Fear of Contagion

By Fred Guterl

Adela Maria Gutierrez of Oaxaca probably thought she had a bad cold. She worked as a pollster at a government office in Oaxaca, going door to door to gather census data. She lived with her husband and three children and had no health insurance, so when she began running a fever she went to a private doctor, who prescribed antibiotics. Five days later, she was coughing up blood. She returned to the doctor, who gave her something else, but the very next day her hands and feet started to turn blue. She went back to the doctor a third time, and he sent her to the hospital. The diagnosis was pneumonia. On the second day of her hospitalization, she developed hypoxic encephalopathy, which means her brain wasn’t getting enough oxygen. Doctors put her on a ventilator. On April 13, eleven days after her first doctor’s visit, she suffered cardiac arrest and died. In those last few days, it wasn’t the illness they were fighting so much as Gutierrez herself, or more specifically, her immune system. It was working so hard to fight off the virus, it was killing her in the process.

About the time Gutierrez died, Dr. Richard Besser ran into Anne Schuchat in the corridors of the Atlanta headquarters of the Centers for Disease Control, the quasi-governmental agency charged with overseeing the nation’s health. Besser had taken over at the CDC only a few months before. He had been head of the center’s terrorism and emergency-preparedness division when the newly installed Obama White House staff had tagged him to run the agency. Tom Daschle, the former Senate majority leader, was Obama’s favorite to become the next secretary of health and human services, but the appointment was dragging on. Schuchat was the CDC’s influenza point person—she ran a weekly influenza strategy meeting at CDC—and she was concerned. An unusual outbreak had shown up on her radar, and a few odd coincidences as well. “Ann said, ‘I think you should come to the meeting on Wednesday. There are these two cases of swine flu from San Diego. There’s going to be a presentation on that. It’s something I really think you need to engage in.’ So I went to the meeting.”

By then, a few other cases had turned up in Texas. There had been an outbreak in Mexico, and reports of a higher-than-usual mortality rate had begun to circulate. “There was a concern that these might be related,” said Besser. The CDC activated its emergency operations center.

You might think that the world’s influenza surveillance network is highly formalized and automated, with information flowing from the remotest doctors’ offices to command and control centers at the speed of light. But the reality is different. When it came time for the CDC—the nation’s disease watchdogs—to find out what was going on, they drew on a loose connection of acquaintances—“back channels,” as Besser put it. After the meeting, Besser’s lieutenants got on the horn and called around. They called their colleagues in the public health labs in Winnipeg and Mexico City, compared notes, and concluded that they were all probably dealing with the same virus, and that it was something completely new.

Something new—words no influenza specialist wants to hear.

A ripple of fear began to spread through the public health community. Not only was this virus new, it also bore a striking resemblance to the deadliest flu virus on record—the H1N1 bug that caused the 1918 pandemic.

It was a frightening precedent. In 1918, the H1N1 virus burned through the world in less than two years, despite the lack of air travel, leaving 50 million to 100 million people dead in its wake. (Nobody knows precisely how many died. Information about influenza deaths was hard to come by back then, and in many ways it still is.) At the time, the world held 1.6 billion people. By simple extrapolation to the current population of more than 7 billion, a similar disaster today would leave 180 million to 375 million dead.

Thursday, April 23, was take-your-daughters-and-sons-to-work day. New York City’s public health office was crawling with kids. “My office was extremely chaotic,” says Marci Layton, the assistant commissioner for communicable diseases. “There were kids everywhere.” She and a colleague, with her kids in the room, took a conference call that day with the CDC, and that’s where she first heard of the outbreak in Mexico and the oddball cases in San Diego and Texas.

That was also the afternoon a sharp nurse at St. Francis prep school in Queens called the health officials to alert them about a number of students who had come into her office complaining of symptoms much like strep throat. By the time Layton had heard of the school outbreak, school was over and the children had gone home. With cooperation from the principal and the school, they got phone numbers and called the children’s parents at home.

The next day, Layton came to her office and read her e-mail. Canada’s Winnipeg lab and the CDC had confirmed that the virus that had caused the outbreaks in Mexico and the United States was indeed swine flu— H1N1. Layton immediately dispatched health workers to St. Francis to get samples.

About five p.m. the samples arrived in the city’s lab, where health workers were waiting. They worked into the night and by two a.m. had their answer: St. Francis was most likely having an outbreak of H1N1, the same as the virus in Mexico.

