The Fatal Strain (14 page)

“We were fighting with each other and not the virus,” admitted Dr. Kumnuan Ungchusak, a senior Thai health official, in a remarkably frank lecture delivered in May 2006 at a medical conference in Singapore. As the director of epidemiology in the ministry’s disease-control department, Kumnuan had been uniquely positioned to investigate the threat to human health that began emerging with the mass poultry deaths in November 2003. But he continued, “Nobody dared to speak that this was H5N1.” He urged his listeners from countries facing the epidemic—by that time the virus had spread to birds in more than fifty countries—not to repeat Thailand’s mistake in withholding information. “We should have declared this a couple of months before so we can save a lot of poultry and we can save a lot of lives.”

I was in the audience as Kumnuan recounted his experience and was surprised by his public candor. After he finished, I asked him privately to expand. Why wouldn’t anyone in the health ministry reveal the truth? “At the time,” he explained, “there would be a large impact on exports. There was a lot of reluctance to inform the public about it. This is a very bitter story.” But specifically, I pressed him, who gave the order to keep quiet? “I don’t want to pinpoint,” he demurred.

What Kumnuan remained reluctant to say was that the poultry sector’s pull had extended beyond the ranks of the agriculture ministry to the very top of the Thai government. The industry had influential advocates in the tight inner circle of Prime Minister Thaksin Shinawatra. A telecommunications tycoon turned politician, Thaksin had come to office in a landslide in 2001 vowing to turn around the struggling Thai economy by running it like a corporation. He had indeed succeeded in resuscitating the economy by 2003, achieving some of the highest growth rates in Asia and promising even faster growth in the year ahead. He had also demonstrated his impatience with those who got in the way of his economic juggernaut. Thaksin labeled himself the CEO-prime minister. His critics called him autocratic and vengeful.

 

 

In mid-January 2004, nearly a month after Prasert produced proof of a flu outbreak among Thai chickens, Deputy Agriculture Minister Newin Chidchob was still vowing it wasn’t so. “Irresponsible media and some groups of people are trying to spread this rumor,” he told reporters. “There is no bird flu here.” His assurances were endorsed three days later, on January 19, by David Byrne, the European Union’s health commissioner, who was visiting Bangkok on a previously scheduled trip. Part of his job was to protect European consumers, and, after a briefing from agriculture officials, he pronounced Thai chickens to be safe. “There’s absolutely no evidence of the existence of bird flu in Thailand,” Byrne said in remarks he would soon furiously retract.

The next day, as television cameras rolled, Prime Minister Thaksin and his cabinet ministers tucked into a luncheon feast of spicy chicken soup, minced chicken salad, chicken biryani, chicken teriyaki, and grilled, boiled, curried, and fried chicken, capped by a healthy serving of the Thai leader’s trademark bravado. “Come and join us. Are you scared?” the prime minister taunted reporters. With anxiety mounting among consumers, Thaksin’s response was to order up the repast and claim all was well. “It’s the best chicken in the world, Thai chicken,” he offered between bites. “It’s very good. It’s safe.”

But WHO already knew better. A week earlier, on January 14, the
agency’s office in Bangkok had received a confidential tip from a government epidemiologist reporting that bird flu had been detected in a recent poultry outbreak and tests had determined it was an H5 virus. Though more analysis was needed, the scientific implication was that the strain was a novel H5N1. This troubling disclosure was forwarded to WHO headquarters in Geneva, where infectious-disease specialists asked the Bangkok office to get more specifics from the Thai government.

These inquiries were repeatedly spurned. WHO’s chief representative in Thailand and his staff were informed by their government counterparts that only the health minister could release details, and she remained tight-lipped. So over the coming days, the WHO team in Bangkok grew increasingly exasperated, venting frustration in e-mails and conversations with Geneva.

