Chapter 1
The Secret Killer

Months before the World Health Organization declared it a worldwide health threat and gave the disease its name, SARS had begun infecting people in Guangdong Province, in southern China. At the beginning, however, few health professionals were worried about it at all.

A Cold? The Flu?

It was in November 2002 that the first cases were seen in the rural areas of Guangdong Province. People complained about headaches, aching muscles and joints, as well as a loss of appetite. 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, believing that the symptoms would fade after a few days.

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

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

"We Didn't Take Any Preventive Measures"

One young nurse who became ill says that she had been looking after a patient who came to the hospital with flu-like symptoms, as well as a severe cough. "The whole forty minutes [she was with him] he was coughing and expelling huge amounts of phlegm." This was unusual, she says, for a cough of that nature was not normally a symptom of the strains of flu she had seen. But although his illness was a mystery, the staff did not wear masks when tending to him. "We didn't take any preventive measures," she says, "as we normally don't wear masks when taking care of flu patients."⁵

The patient's condition deteriorated quickly, and he was transferred to a larger urban hospital, where he died. Meanwhile, the nurse became ill. With a high fever, aches, and fatigue, she thought she might be overworked or had maybe caught the flu. But medicines and rest did not help her symptoms at all, and she was admitted to the hospital where ten other staff members had become sick with similar complaints.

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

My lungs haven't got back to normal and I still feel tight in the chest. I suffer from a bad insomnia; most nights I can only sleep for a couple hours. My muscles are so weak I can hardly lift anything, and my eyes are swollen and red. But the thing that disturbs me the most is my right leg. I can't walk, can't even move the leg without feeling an excruciating pain in my joints. I used to be very active, very physical.⁶

News via the Grapevine

But even though there were many such stories among people who were battling the disease, the Chinese remained secretive. They refused to release information about the illness in the newspapers or television. Government officials did not want to alarm the citizens, nor did they want to admit that there was a contagious, deadly disease that they were unable to contain. Such an admission would cause a mass panic and would almost certainly affect the foreign investment on which China had become dependent. Since the Chinese media are all tightly controlled by the government, no details were released about the disease, and doctors were told not to discuss it—even with health professionals in other parts of China.

However, many Chinese health care workers were alarmed by the disease, and on many of the most popular Chinese Internet sites doctors and nurses passed along rumors that people were dying from a mysterious new form of pneumonia. It soon became clear to provincial officials that they could not remain silent about the disease. On February 11, 2003, Guangdong officials ordered the health minister to make a public announcement, acknowledging that there was a form of pneumonia that had killed five people and infected hundreds of others. At the same time, however, the health minister reassured the Chinese people that there was nothing to fear, since the disease was now completely under control.

The government in Beijing, China's capital, was worried about the effects of such news on China's reputation as a modern, growing nation. Determined that there be no further rumors or questions about the disease, officials ordered the people of Guangdong to refrain from talking about it. It was best, they warned, "to voluntarily uphold social stability, not believe in rumors, not spread rumors."⁷ In addition, the police were instructed to meet with Chinese Internet webmasters and order them to write only positive things on their websites about the nation's efforts to combat the disease.

Coming to the City

But it was difficult for the people in Guangdong to remain silent about SARS when it was obvious that the disease was not under control at all. In fact, there was a growing problem as some rural patients—frightened because they were not getting better in their local hospitals—traveled to Guangzhou, the large capital city of the province. Because of the lack of information on the disease, the large metropolitan hospitals of Guangzhou were unaware of the seriousness and highly contagious nature of SARS. While the local hospitals had learned to isolate SARS patients to keep them from infecting others, the metropolitcan hospitals found out the hard way.

Nurses at the Number 2 People's Hospital in Guangzhou say that they will always remember February 2003 as a time when they were all endangered. A very sick man had visited various hospitals in the city—including Number 2. No health care workers knew enough about SARS to isolate the man; in fact, none of the staff who examined him used masks or gloves. As a result, dozens of doctors and nurses became infected. Says one nurse from Number 2, "He was very sick, but who knew there was something so terrible going around?"⁸

The rapid growth of the number of cases began to cause panic among the public in Guangdong. "On the streets here," noted New York Times reporter Elizabeth Rosenthal who was visiting Guangdong Province, "rumors abound, and people feel they cannot protect themselves in the absence of information."⁹ That absence of information left a vacuum that was quickly filled by various theories about the nature of the disease, ranging from an exotic form of flu to anthrax or some other weapon that had leaked from a military base. Hoping to protect themselves from the germs, people wore surgical masks on the streets, and if they could not find the real thing, they fashioned them from gauze and tape.