Health authorities in New York City and Atlanta then had to make some decisions—without knowing how virulent the virus in question was. Remember, virologists can’t tell, even if they sequence a virus’s genome, whether it’s going to be a lion or a pussycat.

The quickest way to spread a flu virus is to keep the schools open. Should New York City close St. Francis? Should it close all the city’s schools? What about schools across the nation?

The question was politically charged. With so little known about the virus, Besser’s instincts were to err on the side of caution. “There was a school outbreak in New York. We were concerned about children being a way of spreading flu within the community, as well as children being likely victims of this flu. We worked on drafting guidelines for this pandemic. The initial guidance was that if you have a confirmed or suspected case, you would shut your school down until you had a chance to investigate this further. This guidance was developed and put on the Web.” Besser’s team then revised this recommendation: The CDC posted on its website advice to close schools for two weeks if flu was suspected.

About this time, Besser was called to Washington to brief the president. Besser went to the White House and gave a short talk to the president and his cabinet and answered their questions. In the end, the White House persuaded Besser to reconsider the recommendation. Instead, the CDC would wait a week to see what data emerged about the Mexico outbreak—such as what proportion of people who had contracted the virus died.

It was a political compromise to forestall panic, at the risk of giving the virus time to spread. It turned out to be the right call. The very next day, according to Besser, the CDC got information from Mexico that the mortality rate of the virus was lower than initially feared, and that closing schools wouldn’t be necessary after all. St. Francis remained open. No harm was done.

We all know how the 2009 virus story ended. We lucked out. By June, data from Mexico and the United States showed that the new H1N1 virus was mild; early high mortality rates in Mexico had been exaggerated. When the virus resurfaced in the northern hemisphere in the fall, it remained mild—unlike the bird flu virus that returned with devastating effect to the poultry farms of Pennsylvania in 1983.

But what would have happened if the H1N1 virus of 2009 had been as virulent as the 1918 flu, or even the bird flu virus of Pennsylvania? Kawaoka’s analysis of the 1983 bird flu showed that a single mutation had turned a mild disease into a deadly one.

Here’s a scenario that could answer that question. Imagine that the data coming back from Mexico hadn’t been such a relief. Here, based on what we know did happen during the 2009 pandemic, is how things might have gone.

By early May, schools in New York City and across the nation have been open for two weeks, as officials grew more and more concerned that the virus could be lethal. The kids at St. Francis who were part of the original outbreak have been moved to intensive care, and the first one dies—a healthy young soccer player who had never even logged a sick day. By the time the CDC calls for school closings, parents had already started keeping their kids home. They drop the kids at the mall and the rec centers, where they continue to spread the disease.

The information from Mexico confirms the worst fears of the epidemiologists: the new H1N1 flu is indeed deadlier than anything we’ve known since the 1918 flu, and possibly worse than that. Mortality rates of 60 percent—the same as for those few unfortunate souls who contracted H5N1 bird flu in 2004—are confirmed for H1N1. Reports from Mexico City wind up on television screens around the country. Mexican hospitals are overwhelmed with intakes, people are dying in the hallways, and supplies grow short. Politicians go on television to warn people not to panic, that hospitals in the United States will not run out of supplies or beds.

The workers at the New York City health department are mobilized. The city’s labs on First Avenue are now staffed continuously, and infantry are posted outside to maintain order. The military and the FBI are also present inside the labs, because the crisis has provoked the obvious question: is this a natural outbreak or the work of terrorists who have fashioned a deadly bioweapon disguised as influenza? Meanwhile, city scientists are busily testing samples to track the virus’s progress through the city, and to get a handle on any mutations that might make things better, or worse.

In Washington, the head of the CDC steps off a plane and makes his way to the White House to brief the president and his cabinet officials. He has already met with the heads of influenza and emergency preparedness. The president and his staff want to know how bad the outbreak could get, and what steps should be taken to head it off. The CDC head tells them the frightening truth: that millions of people will surely die, and nothing can stop it.

There is a silence around the table as the president takes stock of what the CDC head sitting across from him has said. “Should we close the borders?” the president asks.

One of the first things that happened during the 2009 outbreak is that politicians started calling for the nation to close its borders with Mexico. Fortunately cooler heads prevailed. This policy would have been misguided on at least two counts. For one thing, the 2009 H1N1 virus had already crossed the border by the time officials knew about it. It is also doubtful that the virus originated in Mexico—the more likely source was U.S. pig farms, where precursors of the virus rattled around for years before picking up the mutations they needed to take flight.

