complete at most a few dozen each day. Soon, instead of missing cases, Turkey was reporting false positives. The crest of the epidemic suddenly seemed to rise far higher than anyone had seen before. The government would eventually announce more than twenty human cases. But follow-up testing by WHO partner labs outside the country could confirm only a dozen.
Researchers in Indonesia reported similar problems with their initial flu tests. So did doctors in Thailand, who said in 2006 that these tests were actually becoming less able to detect the virus over time. Though rapid tests for seasonal influenza are commercially available and widely used, WHO says they are not sensitive enough to be used for bird flu. False negatives are common, and even positive results cannot distinguish between H5N1 and other influenza strains. Both the U.S. government and European Union have funded efforts to come up with a fast diagnostic test for bird flu. In spring 2009, the U.S. Food and Drug Administration approved the initial marketing of a test that can take less than forty minutes to work.
PCR tests that check for genetic evidence of the virus are more accurate but take several hours, longer than some victims can afford. And should the world face an emerging pandemic, even a short delay in detecting the virus could scuttle hopes of slowing its progress. Moreover, these are expensive tests that are frequently ill suited to much of Asia and elsewhere in the developing world. They require precise sampling, highly trained technicians, and the proper primers. As the virus strain mutates, which it does with haste, existing primers may no longer match and the tests will fail. And poorly matched primers can incorrectly detect other genetic material in the sample and yield a false result. Tests for antibodies to the virus can be even more accurate, especially established techniques like microneutralization. But these often demand labs with sophisticated safeguards. And they take much longer. Since antibodies to a virus appear only after the infection, these tests are of little use for responding to the disease in real time. A pandemic could be well on its way before antibody tests confirmed it. The “gold standard” for laboratory science is growing the live virus itself from a sample, traditionally in eggs, and using this to identify the pathogen. But this too is a long process. And for the many countries that lack high-security labs, the risk of the live virus escaping makes this technique far too risky.
The uncertainty goes well beyond testing. Flu specialists have been asking themselves for more than a decade why they know so little about the novel strain. Not long after it first crossed to people in 1997, researchers had already ascertained that the disease could be contracted through exposure to infected birds. But as Fukuda explained, exposure could mean many things. “Do you have to touch it? Do you have to rub your face after you touch it to get the virus near your mouth or your nose? If your face is close enough to infected birds, does that mean you can really breathe it in?” Maybe you don’t have to touch it at all, he suggested. “If you mean proximity, do you mean two feet, five feet, ten feet? Bird feces the same as having contact with birds? Is touching the wall in an area where birds were in the last twenty-four hours, does that count?” These are not idle distinctions. This information would help inform a strategy for stemming the spread of the virus and in turn reduce chances of a sinister mutation.
Research has been slow to offer answers, in large part because it is hard to conduct. Sick people don’t wander into studies. Those who are exposed and infected are often too ill to report how they got that way. Nor are time-consuming field studies involving large numbers of people a priority for countries reeling from these outbreaks. “Most of the countries where the first cases have occurred do not have traditions of analytic field investigation and the high profile of ‘bird flu’ does not encourage immediate openness,” wrote Dr. Angus Nicoll of the European Center for Disease Prevention and Control.
Dr. Michael Perdue, an American microbiologist assigned to WHO’s influenza program for several years, said it is hard to get standardized reporting from countries because each health ministry has its own way of doing things and few are anxious to publicize their disease outbreaks. “When it hits their country, they shut down,” he lamented. “WHO has to walk a fine line between demanding we have to have this information and shutting down the communications with the country, where they say, ‘Whoa, they’re coming after us. WHO is coming after us.’ You don’t get as much information as you like. There’s sort of a fine political dance that you’re doing.”
Perhaps more surprising is the lack of autopsies. Of the first two hundred confirmed deaths from the virus, fewer than a dozen victims underwent these postmortem exams. “This has posed some major problems in understanding the biology of the disease or fully understanding the virus underlying it,” explained influenza researcher Malik Peiris from the University of Hong Kong. Autopsies could examine how the agent wages its assault on the lungs and what other organs might also come under attack. These studies could help explain why some people get infected and not others, why the disease is so severe, and how well antiviral drugs work. “These are all pretty fundamental questions,” Peiris put it to me.
