THE THIN WHITE LINE: the history of a future avian influenza pandemic

Chapter 1: Outbreak

Interview with Dr. Gregory Branch, Field Epidemiologist, World Health Organization

TORONTO, ONTARIO

[Dr. Gregory Branch works at the WHO headquarters in Geneva, Switzerland, but I am able to arrange a meeting in Toronto. Branch, a native of Ontario who received his medical degree from the University of Western Ontario, has been a virus hunter for most of his career in public health. Virus hunters are field epidemiologists who lead dangerous careers tramping through the bush in the remote corners of the earth——part detective, part hunter, part doctor. Branch has tangled with Ebola in the Congo, sleeping sickness in Central America, cholera in India and malaria and plague in Papua New Guinea.(8) He spent most of the Pandemic in China, part of it hunting for the natural reservoir of the Avian Flu, which has not yet been confirmed.]

    It’s October 6, the middle of the night and I’m in Toronto at an infectious diseases conference, and suddenly I’m jarred awake by the sound of my phone ringing. It was Margaret Redstone, director of GOARN [WHO's Global Outbreak Alert and Response Network] calling from Geneva to tell me she suspected that a highly virulent respiratory disease had emerged in southern China. What she said next hit me like a cold shower. She said, “This could be the big one, Greg.”
    In my profession, this is pretty much the worst thing you can hear.
    It was entirely possible to me that the worst case scenario of a pandemic disease outbreak was being realized in China. Guangdong is a flashpoint for pandemics. It’s a province where people and animals live close together near crowded cities and factories that do extensive business, and host numerous tourists, from the rest of the country and the world. The entire region is hardwired to the entire planet via commercial airplanes.
    As lead field epidemiologist for GOARN, I was told to fly to Hong Kong in the morning and visit with the local WHO office. Dr. Redstone said she wanted me to rub elbows with local health contacts and try to find out what I could about possible outbreaks in Guangdong and Shanghai. As we all know now, the Chinese government was doing the same thing it did during SARS, keeping everything bottled up and refusing to admit that anything was wrong at all in some misguided attempt to protect itself. The WHO had requested information about a suspected epidemic, and asked permission to send a team to check it out. The Chinese, of course, said no.
    The WHO has been criticized, unfairly in my opinion, for not acting more decisively regarding China at the start of the Pandemic. They say we could have prevented it. Hindsight is 20/20, but the reality is that we have major institutional hurdles. For example, we simply can’t barge into countries and order their public health departments around. National sovereignty must be respected; it is part of the ground rules that allow us to exist at all. That means if the country simply refuses to cooperate, without hard proof we can pressure them, but that’s pretty much it——and that takes time and patience. In the case of China, we’re talking the patience of all the saints who ever lived.
    So my mission, it turned out, was to be virtually a spy mission. My job was to gather hard intelligence that the WHO could act on: Was there an epidemic? If so, what was the agent? If a novel virus, what was the risk of a pandemic?
    When I arrived in Hong Kong, I saw little evidence of an epidemic, only its possible halo effect, such as people wearing surgical masks, just like during the SARS outbreak, and cleaned-out drugstores and supermarkets. But a bad seasonal flu, A/Hong Kong, was going around——was this to blame? As it turned out, it would take another week before H5N1 invaded Hong Kong.
    Rumors rippled through the city every few hours. For example, my taxi driver told me not to eat pork, as he’d heard the government had started randomly slaughtering pigs all over Guangdong. If you see things the way an epidemiologist does, such things are notable. Were the Chinese trying to destroy the suspected natural reservoir of a novel virus? Or did it simply mean that Chinese swineherds had suffered another outbreak of blue-ear disease?
    You have to be careful in this field. There’s an epidemiological proverb that says if you hear hoof beats, assume it’s a horse, not a zebra. In other words, don’t go looking for exotic diseases or causes when common causes or ailments are more likely explanations for what you’re seeing. Use the scientific method.
    I had visited Hong Kong before, during the SARS epidemic, and knew the ground and some of the key people. I contacted colleagues at the Microbiology Lab at the University of Hong Kong, a WHO reference lab, but they refused to see me. They didn’t want to talk to me at all; that in itself spoke volumes about the situation, and was actually my first clear sign that something bad was going on. Hong Kong is still very independent from the central government in Beijing, but they had obviously been warned to keep their mouths shut. I suddenly realized that the fact that they knew me actually counted against me, as they knew who I worked for and could easily guess why I was there. I can tell you that this realization made me seriously nervous, and I could only hope that they would continue to keep silent and not tell the authorities about my mission in their country.
    However, I had no choice but to continue. I tried several people at the National Influenza Center, another WHO reference lab, with the same results. I was getting nowhere fast.
    A day later and I’m sitting in my hotel room, thinking furiously. The WHO office had no answers for me despite its best efforts. All I had to work with was a wall of silence in Hong Kong’s influenza community and the increasingly strange rumors among people on the street. Both suggested that something bad was going on in southern China, but I had little hard information, and the WHO doesn’t move on anything unless it has hard facts. Our critics should think about that as well——about what would have happened if we’d cried wolf and turned out to be wrong. Imagine it: The WHO says pandemic and billions of people hear the end of the world. I’m talking huge social disorder, disrupted trade and tourism, huge economic losses, all for nothing. We had to tread very carefully, and I had nothing solid to go on.
    After dinner, there’s a knock at my door and a young woman is standing there who asks me to repeat my name twice before handing me a note telling me to meet her later that night. The note has an address and time. Then she is gone and my heart is pounding. What did this mean? The problem with having a secret mission is a strange paranoia sets in; you begin to interpret every contact as significant to your mission. I laughed at myself, wondering: Was she a horse or a zebra? But I could see no other rational explanation for her visit. If it meant a breakthrough, it was worth the risk of going to see her.
