Diseases and Disorders

SARS

Diseases and Disorders

SARS

Titles in the Diseases and Disorders series include:

AcneAlzheimers DiseaseAnthraxAnorexia and BulimiaArthritisAsthmaAttention Deficit DisorderAutismBreast CancerCerebral PalsyChronic Fatigue SyndromeCystic FibrosisDiabetesDown SyndromeEpilepsyHeadachesHemophiliaHepatitisLearning DisabilitiesLeukemiaLyme DiseaseMultiple SclerosisObesityPhobiasSchizophreniaSexually Transmitted DiseasesSleep DisordersSmallpoxWest Nile Virus

Diseases and Disorders

SARS

Gail B. Stewart

San Diego Detroit New York San Francisco Cleveland New Haven, Conn. Watervil le, Maine London Munich

2004 by Lucent Books. Lucent Books is an imprint of The Gale Group, Inc.,a division of Thomson Learning, Inc.

Lucent Books and Thomson Learning are trademarks used herein under license.

For more information, contactLucent Books27500 Drake Rd.Farmington Hills, MI 48331-3535Or you can visit our Internet site at www.gale.com

ALL RIGHTS RESERVED.No part of this work covered by the copyright hereon may be reproduced or used in any form or by anymeansgraphic, electronic, or mechanical, including photocopying, recording, taping, Web distribution,or information storage retrieval systemswithout the written permission of the publisher.

Stewart, Gail, B.SARS/ by Gail B. Stewart.

v. cm. (Diseases and disorders series)Includes bibliographical references and index.Summary: Describes SARS, its effects on the worlds economy, treatments for the dis-ease, and what may happen if it was to return.Contents: The Secret KillerInvestigating SARSSARS, Politics, and the EconomyLifewith SARSSARS and the Future.

ISBN 1-59018-529-3 (hardback : alk. paper)I. Title. II. Series.

LIBRARY OF CONGRESS CATALOGING-IN-PUBLICATION DATA

Printed in the United States of America

Foreword 8

IntroductionThe Faces of SARS 10

Chapter 1The Secret Killer 13

Chapter 2Investigating SARS 28

Chapter 3Life with SARS 44

Chapter 4SARS, Politics, and the Economy 60

Chapter 5SARS and the Future 76

Notes 91Organizations to Contact 97For Further Reading 99Works Consulted 101Index 105Picture Credits 111About the Author 112

Table of Contents

The MostDifficult PuzzlesEver Devised

CHARLES BEST, ONE of the pioneers in the search for a cure fordiabetes, once explained what it is about medical researchthat intrigued him so. Its not just the gratification of knowingone is helping people, he confided, although that probably is amore heroic and selfless motivation. Those feelings may enter in,but truly, what I find best is the feeling of going toe to toe withnature, of trying to solve the most difficult puzzles ever devised.The answers are there somewhere, those keys that will solve thepuzzle and make the patient well. But how will those keys befound?

Since the dawn of civilization, nothing has so puzzled peopleand often frightened them, as wellas the onset of illness in abody or mind that had seemed healthy before. A seizure, the in-ability of a heart to pump, the sudden deterioration of muscletone in a small childbeing unable to reverse such conditions oreven to understand why they occur was unspeakably frustratingto healers. Even before there were names for such conditions,even before they were understood at all, each was a reminder ofhow complex the human body was, and how vulnerable.

While our grappling with understanding diseases has beenfrustrating at times, it has also provided some of humankindsmost heroic accomplishments. Alexander Flemings accidentaldiscovery in 1928 of a mold that could be turned into penicillin

8

Foreword

has resulted in the saving of untold millions of lives. The isola-tion of the enzyme insulin has reversed what was once a deathsentence for anyone with diabetes. There have been great stridesin combating conditions for which there is not yet a cure, too.Medicines can help AIDS patients live longer, diagnostic toolssuch as mammography and ultrasounds can help doctors findtumors while they are treatable, and laser surgery techniqueshave made the most intricate, minute operations routine.

This toe-to-toe competition with diseases and disorders iseven more remarkable when seen in a historical continuum. An as-tonishing amount of progress has been made in a very short time.Just two hundred years ago, the existence of germs as a cause ofsome diseases was unknown. In fact, it was less than 150 years agothat a British surgeon named Joseph Lister had difficulty persuad-ing his fellow doctors that washing their hands before delivering ababy might increase the chances of a healthy delivery (especially ifthey had just attended to a diseased patient)!

Each book in Lucents Diseases and Disorders series exploresa disease or disorder and the knowledge that has been accumu-lated (or discarded) by doctors through the years. Each book alsoexamines the tools used for pinpointing a diagnosis, as well asthe various means that are used to treat or cure a disease. Finally,new ideas are presentedtechniques or medicines that may beon the horizon.

Frustration and disappointment are still part of medicine, fornot every disease or condition can be cured or prevented. But thelimitations of knowledge are being pushed outward constantly;the most difficult puzzles ever devised are finding challengersevery day.

Foreword9

The Faces of SARS

IT SEEMED, IN the early months of 2003, that the disease cameout of nowhere. No one could pinpoint the first case of severeacute respiratory syndrome (SARS)it probably occurred inNovember 2002but by early 2003 it was roaring through hos-pitals in China and other parts of Asia, as well as in Toronto,Canada, striking down hundreds of doctors and nurses as theytried to care for their patients. It was a ghastly illness; oneHong Kong resident says that watching someone with SARSgasp and fight for breath was like watching a man drown todeath on dry land.1

Thousands of those infected died, and doctors were panicking,for there seemed to be little progress in fighting the new disease,and it continued to spread. As people quickly learned, a danger-ous new disease in the age of jet travel rapidly becomes every-ones problem. By June 2003 there were SARS victims on sixcontinents.

Many EffectsOf course, those primarily affected by the disease were peoplewho became infected with SARS. Henry Likyuen Chan, a thirty-four-year-old doctor in Hong Kong, contracted SARS in the hos-pital where he works. His high fever and racking cough led hisdoctors to fear the worst. In fact, one colleague cried when sheheard Chans gasping attempts to breathe. He eventually recov-ered, but it is clear that the battle with SARS was the most diffi-cult thing he had ever encountered. I am quite an aggressiveperson, he says. That is why I was determined to conquerSARS.2

10

Introduction

But the effects of SARS have been felt by more than the pa-tients and their families. In hundreds of smaller ways, people allover the world had their routines altered because of the disease.Students who had planned on studying in China were told by theCenters for Disease Control to cancel their plans. One twenty-one-year-old law student from Virginia had just begun an intern-ship in Hong Kong when the outbreak hit, and he was calledhome.

In SARS-affected regions, businesses that rely on travelers andtourists struggled and were often forced to cut their work forceto meet payrolls. Airlines with flights to Hong Kong and main-land China were especially hard-hit. In Toronto a girls soccerteam had won the right to compete in an exhibition match inPennsylvania, but the teams coach was told not to come after all.One of the players, a sixteen-year-old, had hoped to show herskills and perhaps get a college scholarship. It was my one bigchance, she says. I was literally crushed.3

The Faces of SARS11

At a 2003 Toronto Bluejays baseball game, a man wears a surgical mask toprotect himself from the SARS virus.

Lily, a sixteen-year-old ice skater from St. Paul, Minnesota, hadbeen planning to attend a clinic in Toronto in April 2003. How-ever, when SARS began spreading in that city, health officialsurged travelers to postpone visits until later. But the clinic isntoffered later, she says. It was my chance to work with a reallygood coach, and it couldnt happen. My mom says I should havemore perspective about this, and think about people who haveSARS and are suffering. I know shes right; theyve got it worseoff than me, but Im still really disappointed.4

Unsettling QuestionsThe emergence of SARS and its spread throughout the world hasraised unsettling questions about contagious disease and medi-cines ability to prevent it. More than ever before, researchers areeager to understand how viruses arise. How can they mutate,and why do some viruses cause so much damage to the humanbody, while others have only faint effects?

While some strides have been made in understanding the na-ture of the SARS virus, a great deal is left unanswered. In a worldthat has recently begun to consider bioterrorism a very possiblethreat, the SARS virus has demonstrated how vulnerable life is inthe face of a new and contagious disease, and how societies, gov-ernments, and economies can be rattled by the tiniest of mi-crobes.

SARS12

13

Chapter 1

The Secret KillerMONTHS BEFORE THE World Health Organization declared ita worldwide health threat and gave the disease its name,SARS had begun infecting people in Guangdong Province, insouthern China. At the beginning, however, few health profes-sionals were worried about it at all.

A Cold? The Flu?It was in November 2002 that the first cases were seen in the ruralareas of Guangdong Province. People complained aboutheadaches, aching muscles and joints, as well as a loss of ap-petite. Few sufferers were concerned; it was November, after all,and it was not unusual to catch a cold or flu during the cool,rainy season. Most continued going to work or school, believingthat the symptoms would fade after a few days.

