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VIA SKYPE, HE HEARD both EIS officers’ reports. Roy had statistics on hospital admissions: double digits at both hospitals. Visits to the ER, hard to say what was only rhinovirus and what was this, but up to 88 possible. Another 134 at the urgent care clinics Harper had contacted.
Harper had twelve death certificates from pneumonia in the last six days. Two of those people were immunocompromised. “One name sounds as if it might be a Muslim, so I assumed already buried, but even if so, we could still test some of the others.”
“We’ll set local public health to that. They have the contacts.” Always better to have sensitive matters dealt with by locals, and asking to take samples from dead bodies was about as sensitive as it got. “You have a map yet?”
“There are three main clusters, including the Washington family. But otherwise, it’s all over town. And no, before you ask, no common habits I’ve been able to detect so far.”
“Me neither,” said Roy. “I interviewed another cluster, and it’s obvious they all caught it from their mother who is, let’s see, sixty-one.”
“Are we still in the public school year here?”
“I’ll Google it,” Harper said. A second later: “Yes, until the first week of June.”
“Damnation. I need to tell them to close down the public schools. Right now.”
“Whoa,” said Roy. “Hell, Glenn, why the panic?”
“I know what it is.”
“What?”
“HPAI, H5N1, with human transmission.”
Roy’s jaw literally dropped.
Harper said, “We’re talking about maybe the index cases of that. Or it jumped from China to here? Or Egypt to here? How?”
Glenn said, “That, we need to find out, and fast. In fact, we need to do everything fast.”
He had wanted to get their reports first, so as not to prejudice them by telling them the kind of flu they were dealing with. “Just to double-check with you both. We aren’t seeing it among—I don’t know, people who go to cockfights. Parakeet owners. People with a few hens in the yard. People who hunt with falcons. Something like that?”
“No,” said Harper. “Not on my end.”
Roy was still in shock.
“Roy?”
“What? No. Fuck, Glenn, I’ve been talking to these people. The aerosols....”
“I know. I’m sorry. If I had any idea, I would have had you on respirators. In fact, you’re both on antivirals as of now.”
Harper seemed to be taking it calmly. She said, “You should be too. You were touching that patient this morning.”
And he had been in the Washington home, which probably had virus on every surface, despite Ms. Washington’s exemplary housekeeping. “I know. I’ll have Emile phone the Philadelphia office after I call Atlanta. They’ll bring us the drugs, respirators, the works. And we’ll get more staff.” He needed to cancel the interview with the public health student. He only wanted people covered by insurance here, professionals who knew what they’d signed up for and had top-notch insurance and access to drugs.
“But where’d it come from?” Harper said, thoughtfully.
“That’s your job to find out. Our jobs, I mean, all of us, but you’re on point on that one for now. I need you to make me some maps in multi colors, lines of transmission, all of that to show people later. Both of you—all three of us—will collect more data, and Harper will make it clear. Pretty to look at and clear.”
“I can do that. What about the public health director? We talked once, on the phone, but maybe you want to be the one to tell him about this.”
“I do. Thank you.”
“Back to the source though. You remember the big brouhaha about the flu researchers a few years ago? Rotterdam?”
How could he forget? Two separate labs, using genetic manipulation methods, had created more dangerous H5N1 and then published their findings. It had been interesting and important work, but the publications had been almost a roadmap for terrorists. And then there were, every year, problems at various labs—escaping viruses, safety protocols breached, you name it. The CDC monitored this, and it levied fines for violations, and it put labs on warning, and occasionally, after repeated warnings, it even shut down a lab. But this could be an escaped virus. He thought about the biggest east coast labs. “What’s closer to us here in Trenton, Boston or Fort Detrick?”
“Googling,” said Harper. “Boston is 180 miles, USAMRIID is 190.”
“I’ll get someone in Atlanta making phone calls to hospitals in those two places, just in case. We’ll see if there are outbreaks there too. Good thinking, Harper.”
Roy said, “I’ll ask about travel within the US, and not just international, from now on.” He seemed to have recovered from his initial shock. “Though a lot of these people are poor, and I don’t think they travel much, we need to be thorough. A hundred eighty miles—that’s drivable for a weekend visit to relatives.”
