Or maybe they were floating through the ductwork at her office, and when she opened her mouth to yawn—
Or did it happen at the gym, as she furiously pumped the elliptical machine and wiped the sweat from her cheek—
Photo by Kendrick Brinson
Influenza is a careless invader, with spikes on its shell like a medieval mace. It hijacks your cells for reproduction and copies itself with blinding speed. The copies are unpredictable. Sometimes they don’t work. But sometimes they work even better than they should. Influenza has a rare talent for profiting from its own production errors.
Maybe your body was immune to the old influenza. It knew what to expect. Its defenses were in place. But one production error can change everything. The body’s defenders are caught by surprise. The battle becomes a massacre.
Ninety-two years ago, at the height of World War I, this exact thing happened. A new kind of flu virus emerged, and humans had no natural defense. It was one of the two deadliest pandemics of all time, with numbers comparable to the Black Death. The average flu strain kills one of every 1,000 people it infects. The Great Influenza of 1918 killed one in forty.
The H5N1 avian flu kills one out of two. You may have heard of it. It was all over the news from 2005 to 2008. It didn’t kill many humans, because it had trouble spreading from one person to the next, but scientists were afraid it might learn how any day. In fact, they’re still worried. No one knows when this virus will stumble upon the solution.
Now for the good news. We are not helpless. In the seventy years since we spied our first virus through an electron microscope, we have dramatically improved our defenses. Smallpox once scarred and blinded untold millions; by 1980 it had been wiped off the face of the earth. Polio used to cripple children all over the world and leave them gasping for breath inside massive iron lungs; today it circulates widely in just seven countries. Seventy years ago malaria left a trail of fever and death across the Southeast. Atlanta was the heart of malaria country, which is why the federal government set up a base here for the disease’s eradication. Workers coated almost 5 million houses with a pesticide called DDT, killing the mosquitoes that spread the parasite. By 1949 malaria was nearly vanquished in the United States, but the agency charged with its removal stayed in Atlanta and took up the fight against other diseases. Today that agency is called the Centers for Disease Control and Prevention, and it is the nationwide headquarters in our war with influenza. Somewhere on its campus off Clifton Road, six miles northeast of Downtown, in a locked freezer guarded with a retinal scanner, there is a resurrected copy of the Great Influenza virus that killed as many as 100 million people. Scientists are studying it for clues to the next pandemic.
Everyone thought the next pandemic would come from Asia, in the form of the H5N1 avian flu. The CDC even held war games under a fictional scenario in which a college student caught the virus in Indonesia and shared it with his swim team at Georgetown University. Almost 800 people took part in the practice runs, trying to simulate how the government would respond to this viral invasion. It was probably useful from an administrative standpoint. But here’s the problem: The 280 workers of the Influenza Division have an impossible mandate. They are told to predict the next move of a virus that makes its living by defying predictions. And so it was both stunning and unsurprising when the next pandemic turned out to be not bird flu from Asia but swine flu from Mexico.
It was April 2009, and the objectives in the Influenza Division were clear. Capture and interrogate the invaders. Break their code. Equip other laboratories around the world to do the same. Hurry. If a new virus was in production, the blueprints could be stolen. The defenders could be prepared for the invasion’s next wave.
Thousands of lives could be saved.
2. The Golden Boy
Even if you knew John Behnken well—and if so, you probably loved him—you may have known nothing about the two small holes in his skull, or the white plastic tube that ran through them, hidden under his skin, from his brain to his abdominal cavity. John almost never talked about it. When asked how he was doing, he would say, “I’m aces,” which meant just fine. And he was. He had an IQ close to 150 and a mechanical engineering degree from Georgia Tech. He had an engaging job and an electric guitar. He had a dozen friends who would bleed for him, or at least take him drinking in Vegas, and a wife who would let him ride motorcycles and occasionally call her Chief, the same thing he called everyone else.
