The Fatal Strain

by Alan Sipress

  A day later, Horby took a call from a journalist asking whether he’d heard reports about a massive die-off of chickens outside Hanoi. He hadn’t. No one at WHO had. “That instantly started ringing alarm bells,” he recalled. “The first day, we thought it was influenza. The second day, we were talking about possible avian flu.”

  Dr. Mai at NIHE came to the same conclusion later that week. She had finally succeeded in discovering her causative agent in a sample from one of the children. It was H5N1 bird flu. But WHO still wanted confirmation from an overseas lab with proven experience and turned to Wilina Lim in Hong Kong, the laboratory chief who had worked on the initial human cases in 1997. It took several days to get her the samples. Vietnamese Airlines had balked at transporting them, so another airline had to be found.

  The results finally came back on Sunday, January 11. Two children had tested positive for the virus. And so had a third person, the mother of one of the dead youngsters.

  WHO put out a worldwide call for reinforcements.

  WHO was coming off a monumental victory six months earlier. The containment of SARS, a previously unknown killer that had spread to four continents before it was checked, marked one of the agency’s greatest successes in a half century of history. But it came at a great price.

  Agency personnel and their allies from dozens of countries had hustled day and night for months on end, often far from home, to uncover the extent of the SARS outbreak, crack its genetic secrets, and ultimately run it to ground. It was a sprint pace at marathon length. And as the death toll had mounted, so had the pressure. Individual governments made relentless demands on the agency. The global media’s appetite for information was insatiable. The prospect of failure was chilling. After the final two countries, China and Taiwan, were declared SARS free in July 2003, the troops were utterly spent. In Geneva, where crisis had built camaraderie, the agency descended into internal bickering as all the disputes and grievances that had been repressed now bubbled up.

  “People were just strung out,” recounted Michael Ryan, who directed WHO’s alert and response program. “Our systems survived. But I use the word survived because it’s like surviving a nuclear explosion. We were still breathing. We were still feeling our limbs to see, were they all there.”

  When the threat of pandemic rose anew in January 2004, the agency was still reeling. “We were thinking, ‘We don’t want to do that again,’ ” Ryan said.

  That was especially true for WHO in Vietnam, which had been among the first countries struck by SARS and among the first to contain it. Pascale Brudon, the auburn-haired Frenchwoman who headed the agency’s Hanoi office, likened the SARS experience to The Plague, by Albert Camus. She said the tension and sense of personal jeopardy had been profound, especially after the loss of Dr. Carlo Urbani. Urbani, an Italian infectious-disease expert assigned to Vietnam, had investigated the country’s initial SARS case, and his early insights into the pathogen ultimately helped the world defeat it. But not before he, too, succumbed. He had been a popular figure, a hang-gliding, motorcycle-riding musician of a man who, while previously working for Doctors Without Borders, had received the 1999 Nobel Peace Prize on that organization’s behalf. His death was staggering.

  When Horby notified Brudon in early January 2004 about what he’d learned at the National Pediatric Hospital, her reaction was, “Oh no, not again.”

  In Geneva, Dr. Klaus Stohr was the head of WHO’s global influenza program. He had never doubted that bird flu would resurface, and he was waiting for the moment. “To prevent an earthquake or an eruption of a volcano, you always prepare for it,” he recalled. “But when it happens, you’re still surprised, still shocked.”

  Stohr wanted to get his flu hunters on the ground fast. But it was proving difficult to assemble a team. “There were some people, all international experts, who said ‘Why should I go? Why should I jump into the frying pan?’ ” he recalled. They were thinking about their families. They were thinking about Carlo Urbani. “It’s too hot for us to go right in the middle of a possible volcano.” They demurred.

  Horby was already on the ground and he, too, was thinking about Urbani. He had assumed some of Urbani’s duties, and like his predecessor, was back in the hospitals, seeing desperately sick patients infected with an uncertain yet catastrophic agent. “It was a very worrying time,” Horby later acknowledged.

  But Uyeki, biding his time in Atlanta since he’d first learned of the outbreak two weeks earlier, couldn’t get there soon enough. “You want to help and you want to find out answers,” he told me. “Yeah, I was ready to go right away. Keiji and I, we’re ready to go.”

  “What do I need?” Uyeki thought. He stocked up on antiviral drugs to dose himself. He collected his protective gear. As a matter of course, he had already been custom-fitted for N95 respirators, what most people call masks, and he replenished his supply. Then he and Fukuda started turning over their command responsibilities in fighting the seasonal flu still raging at home.

  The flu outbreak that began that fall had jolted the American health-care system. It was only seasonal flu, but hospitals and doctors’ offices were flooded with the infirm. Emergency rooms from coast to coast were reporting record numbers of patients, in some cases a hundred a day, and many waiting rooms were standing room only. Some hospitals made other patients give up their beds. Local government officials activated disaster plans. Just a week after Thanksgiving, flu shots already had run out.

  But as nasty as that flu season was, again, it was only seasonal flu. In a pandemic, the health-care system could crumble. Just the initial rumblings of a pandemic, the first weeks of the swine flu outbreak in spring 2009, overwhelmed many American hospitals and clinics as patients with little more than common colds, or no symptoms at all, clamored to be checked out. A mild pandemic with a relatively low death rate would still sicken at least a quarter of the population, sending millions of petrified, sniffling Americans to the hospital. In a more severe epidemic, our broader society as we know it could be in jeopardy. That’s the lesson of Philadelphia.

  As a young reporter, I worked there for eight years—it was my first big city—and I got to know its streets well. I never realized I was sharing the ghostly geography of the worst calamity ever to befall the United States.