Within three or four days, however, patients found that theyfelt worse, not better. Many were experiencing dry coughs, fever,and difficulty breathing. Doctors believed it was pneumonia, andprescribed antibiotics and rest. But this disease did not respondto antibiotics or any of the usual remedies for pneumonia. Somepatients developed such difficulty breathing that they werehooked up to respirators. Others died, blue-faced and gaspingfutilely for breath, even with the respirators.

As the weeks passed, doctors in the local Guangdong hospitalsbelieved that they were dealing with a very different sort of pneu-monia than they had ever seen before. The worst part was that,unlike typical pneumonia, this disease appeared to be highly con-tagious. The first patients who sought help from local hospitalsleft a trail of infected health care workers in their wake as theysought relief from their labored breathing and high fevers.

We Didnt Take Any Preventive MeasuresOne young nurse who became ill says that she had been lookingafter a patient who came to the hospital with flu-like symptoms,as well as a severe cough. The whole forty minutes [she waswith him] he was coughing and expelling huge amounts ofphlegm. This was unusual, she says, for a cough of that naturewas not normally a symptom of the strains of flu she had seen.But although his illness was a mystery, the staff did not wearmasks when tending to him. We didnt take any preventivemeasures, she says, as we normally dont wear masks whentaking care of flu patients.5

The patients condition deteriorated quickly, and he was trans-ferred to a larger urban hospital, where he died. Meanwhile, thenurse became ill. With a high fever, aches, and fatigue, shethought she might be overworked or had maybe caught the flu.

SARS14

A doctor treats a SARS patient in Hanoi, Vietnam, in 2003. The first cases ofthe disease appeared in November 2002 in rural areas of Chinas GuangdongProvince.

But medicines and rest did not help her symptoms at all, and shewas admitted to the hospital where ten other staff members hadbecome sick with similar complaints.

Her symptoms worsened within a day or two. Breathing wasdifficult and I had to be under a respirator for about ten days. Iwas unconscious most of the time. Though she was luckyenough to survive, after more than a month she was still ill:

My lungs havent got back to normal and I still feel tight in thechest. I suffer from a bad insomnia; most nights I can onlysleep for a couple hours. My muscles are so weak I can hardlylift anything, and my eyes are swollen and red. But the thingthat disturbs me the most is my right leg. I cant walk, canteven move the leg without feeling an excruciating pain in myjoints. I used to be very active, very physical.6

News via the GrapevineBut even though there were many such stories among peoplewho were battling the disease, the Chinese remained secretive.They refused to release information about the illness in the news-papers or television. Government officials did not want to alarmthe citizens, nor did they want to admit that there was a conta-gious, deadly disease that they were unable to contain. Such anadmission would cause a mass panic and would almost certainlyaffect the foreign investment on which China had become de-pendent. Since the Chinese media are all tightly controlled by thegovernment, no details were released about the disease, and doc-tors were told not to discuss iteven with health professionals inother parts of China.

However, many Chinese health care workers were alarmed bythe disease, and on many of the most popular Chinese Internetsites doctors and nurses passed along rumors that people weredying from a mysterious new form of pneumonia. It soon be-came clear to provincial officials that they could not remain silentabout the disease. On February 11, 2003, Guangdong officials or-dered the health minister to make a public announcement, ac-knowledging that there was a form of pneumonia that had killed

The Secret Killer15

five people and infected hundreds of others. At the same time,however, the health minister reassured the Chinese people thatthere was nothing to fear, since the disease was now completelyunder control.

The government in Beijing, Chinas capital, was worried aboutthe effects of such news on Chinas reputation as a modern,growing nation. Determined that there be no further rumors orquestions about the disease, officials ordered the people ofGuangdong to refrain from talking about it. It was best, theywarned, to voluntarily uphold social stability, not believe in ru-mors, not spread rumors.7 In addition, the police were in-structed to meet with Chinese Internet webmasters and orderthem to write only positive things on their websites about the na-tions efforts to combat the disease.

SARS16

In an effort to prevent widespread panic, Chinese government officials refusedto release information to the press about the new disease.

Coming to the CityBut it was difficult for the people in Guangdong to remain silentabout SARS when it was obvious that the disease was not undercontrol at all. In fact, there was a growing problem as some ruralpatientsfrightened because they were not getting better in theirlocal hospitalstraveled to Guangzhou, the large capital city ofthe province. Because of the lack of information on the disease,the large metropolitan hospitals of Guangzhou were unaware ofthe seriousness and highly contagious nature of SARS. While thelocal hospitals had learned to isolate SARS patients to keep themfrom infecting others, the metropolitcan hospitals found out thehard way.

Nurses at the Number 2 Peoples Hospital in Guangzhou saythat they will always remember February 2003 as a time when theywere all endangered. A very sick man had visited various hospi-tals in the cityincluding Number 2. No health care workers

The Secret Killer17

A Hong Kong shopkeeper prepares an herbal remedy for a SARS patient.Many Chinese turned to folk remedies to protect themselves from the disease.

knew enough about SARS to isolate the man; in fact, none of thestaff who examined him used masks or gloves. As a result,dozens of doctors and nurses became infected. Says one nursefrom Number 2, He was very sick, but who knew there wassomething so terrible going around?8

The rapid growth of the number of cases began to cause panicamong the public in Guangdong. On the streets here, noted NewYork Times reporter Elizabeth Rosenthal who was visiting Guang-dong Province, rumors abound, and people feel they cannot pro-tect themselves in the absence of information.9 That absence ofinformation left a vacuum that was quickly filled by various theo-ries about the nature of the disease, ranging from an exotic form offlu to anthrax or some other weapon that had leaked from a mili-tary base. Hoping to protect themselves from the germs, peoplewore surgical masks on the streets, and if they could not find thereal thing, they fashioned them from gauze and tape.

A number of folk remedies were circulated, toofrom breath-ing vinegar fumes to eating a diet of turnips. One cure, adoptedby many frightened Chinese, was to smoke more cigarettesor,if one did not already smoke, then start. Advocates of this curebelieved that the tobacco smoke would drive the poisons frompatients lungs, allowing them to breathe more easily. But neitherthe folk remedies nor the antibiotics were effective against SARS,and Chinese health officials were worried.

We Didnt Believe ItThough Chinese officials had tried to keep SARS a secret, bitsand pieces of information about the disease had spread via theInternet to the World Health Organization (WHO) and the Cen-ters for Disease Control (CDC)both international public healthorganizations. When WHOs Outbreak Center, which investi-gates any new and potentially hazardous diseases in the world,made official inquiries to China, they were told that the oubreakwas a new type of fluand that the Chinese health authoritiescould handle it without outside help.

But as word of a growing death count continued to reach be-yond Chinas borders, WHO and CDC officials were convinced

SARS18

that they were being lied to. Chinese officials refused to providemore specific information and repeated orders to its doctors notto respond to any inquiries from WHO or the CDC. Certain thatthere must be more going on in China, WHO officials contacteda Hong Kong laboratory with which they frequently worked,and had lab technicians visit Guangdong hospitals to collect tis-sue samples from some patients.

Worried about losing their jobs, however, the Chinese healthofficials provided tissue samples from patients who were suffer-ing from other germs, and repeated that the outbreak was over.Doctors at the international agencies were skeptical, since antibi-otics would certainly have cured all of the germs in those sam-ples. One CDC doctor said flatly, We didnt believe it.10 As hewould learn very soon, his instincts were absolutely correct.

Spreading Beyond Guangdongs BordersOn February 21, 2003, the one thing that was feared most oc-curredSARS spread beyond Guangdong Provinces borders. Asixty-four-year-old retired lung specialist from Guangdongnamed Liu Jianlun went to Hong Kong for his nephews wed-ding. Liu had been feeling tired, and when he arrived in HongKong he was running a low-grade fever.

As Lius symptoms worsened, he went to a Hong Kong hospi-tal. Understanding that he probably had SARS, Liu advised theemergency room staff to isolate him behind double panes ofglass, which Guangdong regional hospitals had begun doing fortheir patients. He also insisted that before examining him, doc-tors and nurses put on protective masks, gloves, and gowns.Lius cautions undoubtedly saved lives at the hospital; he diedseveral days later, but none of the staff became infected.

But Lius death was not publicized, nor were doctors in otherhospitals in Hong Kong or other places told about the incident.And because he was contagious before he went to the hospital,he inadvertently infected a number of people at the same hotelwhere he was staying. Three young women from Singapore wereinfected, as were two Canadians, a man from Hong Kong, and anAmerican businessman on his way to Hanoi, Vietnam. Not only

The Secret Killer19

had SARS been carried beyond the borders of Guangdong,China, but because of this one case, it would soon be spreadthroughout the world.

A Global ThreatAgain, because of the lack of real information about the disease,hospitals outside of Guangdong Province were ill-equipped todeal with it. In Toronto, for example, a woman who had talked toLiu in Hong Kong became ill and died on March 5, 2003, after in-fecting her son and several doctors and nurses at the Torontohospital where she was taken.

