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
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.
Captan fell ill within days. A nearby clinic diagnosed the illness as a common cold. When it got worse, his father brought him to the local hospital, where he was given injections of antibiotics. Then, as his fever climbed and his breathing began to race, he was rushed by ambulance to Siriraj Hospital, eventually admitted into the pediatric intensive care unit. His white-blood-cell count was plummeting. So was the level of platelets in his bloodstream. Doctors prescribed broad-spectrum antibiotics on the assumption that his pneumonia was caused by a bacterial infection—but to no effect. The disease was unrelenting. So the doctors shifted their diagnosis to a possible viral infection and began treating Captan with antiviral drugs. They notified Prasert, the hospital’s most respected virologist.
The doctors had learned from Captan’s parents about his history of close contact with poultry. His father had related the tale of the rooster. Family members further reported that all three hundred chickens on the uncle’s farm had eventually died or been culled and that all but one of the chickens at Captan’s home had also succumbed.
Prasert was afraid he knew what this meant, that he was seeing his worst fears materialize in his own hospital. But without definitive test results, he was reluctant to go public. “We had suspicions already but couldn’t say anything. At that time, nobody could reveal information to anyone. The information the government was releasing was that we didn’t have any avian flu,” he said with narrowing eyes and an ironic smile. For all his credentials and earlier bluster, Prasert was wary of tangling with Thaksin and his ministers, at least for now. That very week, the agriculture ministry had threatened to sue another research institute and the media for allegedly damaging Thai national interests by exaggerating the number of chickens that had died nationwide. “What could I do?” Prasert asked. “I’m only a small, old man. Who would believe me?”
Subsequent study would reveal the viciousness with which the virus was assaulting the little boy’s body. The disease was decimating his respiratory system, destroying the air sacs and capillaries in his lungs and inundating them with blood. The virus also invaded his intestines, where it established a beachhead and began to reproduce further. The pressure on the ventilator helping him breathe had to be turned up so high that even this was starting to take a toll.
Shortly after he arrived at Siriraj Hospital, initial tests confirmed that Captan had influenza A. A week later, on Thursday, January 22, another set of results came back and showed conclusively that it was the novel strain. Prasert now had proof that the second condition for a pandemic had been met. The virus was again infecting people.
Time was up. Prasert placed three calls in the following hours to officials at the public health ministry, including the minister and the director general of the Thai center for disease control. He rebuked them: “Bird flu has reached humans already.” He also went public with his laboratory evidence of a flu outbreak in chickens, telling reporters that the H5N1 strain was widespread and the “cover-up” had to stop. His efforts were seconded by a top Thai lawmaker, a physician-turned-politician named Nirun Phitakwatchara. Nirun, a member of the Thai Senate,
