Alan Sipress - The Fatal Strain

“Epidemiology is a different world than lab work,” he explained to me over strong coffee. “Most field epidemiologists only understand the basics of what happens in the lab. Laboratory science has advanced so much that it’s impossible for field epidemiologists to keep up. But laboratory results without epidemiological information are limited. If you send in lab samples from the field without epidemiological background, they throw a fit.”

We were sitting in the restaurant of the Santika Hotel, one of the few hotels in town still functioning and a base for humanitarian operations. Around us, relief workers in blue-and-white vests mingled at the buffet with Japanese soldiers in camouflage. Grein was clad informally in a short-sleeve blue shirt open at the collar, brown jeans, and heavy black shoes. The fine lines across his forehead deepened as he tried to regain his train of thought.

“You can’t go by the first piece of information you have,” he resumed. “You have to be able to listen and understand, look for the small details, be a little obsessive, and not give up. You have to keep trying to track down the disease.” He paused to let the point sink in, then continued. “You also have to understand the cultural sensitivities. You are dealing with a lot of people who are grieving, who have lost family members. You have to strike a balance between pushing your agenda and not upsetting the local population.”

During the Marburg investigation in Angola, villagers had stoned his team’s vehicles, forcing WHO to temporarily suspend its efforts. The foreigners had initially descended on the community in the back of pickup trucks wearing what appeared to be strange “astronaut suits” and carried off the victims’ bodies. The locals were prevented from showing their ritual respect to the dead by washing and embracing the corpses. They suspected the foreigners of stealing their loved ones. Grein said the WHO team ultimately defused the confrontation by putting on their protective gear in front of the villagers and taking the time to explain what they were doing. “It takes trust, transparency, and openness. Without it, it’s an uphill battle.”

Despite the potential for cultural miscues, Grein said he found the third world an easier place to work. Developed countries often keep WHO epidemiologists at a bureaucratic distance, preferring to run their own investigations. In developing countries short on resources, he added, “we get to work on the ground.”

In Asia he stalked bird flu through the tropical jungles of Indonesia, the rice paddies and river deltas of Vietnam, and the deep mountain snows of southeastern Turkey. Other WHO epidemiologists had picked up death’s trail elsewhere. Yet for all the months and miles, even the most seasoned investigators had failed to crack the mysteries of the novel strain. “Since it began in Vietnam in 2004, every case was followed up on one way or another but very little is known,” he admitted. The precise incubation period remained unclear because investigators were rarely able to determine the source of exposure and thus the exact moment the victim was infected. But that knowledge would be vital for crafting public health policies to contain an emerging epidemic. Nor had they been able to detail how the virus infected people and why some were susceptible while others were not. These elusive specifics could be crucial for limiting human exposure to the disease and developing drugs to combat it.

Though Grein is the best at what he does, even his own flu investigations have often yielded partial success at most. Frequently victims take their personal histories with them to the grave. It’s simple to blame poultry for the infection since they’re everywhere in Asia, he noted. What’s harder is ruling out the possibility that the source was actually another person. “That’s always going to be a question. You can’t really prove it,” he explained.

When investigators manage to break open a case, the novelty makes it striking. Late in the winter of 2006, they’d hit a wall after the virus had suddenly erupted in Azerbaijan, a former Soviet republic situated on the cusp between eastern Europe and western Asia. Of the eight confirmed cases, seven were from one remote farming settlement so poor that it lacked electricity. All but one of these cases were from the same extended family, mostly girls and all between ages ten and twenty. They’d fallen sick within two weeks of one another. It was the largest family cluster of cases yet recorded, and the intriguing pattern promised new insights into the disease if only it could be deciphered. WHO investigators and their Azeri counterparts trekked to the village over and over, yet the family refused to cooperate, even denying the sickness was bird flu. “They wouldn’t give us any information about how the patients got infected,” recounted Dr. Caroline Brown, a WHO virologist who led the team. “There was no way they were going to talk to us. That’s for sure. Even the young children wouldn’t talk to us.”

The family kept some chickens, but they looked healthy. Other poultry had died in the community, but veterinary officials were claiming it was not bird flu. Brown and her colleagues, however, had heard of a large die-off of wild birds in Azerbaijan a month earlier that was attributed to the flu virus. Next they learned from villagers that dead swans had been found at a lake on a nature reserve near the settlement. At least one member of the stricken family was a hunter, and his neighbors confided that he’d brought home some of the swans. It was an open secret that locals could earn good money by plucking the feathers for making pillows. That was usually the job of teenage girls and young women. But hunting swans was a crime, and the penalty for poaching could run into hundreds of dollars. The family adamantly denied any contact with wild birds, much less infected ones.

As Brown was leaving the family’s house after another frustrating interview, she looked around the garden and spied at least three large, white pillows hanging from a clothesline. “You couldn’t miss them,” she said. “You could see the feathers sticking out.” It was the smoking gun. Later, the mother of one victim later confirmed that, yes, all those afflicted had been plucking contraband swan feathers. This marked the first time that investigators anywhere had proven a link between wild birds and human cases of the virus. Yet the breakthrough, like the Azeri outbreak itself, remains exceptional.

“We don’t know much,” Grein told me with heightened urgency. “All of us, we really need to get our act together to enhance our knowledge and get better tools to fight this disease.”

The clock was ticking on Samaan’s investigation. Somewhere on the wards of a private hospital in neighboring West Java province, the novel strain could be incubating, amplifying, provisioning for an inexorable march toward the capital, toward the international airport only a ninety-minute drive away, toward the regional hub of Singapore another ninety minutes by air. By the time Samaan made arrangements with Indonesian officials to visit the hospital, it was already Saturday morning, and she hadn’t had a chance to line up the minivan. She flagged down a white city taxi on the street near her downtown apartment building. Her translator was off, so she called an Indonesian colleague from WHO and rousted her with a playful, early-morning plea, “C’mon, let’s go save the world.”

Samaan’s career had been building toward this moment. Born to Iraqi parents, she was raised in Kuwait until the political upheaval wrought by Saddam Hussein’s 1990 invasion sent her fleeing as a teenager to Australia. There she went on to study clinical psychology. For a year she worked with refugees detained on the remote South Pacific island of Nauru, a tiny outpost of little more than eight square miles. Many of the migrants, held in camps while applying for amnesty in Australia, were suffering from depression and other maladies. The experience piqued Samaan’s interest in broader issues of public health and led her back to the university to take up epidemiology. During her first stint with WHO, she was assigned to Manila just as bird flu was sweeping East Asia. But she was kept primarily in the office. At her desk by 6:30 A.M. each morning, she was tasked to troll the Internet, international media, and the agency’s own network of informants for rumors and emerging reports of flu outbreaks. A year later she rejoined WHO and headed into the field.