4/5/03

A Chinese farmer, top, feeds his flock of chicken near the outskirts of Guangzhou in southern China's Guangdong province. Livestock in southern China may be the source of the mysterious virus that has caused a global health scare. Photo: AFP

People don surgical masks as they leave a hospital in Guangzhou. Photo: AFP

A man puts on his surgical mask as he carries his newly adopted Chinese child to the departure gate at the Guangzhou airport. Photo AFP

A Tibetan lama use his prayer beads and a handkerchief to make a simple face mask to protect himself against severe acute respiratory syndrome at the Beijing airport. Photo: Ng Han Guan

Foshan is ground zero in the SARS outbreak. As far as can be determined, on Nov. 16, two or three residents in this factory-dense city in the fertile Pearl River delta were stricken with an atypical pneumonia now known as severe acute respiratory syndrome. These first deaths went unremarked. Life is cheap, apparently, when there are 1.4 billion lives.

"We did not take it seriously at the beginning," said an official from the Guangdong Provincial Centre for Disease Control and Prevention.

The pathogen, still unidentified, had picked the perfect petri dish in which to incubate, perhaps mutate, and then spread. Foshan is a metropolis of 3.5 million, engulfed by the urban sprawl of Guangdong's nearby capital. Yet it remains fringed by traditional peasant farms where people and pigs live cheek by jowl.

As such, Foshan is a third-world city with all the usual sanitation problems, but one where many residents are rich enough to travel frequently and far.

From this hybrid of gleaming skyscrapers and farmers' markets selling live chickens and snakes, the mystery pathogen hitched a ride to a hospital in the provincial capital. A Chinese doctor there carried it to a Hong Kong hotel, setting in motion a catastrophic chain of events that would end up with more than 2,200 people infected worldwide and 78 dead, including seven in Toronto.

What did China know, and when did it know it? And why on Earth did it not tell the world? This is not only the story of ancient agricultural practices co-existing with 21st-century technology. This is also the story of a cover-up.

Mindful of its lucrative tourism industry and expanding foreign investment, Beijing fell back on a centuries-old tradition of bureaucratic secrecy and xenophobia. With breathtaking myopia, authorities decided to suppress the news of SARS.

"If they would have acknowledged this early, and we could have seen the virus as it occurred in south China, we probably could have isolated it before it got out of hand," said Dr. Stephen Cunnion, an infectious-disease expert who is installing modern laboratories in China and who is president of International Consultants in Health Inc., in Silver Spring, Md.

"But they completely hid it. They hide everything. You can't even find out how many people die from earthquakes."

This week, Beijing finally admitted it had 1,190 suspect cases and 46 deaths, many more than previously acknowledged. For the first time, it reported SARS cases in Shanghai and three new provinces, Guangxi, Sichuan and Hunan. On Wednesday, after stalling an epidemiological team from the World Health Organization in Beijing for nine critical days, China finally allowed the team to enter Guangdong.

After WHO issued a rare global alert, every single country affected by SARS began providing daily updates - all except China, the mother of all affected areas. With SARS now infecting 17 countries and paralyzing Hong Kong, Singapore and Toronto, some critics are calling China's belated acknowledgment negligent, even criminal.

Without Beijing's co-operation, fighting SARS has been like trying to complete a jigsaw puzzle with half the pieces missing-and with deadly consequences for every delay.

An official cover-up is nothing new in Communist China. In the early 1960s, Beijing hid news of widespread famine precipitated by ill-advised economic policies during Mao's Great Leap Forward. More recently, authorities suppressed news of an outbreak of hepatitis A in Shanghai. And for years, China denied it had AIDS, even as peasants were selling their blood for plasma and being re-transfused with tainted pooled blood.

In the case of SARS, the outbreak picked up steam fast. By mid-November, five more cities in Guangdong province reported having it. By December, a mild panic ensued in one of the cities. Seven hospital staff in Heyuan had been infected.

But information was not shared with other health departments in this province of 80 million people. Instead, the Heyuan paper printed this statement on Jan. 3 from the local health bureau: "No epidemic disease is being spread in Heyuan. . . . Symptoms like cough and fever appear due to relatively colder weather." That was apparently the first report on SARS in the Chinese media.

That month, patients began arriving at Guangzhou hospitals. A pig farmer, a seafood merchant and a 10-year-old boy all came down with an acute pneumonia. After the boy died, hospital workers posthumously nicknamed him "Du Huang" or the Emperor of Poison. He had infected five of them, including an ambulance driver and doctor who later died.