“Good. Work hard, get the facts, come back for a face-to-face meeting at 6:30, and I’ll order in food for that.”
Roy put a finger up. “We need someone who speaks fluent Spanish. A few Hispanics are here and not all speak English. My Spanish is insufficient.”
“Are any of them illegal, you think?”
“Probably.”
Which meant they were not going to want to cooperate with any government officials. To illegals, everyone official was La Migra or might be in league with them. “I’ll tell Emile to send someone bilingual from Philadelphia. And Roy, when we get off the phone, please call Ellis—she’s good and smart and fast. I already told her to have her staff on respirators. Confirm and put an exclamation point on it, would you? Isolation protocols from now on from the moment new patients walk into the ER.”
“Was it a hunch on your part about the respirators?”
“Yeah, borne of experience.” Too bad he had been right.
“This is bad,” Roy said. “Really bad.”
“I know. Eyes on the prize, my friends. Stay safe and let’s try to get this thing contained.”
The next two hours he spent on the phone. He was on with Emile four different times, as new ideas popped into his head.
The Director of Public Health for the county was not answering his private phone. The office said he was in an off-site meeting. It was nearly three in the afternoon before he got in contact with him. “Mr. Alverez, we have a serious situation here,” he said. “There are more cases, and we know what it is. It’s a highly dangerous form of H5N1.”
“That’s bird flu, isn’t it?” He didn’t sound overly concerned.
“It is, but this appears to be a new strain, and it’s deadly. We have possibly a dozen deaths so far, and we’re moving up on two hundred cases in your county. If you could come in to our temporary operation center as soon as you’re free, I’ll show you what we have.”
“Well, my kid’s futbol game—”
“Should be canceled. Keep your kids at home. We’re working on getting the superintendent of your public schools to shut those down. This is a killer flu. It’s contagious, and it’s going to spread fast. They’re likely contagious one or two days without symptoms, and then three with. If there are only a thousand people in this county with it right now, you’ll be able to count yourself lucky. We need to control it, and fast. I apologize for being so brusque, but there’s no time to delay. First thing, we need your help in getting some bodies tested. I’ve emailed you a list of names of people who died of pneumonia recently. It should be time-stamped about one-fifteen or so. Did you get it?”
It took a few minutes for Alverez to catch up, but Glenn kept hammering home how serious their situation was, and by the end of the phone call, he thought the local man was convinced and getting up to speed. “We’ll have a presentation here tonight. Please let me know except for the big hospital’s representatives, you, and our people, who else you think needs to come to that, okay?”
“Okay,” Alverez said. “What kind of death toll are you expecting?”
There was no reason to sugar-coat it. “Sixty percent. If we can somehow hold it to a thousand cases, only six hundred. If we let it spin out of control....”
“Only six hundred. Madre de dios. Should we be warning people?”
“Yes, but let us help you with that, if you would. It’s important to convey seriousness without inciting panic.”
“Can we be in time for the late TV news today?”
Glenn said, “Can your office be ready in time for that? Have a dedicated phone number, extra staff trained to field panicked calls working 24/7, have a method for indigent patients to get care?”
“I...I don’t know. I’ve never dealt with anything worse than an outbreak of salmonella.”
“Be thinking about that.”
“You’ll have to walk me through some of it. Like a phone line for people to call. I hadn’t even considered that.”
“It’s part of why we exist, to help you help the residents of the county keep themselves healthy.”
From then on, the phone didn’t stop ringing. At 5:30, he remembered about food, and he phoned a pizza place that did chicken too, and asked for a mess of food to be delivered, enough for a dozen people.
After ordering, he phoned his mother and left a message. The woman hardly lit at home for an hour before rushing off again to do some other thing. He told her machine that he loved her and warned her that there was a flu coming—a bad one. “Stock up on groceries, and don’t travel, please.” He knew it was useless to ask it of her. Only being handcuffed to the plumbing would keep his mother at home. “Definitely no travel out of town,” he amended. “And avoid big crowds.”
