The Fatal Strain

by Alan Sipress

  Though governments have recently taken steps to gird the world for a pandemic, too little has been done. As I write, epidemic planning for hospitals and public health systems remains wanting. Preparations in other essential sectors, in particular those to ensure supplies of food, water, electricity, and fuel and to maintain public order, are even more deficient.

  It’s surprising how few people know the horrors of 1918. Perhaps that cataclysm is overshadowed in memory by the final months of World War I, a conflict that recast the geopolitics of the world and defined a generation. Perhaps epidemics exist outside of history, ideology, and meaning, and their imprint vanishes like footsteps on the beach, especially when people have no one to blame for their tragedy, no grievance to harbor. It could be that people simply want to forget suffering. Or maybe we believe, as an advanced civilization, we’ve moved beyond plagues. By that reasoning, 1918 belongs to another, remote era of little relevance to today.

  After I started this book, I told friends and colleagues what I was writing. The response wasn’t what I expected. Time after time, they would mention relatives who had died during the Spanish flu, a grandfather’s brother, a distant cousin. My architect told me his uncle and two other kin are buried in Jamaica after perishing in 1918. Then, several months before I finished the first draft, I discovered evidence of another visitation.

  Growing up, I’d heard the story about how my grandmother’s mother, Yetta, had died as a young woman back in Poland. No one seemed to know precisely when, and no one ever mentioned the word influenza. We never connected it to anything else going on in the world at the time. All we knew was that she had been killed by some respiratory disease, maybe tuberculosis, maybe what they called grippe back then.

  My grandmother, we heard, was eight at the time. It turned her life upside down. Soon after, Grandma’s father abandoned the family, leaving her to care for her younger sister and brother. They drifted from place to place, sleeping one night here, another there. Grandma found odd jobs to feed them, even working for a time picking fruit in orchards around Warsaw. Ultimately, her two maternal uncles sent for the children. The pair had earlier immigrated to New York, where one became a political pamphleteer and the other, according to family lore, hosted the longest continuously running pinochle game in the Bronx. Grandma left her homeland and crossed the ocean.

  We’d never done the math to determine what year great-grandmother Yetta died. We couldn’t, because we didn’t know when Grandma was born. Grandma had lied on her American immigration papers to pass for a few years older so she could line up work. Over the rest of her life, the birth date on her government papers was fiction. When she finally passed away in 2006, she herself wasn’t sure how old she was. But my mother later came across Grandma’s marriage contract in an old file. On the back of this crumbling religious document, the date of the wedding was noted in pencil. With that clue, we could calculate Grandma’s birth date. She had been born in 1910. It meant Yetta had died, and our history pivoted, eight years later in 1918.

  The timing wasn’t absolute proof that flu had been the killer. But the odds were overwhelming. The last great epidemic suddenly felt much closer. So did the next.

  Acknowledgments

  One of the secrets of foreign correspondence is how indebted we are to our local assistants. They translate not only language, when necessary, but culture. They help us conceive our stories, arrange logistics, navigate politics, identify the sources and subjects to interview, and, after all that, do old-fashioned reporting, sometimes at great personal risk, with rarely a byline to show for it. So the initial thanks have to go to Yayu Yuniar, a dogged, delightful journalist in Jakarta. Long before Indonesia confirmed its first human case of bird flu, Yayu dove into the basics of microbiology and went out chasing chickens with me. I’m also tremendously grateful to Lilian, Ira, and Sindi Pramudita, who did so much more than manage our office and local affairs in Indonesia. They became our second family. Noor Huda Ismail and Natasha Tampubolon rounded out our team in Jakarta. I also benefited from the hard work, generosity, and insights of local reporters and fixers elsewhere in Asia, in particular Somporn Panyastianpong in Bangkok, Phann Ana in Phnom Penh, K. C. Ng in Hong Kong, and Ling Jin in Beijing. Back in Washington, Jean Hwang was a tireless assistant, working into the wee hours transcribing often inaudible tapes.

