Posted on 04/26/2003 8:00:24 PM PDT by Prince Charles
The Sars outbreak
The day the world caught a cold
It began in a province of China, spread through Hong Kong to reach three continents and now threatens to plunge the world economy into freefall
Gaby Hinsliff and Mark Townsend in London, Ed Helmore in Toronto and John Aglionby in Jakarta
Sunday April 27, 2003
The Observer
Nursing his pint of Guinness in a bar in downtown Toronto, Mike Smith was sanguine yesterday about his chances of surviving the deadly illness sweeping his native city. 'People have over-reacted,' scoffed the media analyst. 'You have a better chance of being hit by a comet than contracting Sars.'
It is less infectious than flu, rarer than TB, less deadly than cerebral malaria. But the sheer speed with which Severe Acute Respiratory Syndrome has hitched a ride around the planet - from the hinterlands of southern China to more than 26 countries worldwide, including Canada and Britain - has captured public imagination worldwide.
The fear of the millennium's first jetset disease is such that in Hong Kong, citizens scared of touching contaminated surfaces tap their pin numbers into cashpoints using their wallets. In Singapore, webcams and electronic tagging are being used to enforce the virtual house arrest of 2,800 people suspected of harbouring the virus. In London, phones are ringing off the hook at Maxmi, a small online business selling £9.99 surgical masks: it says one foreign embassy recently tried to place a bulk order for millions of them.
What the past week has demonstrated is that for all Smith's optimism, convalescing from Sars itself may be easier than recovering from the shock to global confidence. Only one thing travels faster and more unpredictably than a virulent infection: and that is fear itself.
The story begins last November in the heart of the Pearl River Delta, a once remote rural area of China now booming thanks to the overspill of nearby Hong Kong and a rash of sweatshops producing cheap plastic toys.
The first report of a mysterious pneumonia-type bug was here in Guangdong province, in the small university town of Foshan. One theory is that a shrimp salesman carried it the few miles to the nearby larger town of Guangzhou. However it arrived, by February Guangdong was reporting at least 305 cases, many of them treated at Guangzhou hospital - enough for its respiratory disease specialist, Liu Jianlun, to be familiar with its symptoms.
Which makes the elderly doctor's motives in boarding a bus, late in February, for Hong Kong a focus of speculation. Was he, as his family claimed, simply attending a wedding, or did he suspect he was harbouring something local medicine could not cure?
The doctor checked into a room on the ninth floor of the Metropole hotel in Kowloon. The next day he walked the five minutes to a nearby hospital with a temperature and flu-like symptoms, and reportedly asked to be put in isolation.
If he had hoped to protect others, it was too late. One theory suggests he had a sneezing fit in the hotel lift, another that he inadvertently left traces of the virus on the lift buttons.
However it happened, seven other guests sharing his floor on 21 February caught the virus, making the late Liu Jianlun 'patient zero': the human conduit who unwittingly turned a personal tragedy into a global threat. One of the seven, Kwan Siu-Chiu, a 78-year-old Chinese-Canadian, is thought to have brought the disease home to Toronto, where it has triggered more than 330 cases and killed 19.
A Chinese-American businessman returning home to Hanoi brought the disease to Vietnam, while three young Singaporean tourists who had waited in the same lift lobby infected at least 17 medical staff on their return. Cases have now been reported from the Philippines to Bulgaria.
The first most British doctors heard of the mystery bug was when they clicked open an email on the morning of Thursday 13 March, just days before the Gulf war began. An urgent communique from the Department of Health's chief medical officer, Professor Sir Liam Donaldson, urged vigilance for cases of 'acute respiratory illness' in people returning from Hanoi, Hong Kong or Guangdong, with symptoms including muscle pain, coughing, and high temperature.
Asking for such cases to be reported and nursed using 'barrier' methods to prevent infection, Donaldson concluded: 'The cause of these illnesses is as yet unknown.'
