The Fatal Strain Read online

  We were sitting in the restaurant of the Santika Hotel, one of the few hotels in town still functioning and a base for humanitarian operations. Around us, relief workers in blue-and-white vests mingled at the buffet with Japanese soldiers in camouflage. Grein was clad informally in a short-sleeve blue shirt open at the collar, brown jeans, and heavy black shoes. The fine lines across his forehead deepened as he tried to regain his train of thought.

  “You can’t go by the first piece of information you have,” he resumed. “You have to be able to listen and understand, look for the small details, be a little obsessive, and not give up. You have to keep trying to track down the disease.” He paused to let the point sink in, then continued. “You also have to understand the cultural sensitivities. You are dealing with a lot of people who are grieving, who have lost family members. You have to strike a balance between pushing your agenda and not upsetting the local population.”

  During the Marburg investigation in Angola, villagers had stoned his team’s vehicles, forcing WHO to temporarily suspend its efforts. The foreigners had initially descended on the community in the back of pickup trucks wearing what appeared to be strange “astronaut suits” and carried off the victims’ bodies. The locals were prevented from showing their ritual respect to the dead by washing and embracing the corpses. They suspected the foreigners of stealing their loved ones. Grein said the WHO team ultimately defused the confrontation by putting on their protective gear in front of the villagers and taking the time to explain what they were doing. “It takes trust, transparency, and openness. Without it, it’s an uphill battle.”

  Despite the potential for cultural miscues, Grein said he found the third world an easier place to work. Developed countries often keep WHO epidemiologists at a bureaucratic distance, preferring to run their own investigations. In developing countries short on resources, he added, “we get to work on the ground.”

  In Asia he stalked bird flu through the tropical jungles of Indonesia, the rice paddies and river deltas of Vietnam, and the deep mountain snows of southeastern Turkey. Other WHO epidemiologists had picked up death’s trail elsewhere. Yet for all the months and miles, even the most seasoned investigators had failed to crack the mysteries of the novel strain. “Since it began in Vietnam in 2004, every case was followed up on one way or another but very little is known,” he admitted. The precise incubation period remained unclear because investigators were rarely able to determine the source of exposure and thus the exact moment the victim was infected. But that knowledge would be vital for crafting public health policies to contain an emerging epidemic. Nor had they been able to detail how the virus infected people and why some were susceptible while others were not. These elusive specifics could be crucial for limiting human exposure to the disease and developing drugs to combat it.

  Though Grein is the best at what he does, even his own flu investigations have often yielded partial success at most. Frequently victims take their personal histories with them to the grave. It’s simple to blame poultry for the infection since they’re everywhere in Asia, he noted. What’s harder is ruling out the possibility that the source was actually another person. “That’s always going to be a question. You can’t really prove it,” he explained.

  When investigators manage to break open a case, the novelty makes it striking. Late in the winter of 2006, they’d hit a wall after the virus had suddenly erupted in Azerbaijan, a former Soviet republic situated on the cusp between eastern Europe and western Asia. Of the eight confirmed cases, seven were from one remote farming settlement so poor that it lacked electricity. All but one of these cases were from the same extended family, mostly girls and all between ages ten and twenty. They’d fallen sick within two weeks of one another. It was the largest family cluster of cases yet recorded, and the intriguing pattern promised new insights into the disease if only it could be deciphered. WHO investigators and their Azeri counterparts trekked to the village over and over, yet the family refused to cooperate, even denying the sickness was bird flu. “They wouldn’t give us any information about how the patients got infected,” recounted Dr. Caroline Brown, a WHO virologist who led the team. “There was no way they were going to talk to us. That’s for sure. Even the young children wouldn’t talk to us.”

