September 20th, 2005
H5N1 - Killer Flu
Filmmaker Notes: Producer Micah Fink

Producer Micah Fink (right) with director Steven Silver.

“What are you going to do to protect yourself?” Amanda asked me one warm evening in early May, as we were putting Lucas, our 14-month-old son, to bed.

It was a good question.

I had just bought a round trip ticket to Vietnam, which is today the epicenter of the new avian influenza outbreak and accounts for the highest number of human cases in the world.

Avian influenza, also know as the bird flu, is caused by the H5N1 virus which is a parasite-like virus native to wild water birds. In the last six years this virus has undergone an evolutionary mutation that allows it to infect and kill human beings. This caught my attention. The virus was spreading very quickly across East Asia and was reported to have killed almost 70 percent of its victims, most of whom were children younger than 10.

One day very soon, the international flu experts were warning, this killer virus might arrive in Europe and America. It seemed like a good subject for a Wide Angle film.

I had already visited Dr. Kevin Cahill, a tropical disease specialist who has prepared me for a number of overseas trips. Hearing my plans to spend two months in Vietnam reporting on avian flu, he began with the basics: jabs in the arm for Japanese encephalitis, hepatitis B and rabies. Shots for cholera, typhoid and polio weren’t necessary since I had them just two years earlier and they were still effective. Then Dr. Cahill took out his prescription pad. He wrote scripts for the usual suspects: anti-malaria pills, a standard broad-spectrum antibiotic, and Imodium — the traveler’s friend. He also added two new names: Tamiflu, an antiviral in pill form, and Relenza, an antiviral powder that must be inhaled. Both may be effective against avian influenza if taken within two days of becoming symptomatic, but no one really knows. After all, most people hospitalized with bird flu had died — and some of them had been treated with antivirals.

“What kind of symptoms?” I asked.

“If you begin to sneeze or feel sick after you’ve been exposed to the virus,” he said, “take the pills and go right to a hospital.”

Renata Simone, a producer who made a film about the SARS outbreak in Hong Kong in 2003, suggested a basic epidemic survival kit. A box of N-95 facemasks to filter out air born viruses. Latex gloves to wear when visiting patients in hospitals. And Purell, an alcohol based anti-bacterial scrub, which can be used when water isn’t available for washing. Dr. Danny Weinstock, a veterinary researcher, added rubber boots to the list for use when visiting poultry farms and markets, because the virus is often present in the excrement of poultry. He also suggested I practice not touching my face with my hands. “Hands are dirty,” he said, “face is clean.” This, he explained, is the mantra of veterinary pathologists.

I arrived in Hanoi on May 8th, and within a few days found myself shooting with a local fixer named Pham Ba Hung at the infectious disease unit at Bach Mai Hospital’s Institute for Tropical Diseases. We had come to interview Nguyen Sy Tuan, a 21-year old man who was then Vietnam’s last bird flu victim still in a hospital. The epidemic had faded in March and no new cases had been reported in nearly two months.

I found it impossible not to touch my face in the hospital but decided to mimic the behavior of the Vietnamese doctors on the unit. They’ve been dealing with the virus for sixteen months, I reasoned, and should know what’s safe.

Sy Tuan had suffered a nearly fatal infection causing multiple organ failure and had spent 82 days in the hospital. When I met him, he looked like a concentration camp survivor, but he was no longer infected with the virus and just about to be sent home. In the same room, two beds over, was a slender middle-aged man who was wearing a facemask and coughing up a storm. And when Dr. Van, the head of bird flu treatment at the hospital, took off her mask to speak with Sy Tuan, Hung and I removed ours. It was 100 degrees and we found it hard to speak through the thick paper masks. We spent half an hour shooting a brief interview and then shook hands with everyone in the room before we left, feeling pleased with our work.

Three days later, the Vietnamese national news reported that a new bird flu case had been confirmed at Bach Mai Hospital. It was the man sharing Sy Tuan’s room. Hung and I were nervous but decided not to take the drugs. After all, we both felt fine. The rest of my two-week scouting trip went well. I visited a number of other hospitals and met many of the doctors and researchers working on the epidemic. The general feeling was that the virus was being transmitted to people who ate sick chickens and ducks, but strangely, a number of new cases were being reported each week, which could not be tied to any outbreaks in poultry. Another mystery. Could this be some form of human-to-human transmission?