WHO had been on edge practically since the new year. Poultry outbreaks of bird flu had already been detected in South Korea, Vietnam, and Japan. Just a week earlier, Vietnam had confirmed human cases, stoking public fear of a flu pandemic for the first time since Hong Kong’s outbreak six years earlier. Could Thailand be the next front? It was crucial to know. Yet there was little the agency could do. It couldn’t force the Thai government to come clean. Nor could WHO itself go public unless the government cooperated.

As a United Nations agency, WHO was established by its member countries and, like other UN bodies, respects their national sovereignty. Though WHO has been growing increasingly assertive in recent years, pressuring governments on occasion to hunt for infectious diseases on their turf and disclose them when discovered, the agency still largely defers to local politics. Even when an outbreak becomes apparent, WHO cannot dispatch investigators to a country without a formal invitation. And even after they get on the ground, these teams are barred from the field until authorized by the country to proceed.

The agency’s critics fault it for becoming a prisoner of its politics. They accuse it of too often bowing before the dictates and deceits of its member countries, of placing a higher price on diplomatic nicety than on truth. But senior WHO officials, including some who have
personally braved the world’s most horrible pathogens, scoff at the contention that they’re weak or cowardly. They counter that WHO is a creation of international politics and thus, by definition, a creature of one. Otherwise, they say, WHO and its mission could not exist at all.

Nor is WHO some kind of global health department with an army of doctors, nurses, ambulance drivers, and inspectors. It has no labs or hospitals of its own. The oldest disease-control program at WHO, even older than the agency itself, is its global monitoring effort for flu. The perils of pandemic combined with the economic and health impact of seasonal flu made this initiative an early priority. Yet even this program depends entirely on a network of outside labs—at latest count more than a hundred in eighty-plus countries—to track the evolution of flu viruses and help develop suitable tests, drugs, and vaccines.

Mostly, WHO supplements the efforts of individual governments, offering specialized expertise and scarce materiel like stockpiled vaccines for meningitis and yellow fever. To accomplish this, the agency relies on an extensive network of consultants from around the world, both public and private, to help investigate outbreaks, treat the sick, test samples, train local health staff, and deliver medicine, vaccines, and equipment.

These outside allies are people like Prasert, whose career was devoted to forging the institutions and disciplines of modern medical learning in Thailand that now make his country among the most advanced in the region. Yet there was always time for WHO. On a curriculum vitae stretching for several pages of publications and affiliations, Prasert prominently highlights his position as consultant to the World Health Organization. For over three decades, he served on various advisory committees for the agency, most notably the expert panel on viral diseases. He has run a WHO collaborating laboratory for AIDS research and edited an agency monograph on dengue fever.

In Geneva, senior agency officials describe their role in coordinating all this outside expertise by using words like
secretariat, catalyst,
and
platform
. What they mean is that they’re like the salaried fire chief of a vast volunteer brigade.

WHO was born of the optimism that followed the Second World War, when international cooperation in the shape of the freshly minted United Nations and its agencies promised a new chapter in human history. Founded in 1948, WHO set its objective as nothing less than the “attainment by all peoples of the highest possible level of health.” This was an ambitious goal. Yet advances in medical science at the time seemed to be bringing down the curtain on epidemic diseases that long plagued mankind, notably polio and smallpox. By the 1960s, however, WHO suffered a colossal setback with the failure of global efforts to eradicate malaria. It was emblematic of a broader resurgence of infectious disease as microbes mutated, outsmarting new medicines and vaccines, exploiting environmental degradation, poverty, population growth, and humanity’s lapses in vigilance.

As a young American physician, Dr. David Heymann had played a starring role in the eradication of smallpox. He and his WHO team had tracked it to its final havens in India. But soon after, as a new recruit to the CDC, he confronted a pair of entirely new threats. In the summer of 1976, he was dispatched to help investigate a mystery pneumonia spreading through an American Legion convention in Philadelphia. The outbreak, which sickened more than two hundred people and killed nearly three dozen, was ultimately blamed on a previously unknown illness dubbed Legionnaires’ disease. By the end of that same year, Heymann was in Zaire, responding to the first recognized outbreak of a horrible hemorrhagic fever called Ebola. He would end up spending thirteen years in Africa and, during that time, track the Ebola virus deep into the rain forests of Cameroon.

