pandemic.
As Uyeki reviewed the e-mail, he immediately thought of two possibilities, one worrisome and the other worse. “Could the situation be similar to what we are experiencing in the U.S.?” he wondered, thinking about the unusual uptick in seasonal flu. It would hardly be unprecedented for such a strain of human flu to circle the world. “Or,” he pondered, “could these be highly pathogenic H5N1 virus infections?”
He had reason to suspect the latter. Though there was yet no public report of unusual poultry deaths in Southeast Asia, South Korea had officially disclosed a die-off two weeks earlier on a chicken farm outside the capital, Seoul. But Uyeki had little other information to go on. So he replied to the e-mail best as he could, laying out possible diagnoses, suggesting more than a half-dozen different viral infections. Topping the list were influenza of some stripe and an ailment called respiratory syncytial virus infection, or RSV, common among infants. He urged his Vietnamese counterpart to collect samples from the patients and test for those two possibilities.
Uyeki was already acquainted with the Vietnamese doctor and her colleagues in Hanoi. He had first gone to Vietnam three years earlier to collaborate with them on a study looking for evidence of bird flu in live poultry markets. He had stayed in touch, cultivating the relationship as he had with scientists across much of Asia. When SARS broke out in Hanoi in early March 2003, Uyeki returned to help contain the epidemic. He arrived just days after Vietnam’s first case was identified and stayed for a month. Later in the year, he was back yet again, advising the Vietnamese on how to monitor for flu.
When Uyeki first joined the CDC’s influenza branch in 1998, Keiji Fukuda had been on board for two years and had already helped run the investigation into Hong Kong’s H5N1 outbreak. Now the two of them would return together to Asia yet again, trying to decipher whether the new threat was also a passing scare or a harbinger of something far worse.
Uyeki talks about his colleague as he would about an older brother. Both are Japanese American, graduates of Oberlin College in Ohio, and dedicated to a virus that others in Atlanta call “their bug.” They are both among the best at what they do. But while Fukuda is reserved, precise, and methodical, Uyeki is exuberant. Fukuda speaks in carefully crafted arguments, commanding attention with an economy of words. Uyeki’s discourses cascade from topic to topic, detouring through colorful details and intriguing distractions. Fukuda is the kind of man who organizes his day so he can drive his daughter to evening soccer practice. When I last met Uyeki, he was still regretfully a bachelor. His work habits are legend at the CDC. It is not unusual to find him at his desk until one in the morning or later.
So it was no surprise that Uyeki was still in the office when, shortly before midnight on December 29, Dr. Mai’s e-mail reply arrived. “Dear Tim,” she wrote, “these childrens… have fever, cough, difficult breath.” But other symptoms didn’t look at all like flu, she reported. Some of the patients developed diarrhea a few days after the onset of illness and, she added, “died quickly.”
“Died?” Uyeki thought. She hadn’t mentioned that earlier.
Exactly a week later, Dr. Peter Horby got an urgent call on his cell phone. He had driven out of Hanoi that Monday morning to train Vietnamese medical personnel in a nearby province. Horby, a British epidemiologist, had joined WHO’s Hanoi office only a few months earlier after working for several years at the Public Health Laboratory Systems in London, specializing in communicable diseases. He was still learning his way around his new home.
The call was from the director of Vietnam’s National Pediatric Hospital back in Hanoi. He had a mystifying outbreak of respiratory cases. A week earlier, he’d brought these to the attention of senior officials at Vietnam’s health ministry, but they’d brushed him off. So now he was turning to Horby. There was something about the call that told Horby he shouldn’t wait. He broke away from the training session and directed his WHO driver to take him back to Hanoi, directly to the hospital.
The car pulled past the gate and onto the campus of the pediatric hospital, an oasis of soothing greenery and tropical decay in the middle of one of the capital’s most crowded quarters. The institution’s sun-bleached buildings with their ancient wooden doors and paint-chipped balconies were arrayed amid overgrown lawns. Stands of bamboo rose here and there. The grounds were still but for the chirping of birds in the generous shade trees and the occasional sound of a wailing infant. Uniformed nurses walked briskly along the scarred tile walkways. Orderlies in traditional conical hats shuffled past.
