“We may have no choice than to live with the virus,” added Dr. Les Sims, who had been Hong Kong’s chief vet at the time of the 1997 outbreak. “I don’t believe we are going to get rid of this virus from the region even in the long term.”
Though flu specialists had anticipated the return of the novel strain, they were startled by its sudden reappearance in late June 2004. The virus had always surfaced in the cooler weather, and here they were still in the summer. Despite the unprecedented culling of more than 100 million birds in East Asia, the scourge reappeared on farms across Vietnam, eventually returning to Thailand, China, Cambodia, and Indonesia and spreading, for the first time, to Malaysia. New human cases popped up in Vietnam and Thailand. Researchers were reporting that the virus was widespread in ducks, moving into wild birds, and growing ever more lethal in lab animals. Another study concluded that the strain had gained a permanent foothold in Asian poultry.
In August 2004, Vietnam’s
A day after he died, his twenty-five-year-old sister, a local teacher, began to complain of headaches, muscle pain, and difficulty breathing. She was dead within a week. A journalist for
The hospital had already discarded samples from the brother, but lab technicians tested those from his sister and discovered she had bird flu. Health officials also reported that a third family member, a cousin, had also died recently but had never been tested.
Alerted, investigators came to the densely populated town deep in the luscious Mekong Delta, but they struggled to find the source of infection. Though the family raised ducks, chickens, and geese, the birds were all healthy. Investigators reported that “no link could be established with deceased or dying poultry.” But they did learn that the sister had initially cared for her ailing brother, possibly accounting for her infection. This revelation, coupled with the sequence of the cases, persuaded some at WHO that for at least the second time, the virus had hopped from one person to another.
“My personal feeling is that this was almost certainly H2H transmission,” a WHO epidemiologist would write in an internal memo later that year.
This time WHO didn’t announce the conclusion at all. Senior WHO figures and Asian political leaders remained unwilling to acknowledge how far this fatal strain had come.
Scott Dowell was America’s sentinel, watching from his post in Bangkok for threats on the horizon, when he got a call in September 2004 from Thailand’s chief epidemiologist.
“We’ve got a weird situation,” Kumnuan Ungchusak began.
He told Dowell that a local hospital had been routinely watching for cases of bird flu when a woman with severe pneumonia came in. She’d been around chickens, so the staff suspected the virus. Investigators from the health ministry were called. It ended up being a false alarm. But as the officials were preparing to leave, a nurse pulled one of them aside and asked about another woman, who had just died. She, too, had had severe pneumonia. No one had suspected bird flu in this case, Kumnuan said, because the woman hadn’t been around any poultry. But then they learned the woman’s daughter had also died about a week earlier in the countryside.
Kumnuan was going to drive up to the province in the morning to check it out. Did Dowell want to come?
Dowell was an American who ran the CDC’s International Emerging Infections Program, headquartered in a sprawling office park that houses the Thai health ministry. Like the listening posts established by U.S. intelligence agencies during the cold war to monitor developments behind the Iron Curtain, Dowell’s operation was on the front lines of a new struggle, watching for novel diseases that could threaten Americans and their national security.
As he and Kumnuan drove north to Kamphaeng Phet province on that Friday morning, the Thai doctor recounted more of the story. An eleven-year-old girl named Sakuntala Premphasri had lived with her aunt and uncle in a remote village about twenty miles off the main road. Their home was set back in the trees, a traditional, one- room house on wooden stilts with a sloping roof. Like everyone else in the village, the family kept chickens, and they ranged freely in the shady space beneath the house, where the girl often played with her friends and sometimes slept. The birds started dying in August, a few at a time. About four days after the last chickens had keeled over, Sakuntala got sick with a cough and sore throat. She felt feverish. Her aunt took her to a local health center for medicine, but the condition worsened. Days later, the girl was admitted to a district hospital with a high temperature, difficulty breathing, and low blood pressure. An X-ray revealed pneumonia in her lower right lung.
When her mother, Pranee Thongchan, learned of Sakuntala’s deteriorating condition, she rushed to the bedside. Pranee, almost a girl herself at age twenty-six, lived more than two hundred miles away in a Bangkok suburb, where she worked in a garment factory. Pranee had asked her husband, a cabbie, to drive her back to the province to see her daughter. She reached the hospital at midnight. There she cradled the limp body of her little girl, repeatedly kissing her and wiping her mouth. Though the girl kept coughing, a duty nurse reported that Pranee kept her face “attached” to that of her daughter, spending the night beside her “cheek to cheek.”
The next afternoon, with antibiotics failing to make a difference and her body descending into shock, the girl was transferred to the province’s main hospital. When she arrived, she was bleeding heavily from her lungs. Blood oozed from her nose and mouth. Three hours later she was dead.
Pranee brought her daughter’s body to a Buddhist shrine near her parents’ home in Khampaeng Phet for three days of funeral rites. On the third day, Pranee herself began complaining of a headache and fever. Pranee went to the district health center for medicine. When she returned to the Thai capital, she felt even worse. It was getting harder and harder to breathe. Ten days after her daughter died, Pranee checked herself into the Bangkok hospital. By then it was too late. The infection had invaded both her lungs, and nothing could save her.
Alone in the car, Dowell and Kumnuan agreed that her case looked a lot like one of human transmission. “If there is transmission in this way, many people will be interested in this case,” Dowell told his colleague.
Kumnuan kept working his cell phone to get more details. He called his subordinates, who were already in the province. Now they were telling him that other family members might also be sick.
“We need to get samples,” Dowell urged. These specimens would not only confirm the virus but could also show whether it was mutating.
Had they taken samples from the mother? Not yet, Kumnuan answered. Kumnuan called back to Bangkok. He discovered that Pranee’s corpse had already been embalmed. At that very instant, the body was at a Buddhist temple in the capital, about to cremated. Kumnuan ordered his officers on-site to do whatever it took to hold on to the body and hurriedly dispatched a specialist who could conduct a limited autopsy on the fly. He got there just in time, snipping out a specimen of lung tissue. It later tested positive for the virus.
When Dowell and Kumnuan finally arrived at Kamphaeng Phet Hospital, Sakuntala’s thirty-two-year-old aunt had just been brought in. She, too, had chills and trouble breathing, and she was having X-rays taken. They went to the radiology department to have a look. Sure enough, her lungs were clouded over. That raised an alarm. They asked to see her. The woman’s condition was serious—her temperature had spiked at over 103 degrees, and samples she gave that day would later test positive—but unlike in the previous cases, would not be fatal. She mumbled to Dowell and Kumnuan that she’d been the one who buried the sick chickens in the yard, wrapping her hands in plastic bags for protection. But that had already been more than two weeks earlier, beyond the incubation period for flu. She also told them she had cared for her dying niece, staying at her hospital bedside until the very moment Pranee had arrived. That was the telling detail.
The following Monday, September 27, the veteran virologist Prasert Thongcharoen chaired a closed-door meeting convened by Thailand’s Ministry of Public Health to review the cases of Sakuntala, her mother, and her aunt. In attendance were government health officials and medical experts from WHO and the CDC. Eight months had passed since Prasert blew the whistle on bird flu in Thailand. Now it was his mission to have his government and international health agencies formally acknowledge what scientists increasingly believed: The virus could spread among people.