  It was September 11, 1918 when the Spanish flu made its first recorded appearance in Philadelphia, striking the Naval Yard at the foot of South Broad Street. The virus had come ashore with scores of sailors transferred days earlier from Boston, a city already under siege. But Philadelphia’s flu epidemic would evince its full fury only later in the month, after the city had experienced perhaps the greatest orgy ever of human-to-human transmission. Soon the city would be the hardest hit in the country, gripped not only by illness but by terror and social breakdown on a scale unprecedented in American history.

  As autumn broke in 1918, the eyes of Philadelphians, like those of most Americans, were on the war in Europe. Two days after U.S. forces and their allies launched a decisive offensive in the battle of Argonne Forest, attention shifted to the home front with the city’s Fourth Annual Liberty Loan parade. Billed as the largest in Philadelphia’s history, this procession on September 28 would kick off the city’s campaign to raise money for the war effort. As I study an old photograph of that Saturday afternoon in 1918, I can almost see death marching through my neighborhood, retracing the steps I walked daily. Five uniformed sailors, rifles on their shoulders, escort a festooned float bearing a navy patrol boat past the intersection of Broad and Chestnut. Hundreds of spectators are crammed beneath the classical columns of a building that decades later would become my local bank branch. At least two hundred thousand others pack the route along twenty-three blocks of Broad Street, cheering on the passing pageant of marines, sailors, and yeowomen, steelworkers, shipworkers, and makers of “shot and shell,” with horse-drawn eight-inch howitzers, Boy Scouts, women of charity and relief, and Main Line debutantes riding farm equipment. Never would a flu virus more
clearly demonstrate what it means to fully satisfy the third and final condition of a pandemic.

  Philadelphians had barely boarded the streetcars for their Monday morning commute when the epidemic exploded. By Tuesday every hospital bed in town was taken. Thirty-one hospitals, and they were all turning people away. In the historic Society Hill neighborhood, the sick rushed to Pennsylvania Hospital, cofounded by Benjamin Franklin. “When they got there, there were lines and no doctors available and no medicine available. So they went home, those that were strong enough,” a neighbor recalled. Five days after the parade, a doctor at Women’s Medical College of Pennsylvania reported that students had begun filling in for hospital staff who were themselves laid low. “The experiences through which we are passing remind one of the historic records of the plague,” wrote Dr. Ellen C. Potter, a medical professor at the college, in a letter to an academic colleague.

  Just a week after the parade, on Saturday, October 5, doctors in Philadelphia reported 254 deaths in a single day. Five days later, the daily toll was 759, almost precisely triple. Hundreds of thousands were sick.

  Philadelphia General Hospital, in West Philadelphia, was among the first to appeal for help. “Two-thirds of the nursing force were prostrate by the disease with none to replace them in the wards,” reported sisters from the Roman Catholic archdiocese, who time and again answered the call. Almost half the doctors and nurses had themselves been hospitalized. Others had collapsed from overwork. Patients, many violently delirious, were getting minimal care. “Some of the poor sick had had no attention for over 18 hours and some had not been bathed for over a week,” the sisters reported.

  Isaac Starr was a third-year student at the University of Pennsylvania’s School of Medicine. After a single lecture on influenza, he was dispatched to staff an emergency hospital opened in a partly demolished building at Eighteenth and Cherry streets. Starr and his classmates hauled twenty-five beds onto each of five floors. These filled right up with victims. “After gasping for several hours, they became delirious and incontinent, and many died struggling to clear their airways of blood-tinged froth that sometimes gushed from their nose and mouth,” he later wrote. Many died without seeing a doctor. Corpses were “tossed” onto trucks, which hauled them away when filled. “The rumor got around that the ‘black death’ had returned,” he wrote.

  More emergency hospitals were opening every day in garages, parish houses, gyms, armories, nursery schools, and college frats, but often there was barely anyone to staff them. The city established one of the first at the poorhouse in the Holmesburg section. Its five hundred beds were filled in a day. In the second week of October, when a contingent of nuns came in relief, they discovered only twelve nurses caring for the patients. “One can imagine the distress, neglect and misery of these poor creatures. Some did not have their faces washed for days; their bed clothing had not been changed for a like period of time,” one of the sisters recounted. Patients were moaning, coughing, delirious, some rising from their beds and frantically wandering the wards like specters. With only a single orderly for the whole hospital, the dead could lie unattended for hours until volunteers came to haul them out. “The first day we saw 13 bodies carried out to the dead-house within four hours,” the nun continued. “The odor from this dead-house was something awful.”

  Nor was it just the city that was in the crosshairs. The smaller towns in its orbit were also succumbing. In Pottsville, the residence of a wealthy family was converted into a medical facility. “What sights and sounds met us when we entered that room where 84 patients were moaning and crying for help!” one nun wrote. “There were about forty babies in one room, all crying and perfectly helpless, their ages ranging from six days to two and a half years.” All night, the stricken begged for water, ice, or a comforting presence in their final hours. The nun was horrified. “Some,” she said, “were so far gone that worms were crawling out of their mouths.”

  On the streets of Philadelphia, cars bearing medical insignia were mobbed. College classes for pharmacy students were suspended so they could help fill prescriptions until drugstore shelves ran bare. Public services broke down. Nearly 500 police officers stayed off the job. About 1,800 telephone employees failed to show up for work, forcing Bell Telephone Company of Pennsylvania to take out newspaper ads warning it could handle “no other than absolutely necessary calls compelled by the epidemic or by war necessity.”

  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 shorta
ge. 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.