    I later left the hotel and waded into chaos and strange smells of the streets of Hong Kong, the buildings glittering with thousands of lights, the throngs of people walking or bicycling, the occasional car parting the crowd at an intersection. Most people, it seemed, wore a face mask——I was wearing one myself. Eventually, I arrived at the address on the slip of paper in my pocket, which turned out to be a Catholic church, an eight-story structure sandwiched between other tall buildings, its upper floors haphazardly stacked on top of each other like afterthoughts. On the steps of the church, a woman was lighting incense sticks around several oranges she had set there, offerings to ancestral spirits. Such contradictions are the spice of Asia. I walked up to the doors of the church, wondering what to do. Next door, skinny men wearing gym shorts, cell phones and pagers were unloading a truck, shirts off, dragon tattoos emblazoned on their backs.
    A woman called my name, and I turned to see my contact in a car parked on the street. I got in next to her and attempted to shake hands, but she refused, instead making a fist with her right hand wrapping her left hand over it——a traditional Chinese greeting that coincidentally avoids physical contact, which carries the risk of either giving or getting a virus. This reminded me of the SARS epidemic——another sign of the times.
    She started driving. Getting nervous again, I asked her where we were going. She didn’t answer. Instead, she told me her name, Xiaosong Lin, and that she worked for the National Influenza Center. I found out that she had a PhD in virology.
    She said an epidemic raged in Guangdong and health officials could not contain it. The Center had confirmed the agent as a variant of H5N1, highly resistant to generic antivirals and with a mortality rate currently running at about five percent in confirmed cases.
    Bird flu.
    I started asking questions: Had doctors created a profile for the disease? Could they distinguish it from ordinary flu? Was the epidemic peaking, or was the number of cases still growing? What was its transmission factor? Was it confined to Guangdong or were there outbreaks in other communities?
    Dr. Xiaosong didn’t know. She had her piece of the puzzle and that was it. But she wanted to show me something that would give me an idea of what the puzzle looked like when completed, something she had discovered on her own. After that, I would have to confirm what I’d seen without her.
    We drove north. Eventually the dense crowds and lights of Hong Kong fell away and I could sense the mountains rising up around us in the dark as we passed numerous towns and villages. Soon, we approached the border between Hong Kong and the Guangdong province of mainland China. On the other side of the river sprawled Shenzhen, a city with an urban population of more than four million people, one of China’s largest economic centers and ports, one of the birthing places of globalization.
    We’re going to the mainland? I asked her, but she shook her head no, turned the wheel and got onto a secondary road, following it along the river until Shenzhen began to break up into a patchwork of towns and undeveloped land. I was excited; I didn’t know what I would find, but I sensed that I would be shown confirmation of the epidemic. She pulled off the road, parked and got out of the car. When I started to ask questions, she told me to be quiet and stay close behind her. Her flashlight led us along a path leading downhill, and as I stumbled through the brush, I could hear and smell the river below.
    Stopping, Dr. Xiaosong reached into a case on her hip and pulled out a pair of binoculars, which she handed to me. She pointed and turned off her flashlight.
    Look, she said. There. See.
    As my eyes adjusted to the darkness, I looked across the river and saw splashes of light on the far side. Adjusting the binoculars, I could see floodlights and bonfires, and men wearing gloves, hooded plastic white jumpsuits, surgical masks and face shields.
    They were carrying bags from a truck and dumping them on the fires.
    Was I seeing open-air cremation? It appeared to be the orderly destruction of animal wastes——chickens? Pigs? But why at night? Why burning, instead of burying, when so close to Shenzhen’s suburbs? In 1997, after bird flu infected the first human in Hong Kong and chickens were identified as its source, I watched workers like these excavate trenches and bury more than a million culled chickens with a layer of slaked lime, which prevented scavengers and worms from getting at the carcasses. With open-air burning, the workers dig a trench to create an air vent, build a pyre of wood on top of the trench, and light it with kerosene or some other fuel. While it’s cheaper than using an incinerator, it’s riskier and more expensive than burial.
    I never knew what people meant when they said that something scary made their blood run cold. At that moment, I did. Suddenly it hit me: The Chinese were burning people. Cremating human corpses destroyed the evidence of the epidemic and prevented any possibility of having to exhume them later. While I continued to watch, they destroyed at least a hundred corpses.
    It was clear the Chinese were fighting a major epidemic, and Lin was saying to me, Do you see? Do you see it now, what is happening to my country? Will you tell the world what you see? Will you help save China from this, from itself?
    I suddenly became aware of the lights of Shenzhen in the distance. Across the river, four million people lived in the city proper. In Guangdong, more than 110 million people lived, including about 10 million migrant workers and their families from the interior packed into poorly ventilated dormitories and factories. The government was obviously suppressing information about the epidemic and therefore doing little to prevent the spread of disease. Businesses and theaters, shops and schools remained open, and people crowded the streets. People continued to visit and do business there from all over the world and were possibly taking the virus home with them to places where the health systems would have no idea what they were dealing with.
    I believed I was looking at a fire, a fire that had grown out of control, a fire that could not be put out. I needed to warn the world.

Figure 1-2. Estimated mortality due to the avian influenza epidemic in the People’s Republic of China. Overall, an estimated 16.5 million people in China died from Avian Flu.