The boy’s mother was stumped. So was his grandmother. The thirteen-year-old had been among the very first in southern Vietnam to succumb to this new disease. Yet there had been nothing noteworthy about his habits. The women told Uyeki they didn’t keep any poultry in their home. In fact there weren’t even farms in this suburban enclave of Ho Chi Minh City, the former southern capital still known by most of its denizens as Saigon.
Uyeki had followed the outbreak south, remaining just a week in Hanoi before decamping to Ho Chi Minh. He had tracked the virus to the boy’s home, determined to find the source of infection. “They had no idea what this kid did,” Uyeki said later. “Because, like a normal kid, aside from school, they’re playing. It’s not unusual for a parent or grandmother to have no idea what this kid does after school.” Uyeki could find no evidence of exposure to birds, much less sick ones. Nor was anyone else in the family ill. Could the virus now be lurking somewhere else? Perhaps in a new, undiscovered lair?
Sometimes, on disease investigations, fortune breaks your way. As Uyeki and his colleagues filed out of the family’s home, they were an odd sight, a band of strangers in masks. Quickly, curious neighbors started congregating. They showered the investigators with questions. Then Uyeki started doing the asking.
“Oh, yeah,” one neighbor piped up. “That kid, every day after school, he participates in cockfighting.”
Uyeki’s ears perked up. “Where?” he asked.
The neighbor led them down a narrow, paved street. After a couple of hundred yards, they came upon three or four woven baskets on the roadside, each containing a rooster. A little farther they found several more roosters and then a few more beyond that. This was the staging ground for the fights.
“We found out that this kid, along with other boys, every day after school he’d actually hold the cocks,” Uyeki later reported. “So that’s pretty good contact. If you’re holding the rooster, the rear end or the feathers are pretty close to your face. That is what we believed was his risk.” With this discovery, Uyeki had become the first to identify the threat posed by cockfighting, a popular pastime that over the coming years would be repeatedly implicated in bird flu deaths across Southeast Asia.
Other times fortune breaks against you. Days later, Uyeki and his Vietnamese colleagues pulled into a rural village in Tay Ninh province, about fifty miles northwest of Ho Chi Minh City, to investigate the case of a seventeen-year-old girl who had died of bird flu in a local hospital. They parked their van down the dirt road from her home. Chickens foraged in the dust. Pigs grazed on the roadside. Then, dressed in full protective gear, including baby blue disposable aprons and pants, masks, goggles, shower caps, gloves, and rubber shoe coverings, the team got out of the van and slowly approached the house.
But as they did, they discovered they weren’t the only strangers in town. A Vietnamese television crew had also turned up to interview the family. A crowd was forming.
The girl’s mother and grandmother were sitting in the doorway of their home, little more than a shack of bamboo and metal. They spotted the TV crew. They spotted the group of what could only have looked like space aliens. And the grandmother began to shriek. She was afraid. She was resentful of the intrusion at a time when the family was grieving.
But Uyeki wondered whether there was something more. He asked his translator what the old lady was saying. She was shouting over and over that her granddaughter had died of natural causes, insisting there was nothing untoward about the death. Uyeki suddenly realized the histrionics were meant for her neighbors. “She was trying to
reassure them and also trying to deflect any potential stigma,” he concluded. The family was terrified of being ostracized if fellow villagers believed they were infectious or, even worse, cursed. The investigators retreated, deciding the family should be left alone.
As long as the cases were coming one at a time, WHO felt confident that a pandemic virus had not yet broken loose. Each isolated human case was a dead end for the pathogen. Then investigators began to hear about the wedding party.
In late December 2003, a family in the northern province of Thai Binh, a verdant, rice-growing region in the Red River delta, had gathered to prepare for a marriage. On January 3 the couple wed. Four days later, the thirty-one-year-old groom started having trouble breathing. He died in the intensive care unit barely a week after his nuptials. Next his twenty-eight-year-old bride and two younger sisters came down with a cough and fever. Though the wife soon recovered, the sisters were taken to Hanoi, where they were admitted to the tropical disease institute, a six-story cream-colored building on the bustling urban campus of Bach Mai Hospital. Both ultimately tested positive for bird flu.
