Alan Sipress - The Fatal Strain

Mostly, WHO supplements the efforts of individual governments, offering specialized expertise and scarce materiel like stockpiled vaccines for meningitis and yellow fever. To accomplish this, the agency relies on an extensive network of consultants from around the world, both public and private, to help investigate outbreaks, treat the sick, test samples, train local health staff, and deliver medicine, vaccines, and equipment.

These outside allies are people like Prasert, whose career was devoted to forging the institutions and disciplines of modern medical learning in Thailand that now make his country among the most advanced in the region. Yet there was always time for WHO. On a curriculum vitae stretching for several pages of publications and affiliations, Prasert prominently highlights his position as consultant to the World Health Organization. For over three decades, he served on various advisory committees for the agency, most notably the expert panel on viral diseases. He has run a WHO collaborating laboratory for AIDS research and edited an agency monograph on dengue fever.

In Geneva, senior agency officials describe their role in coordinating all this outside expertise by using words like secretariat, catalyst, and platform . What they mean is that they’re like the salaried fire chief of a vast volunteer brigade.

WHO was born of the optimism that followed the Second World War, when international cooperation in the shape of the freshly minted United Nations and its agencies promised a new chapter in human history. Founded in 1948, WHO set its objective as nothing less than the “attainment by all peoples of the highest possible level of health.” This was an ambitious goal. Yet advances in medical science at the time seemed to be bringing down the curtain on epidemic diseases that long plagued mankind, notably polio and smallpox. By the 1960s, however, WHO suffered a colossal setback with the failure of global efforts to eradicate malaria. It was emblematic of a broader resurgence of infectious disease as microbes mutated, outsmarting new medicines and vaccines, exploiting environmental degradation, poverty, population growth, and humanity’s lapses in vigilance.

As a young American physician, Dr. David Heymann had played a starring role in the eradication of smallpox. He and his WHO team had tracked it to its final havens in India. But soon after, as a new recruit to the CDC, he confronted a pair of entirely new threats. In the summer of 1976, he was dispatched to help investigate a mystery pneumonia spreading through an American Legion convention in Philadelphia. The outbreak, which sickened more than two hundred people and killed nearly three dozen, was ultimately blamed on a previously unknown illness dubbed Legionnaires’ disease. By the end of that same year, Heymann was in Zaire, responding to the first recognized outbreak of a horrible hemorrhagic fever called Ebola. He would end up spending thirteen years in Africa and, during that time, track the Ebola virus deep into the rain forests of Cameroon.

Heymann would later point to 1976—with its outbreaks of Legionnaires’ disease, Ebola, and also swine flu in the United States—as an inflection point in public health history. Man’s conceit was that modern medicine and potent drugs had given him mastery over emerging diseases. But the events of 1976 started to rekindle the world’s concern about these threats, Heymann told me, and the appearance of the AIDS pandemic dashed any remaining illusion of invincibility. “HIV-AIDS really caught the world off guard,” he said. “This really changed the thinking. The world realized the vulnerabilities.”

In 1995, WHO tapped Heymann to establish a program on emerging and communicable diseases. Storm clouds were gathering at all points of the compass: pneumonic plague in India, cholera in Latin America, resurging tuberculosis in Russia and Ukraine, Ebola in central Africa, meningitis across the whole of that continent, and an unprecedented epidemic of dengue fever in nearly sixty countries. Under Heymann, the agency overhauled its intelligence gathering, integrating a system developed by the Canadian health department that mines the Internet for reports and rumors of disease outbreaks. Next Heymann and his colleague Guenael Rodier set up what they called a global strike force, tapping disease investigators from more than a hundred universities, hospitals, and ministries who could get their boots on the ground within two days of any reported outbreak.

Then came SARS. In a matter of weeks in 2003, this novel respiratory disease spread to four continents, striking the economic heart of Asia, putting global air travel in jeopardy, and raising the specter of a worldwide epidemic. WHO’s rapid response contained the epidemic before it became entrenched. This success consolidated the agency’s role in managing outbreaks around the world. That largely explains why WHO, and not the CDC, took the lead in responding to the human cases of bird flu when they erupted in 2004.

SARS was a close call. It underscored the need to rewrite the global code of conduct called the International Health Regulations. The new rules, which took effect in the middle of 2007, require countries to notify WHO within twenty-four hours of any outbreak posing a global threat. Previously, the requirement applied only to yellow fever, plague, and cholera, a legacy of the nineteenth century, when European governments sought to forestall pestilence from the East. Now it was flu, again rising from the East, which posed the greatest menace.

The adoption of the regulations emboldened WHO. “When we come to an assessment that our assistance is needed, we have to push our agenda,” said Dr. Michael Ryan, the burly Irishman who runs the agency’s alert and response operations. But WHO is still ultimately constrained. Governments like the one in Bangkok can continue to tell it to buzz off. “At the end of the day, you are dealing with sovereign states,” Ryan added. “That has to be respected.”

One day before WHO was tipped off to the spreading epidemic in Thailand, a six-year-old boy with symptoms of pneumonia was rushed to Prasert’s hospital. He had a fever of 104 degrees and was desperately short of breath. Within twelve hours, his breathing had grown so labored that the doctors placed him on a ventilator. It seemed at first to do little good, so they kept cranking up the pressure on the device until they could finally achieve an adequate flow of oxygen. An X-ray revealed that the boy’s lower right lung had gone cloudy white, indicating that fluid was flooding the airspaces. The cloud spread a day later to the upper right lung. The next day, it progressed to the left one. The boy, Captan Boonmanut, had been brought to Siriraj Hospital from his home province of Kanchanaburi, located eighty miles from Bangkok near the western border with Burma. Outside Thailand, Kanchanaburi is best known for the Death Railway, built during World War II by Japanese occupying forces to supply its front lines, using Allied prisoners of war and Asian forced labor. At least sixteen thousand POWs perished from disease, hunger, and exhaustion, as did many more of the locals. This brutal chapter was captured in the Oscar-winning film The Bridge on the River Kwai , and the infamous steel-and-concrete bridge still stands, very much in use. But inside Thailand, Kanchanaburi today means rice paddies and chicken sheds.

Captan was a healthy youngster who had a country boy’s love of farm animals. He would often play with the chickens that roamed his backyard. So when he had been handed a rooster during a fateful visit to his uncle’s nearby farm, the boy had hugged it tight. Like many in rural Thailand, the uncle had raised fighting cocks and at first had high hopes for this particular rooster. But when it got sick, the uncle decided to do what most Southeast Asian farmers do with an ailing bird: eat it. Captan’s parents told me how the boy had cradled the bird in his arms and kissed it during the final moments before it was slaughtered and converted to curry.