  The family kept some chickens, but they looked healthy. Other poultry had died in the community, but veterinary officials were claiming it was not bird flu. Brown and her colleagues, however, had heard of a large die-off of wild birds in Azerbaijan a month earlier that was attributed to the flu virus. Next they learned from villagers that dead swans had been found at a lake on a nature reserve near the settlement. At least one member of the stricken family was a hunter, and his neighbors confided that he’d brought home some of the swans. It was an open secret that locals could earn good money by plucking the feathers for making pillows. That was usually the job of teenage girls and young women. But hunting swans was a crime, and the penalty for poaching could run into hundreds of dollars. The family adamantly denied any contact with wild birds, much less infected ones.

  As Brown was leaving the family’s house after another frustrating interview, she looked around the garden and spied at least three large, white pillows hanging from a clothesline. “You couldn’t miss them,” she said. “You could see the feathers sticking out.” It was the smoking gun. Later, the mother of one victim later confirmed that, yes, all those afflicted had been plucking contraband swan feathers. This marked the first time that investigators anywhere had proven a link between wild birds and human cases of the virus. Yet the breakthrough, like the Azeri outbreak itself, remains exceptional.

  “We don’t know much,” Grein told me with heightened urgency. “All of us, we really need to get our act together to enhance our knowledge and get better tools to fight this disease.”

  The clock was ticking on Samaan’s investigation. Somewhere on the wards of a private hospital in neighboring West Java province, the novel strain could be incubating, amplifying, provisioning for an inexorable march toward the capital, toward the international airport only a ninety-minute drive away, toward the regional hub of Singapore another ninety minutes by air. By the time Samaan made arrangements with Indonesian officials to visit the hospital, it was already Saturday morning, and she hadn’t had a chance to line up the minivan. She flagged down a white city taxi on the street near her downtown apartment building. Her translator was off, so she called an Indonesian colleague from WHO and rousted her with a playful, early-morning plea, “C’mon, let’s go save the world.”

  Samaan’s career had been building toward this moment. Born to Iraqi parents, she was raised in Kuwait until the political upheaval wrought by Saddam Hussein’s 1990 invasion sent her fleeing as a teenager to Australia. There she went on to study clinical psychology. For a year she worked with refugees detained on the remote South Pacific island of Nauru, a tiny outpost of little more than eight square miles. Many of the migrants, held in camps while applying for amnesty in Australia, were suffering from depression and other maladies. The experience piqued Samaan’s interest in broader issues of public health and led her back to the university to take up epidemiology. During her first stint with WHO, she was assigned to Manila just as bird flu was sweeping East Asia. But she was kept primarily in the office. At her desk by 6:30 A.M. each morning, she was tasked to troll the Internet, international media, and the agency’s own network of informants for rumors and emerging reports of flu outbreaks. A year later she rejoined WHO and headed into the field.

  Now, as the taxi finally escaped the congested streets and pulled up beside the pink walls of the five-story hospital, Samaan was hoping to do better. This was a new facility with a clean, white-tiled lobby that contrasted with the filth and disorder just beyond the gates. No sign of panic or plague, just a few parents waiting to have a doctor examine their children.

  The hospital’s personnel director, a woman in a pink blazer, led Samaan through the breezy corridors to a conference room. The hospital�
��s vice president, a woman in a Muslim headscarf and brown batik dress, and three other officials joined them around an oblong table. Samaan briefed them on her investigation. She shared the reports of poultry deaths in the victim’s neighborhood but noted they remained unconfirmed. “So we cannot discount other possible sources of infection,” she told them without revealing her suspicions about the hospital. Then she asked about the victim’s recent work history. The personnel director recounted that the victim had reported for the afternoon shift on New Year’s Day complaining of fever and chills. She had been initially diagnosed with dengue fever or possible typhoid. “We let her go home early,” the director said. The ailing woman had never returned. Her disappearance, the director said, had left the maternity ward short staffed.

  So the victim, it turns out, had been a midwife. That was a welcome detail. Because the maternity department tended to see healthy patients, this reduced the chances that the woman had contracted the illness in the hospital. It would also be easier to spot anyone else in the ward she might have infected. But Samaan was not yet sanguine.