  The Washington Post has always been a special place. Yet with each passing year, as other newspapers succumb to the financial pressures of our troubled industry, the Post’s commitment to great journalism becomes ever more exceptional. That dedication has flowed from the top, from Donald E. Graham, Boisfeuillet Jones Jr., and now Katharine Weymouth. For the opportunity to report from Southeast Asia, I’m grateful to former executive editor Leonard Downie Jr. and former managing editor Steve Coll, as well as to Philip Bennett, who was assistant managing editor for foreign news when I shipped out to Asia and managing editor when I returned. On the foreign desk, a string of talented editors had a hand in my writing about flu, including David Hoffman, Peter Eisner, John Burgess, Kathryn Tolbert, Tiffany Harness, and Jason Ukman. Thanks also to Nils Bruzelius, the deputy national editor for science and health, and news researchers Bob Lyford and Rob Thomason for their help.

  The fraternity of flu writers is surprisingly small, given the drama and stakes of the subject. Yet in recent years I’ve been fortunate to count myself in the company of some terrific journalists. I’ve benefited from the work in Asia of Margie Mason of the Associated Press and Nicholas Zamiska of the Wall Street Journal. Closer to home, the standard has been set by Helen Branswell of the Canadian Press, Maggie Fox of Reuters, and Maryn McKenna, formerly of the Atlanta Journal-Constitution . In Jakarta, I was blessed with colleagues who were both good friends and reliable road companions at the toughest of times, in particular Rick Paddock of the Los Angeles Times, Shawn Donnan of the Financial Times, and John Aglionby of the Guardian and later the Financial Times. A special note of gratitude goes to Dean Yates of Reuters and to Mary Binks.

  This would have been a very different book if not for the cooperation of countless individuals at the World Health Organization. I cannot name them all, and a fair number wouldn’t want me to. But I would like to acknowledge several members of the agency’s public affairs staff, past and present, including Maria Cheng, Peter Cordingley, Bob Dietz, Sari Setiogi, and Roy Wadia. Both in reporting for the Post and in researching this book, I found them consistently helpful. Mary Kay Kindhauser’s efforts in facilitating my reporting in Geneva were invaluable. And I’m particularly grateful to Dick Thompson and Kris tin Thompson for their professional assistance and personal kindness. There were also many at other agencies who took time to share their expertise and give me crash tutorials, including at the UN Food and Agriculture Organization, the World Animal Health Organization, and the Centers for Disease Control and Prevention. Nor can I say enough about the helpful staff of the U.S. National Library of Medicine or the team at the University of Minnesota that maintains the awesomely comprehensive Center for Infectious Disease Research and Policy (CIDRAP) Web site, www.cidrap.umn.edu.

  It’s not possible to credit the scores of scientists, public health experts, and medical specialists who agreed to be interviewed or offered me guidance. But I would be remiss if I didn’t single out the following for thanks. Michael Perdue, formerly of WHO in Geneva and now at the U.S. Biomedical Advanced Research and Development Authority in Washington, has been a great resource for me on the science of the virus. Michael Osterholm, director of the Center for Infectious Disease Research and Policy in Minneapolis, has steered me right when I’ve been stumped by questions about the evolution of the threat. I’m also smarter for the repeated insights of Malik Peiris in Hong Kong, one of the world’s premier researchers into respiratory viruses.

  This book never would have been written at all without the intervention of three Post colleagues. David Maraniss encouraged me to embark on this project when I was still unsure whether to do so. Dana Milbank offered s
age advice across a kitchen counter on how to frame the book, finally unlocking its potential. And Sandy Sugawara gave me the time to pursue the project even if the timing was inopportune. I’m beholden to all three.

  I owe a major debt of gratitude to my very wise agent, Raphael Sagalyn. He immediately spotted the potential of this project, but for months kept pushing me to rethink and refine the conception until I got it right. Then he ran with it. At Viking Penguin, my editor Ales sandra Lusardi has been a very sharp reader and elevated the writing by helping me bring the main themes to the fore while pruning back overgrowth in the storytelling.

  In everything, I’m indebted to my parents for their love and gift of intellectual curiosity. Most of all, I’m grateful to Ellen, my partner in all things, for her understanding and encouragement. There’s no one else I’d rather travel to the ends of the world with.

  Notes

  Prologue

  2 All flu viruses in fact emanate: See, for instance, R. J. Webby and R. G. Webster, “Emergence of Influenza A Viruses,” Philosophical Transactions of the Royal Society of London B: Biological Sciences, 356, no. 1416 (Dec. 29, 2001): 1817-28.

  6 a repeat of the Great Influenza: For a definitive account of the 1918 pandemic, see John M. Barry, The Great Influenza: The Epic Story of the Deadliest Plague in History (Viking Penguin: New York, 2004). See also Alfred W. Crosby, America’s Forgotten Pandemic: The Influenza of 1918, 2nd ed. (New York: Cambridge University Press, 2003).