He caught his sister at home and told her the same thing.
“Are the kids at risk?” she asked.
“Very much so. When it arrives, I know they won’t want to be home, but keep them there anyway. They can play in the yard, but not with other children. And sis, do me a favor?”
“Of course.”
“Go to my condo, get my work uniform out—that’s the khaki one. Oh, and hell, the dress blues too, in case I have to be on local TV at some point. Overnight them, please.”
“Wow. You’ve never asked for that before.”
“I’ve never seen anything like this before. Not in the United States. I honest to God don’t think we’ll be able to stop it. And it’s a killer.”
Her voice sounded troubled as she said, “I’ll do that right now.”
The public health student was terribly disappointed when he phoned and told her he wouldn’t be needing her after all. He had to bite his tongue to keep from telling her what was coming, but that wasn’t his job, and starting rumors wasn’t a good idea.
Didn’t keep you from telling Mom and Sis, eh?
Yeah. But he was only human.
––––––––
HARPER WAS EARLY FOR the meeting and hooked her computer to the projector to test it. Nurse Ellis was there fifteen minutes early. She looked at the food that had just been delivered and said, “Don’t believe in plates?”
“Damn, I didn’t think.”
“There’s a dollar store just around the corner. I’ll be right back.” She was gone before he could hand her some cash.
She came back ten minutes later with two bags loaded with paper plates, plastic utensils, a real but cheaply-made knife, napkins, salt and pepper in cardboard shakers, two boxes of facial tissue, a giant container of antibacterial wipes, and a bottle of ibuprofen. He handed her two twenties, and she gave one back along with the receipt.
The meeting was with the three CDC people, the Director of Public Health, both hospitals’ infection control officers, the family doctor who treated the Washington family, and the superintendent of public schools. There was also someone Jose Alverez had brought along, a woman from the mayor’s office, Deena Simms.
Glenn wasn’t sure whether to be grateful for the thought or not. In any case, he apologized to her for not thinking of asking her directly, just after he apologized for not shaking her hand. “My only excuse for not contacting the mayor is that I’m only five hours into understanding what’s going on here.”
“What is going on here? Jose said an epidemic?”
“Yes. In fact, let’s sit down and get going, and I’ll be learning more from my ground troops right along with you.” He glanced up at Harper. “Ready?”
She nodded. Roy flipped off half the lights in the room and Harper began. “Doctors Stevens, Gillens, and I have been trying to find out the extent of the disease in Union County.”
Ms. Simms said, “I’m sorry, but I’m brand new to this. What disease?”
Harper said, “Influenza. This particular strain is H5N1 avian flu, something we call HPAI, for Highly Pathogenic Avian Influenza. There are two categories of avian flu: one that kills no more people than most other kinds of flu, and one that is terribly dangerous to humans. Until now, the only way you could get the dangerous sort was by being in Asia and coming into contact with an infected fowl.
“But now, two very bad things have happened at once. It’s here, in Trenton. And somehow, the virus has mutated enough so that it can move not just from animal to human, but apparently from person to person. Here’s what we know so far about the extent of its spread.” She started going through maps she had prepared.
Glenn was impressed. Her intelligence and organizational skills weren’t surprising him—those, he had anticipated. But she was also adept at explaining things in a way a non-expert should be able to follow.
“You can see a cluster here, in the neighborhood where one family lives. Four of those cases came via direct contact—people who lived with the first verified fatality. But there are other cases now in that neighborhood, suggesting it has been passed along at the corner market or something of the sort. Three of the family members attend a church regularly—two were there on Sunday, probably contagious during the service, and I suspect we’ll see infection coming from that point of contact too.” She looked at Glenn. “I contacted the pastor, and he says there’s a good deal of hugging, handshaking, and so on during services, and that church attendance was high.”
“Tell me why that matters.” Ms. Simms again.