When her son Tse visited the emergency room of the same hos-pital on March 7, staff doctors and nurses knew nothing aboutthe disease and had no idea how contagious Tse was. He had afever and a cough, remembers one nurse, and he was having ahard time catching his breath. And he looked scared.11

Tse was placed in a bed of an observation ward and infectedtwo men in nearby beds, who in the days ahead infected dozensof others with whom they had contact. At that point, says oneToronto doctor, there was no concept of how infectious [Tse]was.12 By May 15 there would be at least 145 cases of SARS, withnineteen people dead of the disease.

An Official AlertWith new information that the disease had spread to Canada andother countries, WHO officials issued a global alert on March 12,2003. With the limited amount of information it possessed, theagency warned of the new disease and urged travelers and air-line crews around the world to watch for symptoms. It also rec-ommended that doctors and nurses isolate anyone presentingsymptoms that seemed suspicious and take precautions by usingprotective suits, gloves, and masks when treating patients.

The warning to health professionals was apt, for doctors andnurses were among the hardest hit by SARS. By the middle ofMarch 2003 the emergency room at Scarborough Grace Hospital,where Tse was treated, had to shut down because of a shortageof healthy staff members. Thousands of Toronto citizens who had

SARS20

visited the hospital or had been treated there were told to isolatethemselves at home for ten days to avoid infecting others.

In Hanoi, the American businessman infected twenty healthcare workers. Of the three women from Singapore, one visitedthe Tan Tock Seng Hospital, and left ninety-two people sickatleast one-third of them health care workers.

The Secret Killer21

At the entrance to ahospital in Hanoi,Vietnam, a bust ofFrench chemist LouisPasteur wears asurgical mask. FromChina, SARS quicklyspread intoneighboring Vietnam.

Worst in ChinaChina remained the hardest hit by the growing epidemic, and thegovernment continued its policy of secrecy and noncooperationwith international authorities. WHO asked for permission tovisit China so that doctors could review data about the first out-break in Guangdong. The response by the Chinese was, says oneWHO official, dead silence.13

The fact that their government was continuing to be secretivecaused panic among the Chinese public. Villages erected barrierson the roads leading in and out of town to be sure that outsidersdid not bring the disease in. Rumors circulated like wildfire, too,

SARS22

World Health Organization officials visited China to research the extent of theSARS outbreak. Initially, the Chinese government refused to cooperate withthe officials.

noted one observer. Grannies . . . whispered that the entire cap-ital was going to be quarantined, while Internet chat roomsbuzzed with claims that the disease was a conspiracy courtesy ofthe Americans and the Taiwanese.14

In early April SARS hit Beijing, infecting ninety people at alarge downtown hospitalseventy of them nurses and doctors.Yet when asked if it was safe for tourists to come to the city, onegovernment representative minimized the risks, stating thatthere had been only thirty-seven cases, and the disease had beencontained by Chinese health care workers. Of course [tourists]can travel, he said. We think its very safe.15

Were FrustratedInternational health officials, however, were not convinced.One WHO representative was adamant that the stonewallinghad to stop. We have clearly told the government, he said,the international community doesnt trust your figures.16

Many doctors around the world demanded more information incase SARS appeared among their citizens. In the United States,Secretary of Health and Human Services Tommy Thompson alsoexpressed his exasperation with the Chinese government for be-ing overly concerned about their image and insisted that WHOand the CDC only wanted to help China contain the disease.Were frustrated, he said. We want to work in greater collab-oration with them.17

By the end of April, however, the government finally ac-knowledged that SARS was not completely contained and thatan accurate count of those with SARS in Beijing was 339, ratherthan 37, as previously announced. Within a week, the figure hadjumped to 900 confirmed cases. To try to contain the disease, thegovernment ordered the quarantine of all offices, hotels, restau-rants, and residential buildings that might have been visited bypeople infected with SARS. By quarantining, or isolating, peoplewho were already sick or who had been exposed to the disease,doctors hoped to minimize the chance of them infecting morepeople. The order for a two-week quarantine left more than twothousand doctors, nurses, and patients at Peking Universitys

The Secret Killer23

Peoples Hospital in downtown Beijing isolated among 90 con-firmed cases of SARS70 of them health care workers.

Although the government stressed that there was little tofear, Beijing residents were behaving otherwise. By the end ofthe month the city of 13 million resembled a ghost town, mostcitizens having taken refuge in their homes, hoping to avoidcatching the disease that the government refused to talk aboutopenly.

While these were aggressive steps for Chinese leaders to take,many experts believe that the government was still attempting tohide the extent of the epidemic from WHO and the rest of theworld. For instance, Chinas leaders were so worried about anoutbreak in Shanghai, the nations banking and commercial cen-ter, that they ordered Shanghai officials to preserve the citys rep-utation as SARS-free at any cost. Doctors in Shanghai,however, admitted to reporters that there were at least 30 con-

SARS24

A World Health Organization official meets with reporters after the Chinesegovernment allowed him to examine patients afflicted with SARS.

firmed cases in the city already, but the government was firm inits order. All I have been told, one health official in Shanghaiexplains, is that we must maintain the image of Shanghai as aplace without a SARS problem.18

Hiding in AmbulancesEven when WHO representatives were finally permitted to enterChina for the purpose of investigating the nature of the disease,the stonewalling continued. Chinese doctors were instructed tofollow what was called the policy of the Three NosNo talk-ing to the media about the nature of SARS; no talking to the pub-lic about doctors personal experiences treating the disease; andno communicating with the WHO about anything to do withSARS.19

When WHO representatives visited Beijings China-JapanFriendship Hospital on April 21, 2003, for example, they wereshown a ward containing only two SARS patients. The rest, saysreporter Hannah Beech, were being driven around the city in am-bulances until the WHO doctors left the hospital. Inside the am-bulances, she explains, was a deadly secret: 31 coughing,shivering hospital Workers who had caught . . . SARS from theirpatients.20

Fearing that they would be fired if they talked to the interna-tional media, doctors and nurses remained silent when askedabout the epidemic. Their only comments were off the record,and at those times they admitted that the threat of SARSthroughout the country was far more than the government wasletting on. One doctor apologized that he was not allowed tospeak with an American reporter. Im embarrassed that I canttalk to you, he said. I had really wanted to, but Im young, andI cant afford to lose my job.21

One health minister, however, was angry that China was beingjudged harshly by other nations for its methods of dealing with thecrisis. He feels that because China is such a populous nation, thegovernment cannot afford to make decisions based on what is bestfor individual people, but rather must think of the majority. Youforeigners value each persons life more than we do because you

The Secret Killer25

have fewer people in your countries, he says. Our primaryconcern is social stability, and if a few peoples deaths are kept se-cret, its worth it to keep things stable.22

More Questions than AnswersBut stability was hard to maintain as the disease continued tospread. Doctors had believed that SARS was spread only by closehuman contactfrom inhaling the spray of a cough or sneeze ofan infected person. In Hong Kong, however, that theory provedfalse. In less than a week, 250 residents of a thirty-three-floorhousing development contracted SARS, and most of those peo-ple had never met one another. Clearly, close human contact had

SARS26

Chinese government officials brief reporters about the SARS virus in April 2003after 250 residents of a Hong Kong apartment complex contracted the disease.

not occurred, yet the disease spread quicklyby the end of Aprilinfecting a total of 1,527 in Hong Kong.

As in other cities around the world, quarantine seemed theonly method of containing SARS, although doctors were noteven certain whether that would work. Meanwhile, hospitalswere running out of space, people were fleeing affected areas,and those who had been exposed to the disease were herded intoseclusion until doctors felt that they were no longer at risk ofcoming down with SARS.

As doctors and researchers struggled for answers, they weremet with more questions. Where did the disease come from, andhow exactly was it spread? Was there any medication that wouldhelp SARS victims? One Toronto doctor voiced his frustration asmore patients with symptoms continued to show up in the citysemergency rooms. The difficulty is were facing an enemy thathas no known shape, no identity, and no known effective treat-mentand thats causing the most concern.23 Clearly, the inter-national medical community had a difficult task ahead.

The Secret Killer27

Investigating SARS

LONG BEFORE SARS was an international epidemicwhen itwas still a mysterious disease affecting people in Guang-dong Province, doctors around the world were hearing rumorsby way of the Internet. Always concerned about the emersionof a new illness, WHO researchers around the world werekeeping track of any information they could get about thepneumonia-type illness.

Six PercentAny new disease causes worry, and there have been a number ofkillers that have emerged in the past quarter centuryfrom AIDSto Ebola. In addition, WHO doctors around the world have mon-itored oubreaks of well-known but dangerous diseases such asmalaria and cholera. In many cases, the disease can be identifiedand contained in one area before it spreads out of control. How-ever, the most frightening of all scenarios, say experts, is that ahighly contagious disease that is unknown to doctors reaches aninternational airport, thus spreading it to other nations beforeanyone is even aware of it. That is just what happened with SARS.

Of course, no one knew then how deadly the disease might beor how contagious. The numbers of people dying of SARS werevery small compared with, say, the numbers dying from AIDS ina single yearwhich totaled 3 million worldwide in 2002. Withthe data they had, doctors estimated that the death rate of SARSwas about 6 percentin other words, of every one hundred peo-ple infected with SARS, six died.