  6 at least 50 million lives: N. P. Johnson and J. Mueller, “Updating the Accounts: Global Mortality of the 1918-1920 ‘Spanish’ Influenza Pandemic,” Bulletin of the History of Medicine 76, no. 1 (Spring 2002): 105-15.

  7 “accelerated number of near-misses”: Anita Manning, “New, Deadly Flu Pandemic ‘Inevitable,’ Experts Warn,” USA Today, Mar. 2, 2004.

  7 theater of conflict that is Asia: Dr. Michael T. Osterholm of the University of Minnesota has called Asia “the genetic roulette table for H5N1 mutations.”

  7 first documented global outbreak: C. W. Potter, “A History of Influenza,” Journal of Applied Microbiology 91 (2001): 572-79.

  7 since the twelfth century: August Hirsch, Handbook of Geographical and Historical Pathology (London: New Sydenham Society, 1883).

  Chapter One: The Revenge of Begu Ganjang

  This chapter draws on interviews with disease specialists from the World Health Organization and the U.S. Centers for Disease Control and Prevention, officials from the governments of Indonesia, North Sumatra province, and Karo district, and medical professionals and residents in North Sumatra province, as well as internal documents from WHO and the governments of Indonesia, North Sumatra, and Karo.

  13 cruise ships in Alaska: An account of the investigation can be found in Timothy M. Uyeki et al., “Large Summertime Influenza A Outbreak Among Tourists in Alaska and the Yukon Territory,” Clinical Infectious Diseases 36 (2003): 1095-1102.

  13 island nation of Madagascar: Accounts of the investigation into the outbreak can be found in “Influenza Outbreak—July-August 2002,” Morbidity and Mortality Weekly Report, 51, no. 45 (Nov. 15, 2002): 1016-18; and Weekly Epidemiological Record 2002, no. 46 (Nov. 15, 2002): 77, 381-88.

  18 At Imperial College London: Neil M. Ferguson et al., “Strategies for Containing an Emerging Influenza Epidemic in Southeast Asia,” Nature 437 (Sept. 8, 2005): 209-14.

  18 A separate team: Ira M. Longini Jr. et al., “Containing Pandemic Influenza at the Source,” Science 309, no. 5737 (Aug. 12, 2005): 1083-87.

  19 “No attempt has ever been made”: “WHO Activities in Avian Influenza and Pandemic Influenza Activities, WHO, Jan.-Dec. 2006, 16. The approach was quickly embodied in WHO planning. See “WHO Pandemic Influenza Draft Protocol for Rapid Response and Containment,” updated draft, WHO, May 30, 2006.

  19 WHO’s emergency containment plan: The strategy is described in the finalized WHO protocol. See WHO, “WHO Interim Protocol: Rapid Operations to Contain the Initial Emergence of Pandemic Influenza,” updated Oct. 2007.

  20 “It will require excellent surveillance”: WHO, “WHO Activities in Avian Influenza and Pandemic Influenza Activities: January-December 2006,” p. 16.

  25 by the time Puji was buried: A local account of the cases and grassroots response is “Report Regarding Bird Flu Disease in Karo Regency, from the Karo Regent Daulat Daniel Sinulingga to the Governor of North Sumatra in Medan, Kabanjahe,” May 31, 2006.

  28 According to Batak lore: Interview with Juara Ginting, an anthropologist who grew up in Karo district and studied Batak belief and superstition at North Sumatra University before pursuing a master’s degree at Leiden University in the Netherlands.

  29 beheaded a chicken: Margie Mason, “Officials Backtrack Bird Flu Cluster,” Associated Press, May 26, 2005.

  29 scores of poultry traders: Jason Gale and Karima Anjani, “Indonesian Bird-Flu Victim Sought Witchdoctor, Shunned Hospital,” Bloomberg, May 26, 2005.

  29 “significantly delayed”: WHO, “Avian Influenza Cluster, Karo, North Sumatra, May 2006, WHO Interim Report.”

  30 “universally refused”: Ibid.

  38 senior Indonesian officials: See, for instance, Health Minister Siti Fadilah Supari, quoted in Tubagus Arie Rukmantara, “Awareness and Prevention Key in Bird Flu Fight,” Jakarta Post, July 28, 2006.

