Most people stayed cooped up in their homes, often low on food, at times dying there unattended. What volunteers from Holy Name Parish discovered in one Fishtown home was not uncommon. “In the parlor were the dead bodies of the married son and his wife who had died a few days previously,” a nun wrote. “A daughter was dying in the adjoining room, alone, while her mother was seriously ill upstairs. The only attendant they had was the father who was too sick to realize what he was doing.”
During the second week of October, 2,600 people died of flu in Philadelphia. Another 4,500 died a week later. There was no longer anywhere to put their bodies. At the city morgue, abandoned corpses were stacked three and four high in the corridors and spilling out onto
Wood Street. Bodies were piling up on the porches of row houses, in closets and garages, uncollected for days. “The smell would just knock you,” Elizabeth Struchesky remembered decades later.
Police wagons, mortuary trucks, and even horse-drawn carts plied the street, and people were called to bring out their dead. “They were taking people out left and right. And the undertaker would pile them up and put them in the patrol wagons and take them away,” recalled Louise Apuchase, who said her family was the only one in her neighborhood spared by the flu. “Directly across the street from us, a boy about seven, eight years old died, and they used to just pick you up and wrap you up in a sheet and put you in a patrol wagon. So the mother and father [were] screaming, ‘Let me get a macaroni box.’ ” There were no more coffins. “ ‘Please, please, let me put him in the macaroni box. Let me put him in the box. Don’t take him away like that.’ ”
Nor were there enough embalmers. Nor gravediggers. “They had so many died that they keep putting them in garages,” recounted Anne Van Dyke, whose mother had volunteered to shave the corpses.
The highways department finally dispatched a steam shovel to dig mass graves in a field at Second and Luzerne streets. Prisoners were pressed into service to bury decomposing bodies that others refused to touch. The few available caskets were priceless, and people were stealing them. A fresh supply had to be shipped in by rail under armed guard.
By the time the plague had finished claiming 12,897 Philadelphians in late November, the compassion and common decency that bound society together had been shredded. The nuns found babies without milk and adults without water. They even happened across children newly orphaned and abandoned in their homes. One nun later reflected, “It was the fear and dread of the scourge on the part of kindred and neighbors, who ordinarily would have cared for friends.”
Much of the world still knows what it is to live with death. Not to take old age for granted. To see, in fact expect, that children will die. Most Americans, by contrast, have forgotten 1918.
Yet the American health-care system, with its promise of the highest quality care for those who can afford it, is intensive, expensive, and
particularly vulnerable to the extraordinary demand for medical care that would accompany even a mild flu pandemic. “It’s a more brittle system,” Fukuda told me. “The ability to meet an upsurge in patients is not one of the virtues of that kind of system. Whereas in a lot of the developing countries, where you have more flexibility in terms of the health-care system, ironically it may be those systems that are able to cope.”
In the United States, the health-care system has been under tremendous financial pressure to operate on the margin. Hospitals have been closing around the country, with the number offering critical care tumbling 14 percent between 1985 and 2000. By 2005, vacant ICU beds were rare. Some of these beds have been removed because of a severe nursing shortage. So, too, intensive care doctors have also been running short. Emergency rooms are being shuttered, about 10 percent of the national total between 1995 and 2005, and a survey of American emergency physicians revealed that almost 90 percent said their departments were routinely overcrowded. Ambulances are commonly diverted from one ER to another—on average, somewhere in the country, of once every single minute.
When researchers from the U.S. Government Accountability Office explored in 2008 whether hospitals were preparing for a mass casualty event like a pandemic, they learned that hospital executives were too preoccupied with day-to-day financial problems. The same researchers reported that federal funding for hospital emergency preparedness had decreased 18 percent from 2004 to 2007.
“Medical economics is really pushing toward downsizing of hospitals, reducing the number of staff, reducing the number of unoccupied beds,” Fukuda said. “When you look at pandemic influenza, which is a one-period-of-time occurrence, that absolute increase in cases cannot be handled so easily. You cannot handle it without having a lot of staff. You cannot handle severe cases without having hospital beds.”
