The Fatal Strain (17 page)

“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 among the first to contain it. Pascale Brudon, the auburn-haired Frenchwoman who headed the agency’s Hanoi office, likened the SARS experience to
The Plague,
by Albert Camus. She said the tension and sense of personal jeopardy had been profound, especially after the loss of Dr. Carlo Urbani. Urbani, an Italian infectious-disease expert assigned to Vietnam, had investigated the country’s initial SARS case, and his early insights into the pathogen ultimately helped the world defeat it. But not before he, too, succumbed. He had been a popular figure, a hang-gliding, motorcycle-riding musician of a man who, while previously working for Doctors Without Borders, had received the 1999 Nobel Peace Prize on that organization’s behalf. His death was staggering.

When Horby notified Brudon in early January 2004 about what he’d learned at the National Pediatric Hospital, her reaction was, “Oh no, not again.”

In Geneva, Dr. Klaus Stohr was the head of WHO’s global influenza program. He had never doubted that bird flu would resurface, and he was waiting for the moment. “To prevent an earthquake or an eruption of a volcano, you always prepare for it,” he recalled. “But when it happens, you’re still surprised, still shocked.”

Stohr wanted to get his flu hunters on the ground fast. But it was proving difficult to assemble a team. “There were some people, all international experts, who said ‘Why should I go? Why should I jump into the frying pan?’ ” he recalled. They were thinking about their families. They were thinking about Carlo Urbani. “It’s too hot for us to go right in the middle of a possible volcano.” They demurred.

Horby was already on the ground and he, too, was thinking about Urbani. He had assumed some of Urbani’s duties, and like his predecessor, was back in the hospitals, seeing desperately sick patients infected with an uncertain yet catastrophic agent. “It was a very worrying time,” Horby later acknowledged.

But Uyeki, biding his time in Atlanta since he’d first learned of the outbreak two weeks earlier, couldn’t get there soon enough. “You want to help and you want to find out answers,” he told me. “Yeah, I was ready to go right away. Keiji and I, we’re ready to go.”

“What do I need?” Uyeki thought. He stocked up on antiviral drugs to dose himself. He collected his protective gear. As a matter of course, he had already been custom-fitted for N95 respirators, what most people call masks, and he replenished his supply. Then he and Fukuda started turning over their command responsibilities in fighting the seasonal flu still raging at home.

The flu outbreak that began that fall had jolted the American health-care system. It was only seasonal flu, but hospitals and doctors’ offices were flooded with the infirm. Emergency rooms from coast to coast were reporting record numbers of patients, in some cases a hundred a day, and many waiting rooms were standing room only. Some hospitals made other patients give up their beds. Local government officials activated disaster plans. Just a week after Thanksgiving, flu shots already had run out.

But as nasty as that flu season was, again, it was only seasonal flu. In a pandemic, the health-care system could crumble. Just the initial rumblings of a pandemic, the first weeks of the swine flu outbreak in spring 2009, overwhelmed many American hospitals and clinics as patients with little more than common colds, or no symptoms at all, clamored to be checked out. A mild pandemic with a relatively low death rate would still sicken at least a quarter of the population, sending millions of petrified, sniffling Americans to the hospital. In a more severe epidemic, our broader society as we know it could be in jeopardy. That’s the lesson of Philadelphia.

As a young reporter, I worked there for eight years—it was my first big city—and I got to know its streets well. I never realized I was sharing the ghostly geography of the worst calamity ever to befall the United States.

It was September 11, 1918 when the Spanish flu made its first recorded appearance in Philadelphia, striking the Naval Yard at the foot of South Broad Street. The virus had come ashore with scores of sailors transferred days earlier from Boston, a city already under siege. But Philadelphia’s flu epidemic would evince its full fury only later in
the month, after the city had experienced perhaps the greatest orgy ever of human-to-human transmission. Soon the city would be the hardest hit in the country, gripped not only by illness but by terror and social breakdown on a scale unprecedented in American history.