Professor Nguyen Thanh Liem, the hospital director, met Horby on his arrival. Three other doctors, including the heads of intensive care and infectious disease, were asked to join them. The doctors told Horby they feared that SARS might again be breeding within their walls. During the previous three months, they had admitted eleven children with unusual respiratory ailments, and seven had died. The other four remained hospitalized. Yet another child, the sibling of one of their cases, had succumbed a week earlier from a similar illness in a provincial hospital.
Horby inquired about the background of the children. There didn’t seem to be an obvious pattern. They ranged in age from nine months to twelve years. They came from a variety of places outside Hanoi, mostly from the countryside but in a pair of cases from town. There were no reported outbreaks in their communities or in their schools.
The doctors escorted Horby to the intensive care unit to see the four surviving children. They had all been healthy just weeks earlier. At first it was just a runny nose, dry cough, and fever. Then the infection grew violent and spread to their lungs. When Horby reviewed the chest X-rays, they were desperately clouded. Their white blood count was low, suggesting the infection was not bacterial but viral. It was likely, Horby concluded, they would die.
“How unusual is this?” he asked the doctors.
“It’s unusual,” Liem replied. “They’re not responding to treatment and we don’t have a diagnosis.”
Horby quickly surmised it wasn’t SARS. That disease had largely bypassed children. It was more likely a pathogen called adenovirus, or perhaps flu. They agreed to conduct more tests on the patients and to press the health ministry about similar cases at other hospitals. WHO would supply masks, gloves, goggles, and face shields to the staff at the pediatric hospital.
A day later, Horby took a call from a journalist asking whether he’d heard reports about a massive die-off of chickens outside Hanoi. He hadn’t. No one at WHO had. “That instantly started ringing alarm bells,” he recalled. “The first day, we thought it was influenza. The second day, we were talking about possible avian flu.”
Dr. Mai at NIHE came to the same conclusion later that week. She had finally succeeded in discovering her causative agent in a sample from one of the children. It was H5N1 bird flu. But WHO still wanted confirmation from an overseas lab with proven experience and turned to Wilina Lim in Hong Kong, the laboratory chief who had worked on the initial human cases in 1997. It took several days to get her the samples. Vietnamese Airlines had balked at transporting them, so another airline had to be found.
The results finally came back on Sunday, January 11. Two children had tested positive for the virus. And so had a third person, the mother of one of the dead youngsters.
WHO put out a worldwide call for reinforcements.
WHO was coming off a monumental victory six months earlier. The containment of SARS, a previously unknown killer that had spread to four continents before it was checked, marked one of the agency’s greatest successes in a half century of history. But it came at a great price.
Agency personnel and their allies from dozens of countries had hustled day and night for months on end, often far from home, to uncover the extent of the SARS outbreak, crack its genetic secrets, and ultimately run it to ground. It was a sprint pace at marathon length. And as the death toll had mounted, so had the pressure. Individual governments made relentless demands on the agency. The global media’s appetite for information was insatiable. The prospect of failure was chilling. After the final two countries, China and Taiwan, were declared SARS free in July 2003, the troops were utterly spent. In Geneva, where crisis had built camaraderie, the agency descended into internal bickering as all the disputes and grievances that had been repressed now bubbled up.
“People were just strung out,” recounted Michael Ryan, who directed WHO’s alert and response program. “Our systems survived. But I use the word survived because it’s like surviving a nuclear explosion. We were still breathing. We were still feeling our limbs to see, were they all there.”
When the threat of pandemic rose anew in January 2004, the agency was still reeling. “We were thinking, ‘We don’t want to do that again,’ ” Ryan said.
That was especially true for WHO in Vietnam, which had been among the first countries struck by SARS and