Six percent is a fairly low death rate as long as the disease isrelatively contained in a particular area and not extremely conta-

28

Chapter 2

gious. However, with a disease that spreads easily from personto person, it is an extremely worrisome rate. Researchers point toa strain of flu in 1918 with a death rate of less than three percent,but which was so highly contagious that it killed between 25 mil-lion and 40 million people worldwide in eighteen months.

As time went on and more people became infected with SARS,doctors became more alarmed. One aspect of the new diseasethat worried WHO researchers was the high infection rate amonghealth professionals. In Hanoi, Vietnam, for example, 56 percentof the doctors and nurses who came into contact with the diseasebecame infected. Says Julie Gerberding, director of the CDC, Wenever see that kind of rate.24

WHO officials alerted the CDC in Atlanta, informing themthat as soon as WHO doctors were able to get tissue and bloodsamples from patients with the disease, they would send them to

Investigating SARS29

Patients in Singapore wait to be tested for SARS. Although SARS has arelatively low death rate, the disease is particularly worrisome because of itshighly contagious nature.

the CDCs Building 15, where the most feared diseases on theplanet are studied. From what doctors knew about SARS thus far,it seemed to fit in the category of what are known as specialpathogensgerms that are both contagious and deadly, with thepotential to kill a great many victims.

Guessing WrongTissue and blood specimens were delayed, however. For onething, autopsies are quite rare in most Asian hospitals, and doc-tors at first were reluctant to authorize the taking of lung tissuesamples. When some hospitals were finally persuaded to beginreleasing specimens, their transport to the research facilities wasdelayed because many international shippers refused to carry

SARS30

Because they have weak immune systems, ducks are breeding grounds fornew viruses. Many disease-causing viruses originate with animals.

such hazardous material. By March 10, 2003, specimens werebrought to various research facilitiesincluding Building 15 inAtlantaby U.S. military planes, and doctors began to inspectthe vials of blood, sputum, and bits of tissue from patients lungsor throats.

One of the early assumptions about SARS was that it wouldprove to be a new type of influenza, or flu virus. After all, manystrains of flu have originated in rural areas of China, where peo-ple and livestock often live very close to one another. Epidemiol-ogists, doctors who study the transmission of diseases, say thatmany viruses that cause disease in humans actually originatewith animals. Ducks, because they have weak immune systems,seem to be breeding grounds for new viruses. In a ducks body,such viruses can mutate and then are able to jump to pigs, andfrom pigs to people. Many strains of flu have originated this wayin southern China, where the living conditions of ducks, pigs,and people create what one researcher termed a toxic stew.25

Other news gave researchers even more support for their the-ory of a new strain of flu. They heard of a new bird flu in Chinathat had made some people sick. Perhaps, doctors reasoned, thestrange new SARS disease was another mutation of the birdvirus, but this time more virulent and contagious than usual.We put one and one together, explains one researcher, andthought this was the [bird flu virus] beginning its trip around theworld.26

A Difficult Job for a Crisis TeamThe scramble to learn about the mystery disease began in mid-March, when WHO doctors were alerted that a Toronto womanhad become infected. Apparently, SARS had hopped continents.WHO issued its first global warning, alerting travelers that whatappeared to be a very dangerous contagious disease had becomea worldwide health threat.

On March 17, 2003, WHO officials called the top epidemiolo-gists throughout the world to form a crisis team that wouldtackle the problem of identifying the cause of the disease. Doc-tors in China had easily ruled out bacteria as the cause of SARS.

Investigating SARS31

Bacteria would have been visible under their microscopes, andantibiotics, which are powerful killers of bacteria, would havehad an effect on the disease. The prevailing theory was that itwas a virus, but even for the best researchers in the world, iden-tifying the virus would be difficult. After all, it had taken morethan three years for researchers to isolate and identify the AIDSvirus.

Identifying viruses is far more difficult than identifying bacte-ria. Bacteria are living organisms and can be observed with afairly standard microscope. Viruses, however, are very tinysome are a million times smaller than bacteria. In addition,viruses act in different ways than bacteria, since they can surviveonly when inside a living cell. In fact, scientists believe thatviruses are not true living things, since they cannot survive or re-produce on their own. Seeing and identifying one extremely tinyvirus within a cell, when scientists are not aware of what they arelooking for, is difficult, time-consuming work.

SARS32

Researchers were able to deduce that a virus is responsible for SARS becausethe pathogen did not respond to antibiotics and was invisible under amicroscope.

The Medical Equivalent of Shock and AweThere are other factors that often slow work for scientists. Labora-tories are exceptionally expensive places to run, and scientists areoften in competition with one another to find a new medicine orvaccine that can bring in funds for research. For that reason, re-search facilities are rarely willing to consolidate or share informa-tion, since they view one another as rivals. And because there is nogreater achievement for a scientist than discovering a pathogen orits cure, the scientists themselves are often competitors.

The director of WHOs crisis team, Dr. Klaus Stohr, says thatbecause of the immediate threat of the new disease, it was notdifficult to convince the doctors to lay aside the competitiveness.They agreed to work together, sharing patient data, lab results,and other information. These are all famous microbiologistswhose lifes dream is to discover a virus, put their name on it andwin the Nobel Prize, says Stohr. But they understand that ouronly chance to put this thing back in the bottle is if we all worktogether.27

Stohr set up a website with a secure password for the partici-pating epidemiologists. He also arranged twice-a-day conferencecalls so the team could discuss any new theories or ideas, resultsof lab tests, and so on. The results were beyond anything Stohrcould have anticipated. Not only did the team identify the causeof the disease, but it did so in less than seven weeks. The speedat which the battle against SARS was waged, says one researcher,was the medical equivalent of shock and awe [the phrase Presi-dent George W. Bush had used to describe the U.S. attack onBaghdad in March 2003].28

A Surprising CulpritThe first significant step in the process was to drop infected tis-sue or blood into flasks of cells containing a culture of monkeykidney cells, called Vero cells. Vero cells are especially good forbreeding viruses, and scientists often use a Vero cell solution toindicate the presence of a virus. One scientist at the CDC in At-lanta noticed that one of the flasks that contained a mixture ofVero cells and throat tissue from a patient had turned from

Investigating SARS33

cloudy to clear. The clear areas meant that something was killingthe Vero cells.

The flask material was processed so that it could be viewedunder a special electron microscope, which magnified it overeighty thousand times. Many researchers believed that the mi-croscopic view would show a pathogen from the family ofviruses that cause various strains of flu. What they saw, however,was something they never expected: a coronavirus.

Coronaviruses are easily identifiable by their round shapecrowned with what look like spikes under an electron micro-scope. (The viruses get their name from the Latin word corona,meaning crown.) One reporter who viewed the viruses in aHong Kong lab notes that magnified 100,000 times, the organ-isms are fuzzy little balls that fill the screen and look like theburrs that stick to your pants during a hike through the woods.. . . You can just make out tiny hooks poking out of the sphericalbodies.29

But while coronaviruses can make animals very sick and areoften seen in livestock infections, in humans they had never beenknown to cause anything more serious than a cold. Never hadscientists seen anything in the coronavirus family that couldcause pneumonia or anything as deadly as this new disease.

Trying Out a New ToolThe next step was to find out more about this particular coro-navirus. To do that, WHO researchers sent samples of the virusto a laboratory at the University of California in San Francisco.Doctors there have a new tool called a DNA microarray, withwhich they can pinpoint a virus by examining a fragment of itsgenetic makeup.

The DNA microarray contains a slide spotted with fragmentsfrom over one thousand viruses known to science. If the WHOsample has any fragments that match up with the samples on theslide, spots will light up on a special scanning device. Then thearmy of spots is displayed on a computer monitor, and when atechnician slides a cursor over any lit up spot, the name of thevirus will pop up.

SARS34

In this case, researchers were excited to see several spots lightup on the microarray. The good news was that there were geneticsimilarities to three known coronaviruses that infect animals. Thebad news was that the mystery virus was not identical to any ofthem. It was a new virus, never seen or studied.

Investigating SARS35

The SARS virus is pictured inside a human cell. Scientists used a new toolcalled a DNA microarray to study the coronavirus that causes SARS.

Suddenly Theyre Rock StarsThe scientific community realized that the dangerous unknowncoronavirus was a problem. While there are many researcherswho study viruses, there were not many who specialized in coro-naviruses. One doctor says that because coronaviruses had neverbeen a serious threat to people and were difficult to grow orstudy in a laboratory, the topic had become a sleepy little cornerof virology.30 Far more researchers were interested in studyingviruses that cause Ebola, West Nile disease, or AIDSall ofwhich are known killers. With the discovery of this particularvirus, however, coronaviruses became a hot topic, and anyone

SARS36

A man suffers from Ebola in a hospital. Before discovering SARS, researchersneglected coronaviruses, focusing instead on the viruses responsible for suchepidemics as Ebola and AIDS.

who specialized in them was in great demand. Suddenly,laughs one virologist, theyre rock stars.31

After adding such specialists to the WHO team, researchersconcentrated their efforts on the puzzling new coronavirus. Likeothers in its family, the SARS virus has spikes coated with pro-teins, which are designed to latch onto the cell of an organismin this case, most likely an animal victim. The surfaces of ananimals cells have receptors, which are designed to link up withimportant body chemicals, such as insulin. A virus whose spikesmatch up with a cells receptors can then latch onto the cell andinfect the animal.