As autumn broke in 1918, the eyes of Philadelphians, like those of most Americans, were on the war in Europe. Two days after U.S. forces and their allies launched a decisive offensive in the battle of Argonne Forest, attention shifted to the home front with the city’s Fourth Annual Liberty Loan parade. Billed as the largest in Philadelphia’s history, this procession on September 28 would kick off the city’s campaign to raise money for the war effort. As I study an old photograph of that Saturday afternoon in 1918, I can almost see death marching through my neighborhood, retracing the steps I walked daily. Five uniformed sailors, rifles on their shoulders, escort a festooned float bearing a navy patrol boat past the intersection of Broad and Chestnut. Hundreds of spectators are crammed beneath the classical columns of a building that decades later would become my local bank branch. At least two hundred thousand others pack the route along twenty-three blocks of Broad Street, cheering on the passing pageant of marines, sailors, and yeowomen, steelworkers, shipworkers, and makers of “shot and shell,” with horse-drawn eight-inch howitzers, Boy Scouts, women of charity and relief, and Main Line debutantes riding farm equipment. Never would a flu virus more clearly demonstrate what it means to fully satisfy the third and final condition of a pandemic.

Philadelphians had barely boarded the streetcars for their Monday morning commute when the epidemic exploded. By Tuesday every hospital bed in town was taken. Thirty-one hospitals, and they were all turning people away. In the historic Society Hill neighborhood, the sick rushed to Pennsylvania Hospital, cofounded by Benjamin Franklin. “When they got there, there were lines and no doctors available and no medicine available. So they went home, those that were strong enough,” a neighbor recalled. Five days after the parade, a doctor at Women’s Medical College of Pennsylvania reported that students had begun filling in for hospital staff who were themselves laid low. “The experiences through which we are passing remind one of the historic
records of the plague,” wrote Dr. Ellen C. Potter, a medical professor at the college, in a letter to an academic colleague.

Just a week after the parade, on Saturday, October 5, doctors in Philadelphia reported 254 deaths in a single day. Five days later, the daily toll was 759, almost precisely triple. Hundreds of thousands were sick.

Philadelphia General Hospital, in West Philadelphia, was among the first to appeal for help. “Two-thirds of the nursing force were prostrate by the disease with none to replace them in the wards,” reported sisters from the Roman Catholic archdiocese, who time and again answered the call. Almost half the doctors and nurses had themselves been hospitalized. Others had collapsed from overwork. Patients, many violently delirious, were getting minimal care. “Some of the poor sick had had no attention for over 18 hours and some had not been bathed for over a week,” the sisters reported.

Isaac Starr was a third-year student at the University of Pennsylvania’s School of Medicine. After a single lecture on influenza, he was dispatched to staff an emergency hospital opened in a partly demolished building at Eighteenth and Cherry streets. Starr and his classmates hauled twenty-five beds onto each of five floors. These filled right up with victims. “After gasping for several hours, they became delirious and incontinent, and many died struggling to clear their airways of blood-tinged froth that sometimes gushed from their nose and mouth,” he later wrote. Many died without seeing a doctor. Corpses were “tossed” onto trucks, which hauled them away when filled. “The rumor got around that the ‘black death’ had returned,” he wrote.

More emergency hospitals were opening every day in garages, parish houses, gyms, armories, nursery schools, and college frats, but often there was barely anyone to staff them. The city established one of the first at the poorhouse in the Holmesburg section. Its five hundred beds were filled in a day. In the second week of October, when a contingent of nuns came in relief, they discovered only twelve nurses caring for the patients. “One can imagine the distress, neglect and misery of these poor creatures. Some did not have their faces washed for days; their bed clothing had not been changed for a like period of time,” one of the sisters recounted. Patients were moaning, coughing,
delirious, some rising from their beds and frantically wandering the wards like specters. With only a single orderly for the whole hospital, the dead could lie unattended for hours until volunteers came to haul them out. “The first day we saw 13 bodies carried out to the dead-house within four hours,” the nun continued. “The odor from this dead-house was something awful.”

Nor was it just the city that was in the crosshairs. The smaller towns in its orbit were also succumbing. In Pottsville, the residence of a wealthy family was converted into a medical facility. “What sights and sounds met us when we entered that room where 84 patients were moaning and crying for help!” one nun wrote. “There were about forty babies in one room, all crying and perfectly helpless, their ages ranging from six days to two and a half years.” All night, the stricken begged for water, ice, or a comforting presence in their final hours. The nun was horrified. “Some,” she said, “were so far gone that worms were crawling out of their mouths.”

On the streets of Philadelphia, cars bearing medical insignia were mobbed. College classes for pharmacy students were suspended so they could help fill prescriptions until drugstore shelves ran bare. Public services broke down. Nearly 500 police officers stayed off the job. About 1,800 telephone employees failed to show up for work, forcing Bell Telephone Company of Pennsylvania to take out newspaper ads warning it could handle “no other than absolutely necessary calls compelled by the epidemic or by war necessity.”