“Did she talk about going to a poultry market?” Samaan pressed, following up on the tip from the previous day.
“Sometimes she would go after work,” Swarni recalled. The young midwife mentioned a particular market in East Jakarta and then giggled softly, covering her mouth. Samaan waited for the rest of the answer, puzzled. “She would go buy chicken feet,” Swarni added. “That was one of her favorite foods.”
Epidemiologists are often faced with two complementary questions. The first is like the one that was stumping Samaan: Why does someone fall sick? The second question is less obvious, though the answer can be even more revealing: Why
For each victim laid low by bird flu, there are hundreds, perhaps thousands, who should have been. These are the cullers, the armies of peasants, soldiers, veterinary officers, and day laborers who have slaughtered several hundred million birds across Asia, Africa, and Europe since 2003 in an orgy of bloodletting aimed at exterminating infected flocks and stemming the spread of the virus. They often did so with minimal protection, lacking masks, goggles, and even gloves. Yet a full decade passed after H5N1 claimed its first confirmed victim in 1997 before a single culler ever got seriously sick—a Pakistani man who died shortly after helping carry out a two-day poultry slaughter in October 2007. In Vietnam alone, more than ten thousand people participated in the great massacre without a reported case. This mystery has defied explanation, posing one of the great riddles confronting flu investigators.
Field sampling has revealed that some cullers were in fact exposed to the pathogen. Five South Koreans who helped stamp out infected flocks eventually tested positive for antibodies though none ever became ill, and a lone culler in Indonesia also showed elevated antibodies without any outward sign of illness. So, too, nine workers who helped carry out Hong Kong’s mass slaughter in 1997 tested positive, with only one displaying mild symptoms. These findings suggested that bird flu may have spread farther than the flu hunters suspected but that many human cases were asymptomatic. If so, this would not be welcome news. It would mean a greater chance for the strain to stumble across the genetic mutations required to unlock a pandemic. Field investigators turned up other worrisome evidence. Blood taken from two elderly but otherwise healthy relatives of Vietnamese victims in 2005 had antibodies to the virus. A year later, a pair of young brothers in Turkey were also positive despite showing no symptoms.
But these instances proved to be rare exceptions. Efforts to uncover a rash of asymptomatic cases have found none. In one telling study, researchers canvassed nearly a hundred homes in a Cambodian village where a man had contracted the virus days earlier. Poultry outbreaks were widespread. If the virus were adept at causing cryptic cases, certainly some would turn up here. But not a single one of the 351 villagers tested had antibodies. A subsequent study of 674 people in two Cambodian villages where there had been both human and poultry outbreaks revealed that 7 of the villagers, or about 1 percent, had antibodies to the virus, indicating they’d been exposed even if they hadn’t had symptoms. For some reason, they were all younger than eighteen. Though this last study suggested some mild cases were being overlooked by health officials, the results hardly signaled a silent epidemic. The enigma of the cullers endured.
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