In Guangzhou, staff at the No. 2 Sun Yat-sen Hospital later dubbed the seafood merchant "a walking biological weapon." He seemed to have infected everyone around him.

Still, Chinese authorities made no official statement. Instead, they ordered journalists not to report on the outbreak. A reporter at a Shenzhen newspaper said the ban came even as his manager passed out Chinese herbal medicine, supposedly to fight the disease.

In late January, a newspaper in Zhongshan, one of the affected cities, published a brief message from provincial authorities: "This virus has been present in Guangzhou for more than a month, and the illness of those afflicted has been effectively treated and controlled. There is no need for people to panic."

Rumours began to circulate. Some people sent this text message via their cell phones: "A fatal flu has broken out in Guangzhou." Another rumour said bioterrorists had struck Guangzhou's World Trade Centre building and 100 people had fallen ill. Managers there reacted by disinfecting the whole skyscraper and vaporizing vinegar through the ventilation system.

By Feb. 1, the Lunar New Year, south China experienced a run on vinegar, considered a good way to fumigate a room. "You go into some offices in Guangzhou, the whole damn building smells like vinegar, from the entrance to the elevator and up to the office," said Ben Mok, a Canadian who is the general manager for Coca-Cola Inc. in northeastern China.

On Feb. 9, Roche Group, the Swiss pharmaceutical giant, saw a marketing opportunity in Guangzhou. It held a news conference and handed out a fact sheet touting one of its anti-viral medicines, Tamiflu. Sales went so well that Roche shipped more in from its Shanghai factory.

Guangdong law-enforcement authorities warned Roche that it would be "seriously punished if it was found to have spread rumours that Guangdong was in the grip of pneumonia and bird-flu outbreak." Roche denied that it had spread rumours, saying Tamiflu sales had been strong even before the press conference.

The outside world remained oblivious until Feb. 10. On that day, Dr. Cunnion, the infectious-disease expert, posted the first query on ProMed-mail, a Web site run by the International Society for Infectious Disease.


"Does anyone know anything about this problem?" Dr. Cunnion asked, pasting in this message from a friend of a friend: "Have you heard of an epidemic in Guangzhou? An acquaintance of mine from a teachers' chat room lives there and reports that hospitals there have been closed and people are dying."

Jack Soo, a translator in Kuala Lumpur, replied the same day, posting anecdotal reports from China. The secret was out.

The same day that Dr. Cunnion in Maryland was posting back and forth with Mr. Soo in Malaysia, Beijing formally asked for help from the World Health Organization. That, however, didn't mean it wanted WHO to actually show up. For more than a week, it dickered over the experts WHO wanted to send.

On Feb. 11, the Guangdong Provincial Health Bureau gave its first press conference. Between Nov. 16 and Feb. 9, it said, 305 people were infected and five died. But the outbreak "has been brought under control." Again, the mantra: no problem, don't worry.

Next Magazine, Hong Kong's top-selling weekly, decided to send reporters into Guangdong. They went to the No. 2 Sun Yat-sen Hospital, where five doctors and nurses were rumoured to have died.

Next published its story on the mystery pneumonia in mid-February. "We put it on the cover," said Yeung Wai-hong, the magazine's publisher. "At the time, nobody took us seriously."

Meanwhile, one doctor, Dr. Liu Jianlun, was working long hours at the No. 2 Sun Yat-sen Hospital, caring for patients suffering atypical pneumonia. On Feb. 15, he received a phone call inviting him to his nephew's wedding in Hong Kong. By then, 45 people at the hospital had come down with SARS. Dr. Liu, 64, had already been feeling unwell for several days himself, but he didn't want to miss the wedding.

He also wanted to use the opportunity to drop in on researchers at the University of Hong Kong, to discuss the mystery illness that had killed several of his colleagues.

Dr. Liu and his wife made reservations at a three-star Hong Kong hotel called the Metropole. On Feb. 21, they traveled there by bus. By the time he checked in, he had a high fever and a dry cough. The reception clerk assigned him to the ninth floor. That afternoon, Dr. Liu took a long nap, then struggled to get ready for dinner with his sister's family.

Experts now theorize that Dr. Liu must have infected at least seven others on the ninth floor while waiting for the elevator. They include a 78-year-old Toronto woman who was checking out, a man from Vancouver, an American businessman, three women from Singapore and a 26-year-old Hong Kong man visiting a friend on the ninth floor. Each would catch SARS from Dr. Liu. They would spread it to the world.

The next day, Dr. Liu felt so ill he went to the Kwong Wah Hospital, just down the street from the Metropole. There, he warned staff that he was highly infectious. He demanded a mask and an isolation ward behind double-sealed doors with reduced air pressure. Then, Dr. Liu gave stunned doctors a brief history of the illness, before falling very sick.

