed take the tablets for protection. Health teams also distributed the drugs in three other villages, providing medicine to the Gintings’ neighbors, their relatives, and the driver and conductor of the minivan that brought Dowes to Jandi Meriah. A total of fifty-four people who might have been infected by him were placed under voluntary quarantine and asked to remain in their homes, or at least in their villages, for two weeks. Few listened.

Heni Boru Bangun, a forty-seven-year-old in-law, was among those who had the closest contact with Dowes, helping to care for him when he was in hiding. She had stayed in the same house with him for four days. Less than a week after he died, Heni broke quarantine, traveling to the next province to visit her mother.

I asked Heni whether she had taken the Tamiflu she’d been given. She said she had finished only two of the ten tablets required for a full course. “I was afraid of the side effects,” Heni explained. I looked at her adult son, who had been watching me suspiciously. “They gave me ten tablets but I only took three or four,” he volunteered. His wife, who had also helped look after Dowes, had declined to take any.

Heni disappeared into the back room of her house and returned with the thin white box of Tamiflu. She opened it and dumped the contents on the wood floor. Out tumbled the eight remaining yellow and white tablets still in their wrapper for me to see—and, with them, some harsh truths about our hopes for bending nature to our will and forestalling a pandemic.

According to the computer models that underpin WHO’s planning, the difference between success and cataclysm is measured in days, and the conditions for snuffing out an emerging pandemic are unforgiving. Yet in the dry run of North Sumatra, the virus had been spreading among the Gintings long before it was diagnosed, and in some cases, rather than seeking medical care, they ran. When public
health officials finally responded, they were repeatedly chased off. The victims and their contacts refused to share information and samples vital for containing an outbreak, likewise rebuffing appeals to take antiviral medicine, obey quarantine, or even take rudimentary steps to avoid exposure to those stricken. It was as if the highlanders had done everything imaginable to accelerate the spread of the disease.

“If this were a strain with sustainable transmission from human to human, I can’t imagine how many people would have died, how many lives would have been lost,” said Dr. Surya Dharma, who was head of communicable disease control for North Sumatra.

If there was any encouraging news from North Sumatra, it was only this: the novel strain had not spread beyond the one family. In its current form, the virus was still tough to catch. But influenza viruses inexorably mutate. It had now, for the first time, demonstrated the capacity to jump not only from one person to another, but also onto a third.

Only nine years earlier, flu specialists had assumed that this strain couldn’t infect anyone at all. When it had, alarms sounded around the world.

CHAPTER TWO

A Visitation from Outer Space

K
eiji Fukuda had been anticipating this call his entire career. It came in August 1997, when he was busy caring for patients at San Francisco’s Mount Zion Hospital, deep into a clinical rotation he would do a couple of weeks each year to keep his skills as a physician sharp. After he came off the wards, a hospital staffer mentioned that the CDC, where Fukuda worked most of the year as the country’s top influenza investigator, had been trying to reach him.

Fukuda suspected something was wrong. He quickly returned the call, which had come from a laboratory in the CDC’s influenza branch, and the lab director filled him in on some tests her scientists had just completed on a sample from Hong Kong. It looked as though someone had been infected by a new virus, a novel strain of flu called H5N1. The victim had died.

“It was a jolt,” Fukuda recounted. “It was an unusual call. But it was the call you are kind of always waiting for in the field of influenza.”

His mind instantly started to race. This was a strain that had never before infected humans, at least as far as scientists knew. That meant no one had immunity to the pathogen and everyone could be vulnerable. “How many other people have been infected?” Fukuda wondered to himself at the time, adrenaline pumping. “Are we missing anyone else? Right now, what’s going on?”

It took a few hours to arrange a larger conference call. The CDC
hooked in Fukuda along with Dr. Nancy Cox, the chief of the influenza branch, who had been tracked down while vacationing with her family at a horse ranch in Wyoming. Flu was their field, some would say their obsession, and they instantly understood what was at stake. “The idea of a pandemic coming on is one of the things you know is always possible,” Fukuda said. “Perhaps this is the start of that pandemic.”

Joining them on the call from Hong Kong was Dr. Margaret Chan, a Canadian-trained doctor who ran the city’s health department. She had never spoken with Fukuda before. Nor did she know much about pandemic flu. Over the next decade, she would become intensely familiar with both, gaining a perspective on influenza shared by few on Earth. But in 1997, it was all new. Chan peppered the CDC specialists with questions. “Is this a big threat or not?” she asked. They admitted they weren’t sure. They explained that the lab might have made a mistake. Even if the test result was accurate, it might reflect merely a single, isolated infection. But they cautioned her that the case could also be a harbinger of something larger. Chan was quick to appreciate the horrific implications. She told them she needed help. Hong Kong couldn’t get to the bottom of this alone. Before the call was over, Fukuda knew he was bound for Asia.