Medicine would run out. Oxygen, crucial for treating those with lung disease, could be gone within days. The producers of medical oxygen are few, and the fleet of tanker trucks required to haul fresh supplies is far too small. There would be a tremendous shortage of ventilators. Most of this equipment is already being used in the
everyday treatment of critical-care patients. In a severe pandemic, about 740,000 people would require ventilation, according to the U.S. Department of Health and Human Services, while studies put the existing stock at between 53,000 and 105,000.
Infectious-disease experts now debate whether the industrialized world might actually be more vulnerable today than it was in 1918. After nearly a century of medical progress, how could this be? No doubt there have been some astounding advances in hospital care. The development of antibiotics alone might save millions who would have died in 1918. Many, perhaps most, of the Spanish flu’s victims succumbed not to the virus itself but to secondary bacterial infections that are now treatable.
But consider this: In the United States, 80 percent of all prescription drugs are now produced overseas. They are delivered to drugstores just hours before they’re dispensed. In a pandemic, international shipping could come to a halt as countries impose travel bans and quarantines, companies suspend operations, and employees fall sick or stay home. Once again, pharmacy shelves would run bare. Nor would it just be flu medicine and antibiotics. Within days, medication for heart disease, high blood pressure, and depression would vanish, and insulin for diabetics would disappear. Many hospitals now maintain minimal inventories, receiving three rounds of medicine and other equipment each day. These supplies, too, could evaporate, and with them many forms of critical care.
Since the novel strain reemerged in 2003, Dr. Michael T. Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota, has been warning of the perils inherent in modern commerce. The economies of countries like the United States now more than ever depend on just-in-time supply chains and offshore sourcing of essential goods and services. “The interconnectedness of the global economy today could make the next influenza pandemic more devastating than the ones before it,” he wrote. “Even the slightest disruption in the availability of workers, electricity, water, petroleum-based products and other products or parts could bring many aspects of contemporary life to a halt.” With little surge capacity of their own, Osterholm projects that countries
facing a major pandemic would run short on everything from soap and lightbulbs to gasoline and spare parts for municipal water pumps, and, of course, food.
Four days after lab tests had come back positive for bird flu in Vietnam, Klaus Stohr in Geneva convened an unpublicized conference call on January 15, 2004, with a half dozen of the world’s leading influenza specialists. He wanted to know what he was up against.
“A critical situation, unprecedented,” said Dr. John Wood, senior virologist at Britain’s national biological institute. “We have to behave as if it could go to pandemic.”
“Very, very serious,” said Dr. Masato Tashiro, head of virology at Japan’s national infectious-disease institute. The likelihood of human transmission is rising, and this, he said, “would be devastating. [Something we] have not yet experienced before.”
Just two months earlier, Dr. Robert Webster from St. Jude Children’s Hospital had coauthored an article for
Science
magazine warning that the world was unprepared for a flu pandemic. Now the dread scenario seemed to unfolding. But the extent of the outbreaks caught even him by surprise.
“A very unusual event,” Webster said.
These superlatives reinforced Stohr’s concern. Stohr himself was not formally schooled in flu. Trained as a veterinarian in East Germany before the Berlin Wall came down, he had established himself as a national authority on rabies. His work caught WHO’s eye, and he was recruited to the agency, where he was later tasked with restructuring an influenza operation then considered a backwater. He joined the fraternity of flu hunters.
“Klaus was very excited,” a colleague said, recalling those uncertain days in early 2004. “It’s one of the things they wait for their whole life. Pandemic, it’s the big one.”
Reared on the grinding shortages of the Eastern Bloc, Stohr was skilled at marshaling scarce resources. Now he cobbled together a global response from an agency strapped and weary. He massaged the bureaucracy, spinning out long lists of urgent tasks as he walked the
halls, assigning them with dispatch. He stoked the enthusiasm and anxiety of his staff with talk of pandemic and helped position the agency to ensure it got a piece of this action.