I flew back from Hanoi via Seoul, Korea, to Washington, DC, for a meeting and checked into a hotel. That night the air-conditioning was blasting and when I woke, I felt congested. The incubation period for avian flu is believed to be between 6 and 15 days, roughly, and I was suddenly glad that I hadn’t gone straight home to my family. I went to my meetings that day, but sat in a corner and didn’t shake any hands. By that evening, I felt worse. I decided to call Dr. Cahill’s emergency number. I got though almost immediately and he said if I was very concerned I should go to a local hospital emergency room and have an X-ray taken, which might or might not show if the virus was infecting my lungs. But he suggested that I wait until morning to see if I felt any better. “It might just be traveler’s symptoms,” he said. He also recommended I not take the antiviral drugs just yet, because “it will just confuse matters if you do come in for treatment.” It turned out to be good advice. I had a restless night, but when I woke near dawn, I felt better and my symptoms soon disappeared.

Two weeks later, I was back in Hanoi with Steven Silver, a Canadian director, Petra Graf, a British camerawoman, and Andy Hoare, our soundman, also from England. We used the same basic precautions. We carried stockpiles of Relenza and Tamiflu (which Steven decided to take preventatively), masks, latex gloves, high rubber boots and lots of small bottles of Purell. When filming in the infectious disease wards in hospitals, we also wore paper hospital gowns and rubber goggles, and I warned everyone not to take off their masks for any reason. New human cases of bird flu were now being regularly reported around the country.

We revisited the hospitals and patients I had met on my first trip. We spent three weeks in country; traveling from the Red River Delta in the north to the Mekong Delta in the south and shooting on chicken farms, poultry markets, and slaughterhouses. Our final day was spent back at Bach Mai Hospital in Hanoi where Sy Tuan had returned for a checkup with Dr. Van. After filming their interaction, Dr. Van told us she now had four confirmed cases of H5N1 and seven suspected cases on her ward.

All in all, our shoot went very well. There was only one small issue.

On Friday, June 24th, our last day of shooting, Petra Graf, our fabulous camerawoman, began to feel ill. At first it was just the sniffles and a little congestion and she insisted she was well enough to fly home the next day. After all, we had been moving between air-conditioned offices and 105-degree heat in the Mekong Delta and a slight cold seemed a reasonable reaction after completing three weeks of hard shooting.

But by the time she arrived back home in London, Petra had developed a serious respiratory infection and was coughing and feeling miserable. Now Petra is a very tough person and she wanted to just lie low at home, but we strongly recommended that she consult her doctor. Which she did. And after she explained where she had been and what she had been doing, Petra’s doctor called the public health service for advice and then told her to go straight home and wait for further instructions. A few hours later her doorbell rang. She discovered two medics wearing full biohazard space suits on her stoop, as well as an ambulance, lights flashing, in the street. Ordered into a biohazard suit, she was driven to a special entrance of the Royal Free Hospital in London. A crowd of doctors was waiting.

Petra was wheeled into a special containment unit, where she spent the next three days in isolation, sleeping under disposable paper sheets, wearing disposable paper gowns, and tended by an endless stream of anxious doctors and nurses in biohazard gear. The Minister of Health was being briefed regularly, she was informed. “I wasn’t worried the first day,” she later told me. “But after the second day, with everyone so careful and anxious, it began to occur to me that I might really be infected with the virus — and then I got scared.” After three rounds of testing came up negative, she was allowed to return home to recover. Her housemate, however, was ordered to take Tamiflu, just as a precaution. Petra was the first case to trigger the British Public Health Service’s bird flu emergency response system.

I don’t think the response was overdone. England, like many countries around the world, is now on high alert for human cases of H5N1. Given the high volume of international travel, a newly infectious virus might arrive in Europe or the United States within days of appearing in Asia. This is exactly what happened with SARS in February 2003, infecting some 800 people in 80 countries around the world in just a few weeks.

The last time a major avian flu virus became capable of passing easily among people was in 1918, and it caused some 50 million deaths around the world. The World Health Organization is warning that the world may be again on the verge of something terrifyingly similar — and after seeing what the avian flu has done to its victims in Vietnam, I can only hope that the world’s governments will prepare themselves as best they can. “It is not a matter of if an epidemic will happen,” Hans Troedsson, the World Health Organization’s representative in Hanoi told us just before we left Vietnam. “It is a matter of when.”

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