A number of folk remedies were circulated, too—from breathing vinegar fumes to eating a diet of turnips. One cure, adopted by many frightened Chinese, was to smoke more cigarettes—or, if one did not already smoke, then start. Advocates of this cure believed that the tobacco smoke would drive the poisons from patients' lungs, allowing them to breathe more easily. But neither the folk remedies nor the antibiotics were effective against SARS, and Chinese health officials were worried.

"We Didn't Believe It"

Though Chinese officials had tried to keep SARS a secret, bits and pieces of information about the disease had spread via the Internet to the World Health Organization (WHO) and the Centers for Disease Control (CDC)—both international public health organizations. When WHO's Outbreak Center, which investigates any new and potentially hazardous diseases in the world, made official inquiries to China, they were told that the oubreak was a new type of flu—and that the Chinese health authorities could handle it without outside help.

But as word of a growing death count continued to reach beyond China's borders, WHO and CDC officials were convinced that they were being lied to. Chinese officials refused to provide more specific information and repeated orders to its doctors not to respond to any inquiries from WHO or the CDC. Certain that there must be more going on in China, WHO officials contacted a Hong Kong laboratory with which they frequently worked, and had lab technicians visit Guangdong hospitals to collect tissue samples from some patients.

Worried about losing their jobs, however, the Chinese health officials provided tissue samples from patients who were suffering from other germs, and repeated that the outbreak was over. Doctors at the international agencies were skeptical, since antibiotics would certainly have cured all of the germs in those samples. One CDC doctor said flatly, "We didn't believe it."¹⁰ As he would learn very soon, his instincts were absolutely correct.

Spreading Beyond Guangdong's Borders

On February 21, 2003, the one thing that was feared most occurred—SARS spread beyond Guangdong Province's borders. A sixty-four-year-old retired lung specialist from Guangdong named Liu Jianlun went to Hong Kong for his nephew's wedding. Liu had been feeling tired, and when he arrived in Hong Kong he was running a low-grade fever.

As Liu's symptoms worsened, he went to a Hong Kong hospital. Understanding that he probably had SARS, Liu advised the emergency room staff to isolate him behind double panes of glass, which Guangdong regional hospitals had begun doing for their patients. He also insisted that before examining him, doctors and nurses put on protective masks, gloves, and gowns. Liu's cautions undoubtedly saved lives at the hospital; he died several days later, but none of the staff became infected.

But Liu's death was not publicized, nor were doctors in other hospitals 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 hotel where he was staying. Three young women from Singapore were infected, as were two Canadians, a man from Hong Kong, and an American businessman on his way to Hanoi, Vietnam. Not only had SARS been carried beyond the borders of Guangdong, China, but because of this one case, it would soon be spread throughout the world.

A Global Threat

Again, because of the lack of real information about the disease, hospitals outside of Guangdong Province were ill-equipped to deal with it. In Toronto, for example, a woman who had talked to Liu in Hong Kong became ill and died on March 5, 2003, after infecting her son and several doctors and nurses at the Toronto hospital where she was taken.

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

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

An Official Alert

With new information that the disease had spread to Canada and other countries, WHO officials issued a global alert on March 12, 2003. With the limited amount of information it possessed, the agency warned of the new disease and urged travelers and airline crews around the world to watch for symptoms. It also recommended that doctors and nurses isolate anyone presenting symptoms that seemed suspicious and take precautions by using protective suits, gloves, and masks when treating patients.

The warning to health professionals was apt, for doctors and nurses were among the hardest hit by SARS. By the middle of March 2003 the emergency room at Scarborough Grace Hospital, where Tse was treated, had to shut down because of a shortage of healthy staff members. Thousands of Toronto citizens who had visited the hospital or had been treated there were told to isolate themselves at home for ten days to avoid infecting others.

In Hanoi, the American businessman infected twenty health care workers. Of the three women from Singapore, one visited the Tan Tock Seng Hospital, and left ninety-two people sick—at least one-third of them health care workers.

Worst in China

China remained the hardest hit by the growing epidemic, and the government continued its policy of secrecy and noncooperation with international authorities. WHO asked for permission to visit China so that doctors could review data about the first outbreak in Guangdong. The response by the Chinese was, says one WHO official, "dead silence."¹³

The fact that their government was continuing to be secretive caused panic among the Chinese public. Villages erected barriers on the roads leading in and out of town to be sure that outsiders did not bring the disease in. Rumors circulated like wildfire, too, noted one observer. "Grannies… whispered that the entire capital was going to be quarantined, while Internet chat rooms buzzed with claims that the disease was a conspiracy courtesy of the Americans and the Taiwanese."¹⁴

In early April SARS hit Beijing, infecting ninety people at a large downtown hospital—seventy of them nurses and doctors. Yet when asked if it was safe for tourists to come to the city, one government representative minimized the risks, stating that there had been only thirty-seven cases, and the disease had been contained by Chinese health care workers. "Of course [tourists] can travel," he said. "We think it's very safe."¹⁵