  “Can you look at the hospital records?” she asked. “If you concentrate on the ten days before she felt sick, would she have had contact with anyone who had an influenza-like virus?”

  The hospital’s vice president said that was an easy one to answer. She referred to a report in front of her. The victim hadn’t come to work at all in the week before she became ill. She had been on vacation.

  “That’s not what the family told us,” Samaan objected politely. “They said she was working.”

  “We’ll double-check our records. But maybe she was working in another hospital?” the vice president responded, suggesting a new, disquieting possibility.

  The personnel director produced a stack of schedules and time sheets. Samaan and several others huddled around. The documents showed, in fact, that the family was right: The woman had indeed reported for work four times during the final week of December. Two dates in particular drew Samaan’s interest. The woman had worked the overnight shifts on December 27 and 28, just when she would have likely contracted the virus. Samaan made a mental note.

  Glancing up from the time reports, she asked whether any of the women who had given birth in the maternity ward had gotten sick. Nothing unusual, she was told. She inquired after the other midwives. All healthy. She requested to meet a few.

  The maternity department was spotless. It had twenty-three beds in a series of rooms, mostly vacant at the moment. Four newborns slumbered in small, glass-sided cribs. The private waiting room was large, with padded chairs, a sofa, and a television on the counter. An air conditioner hummed in the wall.

  The personnel director showed in a pair of midwives dressed in pink uniforms. The younger one, a slight woman with short brown hair and lively eyes, named Swarni, was the chattier of the pair. Samaan asked about the last time she saw her dead colleague.

  “I wasn’t working the same shift as her that day,” Swarni began. “I was leaving after the morning shift, and she was arriving for the afternoon shift.”

  Samaan nodded.

  “I asked her why she was wearing a jacket,” Swarni continued. “She said she wasn’t feeling well. The next time I saw her, she was in the intensive care unit.”

  Samaan asked the midwives how they were feeling. They reported their health was good, further allaying Samaan’s concern that the hospital was the source of infection. She shifted her line of questioning, asking about the woman’s final days.

  “Did she do anything before she got sick that comes to mind? Any activities?”

  “She mentioned she had been coughing for a while. That’s all.”

  “Did she talk about going to a poultry market?” Samaan pressed, following up on the tip from the previous day.

  “Sometimes she would go after work,” Swarni recalled. The young midwife mentioned a particular market in East Jakarta and then giggled softly, covering her mouth. Samaan waited for the rest of the answer, puzzled. “She would go buy chicken feet,” Swarni added. “That was one of her favorite foods.”

  Epidemiologists are often faced with two complementary questions. The first is like the one that was stumping Samaan: Why does someone fall sick? The second question is less obvious, though the answer can be even more revealing: Why doesn’t someone fall sick?

  For each victim laid low by bird flu, there are hundreds, perhaps thousands, who should have been. These are the cullers, the armies of peasants, soldiers, veterinary officers, and day laborers who have slaughtered several hundred million birds across Asia, Africa, and Europe since 2003 in an orgy of bloodletting aimed at exterminating infected flocks and stemming the spread of the virus. They often did so with minimal protection, lacking masks, goggles, and even gloves. Yet a full decade passed after H5N1 claimed its first confirmed victim in 1997 before a single culler ever got seriously sick—a Pakistani man who died shortly after helping carry out a two-day poultry slaughter in October 2007. In Vietnam alone, more than ten thousand people participated in the great massacre without a reported case. This mystery has defied explanation, posing one of the great riddles confronting flu investigators.

  Field sampling has revealed that some cullers were in fact exposed to the pathogen. Five South Koreans who helped stamp out infected flocks eventually tested positive for antibodies though none ever became ill, and a lone culler in Indonesia also showed elevated antibodies without any outward sign of illness. So, too, nine workers who helped carry out Hong Kong’s mass slaughter in 1997 tested positive, with only one displaying mild symptoms. These findings suggested that bird flu may have spread farther than the flu hunters suspected but that many human cases were asymptomatic. If so, this would not be welcome news. It would mean a greater chance for the strain to stumble across the genetic mutations required to unlock a pandemic. Field investigators turned up other worrisome evidence. Blood taken from two elderly but otherwise healthy relatives of Vietnamese victims in 2005 had antibodies to the virus. A year later, a pair of young brothers in Turkey were also positive despite showing no symptoms.

