A day after he died, his twenty-five-year-old sister, a local teacher, began to complain of headaches, muscle pain, and difficulty breathing. She was dead within a week. A journalist for
Tuoi Tre
got wind of the cases and publicized them.
The hospital had already discarded samples from the brother, but lab technicians tested those from his sister and discovered she had bird flu. Health officials also reported that a third family member, a cousin, had also died recently but had never been tested.
Alerted, investigators came to the densely populated town deep in the luscious Mekong Delta, but they struggled to find the source of infection. Though the family raised ducks, chickens, and geese, the birds were all healthy. Investigators reported that “no link could be established with deceased or dying poultry.” But they did learn that the sister had initially cared for her ailing brother, possibly accounting for her infection. This revelation, coupled with the sequence of the cases, persuaded some at WHO that for at least the second time, the virus had hopped from one person to another.
“My personal feeling is that this was almost certainly H2H transmission,” a WHO epidemiologist would write in an internal memo later that year.
This time WHO didn’t announce the conclusion at all. Senior WHO figures and Asian political leaders remained unwilling to acknowledge how far this fatal strain had come.
Scott Dowell was America’s sentinel, watching from his post in Bangkok for threats on the horizon, when he got a call in September 2004 from Thailand’s chief epidemiologist.
“We’ve got a weird situation,” Kumnuan Ungchusak began.
He told Dowell that a local hospital had been routinely watching for cases of bird flu when a woman with severe pneumonia came in. She’d been around chickens, so the staff suspected the virus. Investigators from the health ministry were called. It ended up being a false alarm. But as the officials were preparing to leave, a nurse pulled one of them aside and asked about another woman, who had just died. She, too, had had severe pneumonia. No one had suspected bird flu in this case, Kumnuan said, because the woman hadn’t been around any poultry. But then they learned the woman’s daughter had also died about a week earlier in the countryside.
Kumnuan was going to drive up to the province in the morning to check it out. Did Dowell want to come?
Dowell was an American who ran the CDC’s International Emerging Infections Program, headquartered in a sprawling office park that houses the Thai health ministry. Like the listening posts established by U.S. intelligence agencies during the cold war to monitor developments behind the Iron Curtain, Dowell’s operation was on the front lines of a new struggle, watching for novel diseases that could threaten Americans and their national security.
As he and Kumnuan drove north to Kamphaeng Phet province on that Friday morning, the Thai doctor recounted more of the story. An eleven-year-old girl named Sakuntala Premphasri had lived with her aunt and uncle in a remote village about twenty miles off the main road. Their home was set back in the trees, a traditional, one-room house on wooden stilts with a sloping roof. Like everyone else in the village, the family kept chickens, and they ranged freely in the shady space beneath the house, where the girl often played with her friends and sometimes slept. The birds started dying in August, a few at a time. About four days after the last chickens had keeled over, Sakuntala got sick with a cough and sore throat. She felt feverish. Her aunt took her to a local health center for medicine, but the condition worsened. Days later, the girl was admitted to a district hospital with a high temperature, difficulty breathing, and low blood pressure. An X-ray revealed pneumonia in her lower right lung.
When her mother, Pranee Thongchan, learned of Sakuntala’s deteriorating condition, she rushed to the bedside. Pranee, almost a girl herself at age twenty-six, lived more than two hundred miles away in a Bangkok suburb, where she worked in a garment factory. Pranee had asked her husband, a cabbie, to drive her back to the province to see her daughter. She reached the hospital at midnight. There she cradled the limp body of her little girl, repeatedly kissing her and wiping her mouth. Though the girl kept coughing, a duty nurse reported that Pranee kept her face “attached” to that of her daughter, spending the night beside her “cheek to cheek.”
The next afternoon, with antibiotics failing to make a difference
and her body descending into shock, the girl was transferred to the province’s main hospital. When she arrived, she was bleeding heavily from her lungs. Blood oozed from her nose and mouth. Three hours later she was dead.
