Alan Sipress - The Fatal Strain

At times, epidemiologists have also been stumped by the converse scenario: sick humans without sick birds. Indonesia detected its first human case in mid-2005 and over the following year confirmed that fifty-four Indonesians had the virus. Yet Samaan and her fellow investigators were unable to identify a possible source of infection in a quarter of those cases. During 2007 nearly one-third of the Indonesian cases were ruled inconclusive because there’d been no direct contact between the victims and poultry of any sort. Tjahjani Widjas tuti, head of the agriculture ministry’s bird-control unit, called the behavior of the virus in Indonesia “mysterious.”

One morning in July 2005, just days after the country’s first human case was announced, I drove west out of Jakarta and two hours later found myself unexpectedly in a California-style subdivision of palm-lined streets and middle-class bungalows. Health officials had reported earlier in the week that three residents of the town had succumbed to bird flu. The deaths of Iwan Siswara Rafei, a government auditor, and his daughters marked Indonesia’s first confirmed fatalities from the virus. I had expected to find a typical Javanese village, with serpentine alleys, ramshackle homes fashioned partly from bamboo, and scrawny hens scavenging in the mud. Instead Villa Melati Mas was a gated bedroom community of bankers, businessmen, and doctors. Neighbors were anxiously trading rumors across the metal fences separating their neatly landscaped yards. Mothers were keeping their children off the quiet streets, and some families were considering whether to pack up their belongings in their SUVs and abandon their homes.

“We’ve really got a panic attack,” said Kresentia Widyanto, a mother of three in a floral housedress. “People have been asking, ‘Do we need to evacuate and go somewhere else, to vacate this place?’” For fifteen years, Wiydanto and her husband, a physician, had lived around the corner from Rafei’s brown cottage with its pitched terra-cotta roof and sweet purple flowers out front. Widyanto’s son was eight years old, the same age as Rafei’s older daughter, Sabrina. When the girl was hospitalized a month earlier with a high fever, diarrhea, and cough, word spread quickly. Rafei’s second daughter, one-year-old Thalita, developed symptoms days later, followed by Rafei. “I’m wondering why this happened,” Widyanto told me while she finished her business with a street peddler selling broccoli and cauliflower. “Can we get it? We’re trying to be calm.”

But despite a six-week investigation by Samaan and her colleagues from WHO, the Indonesian health ministry, and the U.S. Navy lab, they remained utterly stumped. Even Grein was called in to help. Around the subdivision, a few parrots and other pet birds twittered from cages hanging on porches and balconies. But neighbors did not raise their own poultry, instead shopping at a Western-style supermarket. A solitary pet bird in the neighborhood tested positive for the virus, but Rafei’s home was free of contagion. Tests conducted on him and his daughter, coupled with the timing of their deaths, suggested that the virus might have been passed among family members. Yet this was never confirmed, and the original source of infection was never discovered.

Rafei’s wife and mother both told me they had no idea how he and the daughters got sick. Rafei was a busy professional who set out early every morning on his long commute to Jakarta’s downtown financial district and returned late in the evening, leaving little time for side trips to farms or chicken markets. His wife, Lin Rosalina, eyes red from crying, said she was also certain her children had not come into contact with live poultry. “I’m very sure,” she added, switching from Indonesian to English to make the point.

Her family’s tragedy also highlighted yet another mystery. In clusters of cases, the virus has targeted blood relatives almost without exception. The disease that struck down Rafei passed over the remaining members of his household: his wife, two housekeepers, and his son. All but the last were unrelated to him by blood. By 2008 there were already more than three dozen family clusters across Asia and beyond, representing about a quarter of all confirmed cases, and in the overwhelming majority these involved blood relations like siblings, parent and child, children and grandfather, or niece and aunt. Rarely did both husband and wife test positive.

One of the largest clusters occurred in January 2006 in Cipedung, a destitute, hard-bitten village along Java’s north coast. Unlike in the case of Rafei, there was little question where this family caught the bug. They had two dozen chickens, which regularly straggled into their flimsy bamboo shack, sleeping on the dirt floor beneath the platform beds. In the previous weeks, the virus had raced through this small flock. One by one, the chickens got drowsy and died. When the last six birds developed symptoms, the father, a meatball peddler, helped his brother slit their throats beside a large palm in their front yard. The chickens were plucked and cooked in coconut milk for a family feast. By the time I caught up with the family at a hospital in the provincial capital, Bandung, the father was huddled on a cot wrapped in a gray blanket, haggard and unshaven, under treatment for the virus. In an adjacent room, a teenage daughter with a fever lay sprawled on a bed under observation. Two other children had died before they ever got to the hospital.

The question was why the mother had been spared. Just beyond the doors, in a quarantined waiting room, she kept vigil. “I don’t know why I’m healthy,” the woman, Buenah, whispered to me. She was a short, frizzy-haired peasant with tired brown eyes, wearing only a surgical mask for protection. For my part, the hospital staff had outfitted me in a white hooded jumpsuit with goggles and a respirator and sent me in alone to speak with Buenah. The rubber gloves were making it difficult to take notes. “I don’t have a fever, cough, or symptoms,” she related. “I really don’t know why not.”

Outside the isolation ward in Hasan Sadikin Hospital, her relatives were camped on the lobby floor, spending nights on thin, woven mats, wondering how she had escaped the curse. “It’s really incomprehensible to us,” said Surip, her husband’s cousin.

Could the rest of Buenah’s immediate family have had more contact with sick chickens than she did? That’s doubtful. Relatives and local agriculture officials explained to me that as a rural homemaker, she was in daily contact with livestock. Could the three children have caught the virus by playing with chickens and then passed it on to their father but not their mother? Relatives and fellow villagers reported that it was Buenah who usually looked after the children and that for days she had carried her ailing son in a sling across her chest. Could Buenah, who complained of high blood pressure, have skipped the repast of chicken and coconut milk? No, she and the rest of the extended family all took part.

During the coming months, as epidemiologists turned up this intriguing pattern of clusters over and over, flu specialists came to suspect some kind of coding in the genes that made some people susceptible to infection and others not. If understood, this could help design ways to slow or even stop an emerging epidemic. But the genetic mechanism has remained unclear. And some researchers even countered that statistical chance alone could account for what appears to be genetic susceptibility.

Markets still made Samaan uneasy. When she first started investigating flu cases in Indonesia, she was always fretting about catching the virus. “I counted the sneezes I’d make,” she recalled. As she got better acquainted with the behavior of bird flu, she worried less about catching it at victims’ homes or from their families. But traditional Asian poultry markets remained scary places where butchers, birds, and buyers all converged, swapping their microbes among splattering blood and flying feathers. It took courage for Samaan to brave a live market even when she wore a mask. But the trail of her victim’s killer now led back to one of the capital’s largest, a vast covered complex encompassing several city blocks in East Jakarta known as the Kramat Jati Market.