Once a cell is invaded by a coronavirus, the virus takes over thereproductive system of the cell and uses it to replicate itselfupto one thousand times per cell. This process eventually kills thecells, and the animal becomes sick. The key, says coronavirus ex-pert Kathryn Holmes, is to find out how the SARS viruswhosegenetic material most resembles an animal, not a human, virusbegan infecting people in the first place. We know the peoplegetting SARS now are catching it from people, not from being ex-posed to unusual animals, said Holmes. But where did it comefrom?32

Frustrating MutationsHolmes and other experts believe it is likely that an animal virusmutated, and its protein spikes changed in such a way that theycould latch onto human cells. Perhaps the barbs on the spikes al-tered in mutation, enabling them to be more of a threat to a hu-man host. Researchers working on mapping the viruss geneticmakeup support that theory, for in twelve different laboratories,twelve genetic profiles have been noted.

Researchers believe that the variety of genetic profiles is due tothe primitive nature of coronaviruses. All known coronavirusesare composed of single strands of genetic material which has nobuilt-in system to spot errors as it reproduces, as other virusesdo. That means that every time the virus replicates itself, itchanges in a very slight way. Notes one virologist, Corona-viruses mutate for a living.33

Investigating SARS37

This constant mutation is frustrating to scientists who aresearching for a reliable tool for doctors to diagnose patients. Insome diseases, doctors can perform blood tests to look for anti-bodiesthe bodys response to a particular germ that containsthe genetic code of the virus. With an ever changing code, how-ever, the coronavirus makes diagnosis tricky, for the antibodies inone patient may look different from those of another patient.You look for symptoms like a cough, fatigue, a low-gradefever, says one doctor. But that pretty much sums up a case ofthe flu, doesnt it? Its no wonder that so many SARS patientshave been hospitalized in [regular hospital] wards, when theyshould have been isolated.34

Returning to GuangdongTo find answers to the viruss beginnings, some researchers wentto Guangdong Province, where the first cases of SARS occurred.Scientists noted that the first victims of the disease were peoplewho worked in the many live animal markets throughout theprovince. A visit to a market just an hour south of the provincescapital showed reporter Elizabeth Rosenthal a place that seemedrife with germs:

In hundreds of cramped stalls that stink of blood and guts,wholesale food vendors tend to veritable zoos that will graceGuangdong Provinces tables: snakes, chickens, cats, turtles,badgers, frogs. And, in summertime, sometimes rats, too. Theyare all stacked in cages one on top of anotherwhich in turnserve as seats, card tables for the poor migrants who workthere.35

Scientists found it easy to imagine how a virus could movefrom such animals to people in the crowded and filthy conditionsof the market stalls, where sick and dying animals were crampedtogether in filthy cages in close proximity to stall workers. To testthat theory, researchers collected specimens from eight differentwild animals sold at the market and found varied strains of thecoronavirus in all eight animals, including civet cats and rats be-ing butchered in the stalls.

SARS38

From Person to PersonAs some researchers concentrated on the beginnings of the virusand its probable jump from animals to people, others tried to un-derstand how it spread from person to person. At first doctorsbelieved that for someone with SARS to infect another person re-quired fairly close proximity, with the infected person sneezingor coughing and those droplets coming into contact with an un-infected person.

However, as doctors began seeing more patients with SARS,they noticed that in all cases, the disease affects the lower part ofa patients lungs. That means that close contact is not necessary.Viruses that arise from the lower lungs tend to come out in a fineaerosol, rather than heavy droplets from sneezes and bronchialcoughs. The aerosol is so light that it can linger for a much longertime in the air.

Investigating SARS39

A scientist studies the SARS virus for clues about how it spreads from personto person. Scientists discovered that close contact is not necessary fortransmission of the pathogen.

In addition, scientists found that the SARS virus can live out-side the body for up to twenty-four hours, which means that itmight be possible for an infected person who touches a doorknobor elevator button, for example, to leave an active virus for some-one who touches those same objects hours later. That may ex-plain, say scientists, how so many people were infected by oneperson at the Hong Kong hotel in March 2003.

SARS40

Because SARS is so contagious and because the virus can live outside thebody for many hours, doctors must wear protective suits when treatinginfected patients.

A PuzzleBut even that theory could not account for the situation at theAmoy Gardens, a thirty-three-floor housing project in Hong Kong.In March 2003 clusters of people who had never met one anotherbecame infected. By the end of that month, three hundred peoplehad become infected with SARS, and researchers scrambled tofind an explanation for the rapid transmission of the disease. Saidone WHO researcher in mid-March, There is something goingona form of transmission we dont understand.36

Some doctors in Hong Kong were frustrated by their inabilityto pinpoint the method of infection. They worried that the dis-ease might even be spread through heating and cooling ventsfrom one apartment to another. If that disturbing theory weretrue, it would be almost impossible to protect oneself from SARSif anyone in the building had it.

A more plausible theory was put forward in April. Researcherslearned that a kidney patient left a Hong Kong hospital and visitedhis brother at the Amoy Gardens. Without realizing it, the kidneypatient had become infected with SARS at the hospital, where manyearly SARS patients were treated. While at his brothers apartment,the infected man suffered from bouts of diarrhea, and used the toi-let frequently. Researchers believe that it is possible that the SARSvirus was spread throughout the Amoy Gardens by the mans feces.

Once flushed in the toilet, the virus-infected waste could havecontaminated the sewage system through faulty plumbing. Rats,roaches, or other vermin could have come into contact with thevirus in the leaky sewer pipe and carried it throughout the build-ing, where hundreds of people unknowingly became infected.The theory is plausible, but residents of the Amoy Gardens re-mained nervous. We dont really think [the doctors] knowthemselves what the method of transmission is, says onewoman. How do they know? Its just a theory, and no one issure, and that is what makes me frightened.37

Superspreaders?Another puzzling aspect of the SARS epidemic are those peopleknown as superspreadersthose who seem to be able to infect

Investigating SARS41

large numbers of people. From the beginning, scientists havebeen baffled at how one infected person can infect ninety people,while another can be ill without spreading the virus at all. Someresearchers believe that people are superspreaders because of theway they coughperhaps forcing more of the contaminatedphlegm or spray from their lungs than do most patients. Othersbelieve that some people have far more of the virus in their sys-tems for some reason, and that makes them more likely to conta-minate others.

On the other hand, researchers believe that some people whohave had SARS have been able to fight off the virus without be-coming ill. Im quite convinced that some people might havecontracted the infection but not the disease, says one HongKong researcher. Some may develop mild symptoms, like a lit-tle bit of cough and no fever; some may just feel a little tired fora day or two.38

This phenomenon is a mystery, just as the existence of super-spreaders. Having people with the virus who do not become ill,however, is far more beneficial to the public. Scientists know thatmild cases of SARS, where people do not exhibit any serioussymptoms, are a good thing, because they act as natural vaccines.People lucky enough to get only a mild infection will have im-munity from the virus in the future.

No Cure in SightBut for the majority of people, a case of SARS is a very seriousthreatand one for which scientists have yet to find an effec-tive cure. Treatment or prevention of the disease is an ongoingchallenge, but doctors admit that there is much to be learnedabout the virus before cures are found. Until then, researchershope that an existing drug for a different virus might give somerelief.

In Hong Kong, for example, doctors have been giving somepatients a combination of steroids and an antiviral drug calledRibavirin. Though they say it has had promising results in somecases, other researchers are doubtful because the drugs do nothave an effect on the SARS virus in their labs. In other labs, re-

SARS42

searchers are testing other drugs, such as those for hepatitis,AIDS, asthma, and some cancers. They hope that the same en-thusiasm and spirit of cooperation the international science com-munity showed in identifying the virus will cure the disease aswell.

Investigating SARS43

Doctors treat a SARS patient in a Chinese hospital. Researchers continue toinvestigate new and effective ways to treat patients infected with the SARSvirus.

Life with SARS

SARS HAS HAD a dramatic effect on the way people go abouttheir daily lives in places that have had outbreaks of thedisease. Some of these changes have been merely inconvenient,while others serve as frightening reminders of how quickly adisease can turn life upside downnot only for those who areinfected, but for healthy people, too.

Clean Tires and DisinfectantOnce the Chinese government realized that it was necessary toopenly confront the SARS epidemic, life changed quickly for theChinese people. Interestingly, Chinas authoritarian system,which has been widely criticized as repressive, proved to be veryuseful in fighting the epidemic. In a country where the govern-ment rules by fist, notes observer Kathy Chen, its orders tofight [SARS] have been carried out in spades.39

For example, the state-run media were required to run publicservice programs several times each day, informing people howto minimize their risk of infection. Banners were put up in everycity and village reminding people to wash their hands and wearface masks, and volunteers were rounded up to staff checkpointsfor taking peoples temperatures. Chinese officials even decreedthat people must disinfect their bicycle and automobile tires eachday to kill any germs that might have come home with them.