Courtesy of Angela Behnken
Or the time John had to leave Georgia Tech and go home to Alaska because he couldn’t afford tuition anymore. As it happened, his high school sweetheart had a great-uncle with some money. And the great-uncle liked John. And the great-uncle once had his own college education financed by a generous benefactor who asked nothing in return except this: If you succeed financially, maybe someday you could find some deserving youngster and do the same thing. John was delighted, but he had the presence of mind to ask an important question. What if we break up? The great-uncle said this has nothing to do with that. He even wrote it into the contract. John was serious enough about his girlfriend to go looking at engagement rings. But finally they did break up, and the great-uncle kept his promise. The money kept coming. And John found another girl, Angela, who he thought was out of his league, and he took her to Metalsome Mondays karaoke at 10 High in Virginia-Highland and sang her “Interstate Love Song” by the Stone Temple Pilots, which was a big deal because he hardly ever sang. The Golden Boy had more talents than even his friends realized.
It seemed as if he’d won the genetic lottery. By age three he could read the hands of an old-fashioned clock. A few years later his father took him fishing in an aluminum boat on the Cook Inlet, and young John cast his own line and set his own hook and reeled in something heavy. “Daddy,” he said, “I think you better take this one.” At age six John had caught a forty-pound halibut.
And if his Mensa membership card was impressive, his emotional intelligence stood out even more. “He could read people,” his mother said, “even as a child, like nobody else I ever knew.” When you talked he really listened, instead of waiting for his turn, and when he asked how you were doing he actually wanted to know, and if you were stressed over a final he would buy you breakfast, and if you wanted to drink he would be designated driver, and if you were disappointed about being left out of his wedding party he would buy you the groomsman’s watch for Christmas, and if you were about to pop the question to your girlfriend he would help you find a great deal on a diamond by analyzing the unit price in hundredth-carat increments, just as he did with the ring he gave Angela.
John’s gifts even extended to storytelling, and although he kept the story of the white plastic tube to himself, he wrote short fiction for his own amusement and spun yarns to entertain his friends. They loved hearing about Alaska. They actually called him Alaska, more often than Golden Boy, and played along as he told of killing a polar bear with his bare hands. There were other things he planned to accomplish before he died. He wanted to receive an oversized novelty check like the ones from Publishers Clearing House. He wanted to jump in a river with a knife between his teeth.
The grand finale would come after his death. He told everyone he wanted a Viking funeral. He added fresh details with each new telling. His body would be laid in an open boat, along with his sword and shield. His fellow warriors would push the boat out to sea. Then an archer would shoot the boat with a flaming arrow, and fire would consume everything.
When it came the scientists were ready, inasmuch as anyone can be ready for the appearance of several billion hostile creatures whose existence was previously unknown. The scientists fastened their lab coats, pulled on their gloves, and took up their battle stations. It was the third week of April 2009, and virus samples were coming in from California and Texas. Flu season should have been ending, but it was just beginning. At other labs they had tried to break the virus, but their tests all came back the same: unsubtypable, which is to say we don’t know what this is.
The scientists in Atlanta could find out. They had the right weapons, sharpened over years of chasing the avian flu. They had machines of unimaginable sophistication. Through tall panes of glass on the outer western corridor a red sun flared against the Downtown skyline, but the scientists paid no attention because they were in white rooms and long, sunless hallways lined with humming freezers that were crusted in white frost. The scientists moved from the clinical specimen room to the reagent setup room to the instrument room, carrying extraction worksheets. They placed tubes of clear liquid in whirling centrifuges and slurped up the liquid with tools that resembled turkey basters. They cut open RNA isolation kits with scissors and fitted them into extractors with barcode scanners and left them there for thirty-eight minutes, through cycles of lysis and bind and wash and elute, black liquid rising and falling and rising again. They subjected virus samples to the five-target real-time PCR assay, amplifying genetic material for closer inspection. What they found was a strange hybrid of a virus, with genes from bird flu and swine flu and human flu all shuffled into one package. No one could tell how dangerous it was. But they knew it was different enough from the seasonal flu to make the current vaccine useless.
This rapid evolution sets influenza apart from other viruses. The CDC recommends eleven separate vaccines for children under six, for immunity from such diseases as measles, tetanus, polio, and diphtheria. The flu vaccine is the only one you have to get every year to be reasonably sure it’s effective. Last year’s vaccine may do nothing against this year’s flu, because even the so-called “seasonal flu” is always changing. To make matters worse, vaccine production is a slow, laborious process that involves growing viruses in hen’s eggs. It can take six months or more.