  38 “From the lessening of the tension”: Siti Fadilah Supari, It’s Time for the World to Change: In the Spirit of Dignity, Equity, and Transparency, Divine Hand Behind Avian Influenza (Jakarta: Sulaksana Watinsa Indonesia, 2008), 23.

  38 Supari would continue: See, for example, “Minister Denies Bird Flu in RI Spreading by Human-to-Human Transmission,” Antara news agency, Sept. 3, 2007.

  38 were quickly convinced: Georg Petersen, “Investigative Report of a Cluster of Human Avian Influenza Cases, North Sumatra, May 2006,” WHO.

  39 “If he turns out to be positive”: Internal WHO communication from Jakarta, May 21, 2006.

  39 “In response to the possibility”: Ibid.

  40 tested positive for the virus: The specimens collected by Uyeki and his colleagues later showed that the virus had been aggressively mutating as it moved from son to father. See, for example, Santoso Soroeso, “Epidemiology and Clinical Features of Avian Influenza in Indonesia, Questions and Lessons Learnt,” presented at Australia-Indonesia Symposium in Science and Technology 2006, Sept. 13-14, 2006, Jakarta; and also Declan Butler, “Family Tragedy Spotlights Flu Mutations,” Nature 442 (July 13, 2006): 114-15. Initial analysis of the specimens at Hong Kong University also showed that Dowes’s sample had the same signature mutation as the sample from his son. This seemed to be further evidence that Dowes caught the virus from his son, marking the third generation of transmission. This finding was reported at the time by several media and cited by U.S. Secretary of Health and Human Services Michael O. Leavitt. See, for example, Department of Health and Human Services, Pandemic Planning Update II, a report from Secretary Michael O. Leavitt, June 29, 2006. But researchers familiar with the results later said the initial findings regarding a signature mutation were not as conclusive as at first thought. The case for third-generation spread still rests on the case histories of the Ginting family members and the timing of their illnesses.

  42 also onto a third: Politics long prevented researchers from publishing their analysis of human-to-human-to-human spread in the Sumatra cluster. But half a year later, another instance of third-generation transmission was confirmed in Pakistan and later described in a publication. See: “Human Cases of Avian influenza A (H5N1) in North-West Frontier Province, Pakistan, October-November 2007,” Weekly Epidemiological Record, no. 40 (October 3, 2008): 359-64.

  Chapter Two: A Visitation from Outer Space

  This chapter draws on interviews with current and former public health, infectious-disease, and laboratory specialists at the Hong Kong Department of Health and the CDC, as well as animal health researchers in Hong Kong and the United States.

  45 a three-year-old boy: The case
is described in J. C. de Jong et al., “A Pandemic Warning?” Nature 389, no. 6651 (Oct. 9, 1997): 554; and in Kanta Subbarao et al., “Characterization of an Avian Influenza A (H5N1) Virus Isolated from a Child with a Fatal Respiratory Disease,” Science 279, no. 5349 (Jan. 16, 1998): 393-96.

  48 far more than a runny nose and chills: A thorough overview of the clinical spectrum is provided in J. S. Malik Peiris, Menno D. de Jong, and Yi Guan, “Avian Influenza Virus (H5N1): A Threat to Human Health,” Clinical Microbiology Review 20, no. 2 (Apr. 2007): 243-67; and in K. Y. Yuen and S. S. Y. Wong, “Human Infection by Avian Influenza A H5N1,” Hong Kong Medical Journal 11, no. 3 (June 2005): 189-99. WHO has described the symptoms and clinical course of the disease in reports by the agency’s writing committee. See Writing Committee of the Second World Health Organization Consultation on Clinical Aspects of Human Infection with Avian Influenza A (H5N1) Virus, “Update on Avian Influenza A (H5N1) Virus Infection in Humans,” NEJM 358 no. 3 (Jan. 17, 2008): 261-73. The cases in individual countries have also been surveyed and described. See, for example, Hongjie Yu et al., “Clinical Characteristics of 26 Human Cases of Highly Pathogenic Avian Influenza A (H5N1) Virus Infection in China,” PLoS One 3, no. 8 (Aug. 21, 2008): e2985; and Sardikin Giriputro et al., “Clinical and Epidemiological Features of Patients with Confirmed Avian Influenza Presenting to Sulianti Saroso Infectious Diseases Hospital, 2005- 2007,” Annals of the Academy of Medicine (Singapore) 37 (2008): 454-57.