One man from a town in central China learned how stronglythe government felt about containing SARS. Yang Jie, a twenty-two-year-old who worked for a home-improvement company inBeijing, decided to return home for a visit during the height ofthe epidemic. However, before being allowed on the train Yang

44

Chapter 3

had to undergo a thorough physical to make sure that he was notinfected with SARS. During the fourteen-hour train trip, railroadworkers came through his car several times to spray disinfectant.And when he arrived in his home town, Yang and several otherpassengers who had boarded the train in Beijing were put intoquarantine for a week before being allowed to return to theirfamilies.

Are You Feeling Well Today?Travel restrictions were not limited to China, however. At theSingapore airport, all travelers getting off planesregardless oftheir point of originwere greeted by nurses wearing facemasks, goggles, and protective yellow gowns cheerfully saying,Welcome to Singapore! Are you feeling well today?40 Thenurses then guided the passengers through high-tech scanners

Life with SARS45

In an effort to prevent the spread of SARS, the Chinese government orderedcitizens to take many precautions, including disinfecting their bicycles daily.

that would beep if a person had a fever of more than one hun-dred degrees. Anyone setting off the beeper was quickly escortedby masked soldiers to a video-cameraenforced quarantine area.

Singapore was serious about preventing travelers who mighthave SARS from coming into contact with its citizens. Anyonewho balked at being quarantined was fitted with an electronicwristband, and anyone who persisted in trying to escape duringthe ten-day quarantine period was jailed for six months and finedfive thousand dollars. We do what we have to, explained Sin-gapores minister of health. I dont think weve seen anythinglike this before, and it is a global problem. For now, this is a battlethat is being fought with the thermometer and quarantine.41

In many countries around the world, governments enactedstrong restrictions on visitors from a SARS-affected nation. SaudiArabia simply refused to allow Asians or Canadians to enter thecountry. Thailand allowed travelers from China, Singapore, andVietnam to visit, but required that they wear face masks for theduration of their stay.

After Canada experienced an outbreak of SARS, its healthministry requested a ten-day voluntary quarantine from anytraveler from a SARS-affected nation. Those travelers were notrequired to go to a particular facility, as they were in Singapore,but were asked to stay at home, take their temperature every fewhours, and to stay in a separate room from anyone else for tendays. By mid-April, there were believed to be at least seven thou-sand people in Canada under voluntary quarantine.

Life in QuarantineSome of those in quarantine were relatives and friends of peoplewho had developed SARS. Many spent the required two-weekperiod (the longest time known between being exposed to thedisease and showing symptoms of it) at their homes. Besides be-ing told to take their temperatures often and to stay away fromtheir families, they had to resist the temptation of dashing out todo an errand or see a friend.

Thousands of others were put on what was called workingquarantine. Most of these were health care workers who had

SARS46

been exposed to SARS at North York General or ScarboroughGrace Hospitalsthe two facilities that treated the SARS patientsduring the epidemic and which later transferred all patients ex-cept those with SARS to other hospitals in the city. Those work-ers at Scarborough or North York who had been exposed wereallowed to work their regular shiftwearing masks and protec-tive gearbut afterward had to return home.

Peggy Dawson, a twenty-nine-year-old nurse who works atScarborough Grace Hospital, was put on working quarantine,though she says that to the best of her knowledge, she was not ex-posed to anyone with SARS for the period in question. However,

Life with SARS47

A New York man kisses his Chinese bride through a surgical mask. Somevisitors to China and to other countries impacted by SARS were forced tospend up to two weeks in quarantine.

there were other members of the staff, she said, who couldhave been exposed, from people who clean the floors to physio-therapists and respiratory therapists. We all share the same cafe-teria, come in through the same entrance. Its a contact of acontact, and thats why we are all under quarantine, the entirehospital.42 Dawson says that every day she worried that shewould develop symptoms. Every time I put the thermometer inmy mouth, she admitted, Im praying that there isnt achange. She has remained healthy, but says that even thoughshe is out of quarantine she still worries that an epidemicSARSor something elsewill happen again. It has really changed theface of nursing, says Dawson, and changed the face of healthcare forever.43

It Feels like Being in PrisonQuarantine was often far different for people in Asia. Shortly af-ter it was discovered that more than 250 residents of the largeHong Kong housing complex, the Amoy Gardens, had becomeinfected with SARS, health officials descended on Block E of thecomplex and bused the 240 remaining residents to quarantine fa-cilities.

Many of the evacuees were angry, however, for they say thattheir temporary lodging seemed far more conducive to thespread of disease than their housing complex. The facilities towhich they were taken were rundown resort settlements, whichwere cramped and filthy. One woman says that she spent the firstmorning in quarantine disinfecting her cabins toilet withbleachonly to be told that several families would be sharingbathrooms during the quarantine. Said the woman, It feels likebeing in prison.44

In the eastern mainland province of Zhejiang, SARS patientswere quarantined in a government office building. Not only werethose quarantined angry at the lack of facilitiesno beds, for ex-amplebut nonquarantined residents staged violent protests atthe use of those buildings. Breaking windows and smashing fur-niture, townspeople were furious that such buildings were used,calling the quarantine a danger to everyone. They worried that

SARS48

after the quarantine ended, germs would remain in the buildings,endangering citizens. Insisted one protester, They shouldnthave hospitalized patients in the government building, which hasno medical facilities and professional staff.45

Reminders EverywhereThough SARS patients and others quarantined were most af-fected, daily lifeeven for healthy peoplechanged drasticallyduring the SARS crisis in China and other Asian countries. Forchildren in Singapore and China, it meant that school was can-celed until the threat of infection had passed. For parents of veryyoung children, it meant babysitting services, daycares, andpreschools were closed, too. That presented a problem for peoplewho had no older children or other family members to watchtheir young children while they went to work. In Singaporealone, more than six hundred thousand young children were af-fected by the closing of child care services.

There were daily bulletins on radio and television that gavethe totals of new infections and numbers of deaths for the day. Inthese bulletins parents were strongly urged not to take their chil-dren to public places such as the zoo, playgrounds, or shoppingmalls. One woman says that it was especially hard on childrenwho were celebrating birthdays during this time. Parties had tobe canceled. It was probably for the best, she says, since no onefelt like celebrating.

Lest anyone forgeteven for a momentthat there was adangerous disease in the area, there were constant reminderseverywhere one looked. Security officers stationed at the drive-way of our apartment building were stopping everyone, onewoman says, even cabdrivers, to take their temperatures.46

In Singapore, every business person was stopped before en-tering a downtown building and, before using the elevator, hadto fill out a health evaluation form. People were afraid of busesand trains because of the threat of touching a contaminated dooror seat. Instead of relying on public transportation as is usual inmost Asian cities, people opted to ride their bicyclesa decisionthat created massive traffic jams.

Life with SARS49

SARS50

Children in Hong Kong wear masks to protect against SARS. These maskswere in high demand in China as people took precautions to avoidcontracting the disease.

Bambi and Teddy Bear MasksMore than anything else, however, it was the presence of facemasks that served as a constant reminder of the threat of SARS.People rushed to medical supply stores to buy them, hoping tokeep airborne germs away from their noses and mouths. In HongKong, stores were selling more than one thousand masks eachdaysome people were buying hundreds at a time. When onlya few were left on store shelves, shouting matches often brokeout among customers.

On street corners, vendors tried to capitalize on the frenzy. Ona Singapore street, a vendor sold turquoise masks with picturesof Bambi or a teddy bear on them. They appealed to parentswhose small children did not like wearing face masks. My kidsdont want to wear them, said one mother as she bought two ofthe Bambi masks. With cartoons on them, they might changetheir minds.47

Masks seemed to be everywhere SARS was. They were wornby bank tellers, flight attendants, and waiters. Even on television,talk show hosts (and their guests) wore masks, too. But the mask-wearing has brought up some new issues of etiquette that havenever been considered before. For example, business people de-bate whether masks make their clients more or less afraid.Should one remove ones mask when meeting someone for thefirst time? And since touching and handshakes are frowned uponin the age of SARS, how best to greet a valued customer or client?

Cab drivers in Hong Kong and Singapore found that becausethey wore masks, they were losing business. As a result, manyopted not to wear them and left their windows open instead. Too,there was the issue of comfort; the most effective masks are form-fitting, and they can cause discomfort when worn for hours at atime. They are also hard to breathe through when exercising ordoing strenuous work. One American visitor to China felt thatthe mask was more trouble than it was worth. I wear my masksmost places, he said, but its uncomfortable because its humidhere, and in a restaurant when youre trying to eat, its just im-practical.48

Life with SARS51

Fear Among Health WorkersWhile the constant worry about SARS was hard on almost every-one, it was especially troubling for health care workers. Theywere the ones most at risk, and in the early weeks of the disease,it was doctors and nurses in mainland China, Hong Kong, Viet-nam, and Toronto who were infected more than any other group.