Two months had already passed since the World Health Organization made its annual recommendation for the specific strains of influenza on which to base the next season’s vaccine. The new virus made that recommendation meaningless. A new six-month clock would have to begin ticking. And so, even though CDC scientists working day and night prepared a seed strain of the new virus for the private vaccine manufacturers in just twelve days—by all accounts a remarkable accomplishment—it would be almost impossible to get the vaccine to everyone who needed it before flu season began again in the fall.
Seasonal flu kills 3,000 Americans in an average month, more than the entire death toll from the 9/11 terrorist attacks. But most of the victims are already weakened by sickness or old age. As the new flu virus spread through America in the spring and summer of 2009, scientists discovered a striking feature. It seemed to prefer the young and the healthy.
4. The Better Side of Clean
On April 25, the authorities declared a Public Health Emergency of International Concern. They had no choice. The virus didn’t look especially deadly, but even the 1918 virus looked weak in its first wave, before it lowered the U.S. life expectancy by twelve years. A false alarm is better than wildfire.
So people covered their faces and drowned their fear in Purell. At one college graduation it was optional to shake hands with the president. At another college they held a separate graduation for students returning from Mexico. Some people came home from Mexico and went straight to the hospital, even though they had no symptoms. They became known as the “worried well.” In Newton County a seventh-grade boy was sent home from school when he refused to take off his mask. In the media there was debate over “swine flu parties,” modeled after chicken pox parties, in which mothers would theoretically gather children for deliberate infection to give them immunity from a more deadly future strain. It was very hard to find anyone who had actually seen one of these parties, but they were fun to talk about.
Meanwhile, away from the cameras, most people went on with their lives. John and Angela Behnken lived in a brick house in the Glastonberry subdivision of Johns Creek with a German shepherd named Riesling and a mongrel that John had renamed Rufus, from Roo, because Rufus sounded more masculine. “I don’t know what I’d do without you,” John told Angela all the time, and he texted her his love during the workday as she managed production at Gwinnett Magazine and he tested new lighting products for electrical stability. They heard about the new flu virus through the media and regarded it with a modicum of caution. They were, as Angela put it, “on the better side of clean.” They washed their hands regularly, if not obsessively, and went to Thursday night bar trivia without wondering what germs were hiding on the ketchup bottle. If John had any health worries, they mainly concerned sodium, which is why they had stopped eating pizza every other night.
As John and Angela understood it, the virus was a threat primarily to babies, small children, and the elderly. This was partially correct. The CDC’s Advisory Committee on Immunization Practices met July 29 to decide which population groups should take priority when vaccine became available. The list did not include people over sixty-five, because many of them have some kind of residual immunity from an encounter with a similar virus before 1957. It did include pregnant women, healthcare workers, children, caregivers of young children, and young adults. The virus was killing young adults at more than double the rate of the seasonal flu. What is a young adult? In this case the definition was anyone from nineteen to twenty-four.
John turned twenty-seven in August. Angela was twenty-six.
In October, as vaccine trickled out to the high-priority groups, John’s older brother Steve called him to talk about it. Steve had heard something scary on NPR about the new virus, and he and his wife had a daughter a few weeks old. That put them in a priority group. One afternoon Steve skipped out of work and took his wife to the Kendall County Health Department in Illinois, where they waited more than two hours for a shot in the arm. Then Steve called John to ask him about vaccination plans. John said he and Angela would get vaccinated. Just not right away.
“Other people will need it more,” John said. “We’re healthy. We’re young. If anyone’s got the best chance of beating it, it’s us.”
The vaccine is full of captured invaders. They are weakened or killed and then introduced to your body. Your defenders swarm around them and study them and build new armor that will withstand their fire. And when the invasion comes, your defenders are ready for victory. This is how it should work, and usually does. But millions of Americans remain unconvinced.
They have all sorts of reasons. Don’t trust the government. (This includes members of both the right and the left.) Don’t like shots. (A nasal spray is also available.) Don’t like paying for shots. (They’re usually less than $30 and often free.) Don’t like standing in line for shots. (2009 was a special case; usually they’re easy to get.) Don’t think shots will do anything. (The 2009 H1N1 vaccine was up to 90 percent effective in people with strong immune systems.) Don’t think they’re safe. (People worry about a preservative called thimerosal, but thimerosal-free doses are available.) Don’t think the virus is dangerous. (For most people it isn’t. But you never know.) And so forth. Part of the skepticism goes back to a strange national incident from 1976, sometimes called the Swine Flu Affair.
