The Fatal Strain

basics of microbiology and went out chasing chickens with me. I’m also tremendously grateful to Lilian, Ira, and Sindi Pramudita, who did so much more than manage our office and local affairs in Indonesia. They became our second family. Noor Huda Ismail and Natasha Tampubolon rounded out our team in Jakarta. I also benefited from the hard work, generosity, and insights of local reporters and fixers elsewhere in Asia, in particular Somporn Panyastianpong in Bangkok, Phann Ana in Phnom Penh, K. C. Ng in Hong Kong, and Ling Jin in Beijing. Back in Washington, Jean Hwang was a tireless assistant, working into the wee hours transcribing often inaudible tapes.

The Washington Post has always been a special place. Yet with each passing year, as other newspapers succumb to the financial pressures of our troubled industry, the Post’s commitment to great journalism becomes ever more exceptional. That dedication has flowed from the top, from Donald E. Graham, Boisfeuillet Jones Jr., and now Katharine Weymouth. For the opportunity to report from Southeast Asia, I’m grateful to former executive editor Leonard Downie Jr. and former managing editor Steve Coll, as well as to Philip Bennett, who was assistant managing editor for foreign news when I shipped out to Asia and managing editor when I returned. On the foreign desk, a string of talented editors had a hand in my writing about flu, including David Hoffman, Peter Eisner, John Burgess, Kathryn Tolbert, Tiffany Harness, and Jason Ukman. Thanks also to Nils Bruzelius, the deputy national editor for science and health, and news researchers Bob Lyford and Rob Thomason for their help.

The fraternity of flu writers is surprisingly small, given the drama and stakes of the subject. Yet in recent years I’ve been fortunate to count myself in the company of some terrific journalists. I’ve benefited from the work in Asia of Margie Mason of the Associated Press and Nicholas Zamiska of the Wall Street Journal. Closer to home, the standard has been set by Helen Branswell of the Canadian Press, Maggie Fox of Reuters, and Maryn McKenna, formerly of the Atlanta Journal-Constitution . In Jakarta, I was blessed with colleagues who were both good friends and reliable road companions at the toughest of times, in particular Rick Paddock of the Los Angeles Times, Shawn Donnan of the Financial Times, and John Aglionby of the Guardian and later the Financial Times. A special note of gratitude goes to Dean Yates of Reuters and to Mary Binks.

This would have been a very different book if not for the cooperation of countless individuals at the World Health Organization. I cannot name them all, and a fair number wouldn’t want me to. But I would like to acknowledge several members of the agency’s public affairs staff, past and present, including Maria Cheng, Peter Cordingley, Bob Dietz, Sari Setiogi, and Roy Wadia. Both in reporting for the Post and in researching this book, I found them consistently helpful. Mary Kay Kindhauser’s efforts in facilitating my reporting in Geneva were invaluable. And I’m particularly grateful to Dick Thompson and Kris tin Thompson for their professional assistance and personal kindness. There were also many at other agencies who took time to share their expertise and give me crash tutorials, including at the UN Food and Agriculture Organization, the World Animal Health Organization, and the Centers for Disease Control and Prevention. Nor can I say enough about the helpful staff of the U.S. National Library of Medicine or the team at the University of Minnesota that maintains the awesomely comprehensive Center for Infectious Disease Research and Policy (CIDRAP) Web site, www.cidrap.umn.edu.

It’s not possible to credit the scores of scientists, public health experts, and medical specialists who agreed to be interviewed or offered me guidance. But I would be remiss if I didn’t single out the following for thanks. Michael Perdue, formerly of WHO in Geneva and now at the U.S. Biomedical Advanced Research and Development Authority in Washington, has been a great resource for me on the science of the virus. Michael Osterholm, director of the Center for Infectious Disease Research and Policy in Minneapolis, has steered me right when I’ve been stumped by questions about the evolution of the threat. I’m also smarter for the repeated insights of Malik Peiris in Hong Kong, one of the world’s premier researchers into respiratory viruses.

This book never would have been written at all without the intervention of three Post colleagues. David Maraniss encouraged me to embark on this project when I was still unsure whether to do so. Dana Milbank offered sage advice across a kitchen counter on how to frame the book, finally unlocking its potential. And Sandy Sugawara gave me the time to pursue the project even if the timing was inopportune. I’m beholden to all three.

I owe a major debt of gratitude to my very wise agent, Raphael Sagalyn. He immediately spotted the potential of this project, but for months kept pushing me to rethink and refine the conception until I got it right. Then he ran with it. At Viking Penguin, my editor Ales sandra Lusardi has been a very sharp reader and elevated the writing by helping me bring the main themes to the fore while pruning back overgrowth in the storytelling.

In everything, I’m indebted to my parents for their love and gift of intellectual curiosity. Most of all, I’m grateful to Ellen, my partner in all things, for her understanding and encouragement. There’s no one else I’d rather travel to the ends of the world with.

Notes

Prologue

2 All flu viruses in fact emanate: See, for instance, R. J. Webby and R. G. Webster, “Emergence of Influenza A Viruses,” Philosophical Transactions of the Royal Society of London B: Biological Sciences, 356, no. 1416 (Dec. 29, 2001): 1817-28.

6 a repeat of the Great Influenza: For a definitive account of the 1918 pandemic, see John M. Barry, The Great Influenza: The Epic Story of the Deadliest Plague in History (Viking Penguin: New York, 2004). See also Alfred W. Crosby, America’s Forgotten Pandemic: The Influenza of 1918, 2nd ed. (New York: Cambridge University Press, 2003).

6 at least 50 million lives: N. P. Johnson and J. Mueller, “Updating the Accounts: Global Mortality of the 1918-1920 ‘Spanish’ Influenza Pandemic,” Bulletin of the History of Medicine 76, no. 1 (Spring 2002): 105-15.

7 “accelerated number of near-misses”: Anita Manning, “New, Deadly Flu Pandemic ‘Inevitable,’ Experts Warn,” USA Today, Mar. 2, 2004.

7 theater of conflict that is Asia: Dr. Michael T. Osterholm of the University of Minnesota has called Asia “the genetic roulette table for H5N1 mutations.”

7 first documented global outbreak: C. W. Potter, “A History of Influenza,” Journal of Applied Microbiology 91 (2001): 572-79.

7 since the twelfth century: August Hirsch, Handbook of Geographical and Historical Pathology (London: New Sydenham Society, 1883).

Chapter One: The Revenge of Begu Ganjang

This chapter draws on interviews with disease specialists from the World Health Organization and the U.S. Centers for Disease Control and Prevention, officials from the governments of Indonesia, North Sumatra province, and Karo district, and medical professionals and residents in North Sumatra province, as well as internal documents from WHO and the governments of Indonesia, North Sumatra, and Karo.

13 cruise ships in Alaska: An account of the investigation can be found in Timothy M. Uyeki et al., “Large Summertime Influenza A Outbreak Among Tourists in Alaska and the Yukon Territory,” Clinical Infectious Diseases 36 (2003): 1095-1102.

13 island nation of Madagascar: Accounts of the investigation into the outbreak can be found in “Influenza Outbreak—July-August 2002,” Morbidity and Mortality Weekly Report, 51, no. 45 (Nov. 15, 2002): 1016-18; and Weekly Epidemiological Record 2002, no. 46