The CDC had been eager to send in its own team and had already won a nod from senior Vietnamese officials. But WHO, flush with its triumph over SARS, didn’t want to cede control of an emerging pandemic to the big boys from Atlanta. So WHO hurriedly dispatched Dr. Hitoshi Oshitani, its senior East Asian expert on communicable diseases. He was an astute, hard-driving Japanese doctor, a former Africa hand fascinated by diseases of the developing world. He had a humble respect for flu and little patience for politics. But he’d have to tend to both. Oshitani set out to assess the extent of the outbreak and negotiate with the Vietnamese government over permission for a larger team. He insisted that his investigators be allowed into the field. But the Vietnamese health ministry, wary of outside meddling, was reluctant to oblige.
“Avian influenza could be much worse than SARS,” he admonished the skeptical officials. “If this avian influenza becomes a pandemic, it could infect two billion people. Millions of people would die.”
It wasn’t just a line. He personally thought he could be seeing the start of a global outbreak. Oshitani had already helped the world dodge one epidemic by steering Asia’s response to SARS. “Hitoshi suddenly came alive again,” an associate in the regional headquarters recounted. “For people like him, this is what life is about: crises. He immediately understood the implications.” When Oshitani warned that avian flu could dwarf SARS, his exhortation sent shudders through his WHO colleagues. But it also had the desired effect on the Hanoi government.
With the door cracked open, Tom Grein was urgently detoured to Hanoi from a WHO mission in southern China. Grein, who would team up two years later with Uyeki to investigate the Ginting family cluster in Indonesia’s North Sumatra province, became in essence the agency’s player-coach in Vietnam. His was an all-star roster of epidemiologists, virologists, lab technicians, clinical specialists, and veterinary, logistics, and public-affairs experts that would eventually total nearly a hundred personnel. Finally, as part of this international effort,
Uyeki and Fukuda were bound for Vietnam along with five CDC colleagues.
Uyeki quickly peeled off into the field. Fukuda remained in the capital, helping set up a command center in a conference room just off the entrance to WHO’s office in downtown Hanoi, and from there he helped direct the response. “We’re not sure what’s going on,” Fukuda recalled, “and we have to sift through this pretty quickly.” He pressed Vietnamese health and agriculture officials to cooperate, to share their intelligence about the outbreaks and ramp up efforts to contain them. “Don’t be lulled into a sense of false confidence about small numbers,” he urged in meeting after meeting. Though only a handful of human cases had been detected so far, the country could be at jeopardy.
Fukuda’s counsel carried weight. He had unique credentials as a veteran of the Hong Kong outbreak in 1997. Yet these dynamics were different. The Vietnamese were not open to the kind of close partnership he’d established with Hong Kong’s health director, Margaret Chan, which had been central to success. The international team itself was also different, larger and more unwieldy than the exclusively American one he’d led six years earlier. But the outbreak itself looked very similar. Again, it was mostly birds infecting humans. In urban Hong Kong, the source had been markets. Here in rural Vietnam, it was mainly farms. Still, for Fukuda, the killer was no longer a stranger but a known assailant.
The cases continued to come, the pace quickening. Healthy, mainly young victims kept turning up with breathing problems, rising fevers, and tumbling white blood counts. Many had diarrhea. Most died. By the third week of January, the virus had opened a second front in the south of Vietnam with initial cases in a young girl and teenage boy. Poultry outbreaks were also accelerating, proliferating faster than Vietnam could slaughter its afflicted birds and extending throughout the region. Under pressure from Prasert Thongcharoen, Thailand finally stopped its dissembling and confirmed both human and poultry outbreaks. By the first of week of February 2004, four more Asian countries had reported infected flocks: Cambodia, China, Laos, and Indonesia. Most of these countries had never been struck by any strain
of avian flu before. Never had a highly lethal bird flu strain sparked as many outbreaks at once.
Each evening Pascale Brudon, the WHO’s chief representative in Vietnam, gathered team members in the command center to compare notes and briefly unwind. The workload was tremendous, the days long, and the nights late. Yet it didn’t seem to be enough for Geneva. “We had all of this pressure,” Brudon said, “a lot from headquarters from Stohr, saying that this was going to be a terrible epidemic and it was going to be like Spanish flu.”