Six and a half years before John Behnken was born, almost seven years before the white plastic tube was placed in his skull, there was a small influenza outbreak at Fort Dix in New Jersey. The virus looked new and scary and deadly. Government officials huddled together and decided this was their chance to save the day. They devised a plan to vaccinate everyone in America.
The ensuing disaster is recounted in Gina Kolata’s book Flu. Every day in America, people catch pneumonia. They faint. They are diagnosed with multiple sclerosis. They have strokes and heart attacks. And of course this all happened as usual after they took the vaccine, meaning they could blame the government for a coincidence. And they did. It was a landmark case of products liability. By May 1980 there were nearly 4,000 claims for more than $3.5 billion in damages. Not only that: While the vaccine was generally safe, scientists did uncover an exceedingly rare link—still debated in some circles—to a paralyzing neuromuscular condition called Guillain-Barré syndrome. And here’s the worst part. It was all for nothing. The virus didn’t spread. The epidemic never happened. The CDC director lost his job.
So that’s one reason Americans don’t get vaccinated. In 2009 there was another. They couldn’t get it when they wanted it most. This was nobody’s fault; the virus didn’t grow as well in the eggs as scientists had hoped. They wanted three or four vaccine doses per egg, but the virus yielded fewer than two. Then the vaccines had to be poured into syringes, tested for safety and sterility, put through clinical studies, approved by the government. Any shortcut would have been dangerous. Which meant peak supply never aligned with peak demand.
By September 4, the new influenza virus was officially widespread in Georgia. Five people had died and nearly 200 had been hospitalized. Three more months would pass before the vaccine was available to everyone.
6. The Weekend
It could have happened at Costco, as she pushed the shopping cart; or at the office, in a midafternoon lull; or at the gym, on the elliptical machine. Or anywhere. What Angela knows is that she left the bar with a sore throat after Thursday night trivia October 29 but woke up Friday morning feeling good enough for work. As the day went on, she felt an ache in her back and shoulders. She went home and curled up in bed, where John brought her chicken soup.
On Saturday morning John got up and fed the dogs so Angela could rest a little longer. Then he went to the office for a few hours. There was trouble with a machine called a goniophotometer, which measures the intensity of light. Somehow John got the thing to work, which necessitated a call to his oldest brother David for bragging purposes.
Angela felt dizzy when John got home late that morning, but the feeling passed. She thought it was a cold, and not such a bad one. It was Halloween, and they were having a party that night. They got in her Nissan Sentra to run an errand, and as John was driving they talked about the future. He was in night classes at Georgia Tech, working on his MBA, hoping one day to start his own company. They wanted children. Angela wanted a boy; she wondered what John would look like as a small child.
At Union Diamond they met their friend Pete Mehravari to look at engagement rings for his girlfriend, one of Angela’s sorority sisters. Angela had another dizzy spell, with sweating and hot flashes, and had to sit down. John rubbed her back. Pete followed them home. Angela took a nap while John and Pete went to a pawnshop to look at more diamonds. The proprietor wore a black velour Adidas tracksuit that he claimed was a Halloween costume, but neither John nor Pete believed him.
“Do you have any motorcycles?” John said.
“I got one,” the man said, and he showed them a 1943 white Harley-Davidson in mint condition, which John and Pete admired for a while before going back to John’s house to prepare for the party. John made seven-layer dip, his signature dish, and a bunch of friends came over to watch Georgia Tech demolish Vanderbilt in football. Angela’s sister had made Halloween outfits for the dogs—a ballerina costume for Riesling and a Superman cape for Rufus. One of John’s friends heard that Angela wasn’t feeling well, which made him think of swine flu, and he said maybe she should dress up like a pig. At halftime the guys left for a corner bar called TJ’s to watch the second half. Angela stayed home to rest. John was the only one who wore a costume to the bar. He had borrowed his dog’s Superman cape.
A few hours later, John came home and took off the cape.
“I probably got what you got,” he told Angela. “I’m starting to feel under the weather.”
She woke up feeling fine on Sunday morning. John tried to get up and feed the dogs, but he faltered.
“Sweetie, I’m feeling weak,” he said. “Do you mind?”
Angela fed the dogs, and John went back to sleep. When he woke up, she brought him chicken soup and Oreos. She wiped his face with a cold wet cloth and stayed beside him until midafternoon as he drifted in and out of sleep. Around 2:30 she got hungry again. She kissed his face and got out of bed. In the doorway she turned and saw a drowsy half-smile on his face.