Pranee brought her daughter’s body to a Buddhist shrine near her parents’ home in Khampaeng Phet for three days of funeral rites. On the third day, Pranee herself began complaining of a headache and fever. Pranee went to the district health center for medicine. When she returned to the Thai capital, she felt even worse. It was getting harder and harder to breathe. Ten days after her daughter died, Pranee checked herself into the Bangkok hospital. By then it was too late. The infection had invaded both her lungs, and nothing could save her.
Alone in the car, Dowell and Kumnuan agreed that her case looked a lot like one of human transmission. “If there is transmission in this way, many people will be interested in this case,” Dowell told his colleague.
Kumnuan kept working his cell phone to get more details. He called his subordinates, who were already in the province. Now they were telling him that other family members might also be sick.
“We need to get samples,” Dowell urged. These specimens would not only confirm the virus but could also show whether it was mutating.
Had they taken samples from the mother? Not yet, Kumnuan answered. Kumnuan called back to Bangkok. He discovered that Pranee’s corpse had already been embalmed. At that very instant, the body was at a Buddhist temple in the capital, about to cremated. Kumnuan ordered his officers on-site to do whatever it took to hold on to the body and hurriedly dispatched a specialist who could conduct a limited autopsy on the fly. He got there just in time, snipping out a specimen of lung tissue. It later tested positive for the virus.
When Dowell and Kumnuan finally arrived at Kamphaeng Phet Hospital, Sakuntala’s thirty-two-year-old aunt had just been brought in. She, too, had chills and trouble breathing, and she was having X-rays taken. They went to the radiology department to have a look. Sure enough, her lungs were clouded over. That raised an alarm. They asked to see her. The woman’s condition was serious—her
temperature had spiked at over 103 degrees, and samples she gave that day would later test positive—but unlike in the previous cases, would not be fatal. She mumbled to Dowell and Kumnuan that she’d been the one who buried the sick chickens in the yard, wrapping her hands in plastic bags for protection. But that had already been more than two weeks earlier, beyond the incubation period for flu. She also told them she had cared for her dying niece, staying at her hospital bedside until the very moment Pranee had arrived. That was the telling detail.
The following Monday, September 27, the veteran virologist Prasert Thongcharoen chaired a closed-door meeting convened by Thailand’s Ministry of Public Health to review the cases of Sakuntala, her mother, and her aunt. In attendance were government health officials and medical experts from WHO and the CDC. Eight months had passed since Prasert blew the whistle on bird flu in Thailand. Now it was his mission to have his government and international health agencies formally acknowledge what scientists increasingly believed: The virus could spread among people.
This wasn’t the first probable case of human transmission. But the evidence this time was incontrovertible. Sakuntala’s mother, Pranee, hadn’t even been in the same province when her daughter got sick. There was no way they could have caught the bug from the same chickens. In fact, there was no poultry at all in the Bangkok apartment where Pranee lived, nor in the factory where she worked. She had certainly contracted the virus at her daughter’s bedside, and that was the same way the aunt had likely caught it. “It was a clear indication that H5N1 could be transmitted from person to person,” Dowell said later. “Even though a number of us who had studied H5N1 closely over time thought that had probably already occurred, there was a widespread perception that the virus couldn’t be transmitted person to person.”
Dowell told me he faulted WHO and his own institution, the CDC, for too long leading the public to believe that bird flu could not be passed among people. Even if the transmission was limited, it was of grave concern. This was precisely how the virus could become
proficient at spreading, he explained. It was through the process of passing from one human to another that a mutating strain could select the genetic attributes required to become a mass killer.
Once the evidence had been presented, Prasert coaxed his colleagues to accept the inevitable conclusion. He had the rare combination of independence, savvy, and scientific credentials to make it happen.
A day later Thailand’s health ministry announced that the Kamphaeng Phet cluster had been “probable human-to-human transmission” of bird flu.
“For the political leadership in Thailand to say there was person-to-person transmission, that hadn’t happened before,” Dowell recounted. “It’s a testament to Prasert and the influence he was able to wield in Thailand.”
