Alan Sipress - The Fatal Strain

Now, as the taxi finally escaped the congested streets and pulled up beside the pink walls of the five-story hospital, Samaan was hoping to do better. This was a new facility with a clean, white-tiled lobby that contrasted with the filth and disorder just beyond the gates. No sign of panic or plague, just a few parents waiting to have a doctor examine their children.

The hospital’s personnel director, a woman in a pink blazer, led Samaan through the breezy corridors to a conference room. The hospital’s vice president, a woman in a Muslim headscarf and brown batik dress, and three other officials joined them around an oblong table. Samaan briefed them on her investigation. She shared the reports of poultry deaths in the victim’s neighborhood but noted they remained unconfirmed. “So we cannot discount other possible sources of infection,” she told them without revealing her suspicions about the hospital. Then she asked about the victim’s recent work history. The personnel director recounted that the victim had reported for the afternoon shift on New Year’s Day complaining of fever and chills. She had been initially diagnosed with dengue fever or possible typhoid. “We let her go home early,” the director said. The ailing woman had never returned. Her disappearance, the director said, had left the maternity ward short staffed.

So the victim, it turns out, had been a midwife. That was a welcome detail. Because the maternity department tended to see healthy patients, this reduced the chances that the woman had contracted the illness in the hospital. It would also be easier to spot anyone else in the ward she might have infected. But Samaan was not yet sanguine.

“Can you look at the hospital records?” she asked. “If you concentrate on the ten days before she felt sick, would she have had contact with anyone who had an influenza-like virus?”

The hospital’s vice president said that was an easy one to answer. She referred to a report in front of her. The victim hadn’t come to work at all in the week before she became ill. She had been on vacation.

“That’s not what the family told us,” Samaan objected politely. “They said she was working.”

“We’ll double-check our records. But maybe she was working in another hospital?” the vice president responded, suggesting a new, disquieting possibility.

The personnel director produced a stack of schedules and time sheets. Samaan and several others huddled around. The documents showed, in fact, that the family was right: The woman had indeed reported for work four times during the final week of December. Two dates in particular drew Samaan’s interest. The woman had worked the overnight shifts on December 27 and 28, just when she would have likely contracted the virus. Samaan made a mental note.

Glancing up from the time reports, she asked whether any of the women who had given birth in the maternity ward had gotten sick. Nothing unusual, she was told. She inquired after the other midwives. All healthy. She requested to meet a few.

The maternity department was spotless. It had twenty-three beds in a series of rooms, mostly vacant at the moment. Four newborns slumbered in small, glass-sided cribs. The private waiting room was large, with padded chairs, a sofa, and a television on the counter. An air conditioner hummed in the wall.

The personnel director showed in a pair of midwives dressed in pink uniforms. The younger one, a slight woman with short brown hair and lively eyes, named Swarni, was the chattier of the pair. Samaan asked about the last time she saw her dead colleague.

“I wasn’t working the same shift as her that day,” Swarni began. “I was leaving after the morning shift, and she was arriving for the afternoon shift.”

Samaan nodded.

“I asked her why she was wearing a jacket,” Swarni continued. “She said she wasn’t feeling well. The next time I saw her, she was in the intensive care unit.”

Samaan asked the midwives how they were feeling. They reported their health was good, further allaying Samaan’s concern that the hospital was the source of infection. She shifted her line of questioning, asking about the woman’s final days.

“Did she do anything before she got sick that comes to mind? Any activities?”

“She mentioned she had been coughing for a while. That’s all.”

“Did she talk about going to a poultry market?” Samaan pressed, following up on the tip from the previous day.

“Sometimes she would go after work,” Swarni recalled. The young midwife mentioned a particular market in East Jakarta and then giggled softly, covering her mouth. Samaan waited for the rest of the answer, puzzled. “She would go buy chicken feet,” Swarni added. “That was one of her favorite foods.”

Epidemiologists are often faced with two complementary questions. The first is like the one that was stumping Samaan: Why does someone fall sick? The second question is less obvious, though the answer can be even more revealing: Why doesn’t someone fall sick?

For each victim laid low by bird flu, there are hundreds, perhaps thousands, who should have been. These are the cullers, the armies of peasants, soldiers, veterinary officers, and day laborers who have slaughtered several hundred million birds across Asia, Africa, and Europe since 2003 in an orgy of bloodletting aimed at exterminating infected flocks and stemming the spread of the virus. They often did so with minimal protection, lacking masks, goggles, and even gloves. Yet a full decade passed after H5N1 claimed its first confirmed victim in 1997 before a single culler ever got seriously sick—a Pakistani man who died shortly after helping carry out a two-day poultry slaughter in October 2007. In Vietnam alone, more than ten thousand people participated in the great massacre without a reported case. This mystery has defied explanation, posing one of the great riddles confronting flu investigators.

Field sampling has revealed that some cullers were in fact exposed to the pathogen. Five South Koreans who helped stamp out infected flocks eventually tested positive for antibodies though none ever became ill, and a lone culler in Indonesia also showed elevated antibodies without any outward sign of illness. So, too, nine workers who helped carry out Hong Kong’s mass slaughter in 1997 tested positive, with only one displaying mild symptoms. These findings suggested that bird flu may have spread farther than the flu hunters suspected but that many human cases were asymptomatic. If so, this would not be welcome news. It would mean a greater chance for the strain to stumble across the genetic mutations required to unlock a pandemic. Field investigators turned up other worrisome evidence. Blood taken from two elderly but otherwise healthy relatives of Vietnamese victims in 2005 had antibodies to the virus. A year later, a pair of young brothers in Turkey were also positive despite showing no symptoms.

But these instances proved to be rare exceptions. Efforts to uncover a rash of asymptomatic cases have found none. In one telling study, researchers canvassed nearly a hundred homes in a Cambodian village where a man had contracted the virus days earlier. Poultry outbreaks were widespread. If the virus were adept at causing cryptic cases, certainly some would turn up here. But not a single one of the 351 villagers tested had antibodies. A subsequent study of 674 people in two Cambodian villages where there had been both human and poultry outbreaks revealed that 7 of the villagers, or about 1 percent, had antibodies to the virus, indicating they’d been exposed even if they hadn’t had symptoms. For some reason, they were all younger than eighteen. Though this last study suggested some mild cases were being overlooked by health officials, the results hardly signaled a silent epidemic. The enigma of the cullers endured.