The CDC head answers the border-closing question without hesitating. “No, sir,” he says. “Containing the virus is impossible at this point. By the time we had even heard of the virus, it was already too late. It will sweep through the entire population of the nation, and the world, in weeks.”

Panicked politicians get the upper hand and close the nation’s borders. Flights to the United States are canceled, ship traffic halted, and the highways between the United States and Mexico and Canada blocked. Although domes- tic air travel continues, at least for a while, American citizens traveling to Europe and Asia are stuck for the foreseeable future, and visitors to the United States similarly have to wait the crisis out.

“Can we vaccinate people?” asks the president.

“We have been working on a new technology for making quick vaccines, Mr. President, but it is finicky. It might work, but it might not. If it works, we could have vaccines in a month. If not, it will take six months. In either case, we will have casualties.”

The first doses of 2009 H1N1 vaccine were not available until late October, and they weren’t widely available until well into November. This was no screwup—vaccines take months to manufacture. First virologists have to isolate the virus they want to vaccinate against. Then they have to come up with a strain that will cause the immune system to kick into play—a strain that has, in other words, the same heamagglutinin and neuraminidase surface proteins (the H and N in H1N1) as the pathogenic strain. Then they have to neutralize the virus so that it doesn’t cause illness. The traditional way of performing this combination—or reassortment of genes, in the scientific parlance—is to insert the two strains of virus in a chicken egg, let them replicate for a while, then comb through the resulting mish-mash of different viruses for one you need for the vaccine.

“Why didn’t we see this coming? Why aren’t we prepared?”

“Because, Mr. President, nobody thought that an H1 virus that had been circulating for years among humans could turn into a pandemic. We were expecting the next outbreak to be an H5 virus—bird flu. By the time we knew about this H1N1 outbreak, it was already a pandemic. And because it’s a new strain, a vaccine could take months.

“We need to prepare, Mr. President, for mass panic. There will soon be a shortage of hospital beds, respirators, and medical expertise. And then people will start dying.

“There will be a need for mass burials.”

Every health department of every major city, as well as the Department of Health and Human Services and the Pentagon, has a document that it hopes never to have to dust off. It is called the Mass Fatality Plan. It outlines what would need to be done in the event of a disaster such as the next killer influenza epidemic. It assesses the “surge capacity” of local hospitals—how many beds are typically available, how many could be made available by sending some patients home and postponing elective surgery. The New York City area, for instance, has a limited supply of respirators— devices to help people with fluid in their lungs to breathe, which would be essential in a flu emergency. In a 1918-style flu pandemic, these respirators would be at a premium, and hospitals would be forced to ration their use. That means many people would have to be left to drown as their lungs filled up with fluids.

They would have to stay home, since hospital beds would also quickly be filled up. A surge in influenza intakes would quickly overwhelm the nation’s hospitals. Currently there are just under a million hospital beds in the nation. Most hospitals operate at about two-thirds capacity—which comes to roughly three hundred thousand extra beds. An influenza out- break that sickened 1 percent of the nation at once would use up all spare capacity. (That’s assuming, of course, that these beds are distributed uniformly, which of course they aren’t.) If 10 percent of the population marched into emergency rooms, there would be pandemonium.

Sending patients to nearby towns and cities would be pointless because they would likely have their own shortages. A pandemic flu would seem to strike everywhere at once.

By mid-May, hospitals in New York City and several other major cities are at the breaking point. Then, as if by a miracle, the number of casualties begins to level off and decline. For reasons that scientists don’t fully understand, influenza viruses wane in the spring and summer months. The flu season is nearing an end.

But the flu that rages briefly through the spring will come back in the fall. What form the virus takes is impossible to predict: it may morph into something less deadly, or it may turn even more deadly. Only time will tell.

Over the summer, vaccine makers labor to prepare their concoctions, rushing to bring out a vaccine as quickly as possible. By July, officials are certain that they’ll be able to make a vaccine, but they are still months off. Because the flu is new, they need to replicate the virus in the lab, make an attenuated form that won’t harm anyone but will stimulate the immune system to respond, and then test it. What they don’t know is how many shots it will require: two shots per person take longer to produce than one. By August, it’s apparent that the vaccine won’t be ready before late October, at the earliest. Since most people will need two shots, there won’t be enough to vaccinate the entire population until January. To prepare for a rough few months, the federal government moves to stockpile antivirals such as Tamiflu.