Harper said, “Flu spreads mainly through droplets. I sneeze or cough on you, or I speak and emit a fine mist of saliva, and now the flu virus is on you. If you move it from there to your nose, mouth, or eyes, you will likely get the flu. People touch their faces a lot, as perhaps you’ve heard. If you’re on the low end, you do it four times an hour. On the high end, a hundred times. That’s a lot of chances to move the flu virus into your body—or if you have it, onto someone else’s body.”
“Mainly through droplets, you say. How else?”
“Aerosols. It can, in effect, stay in the air after saliva has evaporated. Probably it won’t move far in such a case. Two meters. Six feet. But there are a lot of people who get closer than six feet to you on a typical day, Ms. Simms. If you monitor yourself and count those numbers tomorrow, you’ll doubtless be shocked how many.” She waited for the woman to say more, but she didn’t.
“That was the map of the known cases, residences only. Here’s the map of the residences of the suspected cases, which we’re still working to confirm.” She flipped to a map with many more dots. “And here’s a map derived from known cases, places I can either verify they’ve been or guess at—like the nearest large grocery store for each patient.” This next map of Trenton was a mass of black dots.
“The virus is—or has been—everywhere you see a dot. It’s out there. On a door handle. On money passed to a clerk. In the air after someone sneezed.”
Alverez said, “Everywhere, in other words.”
Harper gave him a sharp nod. “Everywhere.”
She ran through figures next. “Confirmed influenza deaths as of four-thirty this afternoon, four.”
“Five,” Ellis said. “I got a text when I was at the dollar store.”
“Five. Suspected or possible deaths are up to eighteen. ICU patients as of four-thirty today, thirty-two. Hospital admissions, again as of over two hours ago now, two hundred eleven. Doctor or clinic visits, over four hundred.” She looked at Glenn. “Yesterday it was only what?”
“Two dozen cases, but we hadn’t yet begun to dig for others.”
“Still,” said Harper, “the increase from twenty-odd to six hundred plus isn’t just from finding more cases. The disease is spreading. And all of these people, more than six hundred, have already infected others—at a guess, six thousand have been exposed. And those people will infect more. And so on.”
“So what do we do?” Simms again.
“I’ll let Dr. Stevens answer those questions. Any others for me about the numbers?”
Glenn said, standing up, “Do you know the source yet? Do you have an index patient?” He moved to Harper’s side.
She said, “We must still be missing the index patient. I’ll keep looking. We all will.”
“Why does that matter? Shouldn’t we be putting our resources into fixing it?” Ms. Simms said.
“We need to know the vector,” Glenn told her. “How the virus moves from animal host to human, if it is indeed doing that. While yes, you’re right, we’ll be putting most of our resources into preventing more infections moving from person to person and treating those who are already infected, we also need to warn people away from any animal that’s carrying it.”
“What animal is that?”
“Beyond its likely being a bird, we don’t know. But even ‘a bird’ is not a certainty. A mammalian vector is possible.”
The next part of the meeting dealt with hospital requirements—how much of the various antivirals to have on hand, staffing needs, and so on.
“What about vaccines?” Alverez asked. “Shouldn’t we be out there vaccinating everyone right now?”
Glenn said, “There is an H5N1 vaccine for the non-fatal form of the disease. We’re one of only three nations on earth who has it. But we don’t know that it would work in this case, and there are very few doses of it.”
“Why wouldn’t it work?” Ms. Simms again.
“It’s for specific strains. There has been, so far, no strain of highly pathogenic that jumps from human to human, not anywhere on the planet. So there’s every possibility that the vaccine on hand won’t work because this strain is likely to be different, different enough that it’s moving from person to person.”
“How long until you can make a new vaccine?”
“We don’t even know the genetic structure of this strain yet. When we do, it will take months to gear up vaccine production.”
“Can’t you declare an emergency or something? Push it faster?”
“There’s one production system that gets us a vaccine in a month, but only one lab is doing that right now, and only twelve thousand doses, if I recall correctly, can be produced per month there. The traditional way of making vaccine that uses hens’ eggs, that takes six months. You have to infect the egg, wait for the embryo to develop immunity, and in effect steal it from them once that happens. This happens at the rate it happens in nature and can’t be rushed. But there are many labs that can do that.”