“I love you, baby,” she said, with more than the usual force.
“I love you too,” he said.
Downstairs she played with the dogs and called her mother. She felt well enough to consider going to the gym. Then she heard a strange noise from the bedroom and went upstairs to check on John.
“Hey, baby,” she said.
He seemed to be choking. She grabbed his cell phone and called 911 for an ambulance. There was blood in his nose. The dogs were barking. The operator told her to try CPR. Angela pushed on his chest and put her lips to his lips. She almost beat him up trying to get him breathing again. Nothing worked. The paramedics rushed him to the hospital, but it was too late. It was November 1, 2009, five weeks before the pandemic flu vaccine became available to the general public in Georgia. Angela Behnken was a widow at twenty-six years old, and no matter how many times she was told otherwise, she couldn’t help thinking it was somehow her own fault.
“It is my opinion,” Dr. Michele Stauffenberg of the Fulton County Medical Examiner’s office wrote in her autopsy report, “that John Behnken, a 27-year-old white male, died as a result of complications of H1N1 influenza, commonly known as swine flu.” The virus had attacked his airways and filled his lungs with fluid. The manner of death was similar to drowning. No one knows why the virus left Angela alone after forty-eight hours even as it killed her husband. Scientists are still mystified about how the flu chooses its targets, although they suspect a link to genetics. Usually the flu has a coconspirator when it kills—some bacteria or other invader that sneaks in through the open door. This time it did not. Usually, when it proves fatal, it’s because of some preexisting medical condition that weakens its victim—diabetes, morbid obesity, chronic lung disease. John had none of those. Dr. Stauffenberg had done close to 1,600 autopsies, and this was the first time she had seen an otherwise healthy person die from the unaided influenza virus. In life and in death, John Behnken was exceptional. He won the genetic lottery, and then he lost.
The cause of death was not the only surprising thing Dr. Stauffenberg discovered during her examination. It had nothing to do with his death, but it was intriguing nonetheless. In his skull she found a ventricular peritoneal shunt—a white plastic tube.
7. The White Plastic Tube
John was three months old and wouldn’t stop screaming. He arched his back from the pain. The soft spot on top of his skull was bulging. His doctor got on the phone with the Mayo Clinic in Minnesota and told them what was wrong, and the Mayo doctor said, “We need him in Rochester first thing on Friday morning.” They lived in eastern Montana. All five Behnkens piled into the car and crossed the prairie in the dark, about 700 miles, and brought him to the hospital. The doctors said he had a bilateral subdural hematoma, a fluid buildup around his brain. They weren’t sure how it happened, but it was very serious. They had to drain the fluid or he could die.
The doctors drilled two small holes in John’s skull and inserted a Y-shaped plastic tube that went down behind his left ear, through his chest, and into his abdominal cavity, where the fluid would drain without hurting anything. John stayed in the hospital for a month, and the tube kept working for about two more months. After that he didn’t need it, but the surgery to remove it would have been more trouble than it was worth. So the tube stayed. John had the brightest eyes his mother ever saw. He was always happy after that. By age three he could read the hands of a clock. By age six he caught a forty-pound halibut.
Medical science saved countless thousands of people from the influenza pandemic of 2009. More than 80 million took the vaccine that was born in a white room off Clifton Road, six miles northeast of Downtown Atlanta. The pandemic turned out to be mild. It crowded out the seasonal flu, but in its first year it killed fewer than half the people the average seasonal flu does. The vaccine is expected to be plentiful when the fall peak rolls around again. The question is this: How many people here will take it? Georgia has one of the nation’s lowest vaccination rates, and in March it was leading the nation in hospitalizations for swine flu. Officials at the CDC were worried enough to hold a special news conference. The new virus was still circulating intensely.
Medical science saved John Behnken once, giving him twenty-seven years on earth. It could not save him twice. He never got his oversized novelty check. He never got to jump in a river with a knife between his teeth. But he did get something close to a Viking funeral. His friends made sure. They built a three-foot boat out of kindling wood, painted it brown, and filled it with mementos, including aces from a deck of cards and a figurine of a polar bear. They floated the boat in a kiddie pool in the backyard. At night they set it on fire.