Meanwhile, health officials are anxiously watching the progress of the virus around the world. It’s grim. In South America, millions of people are getting sick, and hundreds of thousands are dying. Australia declares a national emergency and appeals for hospital equipment from nations in the northern hemisphere, but helping out is politically difficult if the equipment and medicines will be needed at home. As September nears, the White House decides to order schools to remain closed.

Stock markets around the world, already depressed, greet the news of school closings with a mass sell-off. Prices plummet. Trade comes to a virtual standstill. Even before the virus hits for real, an economic crisis sets in. The only stocks that rise are those of mortuary services.

A trickle of people are allowed to cross national borders, but travel is significantly limited. Airlines are filing for bankruptcy.

By the beginning of October, hospitals are no longer accepting patients. News reports tell of the sick dying in reception areas.

As the dead pile up, some states close their borders to keep medical refugees out. Shipping comes to a stop, causing shortages of heating fuel, food, and medical supplies. Because people are afraid to congregate, absenteeism begins to affect businesses of all sorts. Electrical utilities experience periodic outages due to lack of maintenance staff, who are either sick or home scared.

The army and the National Guard begin to take over the distribution of basic food and medical supplies, and the burying of the dead. As the death toll exceeds 10 million by November, corpses start piling up. A backlog of the dead develops. The federal government mobilizes the army to dig mass graves. It’s a matter of public health: each dead body is a reservoir of disease, waiting to find another host. The army issues directives on attaching identification to the bodies of loved ones so they can, at some later date, be reinterred in family plots. Refrigeration trucks are commandeered to keep bodies from decomposing.

It’s hard even to imagine the effect mortality on the order of a severe pandemic would have on our modern world. You would have to go back to the Black Death that swept through Asia and Europe in the fourteenth century to come up with an analog.

The Black Death struck a very different planet than the one we now inhabit. News traveled slowly back then, and so did people—the trip from Crimea to China, where the disease first emerged, took about twelve months over the mountains and along the hardscrabble roads. The strain of bacteria that caused the plague took several years to make its way across the Eurasian continent, hitchhiking on rats and their fleas.

When it arrived, though, it seemed like Armageddon to those who lived through it. In Europe, it killed about a third of the population—as much as 60 percent in some places. The population of China dropped 50 percent. Observers in Europe reported corpses in the street “packed like “lasagna” in municipal plague pits, collection carts winding through early-morning streets to pick up the previous day’s dead, husbands abandoning dying wives and parents abandoning dying children—for fear of contagion—and knots of people crouched over latrines and sewers inhaling the noxious fumes in hopes of inoculating themselves against the plague. It was dusted roads packed with panicked refugees, ghost ships crewed by corpses, and a feral child running wild in a deserted mountain village. For a moment in the middle of the fourteenth century, millions of people across Eurasia began to contemplate the end of civilization, and with it perhaps the end of the human race.”

The 1918 flu pandemic was not much better. The disease first showed up in army installations during the world war, dropped off over the summer, as flu tends to do, and roared back in the fall. Philadelphia, one of the first cities hit, saw 1,650 cases in the first day. By day five, 2,600 people had died. Within a month, the death toll had risen to 11,000. Doctors and undertakers were inundated. The virus swept through every city in the world, every rural district.

The world of 1918 was slower than the world is now. It took weeks to travel from Europe to America, and not many people made the trip. Influenza viruses now have new possibilities for mischief, and their evolution has only begun to explore them. A creature’s habitat, to a great extent, dictates its potential. The writer John Kelly estimates that pestilence on the scale of the Black Death would claim almost 2 billion lives.

Many people argue that there is something qualitatively different about the trajectory of human civilization in the twenty-first century from the early twentieth or the fourteenth centuries. This is getting close to some kind of fundamental limit—of earthly resources, of habitat, and of the complexity of a planetary ecosystem that we seem unwittingly to have taken charge of. Many scientists believe we are currently on the verge of a “mass extinction event.”

A true mass extinction would make the Black Death look like a mild recession by comparison. It is something that Homo sapiens has never experienced, and will only ever experience once.

Fred Guterl is the executive editor of Scientific American.

Excerpted from The Fate of the Species by Fred Guterl.