Bach Mai was already associated with tragedy. In the waning days of 1972, U.S. B-52s had leveled the hospital during a withering aerial campaign against North Vietnam that came to be known as the Christmas bombing. At least thirty people inside Bach Mai were killed in an attack emblematic of the war’s excesses. After the conflict subsided, the hospital was slowly rebuilt, an inch at a time because of unexploded ordnance. Now, a generation later, Bach Mai again commanded the world’s uneasy attention.
Peter Horby went to visit the sisters the day after they were admitted. “They were well,” he recalled. They were walking around and taking the antiviral drug Tamiflu. But soon they started to deteriorate and within nine days were dead.
Horby set out for Thai Binh to learn more about the cluster of cases. “This was the first time we could investigate something like this,” he said. “Everyone was wondering whether it was human-to-human.”
He interviewed the mother of the three victims. It was a tough conversation. She was distraught. He questioned neighbors. He tried to reconstruct the chain of events and scrutinized the timing of the cases to see whether everyone could have conceivably contracted the disease from the same, single source.
He learned that one sister had handled a duck while cooking. But she had not personally butchered the bird, considered a practice with a high risk of infection, and in any case the duck had seemed healthy. The bride and the other sister had no such exposure at all. There were no birds around their house or, for that matter, in their immediate neighborhood. They lived in town, not on a farm. But the sisters had cared for their ailing brother who, though never tested, almost certainly died from the disease. Horby deduced that the sisters had likely caught the virus directly from him.
Horby drove back to Hanoi and presented his report. The findings were explosive, especially because WHO had been reassuring the world’s media there was no reason to panic as long as there was no human-to-human transmission.
“We really have to be sure,” Brudon told the team members. “We must be really, absolutely sure.”
For several long evenings, they cloistered in the Hanoi command center scrubbing the evidence. The conclusion was clear. “The team was quite convinced after the careful epidemiological investigations done by some members of the team,” Brudon later wrote, “that we were in front of cases of H to H transmission.” She agreed to release the findings.
Almost instantly, Horby said, “the shit hit the fan.” The agency’s upper echelons had not seen the disclosure coming. The next day WHO’s director general, Dr. Lee Jong Wook, called Brudon. He was furious. He castigated her for endorsing what he thought an ill-considered statement. He said she had rattled the world for no reason.
Team members in Vietnam were stunned by Lee’s response. They were sure their hard work had uncovered a fateful twist in the evolution of a killer virus, and this was their reward? They concluded that Lee had buckled under pressure from some of WHO’s member countries, notably the Thais. With the virus also circulating in Thailand, that country’s government was sensitive about any suggestion that the
strain could become epidemic, fearful of the toll this could take on the economy. Thai Prime Minister Thaksin publicly attacked WHO’s statement about human transmission, calling it bad science. “Normally, the ethics of researchers is such that if there is only a slight possibility of something happening, then they will discuss it among themselves. They will not say anything to the public to raise concern,” Thaksin told reporters, assuring them that “the possibility of human-to-human transmission is 0.00001 percent.”
In subsequent statements WHO adopted a far more reassuring tone, minimizing the significance of what the team in Vietnam had discovered. Three leading researchers based in Vietnam, including the director of its National Institute of Hygiene and Epidemiology, later cited the episode, recounting that “temperatures were running high, and any mention of person-to-person transmission of H5N1 was thought by some to be reckless.” They added, “An air of tension . . . surrounds this disease, particularly in the corridors of power within the international health and political communities.”
WHO would later clarify that “limited” human transmission was not a threat. The concern was “sustained” and “efficient” transmission. But the novel strain had now crossed another barrier. In 1997, it had demonstrated it could jump from animals to people. Back then, investigators in Hong Kong had also suspected that the virus could hop from person to person but never had conclusive proof. Now, nearly seven years later, it had shown convincingly that it could.