SARS soon began hitching rides on airplanes, to Hanoi, Singapore and Canada. On Feb. 26, the American businessman flew to Hanoi where he fell sick. Johnny Chen infected 20 health workers there, including Carl Urbani, the WHO doctor who first identified the SARS outbreak.

Mr. Chen was taken back to Hong Kong, where he was admitted to the Princess Margaret Hospital. He died on March 13, but not before infecting dozens more health workers. Dr. Urbani died on March 28.

The three Singapore women survived, but infected health workers at hospitals there, including a doctor who flew to New York and was subsequently admitted to hospital in Germany.

The 26-year-old Hong Kong man was admitted to the Prince of Wales Hospital, infecting dozens more health workers and patients at a third Hong Kong hospital.

"Had Hong Kong known more about the very first cases it treated, it wouldn't have been passed on," said Peter Cordingley, a spokesman at WHO's regional office in Manila. "There were nearly two crucial weeks when this thing was growing and accelerating and nobody knew what it was."

In Toronto, Kwan Sui-chu infected several family members and her doctor. She died on March 5. Her son died at Scarborough Grace Hospital on March 13. Since then, five others have died, and more than 160 people in Canada are suspected of having SARS.

Prompted by the Toronto outbreak, WHO issued its first global alert in decades. On March 12, it called SARS a "worldwide threat" for which there is still no test, treatment or vaccine. That same day, Dr. Liu's hospital transferred all SARS patients to a special infectious-disease hospital. Ward 3 on the 16th floor was abandoned so hastily that last week soiled sheets were still hanging off the beds.

But the WHO alert went unreported in China. Beijing was in the midst of its annual two-week National People's Congress, a sensitive time when the media rarely report bad news.

On March 16, China handed over its first data to WHO scientists. The information raised hopes because it showed that SARS was abating on its own. A Foreign Ministry spokesman, Kong Quan, announced that the outbreak was "effectively under control." That day, Dr. Liu's brother-in-law became Hong Kong's sixth SARS fatality.

International pressure mounted. On March 25, Health Canada stiffened its travel warning, advising against all travel to Hong Kong, Guangdong, Singapore and Vietnam. And for the first time, WHO began linking SARS to the outbreak in south China.

In response, China dramatically increased its numbers. It acknowledged 792 cases in Guangdong and 31 dead, plus three more deaths in Beijing. But it still refused to let the WHO team into Guangdong, a province normally open to tourists and business travelers.

The state-run media remained silent. Asked this week about SARS, Paul Yeung, a Torontonian working for a public-relations firm in Beijing, e-mailed back: "Everything in Beijing is fine at present -- hardly any information has been released -- so it is almost like it doesn't exist here."

On Tuesday, China Daily reported nothing about SARS, except a mention that the Rolling Stones had cancelled their concerts in Shanghai and Beijing. But on Wednesday, the newspaper finally ran a front-page story on SARS, assuring readers that it was under control.

This week, the same hospital where the late Dr. Liu once worked declined comment. "Sorry, we do not really understand. We're not too clear," said a woman reached by telephone at the No. 2 Sun Yat-sen Hospital in Guangzhou.

Gregory J. Rummo, a businessman and syndicated columnist from Butler, N.J., was in south China this week to adopt a baby girl. When he asked his guide in Nanning what to do about SARS, Mr. Rummo reported that the man smiled and told him, "I don't think you have to worry about SARS. Eat right, get enough rest, avoid stress."

The U.S. State Department is worried. It's announced that all non-essential diplomatic personnel and their families may leave Hong Kong and Guangzhou if they wish. The Centers for Disease Control in Atlanta has broadened its travel advisory to include all of mainland China.

Meanwhile, the economic fallout from SARS has hit airlines, hotels and restaurants Amsterdam to Zurich. In Toronto, a large international group of cancer researchers cancelled its annual conference, which had been set to begin today. The loss to the city is pegged at $15-million or more.

WHO, founded in 1948 by the United Nations, has no enforcement powers. After trying polite encouragement, it apparently decided to use language Beijing understood. On Wednesday, with its team still languishing in Beijing. WHO issued a travel advisory for Hong Kong and Guangdong, its first-ever global warning against travel to an area because of an infectious disease.

China got the message. The WHO team could visit Guangdong after all. And Zhang Wenkang, the Chinese Minister of Health, said he was sure that once it became obvious everything down there was hunky-dory, people would surely visit China again.


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