To say that the Lunar New Year, Tet Nguyen Dan, is an all-consuming holiday in Vietnam is something of an understatement. Imagine Christmas, New Year and America's Thanksgiving rolled into one and you begin to grasp the scale of the Tet festival and the centrality to it of food -- especially poultry. During the run-up to Tet, millions of chickens and ducks change hands as Vietnamese families stock up for the coming festivities. The celebrations begin around 23 December with the Feast of the Kitchen Gods, or Le Tao Quan, and continue right into February with an orgy of culinary delights, at which a duck or chicken, either roasted or live and awaiting slaughter, is never far from the table.
In Hanoi, and other parts of northern Vietnam, one of the most popular dishes of all is duck's blood pudding -- a hearty soup made from simmered duck innards and raw duck blood. Traditionally eaten on the eve of Tet -- which this year fell on Feb. 9 -- it is meant to mark the passage from the old to the new. On New Year's Day, and for two weeks after Tet, it is considered bad luck to eat duck. That's when the chickens make their culinary appearance. From the point of the avian flu virus, H5N1, Tet is an accident waiting to happen.
On the morning of Feb. 8, Nguyen Sy Tuan, a 21-year-old man from Thai Binh, a province 160km southeast of Hanoi, visited a neighbor who, like millions of rural Vietnamese, raises chickens and ducks in his yard, and bought some duck for the pot. With the help of his mother he slaughtered the fowl in the kitchen, then poured the duck's blood into a bowl and added vinegar to stop it congealing. He then set about preparing the broth.
ILLUSTRATION: MOUNTAIN PEOPLE
Within an hour or so the pudding was ready and he, his mother, his father and his two sisters, aged 14 and 27, sat down to consume several bowls. Five days later, on Feb. 13, Sy Tuan began to feel unwell. He had a headache and a slight fever. Thinking he had common or garden flu, his family dosed him with aspirin and tucked him up in bed. But two days later, on Feb. 15, his fever shot up to 40 ℃. On Feb. 20, he started coughing and complaining of chest pains.
By the time Sy Tuan was transferred from the local Thai Binh hospital to Hanoi's Institute for Clinical Research into Tropical Diseases two days later, the damage had been done. According to Dr Nguyen Tuong Van, the director of the hospital's emergency ward, it was like looking at a patient "in the advanced stages of HIV."
"When I examined his chest X-ray there were white shadows everywhere," she told me in her consulting office in Hanoi, on a brief respite from her rounds. "I had no choice but to intubate and put him on a respirator."
The shadows were a sure sign that the infection had already invaded Sy Tuan's respiratory tract and begun eating away at his lung tissue. That evening, mindful of scientists' warnings that H5N1 was on the brink of mutating into a virus that could transmit itself between humans, I donned a surgical gown and mask and went to see Sy Tuan for myself.
I found him in a room off a corridor marked "quarantine." A plastic hose led from his mouth to a respirator beside his bed. Although the machine was the only thing keeping him alive it was doing little to ease his breathing. His knees were doubled up in pain and beneath the blanket I could see that his heart was pounding furiously.
To my surprise, Sy Tuan was not alone. In the bed next to him, watching with wide black eyes, was his 14-year-old sister. Two days after her brother had been rushed to hospital she'd also started running a high fever and had to be admitted. Like her brother she would also test positive for H5N1.
"We'd heard about the bird flu, but we never imagined it would infect our family," their older sister, Nguyen Nhung Ngoan, told me in the corridor that evening. 'We are really scared because we know it is a very serious disease.'
Then, grasping her own mask closer to her mouth for protection, she added: "All we can do is pray they will recover."
Since the present strain of H5N1 emerged in Vietnam in late 2003, Van and her counterparts at the tropical diseases institute in Ho Chi Minh City have treated 35 people for bird flu and recorded 18 fatalities -- 13 of them since December. Including Thailand, the next- worst infected country, and Cambodia -- which reported its first death last month -- there have been 46 deaths in southeast Asia since the epidemic began. Those deaths represent 70 percent of all known avian-flu infections. In contrast, SARS, the corona virus which struck Hong Kong and Vietnam in 2002, had a mortality rate of just 10 percent. No wonder scientists are spooked.
"We think it is only a matter of time before H5N1 or a related strain of the virus becomes infectious between humans," John Oxford, a virologist at the Queen Mary and Westfield School of medicine in east London, had warned me before I embarked for Vietnam.
"When that happens it will be too late to do anything about it, which is why we have to prepare now. Forget al-Qaeda, the biggest terrorist threat we face today is Mother Nature," he said.
Oxford isn't the only scientist who fears a viral meltdown. At a conference of international bird-flu experts in Ho Chi Minh City a few days later,
I heard Dr. Shigeru Omi, the World Health Organization's (WHO) Western Pacific regional director, warn that the world was "now in the gravest possible danger of a pandemic."
At that point, Vietnam had not recorded a new H5N1 case for three weeks and the Vietnamese government was hopeful that its stringent anti-poultry measures were at last beginning to pay dividends. Since late 2003, agriculture officials have culled 44 million infected chickens, a sixth of the country's poultry population. And following the most recent outbreaks this winter, the government ordered a further 800,000 chickens killed, and banned the sale of poultry at Ho Chi Minh's unhygienic wet markets.
But for all that these measures had restored confidence in farmed chickens, vets and public health experts attending the conference warned that Vietnam now faced another challenge: the chickens and ducks which roam freely in people's backyards and paddy fields. In particular, Omi said, the Vietnamese should beware of ducks that, according to the latest evidence, were playing a "silent role" in the transmission of the disease, harboring the virus and excreting it in their faeces for up to 17 days without showing any obvious signs of illness.