"We're Frustrated"

International health officials, however, were not convinced. One WHO representative was adamant that the stonewalling had to stop. "We have clearly told the government," he said, "the international community doesn't trust your figures."¹⁶ Many doctors around the world demanded more information in case SARS appeared among their citizens. In the United States, Secretary of Health and Human Services Tommy Thompson also expressed his exasperation with the Chinese government for being overly concerned about their image and insisted that WHO and the CDC only wanted to help China contain the disease. "We're frustrated," he said. "We want to work in greater collaboration with them."¹⁷

By the end of April, however, the government finally acknowledged that SARS was not completely contained and that an accurate count of those with SARS in Beijing was 339, rather than 37, as previously announced. Within a week, the figure had jumped to 900 confirmed cases. To try to contain the disease, the government ordered the quarantine of all offices, hotels, restaurants, and residential buildings that might have been visited by people infected with SARS. By quarantining, or isolating, people who were already sick or who had been exposed to the disease, doctors hoped to minimize the chance of them infecting more people. The order for a two-week quarantine left more than two thousand doctors, nurses, and patients at Peking University's People's Hospital in downtown Beijing isolated among 90 confirmed cases of SARS—70 of them health care workers.

Although the government stressed that there was little to fear, Beijing residents were behaving otherwise. By the end of the month the city of 13 million resembled a ghost town, most citizens having taken refuge in their homes, hoping to avoid catching the disease that the government refused to talk about openly.

While these were aggressive steps for Chinese leaders to take, many experts believe that the government was still attempting to hide the extent of the epidemic from WHO and the rest of the world. For instance, China's leaders were so worried about an outbreak in Shanghai, the nation's banking and commercial center, that they ordered Shanghai officials to preserve the city's reputation as "SARS-free" at any cost. Doctors in Shanghai, however, admitted to reporters that there were at least 30 confirmed cases in the city already, but the government was firm in its order. "All I have been told," one health official in Shanghai explains, "is that we must maintain the image of Shanghai as a place without a SARS problem."¹⁸

Hiding in Ambulances

Even when WHO representatives were finally permitted to enter China for the purpose of investigating the nature of the disease, the stonewalling continued. Chinese doctors were instructed to follow what was called the policy of the "Three No's"—"No talking to the media about the nature of SARS; no talking to the public about doctors' personal experiences treating the disease; and no communicating with the WHO about anything to do with SARS."¹⁹

When WHO representatives visited Beijing's China-Japan Friendship Hospital on April 21, 2003, for example, they were shown a ward containing only two SARS patients. The rest, says reporter Hannah Beech, were being driven around the city in ambulances until the WHO doctors left the hospital. "Inside the ambulances," she explains, "was a deadly secret: 31 coughing, shivering hospital Workers who had caught… SARS from their patients."²⁰

Fearing that they would be fired if they talked to the international media, doctors and nurses remained silent when asked about the epidemic. Their only comments were off the record, and at those times they admitted that the threat of SARS throughout the country was far more than the government was letting on. One doctor apologized that he was not allowed to speak with an American reporter. "I'm embarrassed that I can't talk to you," he said. "I had really wanted to, but I'm young, and I can't afford to lose my job."²¹

One health minister, however, was angry that China was being judged harshly by other nations for its methods of dealing with the crisis. He feels that because China is such a populous nation, the government cannot afford to make decisions based on what is best for individual people, but rather must think of the majority. "You foreigners value each person's life more than we do because you have fewer people in your countries," he says. "Our primary concern is social stability, and if a few people's deaths are kept secret, it's worth it to keep things stable."²²

More Questions than Answers

But stability was hard to maintain as the disease continued to spread. Doctors had believed that SARS was spread only by close human contact—from inhaling the spray of a cough or sneeze of an infected person. In Hong Kong, however, that theory proved false. In less than a week, 250 residents of a thirty-three-floor housing development contracted SARS, and most of those people had never met one another. Clearly, close human contact had not occurred, yet the disease spread quickly—by the end of April infecting a total of 1,527 in Hong Kong.

As in other cities around the world, quarantine seemed the only method of containing SARS, although doctors were not even certain whether that would work. Meanwhile, hospitals were running out of space, people were fleeing affected areas, and those who had been exposed to the disease were herded into seclusion until doctors felt that they were no longer at risk of coming down with SARS.

As doctors and researchers struggled for answers, they were met with more questions. Where did the disease come from, and how exactly was it spread? Was there any medication that would help SARS victims? One Toronto doctor voiced his frustration as more patients with symptoms continued to show up in the city's emergency rooms. "The difficulty is we're facing an enemy that has no known shape, no identity, and no known effective treatment—and that's causing the most concern."²³ Clearly, the international medical community had a difficult task ahead.