As reports of outbreaks among both people and birds continued to pile up, Vietnam resolved to take a terrible gamble. It would seek to exterminate the sickened flocks, the course recommended by international health specialists. But this would mean dispatching thousands of potentially susceptible peasants against an inscrutable enemy. They would fight the virus literally with their bare hands.
Inside the dimly lit coop of one farm outside Hanoi, workers chased the frenzied chickens, trying to pummel them with wooden rods. A bird bolted out the door into the sunlight and a woman lunged, snagging the errant fowl with her unprotected hands. She pounded it senseless, then
stuffed its lifeless body into a sack with other casualties. Dozens of survivors scattered, dodging blows. Feathers flew. Droppings kicked up underfoot.
It was early February 2004, and I had arrived in Vietnam days earlier, anxious to see how authorities were tackling the budding epidemic. Poultry outbreaks had been reported across Ha Tay province, home to much of northern Vietnam’s chicken industry. As I approached the village of Phu Cat just south of the capital, an agriculture official in a blue uniform motioned for me to stop my car. He circled the vehicle, spraying the tires with disinfectant to ensure I was not tracking death into his community. Then, for my protection, another official handed me a 3M mask, surgical cap, rubber boots, and a white Kimberly-Clark jumpsuit and instructed me to put them on. He then joined me in the car and guided us into the village.
We pulled up at a two-story shed. Thousands of chickens on this farm had been marked for death because they might carry the virus. A pair of veterinary officials huddled in the driveway. They were clad in broad masks, caps, and thick goggles, as well as protective suits, gloves, and boots. The local government had dipped into its budget to finance protective outfits for officials but could not afford to buy them for the cullers—the very people on the front line. Upstairs on the second floor was the large, low-ceiling coop where farmworkers were running down their prey, stuffing the battered chicken bodies into sacks, and then heaving them out a window into the bed of a truck below. Most of those called to battle wore only cheap rain slickers and flimsy masks.
One young culler emerged from the shed, dirt and bloodstains speckling his sandaled feet. “I didn’t wear boots or gloves. I didn’t buy any,” he told me. Other farmworkers reported the same. “It’s very dangerous for the people, but we can’t buy everything we need to wear,” added a neighbor. “I’m afraid I’ll get infected from the chickens, but I have to do it because I can’t ask anyone else to do it for me.”
WHO officials were becoming alarmed. The workers in this nationwide slaughter were risking their lives. Even more ominously, they were giving the disease a prime opportunity to remake itself inside their bodies, potentially hatching a new strain easily passed among people.
Then, as springtime approached, the virus seemed to vanish abruptly from all of Asia. The outbreaks ceased like a fever breaking overnight. Most of the flu hunters headed home, still puzzled, but few believed they were gone for good.
“We need to think of it like a war,” urged Dutch scientist Dr. Albert Osterhaus in a conference call with WHO.
“We may have no choice than to live with the virus,” added Dr. Les Sims, who had been Hong Kong’s chief vet at the time of the 1997 outbreak. “I don’t believe we are going to get rid of this virus from the region even in the long term.”
Though flu specialists had anticipated the return of the novel strain, they were startled by its sudden reappearance in late June 2004. The virus had always surfaced in the cooler weather, and here they were still in the summer. Despite the unprecedented culling of more than 100 million birds in East Asia, the scourge reappeared on farms across Vietnam, eventually returning to Thailand, China, Cambodia, and Indonesia and spreading, for the first time, to Malaysia. New human cases popped up in Vietnam and Thailand. Researchers were reporting that the virus was widespread in ducks, moving into wild birds, and growing ever more lethal in lab animals. Another study concluded that the strain had gained a permanent foothold in Asian poultry.
In August 2004, Vietnam’s
Tuoi Tre
newspaper reported that a brother and sister in the southern province of Hau Giang had died under suspicious circumstances. The man, a nineteen-year old high-school student, had just taken his university entrance exam when he fell sick on July 23. Four days later he was admitted to the hospital with a fever, headache, and bloody cough and died after three more days. The local doctors diagnosed the case, apparently incorrectly, as septicemia or blood poisoning and never notified higher government authorities.