  But these instances proved to be rare exceptions. Efforts to uncover a rash of asymptomatic cases have found none. In one telling study, researchers canvassed nearly a hundred homes in a Cambodian village where a man had contracted the virus days earlier. Poultry outbreaks were widespread. If the virus were adept at causing cryptic cases, certainly some would turn up here. But not a single one of the 351 villagers tested had antibodies. A subsequent study of 674 people in two Cambodian villages where there had been both human and poultry outbreaks revealed that 7 of the villagers, or about 1 percent, had antibodies to the virus, indicating they’d been exposed even if they hadn’t had symptoms. For some reason, they were all younger than eighteen. Though this last study suggested some mild cases were being overlooked by health officials, the results hardly signaled a silent epidemic. The enigma of the cullers endured.

  At times, epidemiologists have also been stumped by the converse scenario: sick humans without sick birds. Indonesia detected its first human case in mid-2005 and over the following year confirmed that fifty-four Indonesians had the virus. Yet Samaan and her fellow investigators were unable to identify a possible source of infection in a quarter of those cases. During 2007 nearly one-third of the Indonesian cases were ruled inconclusive because there’d been no direct contact between the victims and poultry of any sort. Tjahjani Widjas tuti, head of the agriculture ministry’s bird-control unit, called the behavior of the virus in Indonesia “mysterious.”

  One morning in July 2005, just days after the country’s first human case was announced, I drove west out of Jakarta and two hours later found myself unexpectedly in a California-style subdivision of palm-lined streets and middle-class bungalows. Health officials had reported earlier in the week that three residents of the town had succumbed to bird flu. The deaths of Iwan Siswara Rafei, a government auditor, and his daughters marked Indonesia’s first confirmed fatalities from the vi
rus. I had expected to find a typical Javanese village, with serpentine alleys, ramshackle homes fashioned partly from bamboo, and scrawny hens scavenging in the mud. Instead Villa Melati Mas was a gated bedroom community of bankers, businessmen, and doctors. Neighbors were anxiously trading rumors across the metal fences separating their neatly landscaped yards. Mothers were keeping their children off the quiet streets, and some families were considering whether to pack up their belongings in their SUVs and abandon their homes.

  “We’ve really got a panic attack,” said Kresentia Widyanto, a mother of three in a floral housedress. “People have been asking, ‘Do we need to evacuate and go somewhere else, to vacate this place?’ ” For fifteen years, Wiydanto and her husband, a physician, had lived around the corner from Rafei’s brown cottage with its pitched terra-cotta roof and sweet purple flowers out front. Widyanto’s son was eight years old, the same age as Rafei’s older daughter, Sabrina. When the girl was hospitalized a month earlier with a high fever, diarrhea, and cough, word spread quickly. Rafei’s second daughter, one-year-old Thalita, developed symptoms days later, followed by Rafei. “I’m wondering why this happened,” Widyanto told me while she finished her business with a street peddler selling broccoli and cauliflower. “Can we get it? We’re trying to be calm.”

  But despite a six-week investigation by Samaan and her colleagues from WHO, the Indonesian health ministry, and the U.S. Navy lab, they remained utterly stumped. Even Grein was called in to help. Around the subdivision, a few parrots and other pet birds twittered from cages hanging on porches and balconies. But neighbors did not raise their own poultry, instead shopping at a Western-style supermarket. A solitary pet bird in the neighborhood tested positive for the virus, but Rafei’s home was free of contagion. Tests conducted on him and his daughter, coupled with the timing of their deaths, suggested that the virus might have been passed among family members. Yet this was never confirmed, and the original source of infection was never discovered.