Heymann would later point to 1976—with its outbreaks of Legionnaires’ disease, Ebola, and also swine flu in the United States—as an inflection point in public health history. Man’s conceit was that modern medicine and potent drugs had given him mastery over emerging diseases. But the events of 1976 started to rekindle the world’s concern about these threats, Heymann told me, and the appearance of the AIDS pandemic dashed any remaining illusion of invincibility.
“HIV-AIDS really caught the world off guard,” he said. “This really changed the thinking. The world realized the vulnerabilities.”

In 1995, WHO tapped Heymann to establish a program on emerging and communicable diseases. Storm clouds were gathering at all points of the compass: pneumonic plague in India, cholera in Latin America, resurging tuberculosis in Russia and Ukraine, Ebola in central Africa, meningitis across the whole of that continent, and an unprecedented epidemic of dengue fever in nearly sixty countries. Under Heymann, the agency overhauled its intelligence gathering, integrating a system developed by the Canadian health department that mines the Internet for reports and rumors of disease outbreaks. Next Heymann and his colleague Guenael Rodier set up what they called a global strike force, tapping disease investigators from more than a hundred universities, hospitals, and ministries who could get their boots on the ground within two days of any reported outbreak.

Then came SARS. In a matter of weeks in 2003, this novel respiratory disease spread to four continents, striking the economic heart of Asia, putting global air travel in jeopardy, and raising the specter of a worldwide epidemic. WHO’s rapid response contained the epidemic before it became entrenched. This success consolidated the agency’s role in managing outbreaks around the world. That largely explains why WHO, and not the CDC, took the lead in responding to the human cases of bird flu when they erupted in 2004.

SARS was a close call. It underscored the need to rewrite the global code of conduct called the International Health Regulations. The new rules, which took effect in the middle of 2007, require countries to notify WHO within twenty-four hours of any outbreak posing a global threat. Previously, the requirement applied only to yellow fever, plague, and cholera, a legacy of the nineteenth century, when European governments sought to forestall pestilence from the East. Now it was flu, again rising from the East, which posed the greatest menace.

The adoption of the regulations emboldened WHO. “When we come to an assessment that our assistance is needed, we have to push our agenda,” said Dr. Michael Ryan, the burly Irishman who runs the
agency’s alert and response operations. But WHO is still ultimately constrained. Governments like the one in Bangkok can continue to tell it to buzz off. “At the end of the day, you are dealing with sovereign states,” Ryan added. “That has to be respected.”

 

 

One day before WHO was tipped off to the spreading epidemic in Thailand, a six-year-old boy with symptoms of pneumonia was rushed to Prasert’s hospital. He had a fever of 104 degrees and was desperately short of breath. Within twelve hours, his breathing had grown so labored that the doctors placed him on a ventilator. It seemed at first to do little good, so they kept cranking up the pressure on the device until they could finally achieve an adequate flow of oxygen. An X-ray revealed that the boy’s lower right lung had gone cloudy white, indicating that fluid was flooding the airspaces. The cloud spread a day later to the upper right lung. The next day, it progressed to the left one. The boy, Captan Boonmanut, had been brought to Siriraj Hospital from his home province of Kanchanaburi, located eighty miles from Bangkok near the western border with Burma. Outside Thailand, Kanchanaburi is best known for the Death Railway, built during World War II by Japanese occupying forces to supply its front lines, using Allied prisoners of war and Asian forced labor. At least sixteen thousand POWs perished from disease, hunger, and exhaustion, as did many more of the locals. This brutal chapter was captured in the Oscar-winning film
The Bridge on the River Kwai
, and the infamous steel-and-concrete bridge still stands, very much in use. But inside Thailand, Kanchanaburi today means rice paddies and chicken sheds.