Because of the shortage of healthy emergency workers inToronto, Canadian physicians contacted doctors they knew in theUnited States and asked for help. As a result, about three hun-dred American doctors agreed to come to Toronto. The Canadiangovernment issued temporary medical licenses to the Americans(physicians are normally allowed to practice medicine only in thecountry from which they received their medical license.)

One of the American doctors who traveled to Canada says thatthe atmophere in the Toronto hospital where she worked wasboth angry and frightened. So little was known about SARSes-pecially how it was transmittedthat health workers felt vul-nerable even with protective gear. The healthy members of thestaff were burned-out because they had to work more shifts tocover for their colleauges who had caught SARS or who were inquarantine. Many were working double or even triple shifts.Theyre not getting enough sleep, they struggle with putting ontheir protective gear, said the chief of infectious diseases at theUniversity of Toronto, and they are worried about getting in-fected themselves.49

Mommy, Are You Wearing Your Mask?Trish Perl, one of the American doctors who came to help inToronto, noticed right away that there was a strange atmosphereat the hospital, with everyone wearing layers of protective geareven in the staff lounges. Some moved to the other end of a meet-ing room when a doctor who had cared for a SARS patientwalked in. It was eerielike you were on Mars or on a newplanet, she says. You sit in meetings, everyone around the tableis wearing an N-95 [high-quality face] mask.50

Perl was struck, too, by the number of doctors and clinicalworkers who are so afraid of SARS that they cannotor will

SARS52

notdeal directly with patients with symptoms that might beSARS. For example, she noted that some would not deal withanyone with a fever of more than one hundred degrees, or whosuffered from a dry cough. One radiologist stayed in his officewith his door closed and refused to have any contact with X-raytechnicians. The only X-rays he would read were those slippedunder his door.

Perl admits that she was fearful before she traveled to Canada,since she was unsure of how bad the situation was. Like otherphysicians, she was concerned about the many health care work-ers who had become infectedeven though they had taken pre-cautions. As I was hugging my little girl on leaving, I thought,

Throughout the first half of 2003, medical supply companies produced a highvolume of surgical masks to meet soaring worldwide demand.

What am I doing? Perl remembers. Is this a smart thing todo? I was very scared at first; I didnt know what I was gettinginto. And when she talked to her children on the telephone, shewas not surprised at what they wanted to know. They wouldsay, Mommy, are you wearing your mask?51

Hungry GhostsSARS has not only changed the routine for doctors and hospitals,but for the families of the victims of SARS. For instance, the dis-ease has forced a change in the cultural rituals associated withdeath. In China, for example, people are expected to remain witha dying family member. A family vigil, known as you zi song zong,is considered extremely important to ensure that after death, thespirit is happy. However, when SARS spread to Hong Kong, doc-

SARS54

Fear of contracting SARS reached as far as Toronto, Canada, after severalcases of the disease were reported there. Here, a boy wears a surgical mask toa Bluejays game.

tors began to realize how vulnerable family members and othervisitors were as they sat with an infected patient. By the end ofMarch 2003 most hospitals in Hong Kong prohibited visits byfamily members. This meant no vigils, and families were upset.

Vigils are important for more than support for a dying lovedone. Many Asian people believe that it is important to note theexpression of a persons face at the moment of death. Families be-lieve that a person who dies with open mouth or open eyes diestrying to communicate something important. To have a lovedone die in such distress can produce guilt within a family thatcan last for many years. The spirits of those who have died withsuch unfinished business are called hungry ghosts, and aregreatly feared. People who have died an early deathfrom adisease or other natural causesare considered dangerous, ex-plains anthropologist Joseph Bosco. Theyve got every right tobe angry at the world, because they were cheated out of their

Life with SARS55

Because scientists were initially uncertain how SARS spreads, finding funeralhomes to perform services for people who died from the disease was difficult.

lives.52 And because of the hospitals need to keep family mem-bers separated from the dying SARS patients, people do notknow the emotional state in which their loved ones died.

Cold and EmptyBecause people were unsure of how SARS was spread, familieshad a great deal of difficulty finding funeral parlors that wouldaccept a SARS victims bodyand even those refused to holdtraditional funeral services. Throughout Asia, funerals are almostalways held with the body displayed, but the threat of SARSchanged that. Funeral directors, worried about spreading the dis-ease from the dead body to funeral guests, insisted on using aframed photograph of the deceased, instead.

Another funeral custom that has been suspended because ofSARS is the ceremonial water buying, in which a family mem-berusually the oldest son or male relativepurchases waterwith which to wash the dead persons face. This symbolic ritualis extremely important to many Asian peopleso much so, saysone funeral director in Hong Kong, that among the older gener-ation in Hong Kong, the greatest insult would be to say, Whenyou die, I hope you have no sons to buy you water.53

Not surprisingly, the funerals for SARS victims tend to besparsely attended, which is disappointing to grieving familiesthat need the support of others. One woman says she felt terriblewhen only a handful of her husbands friends showed up for hisfuneral. I felt the atmosphere was cold and empty, she says. Iwas broken down spiritually and psychologically.54

The Psychological TollAs months went by in SARS-affected countries, many learnedthat there were often psychological effects on residents. In HongKong, for example, many people complained of feeling mentallyfatigued each day. There was no comfort of routine. There wereno concerts to attend, no social get-togethers with neighbors.

Many people found that the sources from which they had al-ways drawn strength were missing. For some it was religion, andthere were noticeable changes in churches in Asia and Canada. In

SARS56

Singapore, for example, the Catholic Church suspended confes-sions in private confessional boothsinstead offering generalforgiveneness to their parishioners. Toronto churchgoers wereasked not to dip their hands in holy water or to share wine atcommunion.

Others in SARS-affected regions missed the support they nor-mally received from their families. Since many foreign businesspeople in Asia had moved their families to other continents in anattempt to avoid SARS, they weathered the ordeal without thecomfort of their spouse and children. Karl Taro Greenfield, a Timemagazine reporter living in Hong Kong, says the experience wasnot just a medical threat but one that affected peoples spirits.The quesions raised alter the rhythm of life itself, he noted.Do you dare dine communally, as is the custom here in Hong

Life with SARS57

Altar boys attend Catholic mass in Hong Kong. Churches throughout areasimpacted by SARS welcomed parishioners struggling with the emotionaleffects of the epidemic.

Kong? Is it safe to work out at the gym? If you do work out, is itadvisable to take a shower in the clubhouse afterward? Do youkiss your children?55

One man said that people put a huge importance on daily ra-dio and television bulletins about SARS, hoping to hear promis-ing news about the disease. Every evening, the Department ofHealth releases the numbers of new infections and fatalities, hesaid. If the numbers are lower than yesterday, we cling to thehope the worst is over. If there are more new cases and deaths,we shudder.56

Psychiatric StudyFor people who have survived SARS, the psychological toll hasbeen documented. In a study of 150 SARS patients in Hong Kong,it has been found that 45 suffered from psychiatric problems whenthey were discharged from the hospital. The problems haveranged from anxiety and mild depression to episodes of posttrau-matic stress and severe panic attacks. Some doctors suggest thatthe psychiatric problems may stem from a reaction to the steroidsand other drugs given in the hospital, but no one is certain.

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The fear of SARS became an overriding factor in the lives of many Chinese,who paid anxious attention to news reports, hoping for promising news aboutthe disease.

Health care workers who survived SARS, experts say, tend tobe more fearful than before they were infected, and that as a re-sult, they have not returned to their jobs as quickly as predicted.Were finding that [because of the psychological factors] it takesquite a long time for some people to get back, says one Torontodoctor, even if they havent been that badly infected.57

One key factor that experts believe is contributing to the psy-chological problems of survivors is the stigma that is attached tothem by society. Many patients found that employers were notwilling to have them return to work because they believed thesurvivors remained a high risk for infecting others in the work-place. One Hong Kong woman was fired after refusing to sign avow to break up with her boyfrienda health care emergencyworker.

Not only recovered patients, but also many doctors, nurses,friends, and relatives of patients have been ostracized, too. OneHong Kong woman who lives at the Amoy Gardens residencewas shunned not only by friends but by her own familyeventhough her area of the housing complex was not affected bySARS or the quarantine. The fear of SARS was so strong that nei-ther her mother nor her eight brothers and sisters would see her,and she was treated as an outcast at work.

Her experience is not uncommon; in fact, Hong Kongs ministerof health finally reacted to the lack of empathy by the public to-ward people remotely affected by SARS, urging people to be lessfearful and more compassionate. Even so, by June 2003, the HongKong Equal Opportunities Commission had received thirty-eightcomplaints of SARS-related discrimination, and officials believedthere would be more filed within the month. Because so little wasunderstood about the disease, those who had been infected andhad survived often remained on societys periphery.

Life with SARS59

SARS, Politics, andthe Economy

WHILE PEOPLE AROUND the world were trying to deal withthe treatment and containment of the disease, civic andnational leaders were dealing with other aspects of SARS. Ofparticular concern was the way a new contagious disease af-fected the economy and politics of places that had sufferedlarge outbreaks of SARS.

