The Fatal Strain

by Alan Sipress

  Six years had passed since the novel strain of flu had crossed to people in Hong Kong in 1997, and the virus had been nearly invisible since then. In the interim, the only confirmed human cases in the world had come several months earlier in a Chinese family. At this moment in late 2003, though Asia was on the brink of an unprecedented outbreak in both birds and people, flu was on few minds. The virus, it seemed, had vanished, lulling much of the world into a naive confidence that the pandemic threat had passed.

  This would become the pattern. Over the next few years, the H5N1 strain would repeatedly raise its head, surfacing in ever more countries and provoking grave public health warnings anew. Yet each time, the virus would stop short of epidemic and then retreat. Politicians would boast they’d cornered the bug. Media attention would fade. Much of the public would forget.

  In 1997, H5N1 had been but one hurdle shy of pandemic, yet that recognition vanished in the silence that followed the Hong Kong outbreak. The virus was a subtype against which no one was immune. It had demonstrated it could infect people. Only the last of the three conditions for pandemic had remained unfulfilled: that the disease could be relayed along a human chain.

  It would fall to Prasert to prove that once again, a novel strain was circulating across the landscape of East Asia. Soon after, he would also reveal that the virus had begun to strike his countrymen. And eventually, as the world watched anxiously to learn whether the virus could be passed from one person to another, Prasert would play a central role in confirming it could. Although Prasert held the title of WHO consultant, he waged this campaign mostly by himself. For while WHO’s flu specialists back in Geneva also suspected something was not right, they had to defer, as they all too often must, to the assurances of a sovereign state that all was well.

  When I first met Prasert in 2005, the bags beneath his eyes had grown heavy and the lids were sagging. The years had generously etched his forehead with fine lines. But his curiosity and intellect remained acute. He was still Thailand’s most eminent virologist and the man who literally wrote the book on flu in his country. His 1998 monograph on the disease begins, “Influenza has been an epidemic illness since ancient times but the flu virus never remains the way it was. It never stops changing.”

  When the Asian flu pandemic of 1957 swept through Thailand, Prasert was just one month out of medical school and beginning his hospital residency. As pandemics go, it was comparatively mild. But for the three months that it throttled Thailand, the flu flooded Prasert’s hospital with the sick and dying. Several dozen of his fellow residents fell victim. The young physician was one of only two healthy enough to attend to patients. Eleven years later, when pandemic revisited Thailand in the form of the Hong Kong flu, Prasert was already emerging as a leading researcher. He devoted his efforts to deciphering the virus’s behavior by scrutinizing the pattern of mass absenteeism at Thai schools and industries.

  Prasert received me in his sixth-floor office at Mahidol University’s microbiology department, where he had established the virology program decades earlier. Siriraj Hospital, home to the department, is a teeming complex of white-and-cream towers rising on the west bank of the Chao Phraya River, which winds through the heart of the Thai capital. The dark waters below bustle with low-slung ferries shuttling commuters and shoppers between the shores, carnival-colored long-tail boats popular with sightseers, and the occasional tugboat dragging a sand barge slowly downriver. On the opposing bank shimmer the fairy-tale pagodas and gold steeples of the Grand Palace, the Temple of the Emerald Buddha, and the other signature sites of royal Bangkok. Prasert’s office was cramped but well air-conditioned, a relief from the hospital’s steamy corridors. Several bouquets of silk-and-plastic flowers brightened the room. As Prasert’s assistants brought us coffee, he slipped on the white lab coat of a man still very much involved in scientific inquiry and sank into the cushions of a purple sofa. Then, after offering a few observations about the merits of Thai coffee beans, he began to recount how he had forced his government to come clean.

  In November 2003, Thai poultry farmers had begun to complain about a disease devastating their flocks. Their chickens at first seemed depressed and lost their appetites. The hens stopped laying eggs. The birds would soon start to wheeze and cough as the sickness ravaged their lungs. Some would develop diarrhea. Many would stagger around as their brains began to hemorrhage, melting into a bloody cranial mush. They would die suddenly, often overnight, and by the thousands. This disease was killing with a speed almost never seen in Thailand or anywhere on Earth.

  Thai agriculture officials investigated and, suppressing the truth, reassured farmers it was nothing serious, just a minor outbreak of fowl cholera complicated by bronchitis. The country’s deputy agriculture minister and livestock chief would both later blame the spiraling death toll on the weather, saying that an abrupt seasonal change had left chickens in a weakened state that made them vulnerable to catching these two infections in tandem. There was no reason to panic. There was certainly no reason, the agriculture officials said disingenuously, for anyone to doubt the quality of poultry raised in Thailand, which at the time was the world’s fourth-largest chicken exporter, annually shipping $1.3 billion worth overseas.

  Prasert heard the initial reports and had no reason to disbelieve them. But he was intrigued. Though he had spent years studying infectious diseases, from dengue fever to HIV-AIDS, fowl cholera was entirely new for him. “I just wanted to see about it,” he explained. So in the predawn hours of a December morning, Prasert headed for the wet market that sprawls across more than a dozen acres beside the Bangkok Noi railway station. There, across from the creaky gray train carriages ferrying farmers from the countryside, Thais continue to shop as they have for generations. Prasert ventured into the warren of crowded aisles, slightly stooped, stepping carefully along floors slick with water and mud, past mounds of pineapples, mangos, hairy ramb utan, and lavender dragon fruit, past chili peppers and curry power heaped high in plastic baskets, past pig heads lined up along white tile countertops and catfish slithering in their trays. Even before he reached the chicken mongers, he could hear the repeated thump of their cleavers as they hacked the birds into wings and legs, feet and ankles, liver and intestines. He asked around until he located several peddlers whose families raised poultry in Nakhon Sawan province, about a hundred miles north. Prasert had heard it was at the center of the fowl cholera outbreak.