WHO released a statement about the Thai cluster that same day, copying the government’s language and for the first time conceding “a probable case of human-to-human transmission.” The virus had crossed a threshold, and so had its antagonists.
But even as they accepted how close H5N1 had now come to an epidemic strain, they had little inkling of what was about to happen. The death of yet another Vietnamese youngster right after New Year’s Day 2005 would mark a new, even larger wave of infections. The virus would extend its reach in the new year as never before. It would soon strike beyond Asia, infecting new continents, multiplying its victims, and confronting the flu hunters with the prospect of imminent pandemic.
PART TWO
CHAPTER FIVE
Livestock Revolution
W
hen Prathum Buaklee dropped out of fourth grade to plant rice like his father and grandfather, he could not envision the revolution that would roll across the wetlands of central Thailand, lifting his family out of destitution and ultimately sending his own sons on to university in Bangkok. The royal capital, though only seventy-five miles southeast of Prathum’s village of Banglane, seemed like another continent in the 1950s. Those sons of Suphan Buri province fortunate enough to escape its hardships first had to find their way to the Tha Cheen River, which slices through the swampy, low-lying plain. Roads were few, little more than muddy tracks rutted by the wheels of cattle carts. So local journeys were often made in wooden rowboats that glided through weedy marshes and along a labyrinth of canals skirting the glistening emerald paddies. Once the travelers reached the river, they would hitch rides on the lumbering, two-story rice barges that hauled the province’s harvest southward. Departing after the worst of the midday heat, they would arrive in Bangkok at dawn the next morning.
Nearly everyone who remained behind grew rice. It was a hard life, long days under the searing, tropical sun, and the rewards were modest. “It wasn’t enough. Just barely enough to make a living,” Prathum recalled, a deep furrow cutting across his broad forehead like freshly tilled earth. He erected a small, traditional house, a leaky hovel of
clapboard and corrugated metal on stilts, and bought himself a bullock cart.
At first, change came slowly to Suphan Buri. In the drier, upland area to the north and west of the province, villagers started cutting down the bamboo forest in the mid-1960s and planting sugar cane. Day by day, the jungle shrank until the cane fields eventually nestled against the base of the mountains. Long-distance bus service was introduced, putting Bangkok only four hours away along a rocky, bone-jarring road.
Then, two decades later, chicken made its debut. A pair of Thai poultry companies, including the Charoen Pokphand enterprise that would ultimately become the country’s premier multinational corporation, came to Suphan Buri, urging rice farmers to raise chicken instead. The companies offered them chicks, feed, and guaranteed prices for mature broilers. Some of this activity was driven by Thailand’s campaign to boost poultry exports. But far more profound changes were also at work. The kingdom had embarked on an ambitious course of economic development, tapping its wealth of natural resources, cheap labor, and open investment climate to become a low-cost manufacturing dynamo. As its shirts, shoes, and consumer electronics crowded American and European shelves, Thailand staked a claim as one of the new Asian tiger economies, recording annual growth rates of nearly 10 percent. This translated into rising incomes for many Thais, especially in the cities, and the new, burgeoning middle class had new, urban tastes. They demanded a better diet, in particular one rich in animal protein. Nowhere was this truer than in the boomtown of Bangkok.
Suphan Buri was strategically located to meet this demand. In the late 1970s, the government had built a paved road linking the province to the capital. Now the Bangkok market was barely two hours away. Many peasants took advantage of cheap land prices to expand their holdings and establish chicken farms. By 1987, Thais had doubled the average amount of chicken they ate. Yet production across the country was growing so fast that prices actually declined, making chicken an even cheaper source of protein than fish or pork and fueling demand further. The consumption of chicken would soon double again.
But the new middle class yearned for variety, and that also meant soaring demand for eggs.
Even as Prathum continued to toil in the rice fields, fellow villagers in Banglane were starting to experiment with hen farms. In 1991 Prathum followed suit. He began with three hundred laying hens, soon adding several hundred more. When his flock grew into the thousands, he abandoned the paddies altogether.