Nothing NewChina was not honest about the SARS outbreak in providing in-formation about the mysterious disease to the international med-ical community. In addition, the government was equallydishonest to its own citizens about SARS. Chinas history con-tains stories of several empires that were toppled because of up-risings by the masses. Lest they suffer the same fate, modernChinese leaders have tried to keep frightening events such as theSARS epidemic a secret. By the governments decision not to betruthful, say experts, Chinese leaders were continuing a trou-bling tradition of covering up the nations medical problems.

For example, in the late 1990s there was a large outbreak ofHIV, the virus that causes AIDS, in the rural areas of centralChina. The disease spread among people who had sold theirblood to traffickers, using needles and other equipment taintedwith the virus. As a result, tens of thousands of people becameinfected with HIV, though the government insisted that only ahandful of people in a remote village were affected by the traf-fickers carelessness.

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Chapter 4

Another example of governmental secrecy occurred in early2003, when more than three thousand schoolchildren in a north-eastern province became illand three diedafter drinkingspoiled soy milk. Again, though thousands of parents were seek-ing medical help for their children, the government denied thatany such thing had happened. As a result of instances such asthese, the government suffered a lack of credibility when peopleeventually learned that their leaders had not been honest withthem.

Angry DoctorsSimilarly, many people feel that Chinas government may sufferbecause of its lack of openness with its citizens about the SARSvirus. Once word of the disease began to leak out, many Chinese

SARS, Politics, and the Economy61

Healthcare workers like this man were angry with the Chinese government forits initial refusal to provide information about the extent of the SARS epidemic.

citizens felt that they had been duped. Many of the angriest peo-ple were health care workers.

To make the numbers of infected people seem low, govern-ment health officials decreed in March 2003 that doctors could nolonger diagnose SARS; instead, for a diagnosis to be official, itmust be made by a medical researcher. But because researcherswere unable to see even one-fourth of the patients suspected ofhaving the disease, many patients whom doctors suspected ofhaving SARS went undiagnosed.

One doctor in Shanghai recalls a patient he saw whose symp-toms almost certainly indicated SARS. He says that he wanted toisolate the patient and begin treating his fever and cough, but be-fore he could begin, he was stunned to find that his patient hadbeen transferred without his knowledge. I never found outwhether he had the disease or not, says the doctor. We doctorsare all left with a lot of questions. I think its shameful to not letus know whats going on.58

MisinformationBut it is not just medical workers who are angry at the govern-ments secrecy. It is almost certain that thousands of Chinese peo-ple became ill, some fatally, because they were not told about theseriousness of the disease. One man says that the governmenthad assured everyone that the risk of SARS was long over, evenwhen health officials knew that the disease was spreading out ofcontrol. As a result of the misinformation, the man says, his wifewas ill and highly contagious for days with SARSand the fam-ily was certain it must be something else.

Chinese journalists, who are largely under the control of theCommunist Party, admit that they were used by the governmentto convince the public that SARS was not a problem. In Shanghai,for example, journalists were told that the number of people inthe city with SARS was highly classified and were warned thatthey would be fired or jailed if they attempted to interview SARSpatients or their families.

At the same time, however, health officials were worried thatunless they educated the public about the symptoms of SARS,

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they would be unable to contain the outbreak in Shanghai, whosepopulation is 16 million. One journalist recalls that his ordersfrom government officials were highly contradictory. Readersare going to be very confused, he tried to explain to theprovinces health minister. On the one hand, we tell them thereare almost no cases in Shanghai. On the other, we tell them thatthey must be very vigilant in avoiding the disease. But if Shang-hai has barely any cases, why does the public have to be worriedabout SARS?59

The Government Doesnt CareOf course, in busy cities like Shanghai and Beijing the ballooningrate of infection from SARS was hard to keep secret. As more andmore people learned of friends and coworkers who had becomeinfected, it became clear to the public that they had been lied to.Many were furious with their government. Its really bad, saysa relative of a SARS victim, that the government doesnt careabout ordinary peoples lives.60

As the disease moved into the more remote parts of China, theresponse was no less angry. The tiny remote villages have limitedhospital facilitiesa shortage which is troublesome under nor-mal circumstances. They lack around-the-clock staff, X-ray ma-chines, and even bed space for more than two or three patients ata time. When people infected with SARS began appearing atthese rural hospitals, health workers were forced to turn manypatients away. This experience showed residents the inadequa-cies of their health care system.

In one village, five or more SARS patients were crammed intoa single ward room which had no door or even a curtain to stopthe spread of germs. Since the hospital staff is minimal, familymembers were encouraged to stay with the patients. BecauseSARS was not supposed to be a problem, however, there was ashortage of face masks, and the families were constantly at riskof catching the disease. We relatives have to stay in that roomwithout any protective measures, all day and all night, com-plained one young man. Its very dangerous, but we have nochoice, if we want to take care of our family.61

SARS, Politics, and the Economy63

Why Didnt the Government Say Anything?If this situation had occurred in the United States or any otherdemocracy, it would hardly be surprising for peoples anger to bedirected at the government. However, China is a nation wherepower is monopolized by the Communist Party. Though it isvery modern in its economic policies, Chinas political systemhas a long history of being resistant to change. The system isclosed and secretive, and has a dismal record regarding humanrights. Protesters have been shot for criticizing the governmentor its actions, and as a result, people tend to keep their anger orfrustration to themselves.

SARS64

Two women try to keep SARS out by blocking the entrance to their village.Such remote rural areas lacked the facilities and resources to properly treatSARS patients.

But people have been outspokenmany for the first timeabout their governments mishandling of the SARS epidemic.One young woman who became infected after tending to hermother and father in the hospital when they had the disease wasangry. If we had known about this disease, we would havestayed away from the hospital, she says. Why didnt the gov-ernment say anything? I blame them for my parents death.62

Many Chinese, fearing for the health of their families, felt thatthe government was less interested in preventing SARS than inkeeping up the pretense that all was well in Chinas cities. In Bei-jing, for example, people were frantically trying to find trans-portation out of the city as shops and restaurants were closingbecause of the SARS threat. When officials urged people to stayhome, they were ignored. Im very worried about getting on atrain with so many people, said one young man in April 2003.But Ill do anything to get out of Beijing. Its simply become toodangerous.63

At Beijing University, students openly rebelled against gov-ernmental orders to stay on campus during the height of the epi-demic. University officials warned students that they wouldsuffer consequencesincluding expulsionif they left. Even so,many students packed their backpacks and left, hoping to avoidcatching SARS. One student said that his classmates did not wantto have their fate controlled by the government, explaining:They said theyd have the control over their own legs.64

For the Sake of the PeopleMuch of the anger has been directed at Chinas new president, HuJintao. Hu, whose ideas are more liberal than his predecessors,had impressed many people in his first presidential speech, for heseemed more committed to honesty and openness than otherleaders had been. He vowed to remember that the well-being ofChinas people was his most important responsibility: Powermust be used for the sake of the people, he urged. Materialbenefits must be sought in the interests of the people.65

However, in the early days of the epidemic Hu allowed gov-ernment health officials free rein in handling the crisis. They

SARS, Politics, and the Economy65

chose to deal with the disease in more traditional waysin thiscase, being secretive about the severity of SARS. It was onlywhen WHO and the international media became involved thatHu realized that he and his government were rapidly losing thetrust of the peoplein addition to that of the international com-munity.

On April 20, 2003, Hu abruptly fired his health minister, re-placing him with a no-nonsense former trade minister, Wu Yi.Wus job was one-dimensionalto head the anti-SARS fight inChina. It seemed clear that for the first time in memory, Chinasgovernment was serious about openly confronting a crisis.

Students quarantined at Beijing University do morning exercises. Manystudents defied government orders and left the campus to avoid contractingSARS.

The Black Box or the SunshineHus supporters were very pleased by his actions. They believedthat his decision to be more open about SARS would benefit thenation. Perhaps, they said, this episode forced China to turn acorner, allowing much-needed reforms. This is [Hus] chance tograb the support of the people and stand up on his own, saidone former party official. China can keep living in a black box,or it can live in the sunshine. If he cant take advantage of the sit-uation and move into the sun now, then when?66

There is strong opposition to Hus openness, however. SomeCommunist Party officials are critical of Hus more liberal views.They predicted that his more open dealing with SARS wouldbackfire, causing panic among the Chinese people. The formerpresident of China, a conservative named Jiang Zemin, is one ofthe most adamant critics of Hu, and experts in Chinese politicspredicted that if the SARS epidemic had not been controlled,Jiang might have regained power. If that had happened, say ex-perts, it would have signaled a return to the more repressiveregimes of past years.

No one doubts that the SARS issue was a political challengefor the Hu presidency. For the Chinese government, noted oneobserver, the SARS crisis presents the gravest threat since thestudent protests at Tiananmen Square [that resulted in more than165 deaths of Chinese demanding democracy] fourteen yearsago.67

Economic DisasterPolitics is not the only thing that has been affected by SARS. InSARS-stricken countries, the epidemic has had a gre