  “They said they didn’t believe it,” he recalled. “They said it wasn’t like fowl cholera. If they have some chickens that are sick with that, they give them tetracycline, and they get better. But these chickens, by the next morning, they’re all dead. So they thought there was something more than that.”

  Prasert was unsure what to make of this skepticism and filed away their dissent. “I didn’t pay much attention to that then,” he said. But within two weeks, when his friends came to him with apologies instead of eggs, he remembered what the farmers of Nakhon Sawan had said.

  His ears now attuned to reports of ailing chickens, Prasert was starting to hear about a bird flu outbreak in southern China. Though Chinese agriculture officials would not disclose the spreading infection for nearly two more months, in late January 2004, the virus had in fact been circulating there for years. This was no secret to Chinese farmers, veterinarians, and researchers, and the rumor soon reached Prasert. He surmised that the flu virus afflicting Chinese poultry was now making chickens sick in Thailand. He suspected that migratory birds had spread the disease from China. But he still needed proof.

  With Thai livestock officials continuing to hide evidence of bird flu, Prasert turned to two colleagues at the Ministry of Public Health. Together they plotted to smuggle poultry samples from the countryside into Bangkok for testing. Since agriculture officials had barred them from visiting chicken farms, Prasert and his colleagues called a farmer in Chachoengsao province, home to the county’s largest concentration of chickens, and recruited him as an accomplice. They arranged for him
to wrap two dead chickens in newspaper and then leave them at the edge of his property like innocent rubbish. The pair of health ministry officials would drive out to the province to collect the contraband carcasses.

  When the officials arrived back in the capital, they called Prasert. “We’ve got them,” they reported. “What should we do now?”

  “Bring them here,” he instructed.

  As a medical facility, Siriraj Hospital was not authorized to test animal samples, just those from humans. But Prasert was sure that veterinary labs would refuse to run tests of the dead chickens, fearing government reprisal, or would decline to tell him the results. “We had to do it ourselves. It was a must,” he said. Prasert immediately turned the samples over to lab researchers at his hospital, who began secretly analyzing them for both influenza and fowl cholera.

  The proof he was seeking came later that evening, “December 19, twenty-hundred hours,” Prasert recounted, flashing a broad smile. The researchers brought him lab results demonstrating that the birds were infected with influenza. The tests were not precise enough to determine whether the virus was specifically H5N1, which had surfaced in Hong Kong in 1997 and had been circulating in China ever since. Siriraj Hospital did not have the right chemical reagents to tease this information out of animal samples. But Prasert was now sure that something more than fowl cholera and bronchitis was troubling Thailand’s chickens. And if it was bird flu, he was convinced it had to be H5N1. That meant that the people of Thailand and beyond were in peril. They had no natural defense against this novel strain of flu.

  Prasert placed an urgent call to senior officials at the health ministry. “I have evidence that this is avian flu,” he notified them. He told them they had to be vigilant. He urged them to prepare for a medical emergency. But he was rebuffed. “For agricultural production, we have nothing to do with that,” one senior health officer responded curtly.

  Prasert was aghast. “This is a public health concern,” he scolded, “and I will not close my mouth. I will talk even louder. I’m retired already and no one employs me. It’s not like I’m a government official.”

  Prasert was not alone in suspecting the worst. Inside Thailand’s health ministry itself, infectious-disease specialists were already speculating that the strange sickness decimating the country’s chickens was flu. Officials in the ministry’s disease-control department later told me they had heard rumors as early as November 2003 about flu outbreaks among birds in China and Vietnam. So the ministry sent out letters across Thailand alerting doctors in the provinces to be on guard. The public health surveillance system, which Thailand put in place months earlier in response to the SARS epidemic, was urgently revamped to monitor for bird flu. But health officials remained mute in public. They issued no advice on how to avoid the virus, no warning against contact with sick birds. There was no public guidance about how to recognize the disease if you caught it and what to do if you did. No effort was made to import and stockpile Tamiflu, which was considered the main remedy for the virus.

  Nor was Prasert the only one with hard lab evidence of a flu epidemic out on the farm. Across town at Bangkok’s elite Chulalongkorn University, researchers had confirmed it was bird flu back in November and even determined that the virus was the H5N1 strain. Associate Professor Roongroje Thanawongnuwech, head of the university’s veterinary diagnostic laboratory, would later disclose that the virus had been found in samples taken from Suphan Buri province, about sixty miles northwest of the capital. His lab used a test called the RT-POLYMERASE chain reaction to reveal the virus’s makeup. Researchers compared their results with GenBank, a public database run by the U.S. National Institutes of Health containing tens of thousands of known genetic sequences, and discovered that the Thai virus was very similar to those previously isolated in Hong Kong and Vietnam. Roongroje later reported that these findings had been turned over to Thailand’s national livestock department. But again the public was not told.

  Thai health officials and researchers were cowed. They were under intense pressure to keep mum. At stake were the country’s lucrative poultry business and its export markets, primarily in Europe and Japan. Hundreds of thousands of Thais were estimated to work on thirty thousand poultry farms and in related industries. While some infectious-disease specialists in the health ministry were anxious to sound the alarm, they were silenced by a powerful agriculture ministry whose primary aim was promoting farm interests.

  “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.