Why so few autopsies? The conventional response from leading researchers and senior officials is that local cultures bar the practice. In Chinese tradition it is said a corpse must be buried intact. Similar strictures are thought to apply in the Buddhist cultures of Thailand and Vietnam and the Muslim culture of Indonesia. “You have to get permission from the family to get that done,” explained Dr. Triono Soendoro, head of laboratory research at Indonesia’s health ministry. “People here are not used to having postmortem procedures.” Had Indonesian officials actually asked families for permission? “No, we haven’t tried,” Soendoro added.
When I broached the subject of autopsies with victims’ relatives, I got surprising responses.
Rini Dina Prasetyaningsih was among the first Indonesians known to succumb to the disease. Months later, I visited her small but comfortable middle-class home in South Jakarta and raised the delicate subject with her husband, Agus Mardeo. “I wouldn’t object to a postmortem as long as it was in the hospital and done by a doctor, as long they didn’t dig up the body after it was buried,” he said. Mardeo’s long, thin face turned somber. “Personally, I really wanted to know what happened to her. I would have been more than happy to have an autopsy.” But he added, “I’m just a common man. I don’t know about these medical procedures. No one suggested the idea to me.”
In a poorer suburb just outside the capital, a woman named Ibu Samida offered the same answer. She received me in her dimly lit living room, where she sat on a tattered couch surrounded by her four children and two grandchildren. The only one missing was her middle daughter, nineteen-year-old Ina, who had died not long before of bird flu. “I would have allowed an autopsy for the benefit of my neighbors and my family and everyone else concerned about the disease,” Ibu Samida said firmly. But again the refrain: “No one asked me. If they had asked, I would have given my permission.”
Yet even with autopsies, field studies, and fast, accurate testing, the answer to the most critical question could remain elusive: What will it take for the novel strain to become a pandemic strain? In other words, what specific genetic changes are required for the disease to become easily passed among people, and what is the sequence of biological events in animals and humans that will foster those changes? Scientists suspect these could involve mutations that make it easier for the virus to bind to human cells. But that’s likely not the whole story. Though modern science has delivered an intimate view of the pathogen’s inner machinery, the world still has little insight into how this fateful transition would work.
David Heymann, who was WHO’s chief of communicable diseases before retiring in 2009, conceded we’re not much further along in that regard than we were in 1918. “We’re handicapped by a lack of knowledge about the risk factors that cause the virus to change,” he said. “There are a lot of things we just don’t know.”
Scientists have little comparative data to go on because there have been only a few flu pandemics in modern times. Despite groundbreak ing work on the genetic makeup of the Spanish flu strain, Fukuda said there’s no way to be sure whether the 1918 experience is relevant to the avian flu virus. And without knowing how a pandemic strain would develop, it is nearly impossible to stop it. What steps should be taken to interrupt the evolution of a pandemic? What practices are speeding it on its way? When do changes in the pathogen represent a real and present danger? When are they a red herring? What to do about them?
“Sometimes the decision is simply ‘Let’s wait.’ We don’t have enough to go on. Let’s see how things evolve,” Fukuda said. “Or, it’s ‘We don’t have as much information as we like but we’re worried enough that if we’re missing something, it’s worth the price of jumping now.’ ”
For five days, WHO had been trying to get a meeting with senior Vietnamese officials. Finally, on the afternoon of Tuesday, June 14, Hans Troedsson’s delegation filed into a conference room at Vietnam’s Ministry of Agriculture and Rural Development, an unremarkable building around the corner from the monumental granite mausoleum, modeled after Lenin’s Tomb, where Ho Chi Minh, father of Communist Vietnam, still lies in repose.
Troedsson was no influenza specialist. He was a Danish doctor who had previously been responsible for children’s health issues at WHO. But as the agency’s chief representative in Vietnam, Troedsson essentially held the