Alverez said, “What sort of stockpiles do you have of the H5N1 vaccine?”
“Two million.”
He breathed a sigh of relief.
“For the whole country. Of hundreds of millions of people.” Glenn held a hand up before Alverez could say more. “In a pandemic, it’s crucial to keep the healthcare system functioning. We have twelve million healthcare workers in the U.S. Four million are nurses, doing hands-on care. And there are not nearly that many doses of vaccine. And the vaccine on hand may well not work anyway, but I’ll tell you right upfront, that’s where it’s going to go first—to the nurses and doctors, lab techs, orderlies, and morgue attendants at your hospitals and urgent care clinics, and the ones elsewhere in New Jersey and Pennsylvania, and wherever else this pops up. So if we’re lucky—and it’d be damned lucky—and the vaccine on hand works on this strain, the healthcare workers will be alive to treat the hundreds of cases that are on their way.” He said, “I’m sorry. I know all of you have family you’d like to get the vaccine, but that’s just not going to happen. There’s a procedure for distributing vaccine during an epidemic, and it will be followed.”
“How the hell do I spin that?” Ms. Simms said.
“My advice? Don’t mention it. Stick with the fact that it’s a new strain and no vaccine for it exists yet. That’s actually the truth. When we develop the new, targeted vaccine in large amounts, from the egg manufacturing process, the first doses to the public will go to children.”
“And what, we expect the healthcare workers not to mention they got a shot first? Not to demand it for their children too?”
“Yes,” Glenn said, making eye contact with Ellis. He didn’t envy her the job of making that go smoothly. “Remembering all the while as we administer the vaccine on hand, it probably won’t be effective anyway. It’s just a...a three-point shot at the buzzer from full court. Probably, we won’t win on that. But we have to try.”
“Keerist,” Alverez said. “Man. I have kids.”
“I know. I’m sorry. And that brings me to what we’re going to tell people to do.” He looked at the faces, all of them worried, all attentive. “First thing, Superintendent, do you have any questions about what we’ve seen here?” He was impressed that the man had wanted to come to learn more.
“No, sir, I do not. I understand now, and thank you for inviting me.”
“What’s the status of schools closing?”
He checked a wristwatch. “There’s nothing we can do about tomorrow. If we didn’t run the buses, there’d be stranded kids whose parents are already at work. Even if we can get the word out tonight on the late local news and our website, that won’t take care of all of it because the word won’t reach everyone. Some children will still show up. If they are in cars, we can have security—or city police if we can get them to help?” He looked at Ms. Simms, who nodded. “Turn the ones in cars around and send them back home. By noon tomorrow, I think we can be down to only twenty percent of students on site. And tomorrow at 3:30 will be the end of the school year. I promise you that.”
“Thank you,” Glenn said, and it was heartfelt.
Ms. Simms said, “So parents will have to stay home from work, and there will be severe economic impact.”
“There will be,” he said. “Get yourself used to that idea.” Also, dead people don’t pay taxes. “If the CFR—the death rate—we know from Asia holds, Trenton could lose half of its citizens in the next year. Real estate prices will tank, for no one will need to buy houses. It will take years—and possibly decades—to recover. And it isn’t as if there’s an antiviral force field around Trenton. We’re trying for containment, and we’ll have a big staff here tomorrow working toward that goal along with Mr. Alverez’s people, but I have to tell you, I’m not optimistic. In six months, the disease will probably be all over the country.”
“Isn’t that your job, to stop that from happening?” she said.
“It is. But no matter what we do, I doubt we can stop it. You are at the leading edge of an epidemic, and you have a chance to show the country how to handle it well.” He held eye contact with her. “Think of Giuliani after 9/11. Your mayor can show himself to have that sort of leadership.”
“Does the governor know yet?” she said.
“No, nor the President, as far as I know. The Director of the CDC will be giving them a call tomorrow morning first thing, once we’ve given our bosses the information you just saw. You’re the first to see it, before them, and the most important, because you’re here, on the ground, in the midst of it.” He was growing tired of pumping the woman up, but that’s what you had to do with political types. This was true if you were in Zaire, or in the mountains of Papua New Guinea working with a headman of a village, and it was true if you were in New Jersey. People are people. They’re panicked and useless, or they’re selfless and hard-working, or they’re self-serving and calculating. You find some of each everywhere you go.
