Alan Sipress - The Fatal Strain

Perhaps more surprising is the lack of autopsies. Of the first two hundred confirmed deaths from the virus, fewer than a dozen victims underwent these postmortem exams. “This has posed some major problems in understanding the biology of the disease or fully understanding the virus underlying it,” explained influenza researcher Malik Peiris from the University of Hong Kong. Autopsies could examine how the agent wages its assault on the lungs and what other organs might also come under attack. These studies could help explain why some people get infected and not others, why the disease is so severe, and how well antiviral drugs work. “These are all pretty fundamental questions,” Peiris put it to me.

Why so few autopsies? The conventional response from leading researchers and senior officials is that local cultures bar the practice. In Chinese tradition it is said a corpse must be buried intact. Similar strictures are thought to apply in the Buddhist cultures of Thailand and Vietnam and the Muslim culture of Indonesia. “You have to get permission from the family to get that done,” explained Dr. Triono Soendoro, head of laboratory research at Indonesia’s health ministry. “People here are not used to having postmortem procedures.” Had Indonesian officials actually asked families for permission? “No, we haven’t tried,” Soendoro added.

When I broached the subject of autopsies with victims’ relatives, I got surprising responses.

Rini Dina Prasetyaningsih was among the first Indonesians known to succumb to the disease. Months later, I visited her small but comfortable middle-class home in South Jakarta and raised the delicate subject with her husband, Agus Mardeo. “I wouldn’t object to a postmortem as long as it was in the hospital and done by a doctor, as long they didn’t dig up the body after it was buried,” he said. Mardeo’s long, thin face turned somber. “Personally, I really wanted to know what happened to her. I would have been more than happy to have an autopsy.” But he added, “I’m just a common man. I don’t know about these medical procedures. No one suggested the idea to me.”

In a poorer suburb just outside the capital, a woman named Ibu Samida offered the same answer. She received me in her dimly lit living room, where she sat on a tattered couch surrounded by her four children and two grandchildren. The only one missing was her middle daughter, nineteen-year-old Ina, who had died not long before of bird flu. “I would have allowed an autopsy for the benefit of my neighbors and my family and everyone else concerned about the disease,” Ibu Samida said firmly. But again the refrain: “No one asked me. If they had asked, I would have given my permission.”

Yet even with autopsies, field studies, and fast, accurate testing, the answer to the most critical question could remain elusive: What will it take for the novel strain to become a pandemic strain? In other words, what specific genetic changes are required for the disease to become easily passed among people, and what is the sequence of biological events in animals and humans that will foster those changes? Scientists suspect these could involve mutations that make it easier for the virus to bind to human cells. But that’s likely not the whole story. Though modern science has delivered an intimate view of the pathogen’s inner machinery, the world still has little insight into how this fateful transition would work.

David Heymann, who was WHO’s chief of communicable diseases before retiring in 2009, conceded we’re not much further along in that regard than we were in 1918. “We’re handicapped by a lack of knowledge about the risk factors that cause the virus to change,” he said. “There are a lot of things we just don’t know.”

Scientists have little comparative data to go on because there have been only a few flu pandemics in modern times. Despite groundbreaking work on the genetic makeup of the Spanish flu strain, Fukuda said there’s no way to be sure whether the 1918 experience is relevant to the avian flu virus. And without knowing how a pandemic strain would develop, it is nearly impossible to stop it. What steps should be taken to interrupt the evolution of a pandemic? What practices are speeding it on its way? When do changes in the pathogen represent a real and present danger? When are they a red herring? What to do about them?

“Sometimes the decision is simply ‘Let’s wait.’ We don’t have enough to go on. Let’s see how things evolve,” Fukuda said. “Or, it’s ‘We don’t have as much information as we like but we’re worried enough that if we’re missing something, it’s worth the price of jumping now.’”

For five days, WHO had been trying to get a meeting with senior Vietnamese officials. Finally, on the afternoon of Tuesday, June 14, Hans Troedsson’s delegation filed into a conference room at Vietnam’s Ministry of Agriculture and Rural Development, an unremarkable building around the corner from the monumental granite mausoleum, modeled after Lenin’s Tomb, where Ho Chi Minh, father of Communist Vietnam, still lies in repose.

Troedsson was no influenza specialist. He was a Danish doctor who had previously been responsible for children’s health issues at WHO. But as the agency’s chief representative in Vietnam, Troedsson essentially held the rank of ambassador. Flanking him were six other foreigners, including senior figures from the United Nations, World Bank, and European Commission.

The Vietnamese side was led by Deputy Prime Minister Nguyen Tan Dung. Considered a reformer within Communist Party ranks, Dung would be promoted a year later to become his country’s youngest prime minister since Vietnam was reunified. He was joined at the table by the agriculture minister and his deputy, the deputy health minister, and five other top officials. Such audiences with senior dignitaries would often merit a few minutes on Vietnam’s nightly news and a mention in the morning papers. But this one was to be strictly confidential.

After opening formalities, Troedsson explained to Deputy Prime Minister Dung the significance of the recent lab findings. They indicated that bird flu infections in Vietnam were more common than previously thought.

“Vietnam could be on the verge of experiencing a nationwide epidemic, which could spread globally and cause a pandemic,” Troedsson continued. If an epidemic broke out, it could do serious harm to Vietnam’s economy and the health of its people. If went global, it could kill as many as 40 million people. So, he warned, WHO might have to elevate the pandemic alert level to either four or five if the test results were accurate. Several UN agencies stood ready to help Vietnam fight the virus and prepare for a pandemic. But the troubling lab results had to be checked by international experts, he insisted. This was urgent.

Troedsson closed with a veiled threat. If the results could not be checked, WHO might have to raise the alert level as a “precautionary measure.”

Then, one by one, Troedsson’s colleagues tightened the vise. Jordan Ryan, the UN’s ranking official in the country, told the Vietnamese it was no longer question of if a pandemic was coming but when , and he urged Dung to do the right thing. Ryan’s counsel carried weight. A dozen UN agencies were active in Vietnam, engaged on multiple fronts, ranging from agriculture to childhood nutrition.

Next came Klaus Rohland, who ran the World Bank office in Vietnam. Over the years, Vietnam had received more than $5 billion in foreign aid for development, and the World Bank was in charge of coordinating that. Rohland told Dung that his country now faced a situation that could be “disastrous.” He strongly advised him to accept WHO’s offer of assistance.