Fukuda finished his rotation in San Francisco, then headed home to pack. He and his wife and two young daughters lived in a suburb of Atlanta, where he had worked for the CDC since 1990. In 1996, he had become chief of epidemiology in the influenza branch.

Fukuda had been bred for the job. His parents were both doctors. His mother was Japanese, his father Japanese American. Born in Tokyo, Fukuda became a New Englander at age three when his family moved to Vermont so his father could take up a medical post there. The future flu hunter earned his own medical degree at the University of Vermont and did his residency in San Francisco before studying public health at the University of California-Berkeley. Influenza became his calling at a time when few infectious-disease specialists paid it much mind. Starting in the 1980s, HIV-AIDS exploded on the American scene and monopolized much of the scientific attention and research money. Like others in the small influenza fraternity, Fukuda
felt “his bug” was slighted. Even short of pandemic, seasonal flu was a proven scourge. “It certainly wasn’t on the radar screen,” he lamented. “People dying year in and year out in fairly large numbers in many countries and still it remains invisible.” Among flu researchers, it was a common grievance.

Yet among them, Fukuda was rare. His fervor was a quiet one. When I met him nearly a decade after the first H5N1 case, his buzz cut was graying but his round face was still youthful. He was one of the few veteran flu specialists whose brow was clear of lines and furrows. I concluded this was due not to any deficit of passion but rather a balance of passions. (Fukuda, who claims he is only a mediocre musician, had decorated an entire office wall with pictures of antique cellos.) His manner is authoritative but reserved. He is brilliant in analysis but measured and soft-spoken in delivery. He is ever polite, even when his colleagues spy irritation smoldering behind his rectangular-framed glasses. Above all, he is calm and calming. So when he worries, those around him get scared.

Fukuda arrived in Hong Kong late one sultry August evening at the head of a small CDC team. By the next morning he was already cloistered at the city health department, mapping out a systematic investigation into the outbreak.

The victim had been a three-year-old boy named Lam Hoi-ka, who had died in the spring. He had been a healthy youngster, the second son of an affluent Hong Kong couple. The father owned a company that manufactured decorative candles at a factory in mainland China. The mother was in charge of the firm’s marketing. They lived in a satellite town called Tseung Kwan O in the lower reaches of the New Territories, an expanse of former wilderness just beyond the congestion of old Kowloon that the Chinese had ceded to the British crown colony of Hong Kong a century earlier. Tseung Kwan O is really more city than town, a modern, highly planned community with scores of high-rise apartment towers, some as tall as fifty stories, amid American-style shopping malls and brightly painted schools and kindergartens. The town sits on a bay of the same name, which means General’s Bay. But the British had called it Junk Bay after the multitude of traditional sailing vessels that once plied the waters. The
community is no longer oriented to the sea but toward cavernous rail and bus depots. Each morning, the apartment towers disgorge thousands of office workers, headed for downtown less than a half-hour commute away.

Hong Kong health officers had already visited Hoi-ka’s family. It had been a hard interview. The family was distraught, and it took a long time to explain to them how an entirely new virus could have claimed their son. Investigators had gathered what information they could from the parents and their housekeeper about the boy’s recent history. None of it seemed exceptional. When Fukuda arrived in Hong Kong, he asked to see the family again, but they refused to talk anymore. He didn’t press it.

Fukuda had other angles to explore. His first priority was to determine whether this was simply much ado about nothing. The positive test result for H5N1 was so startling that he suspected it could be the result of a contaminated sample. Perhaps the boy had never been infected at all. So Fukuda and his team traced the precise route of the specimen. They went to Queen Elizabeth Hospital, the primary referral hospital on Hong Kong’s Kowloon peninsula, to see the intensive care unit where the boy had been treated. They checked to make sure that hospital staff had followed proper sampling procedures, and they examined the equipment. They asked whether any other patients had a similar respiratory disease and could have been the source of the virus. They asked about the health and habits of the staff. Perhaps some nurse had tracked the virus in. The team also visited the health department’s lab at Queen Mary Hospital on Hong Kong island, reviewing how the tests were conducted. They explored whether the virus might have been inadvertently introduced by technicians working at a veterinary lab in the adjacent building. After nearly a week of investigating, there was still no evidence of contamination anywhere.