And you need them all on your side.
Glenn said, “So, on to the ideal response. The ideal response would be, everybody stays home but healthcare workers. Of course, we all know that will not happen. Most people live paycheck to paycheck, and it’s no different here. But for people who don’t work, or those who can afford to take a vacation, or those who might telecommute to work, they should stock up on groceries and prepare to hunker down for a month, until this thing burns its way through Trenton. Next, masks.” He looked to Roy, who pulled a stack of masks from his shopping bag from the medical supply store.
Glenn pulled one out and held it up. “Anyone who feels sick, in the least—just a tickle in the throat or general weakness will qualify—anyone who has been exposed to a sick family member should be wearing one of these whenever they go out. Anyone who lives with an immunocompromised person should be wearing one of these at home too.” He passed the mask to Ms. Simms.
“Realistically, we’d be lucky to get twenty percent compliance with all those recommendations, but we have to try anyway. If we got a hundred percent, we’d have an excellent chance of stopping it here.”
“We need the press on our side,” Alverez said. “Someone needs to do the morning shows, the news. We need a press team.”
“We have people at CDC coming who are experts on that, and they’ll help you.”
“When? When can I talk to them?”
“Tomorrow morning, first thing. Show up here at nine, and I’ll set you up with someone. You too, Ms. Simms, if you want.”
Alverez said, “What should we say today? I still think someone should be on the news tonight saying that there’s a bad flu going around.”
“Good, say that. Try to get people to come in and see a doctor if they feel sick. At the least they should stay home from work. If they must go out when they’re ill, wear masks.” He knew it wouldn’t do much good, but Alverez was right—they should say something today to the public.
Simms said, “Can you help them? The sick ones?”
“We honestly don’t know.” He looked at Ellis. “How’s Ms. White doing on the oseltamivir?”
“Not well.”
“Damn,” he said. “Okay, so we’ve tried two antivirals and aren’t getting much of an effect. There’s a third one approved for flu. If that doesn’t work either, we’re down to simple interventions.”
“Like?” Ms. Simms said.
Ellis bailed him out. “Oxygen. We intubate the worst cases. And the survivors—I assume there’s something to be done when you have a few?” She looked to Glenn.
“We’ll be taking blood from the willing survivors, definitely.” He turned again to Ms. Simms. “It might help us develop a treatment that augments a person’s own immune system. In effect, we might be able to borrow the more efficient immune response from those who fought off the flu successfully. But that takes time too.”
Alverez said, “How do we coordinate all this? It could be a mess. I mean, if there’s a run on masks at the local pharmacies, they should know that’s coming so they can order more now, right?”
“Yes,” he said. “The CDC has experts in various fields, and we’ll be descending on pharmacies and doctors’ offices and clinics in greater numbers tomorrow to help with all of this. But it’ll be a challenge. We all need to work well together. Mr. Alverez is really in charge here, and we’re only here to assist him.”
“But I don’t know how to be in charge of something this big,” Alverez said. “I hate to admit it, but I can’t lie to you.”
“And that’s why we exist, to help get you up to speed. From the numbers Dr. Bail showed you on the screen, I think we’re going to be in uncharted territory. Look, we’ll all make mistakes. We’ll guess wrong. There hasn’t been a big pandemic of flu in the country since the late 1950s. And, I hate to say it, but I think citizens were more willing to trust the medical community then, more willing to follow instructions. This coming month will be a challenge. Of that, have no doubt.”
The meeting went on for another forty minutes. By the end, people were digging into the cold chicken and pizza. Glenn could use some himself. As the locals began to leave, he had to once again remind them to break the hand-shaking habit. It was hard to. His arm kept rising of its own accord too.
It was just a taste of the difficulties everyone would have modifying their behavior when told to. Habits die hard.
People can die hard too. Drowning in bed from the flu filling your lungs is a terrible way to go.