"The public health implications of this are very serious," Omi warned. "How can people avoid exposure to the virus when they don't know which ducks are infected and which are not?"
The ducks are not the only worry, of course. The even bigger unknown is the virus itself. The problem is no one knows how fast and in what direction it is mutating. Avian flu is a type A orthomyxovirus (there are also B and C types, but though they can cause illness they are rarely fatal in humans). Like every influenza virus, H5N1 has hundreds of microscopic spikes protruding from its surface. Most consist of a viral protein called hemagglutinin, which has the unique ability to latch onto respiratory cells and invade them. The other spikes consist of enzymes, neuraminidase, which help the virus spread. It is from the initials of these two proteins -- H and N -- that the avian flu virus gets its name.
What makes H5N1 and other influenza viruses so dangerous is that they are shape-shifters, possessing the rare ability to swap proteins with other influenza viruses to create new influenza viruses. The reason is that, unlike animal cells, which are coded by DNA, the influenza virus consists of RNA and does not possess an accurate proofreading mechanism to correct its genetic mistakes.
Oxford, who keeps an orange, football-sized scale model of the virus on his desk, likens the RNA to coiled springs and the hemagglutinin to blue prongs. During replication, when the virus invades and colonizes human cells, the RNA makes errors, resulting in genetic mutations to the prongs.
Such mutations are known as "antigenic drift." The reason they are dangerous is that they trigger small changes to the hemagglutinin, enabling the prongs to stick better to human cells and evade the antibodies produced by the immune system.
In addition, type A viruses such as H5N1 can also "swap" or re-assort genetic material with other viruses. This process, known as "antigenic shift," occurs when animal strains mix with human strains, producing viruses to which no animal or human has immunity.
"The problem is, one chicken can contain hundreds of thousands of strains of H5N1," Oxford explained.
"Let's say there are a billion chickens in Asia and 10 percent are infected -- that's a vast population of viruses, more than the entire human population of the planet. Now let's further suppose some of these strains have mutated so they can latch not only on to a chicken but on to you or me, but they cannot do it very efficiently. That's the position we appear to be in. If a child catches the virus from a chicken they may transmit it to their mother, but the mother won't be able to go out and infect the grocer," he said.
Armageddon only comes at the next stage, when the virus learns to pass efficiently between humans. By the time that happens, Oxford said, "it's already too late."
He examines his orange ball, pausing to consider the simplicity of the virus and its awesome destructive power.
"At the moment it's a slow greyhound of a virus. It's when it develops into a normal greyhound that we're in for it," he said.
One man who may be able to offer us clues to the virus's mutability is Nguyen Thanh Hung. A 42-year-old cement salesman, with a boyish face and thick black hair, Hung lives on his own in a small apartment approached through a metal grille off a maze-like backstreet in Hanoi. Slight of build, Hung likes nothing better than to tend to his bonsai trees, play his guitar and jog 10km every day.
"It's hard going, but I'm trying to train my lungs," he explained, when I visited him at his apartment on a winter's evening in late February.
Hung has good reason to persevere with his punishing regime. In December his elder brother contracted bird flu and died. Then, four weeks before Tet, Hung also fell ill with H5N1. If it wasn't for his extraordinary physical fitness he might not be here to speak about it today.
Hung's ordeal began on Dec. 24 last year, when he boarded a bus to Thai Binh to attend the funeral of his elder brother's infant son, who had tragically drowned in a fishpond near his home. To mark the occasion, Hung's brother had bought a live duck in the village market and, with the help of his younger brother, slaughtered and cleaned it before Hung arrived. He then prepared the local delicacy -- duck's blood pudding.
On the day of the funeral -- Dec. 25 -- all three men sat down to eat the broth, but Hung and his younger brother found it too salty and hardly touched it. After lunch, Hung took the bus back to Hanoi.
Two days later, complaining of a headache, his brother took to bed. At first, the family put his illness down to grief over the loss of his son, but by Dec. 31 he was running a high fever and coughing.
The family took him to the local Thai Binh hospital, from where he was transferred to Hanoi's Tropical Diseases Institute. There he was seen by Dr. Van, the same physician who has been treating the latest Thai Binh cases. According to Van, she and her colleagues did not initially suspect the elder brother had bird flu, so she gave him a range of drugs to relieve his symptoms. But a few days later his breathing became laboured and she had to intubate and put him on a respirator.
For five days, Hung and other members of the family sat vigil at his bedside.
"He kept struggling to remove the monitor and I had to keep leaning forward to put the mask back on him. I was about 30cm from his face," Hung told me.
Was he wearing a mask himself? "Sometimes, but I found it uncomfortable, so I kept taking it off," he said.
On Jan. 9, Hung's brother died, the disease having spread from his lungs to his kidneys and liver. The following day, back in Thai Binh for his brother's funeral, Hung also began to feel unwell. On his return to Hanoi, now running a high fever, he made an appointment at another hospital, where his wife worked as a nurse. There an X-ray showed a small white shadow on his lung, which was misdiagnosed as tuberculosis.
His fever soaring, Hung decided to check himself into the Tropical Diseases Institute. There he was given five different medications, although not Tamiflu, a costly anti-viral drug used to treat known cases of H5N1 (as yet, there is no vaccine).
This is the first part of a two-part article. Part 2 will appear tomorrow.
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