His warning, the day after the World Health Organisation issued a global alert on the bug, proved timely. Six days later - just as the WHO announced in Geneva that it thought the Far East outbreak was probably under control - a London man recently returned from Taiwan arrived at Brent hospital with flu-like symptoms. Britain's first 'probable' case of Sars - meaning the victim has an unusual type of pneumonia, has visited an infected area and has signs of lung damage, although there is no conclusive test - had arrived.
By 5 April, the toll had risen to six probables, the last of whom had never left the country but had met a Hong Kong business contact at the Marriott Hotel near Heathrow. None needed intensive care, and all have now been sent home.
And at their headquarters in the north London suburb of Colindale, the newly-created Health Protection Agency - which formally took over the Public Health Laboratory Service's job of monitoring infectious diseases less than a fortnight after Britain's first Sars case was reported - is now trying to work out if there have been any true British cases at all.
John Watson, head of respiratory diseases at the HPA, said that while all six had been exposed to infected countries, none is thought to have had contact with a definitely infected person. The possibility remains that their symptoms may have been an awful coincidence. Asked if Sars had peaked in Britain, Watson said: 'It is not so much whether we have had a peak as whether we have had anything.'
The media frenzy over Sars in Britain certainly peaked last Wednesday, with the apocalyptic warnings of Dr Patrick Dixon that the syndrome could be more dangerous than Aids, causing a billion cases a year. Chilling stuff: except that Dixon is not an epidemiologist, but an ex-doctor turned trend forecaster running his consultancy from what he calls his 'cyberbubble', the green-painted attic of his house in Ealing.
A more considered verdict based on the Hong Kong outbreak is expected this week from experts at Imperial College, London. They will argue Sars is harder to catch than first thought - and so unlikely to spread so far - but deadlier, with a death rate closer to 10 per cent than the 4 per cent WHO claims.
But in the absence still of many hard and fast answers on Sars, fear has filled the vacuum. Nearly 1,300 Britons worried about catching the disease have rung the hotline NHS Direct. Boarding school pupils from infected countries are spending the weekend marooned in quarantine camps on the Isle of Wight: Shadow Health Secretary Liam Fox has called for travellers from Asia - such as the 30,000 foreign university students due to start their new term tomorrow - to be quarantined and for draconian new powers to detain and forcibly treat suspected cases.
Privately, Department of Health officials are exasperated by such demands. 'Are we supposed to start rounding up 50,000 people a week on the grounds that they have a cold?' asked one.
The British Medical Association agrees, arguing it is unlikely that people told they had a potentially lethal disease would refuse lifesaving treatment. The problem is not complacency but ignorance, it says. 'Sars shows how badly we deal with uncertainty,' said Vivienne Nathanson, the BMA's head of science and ethics. 'The things everybody wants to know are: is it going to come to Britain, how many people will die, when will there be a vaccine, will we have to live with it for ever - and the answer to all of these is simply: we don't know. A month ago it didn't exist here.'
Dr Michael Fitzpatrick, an east London GP who will lecture on health panics at a conference in London next month, says Sars fits a pattern of modern over-reaction to scares from bioterrorism to global warming.
'As there is a sense of people being more isolated and atomised in society, they are more turned in on themselves,' he said. 'People are obsessed with their bodies, whether they are exercising it, or tattooing it or having plastic surgery on it. Studies show that people feel more ill in western society than they do in Africa, although they clearly aren't.'
But there is a good reason why Sars has captured public - and medical - imagination. For years doctors have feared the emergence of a 'doomsday scenario': a new, contagious, hard to treat virus that would traverse the globe rapidly and kill millions, as Spanish flu did in 1918.
'Sars gave the infectious diseases people a fright because they are always looking around for the next Black Death to appear,' said Dr Joe Neary, chair of the clinical network at the Royal College of GPs. 'But it doesn't have the ingredients that would make a new global pandemic. It kills people, but very few. This isn't it.'
That does not, however, mean something far nastier is not lurking now in a remote corner of the planet. Since the early 1970s, at least 30 previously unknown infections have emerged worldwide, from an outbreak of plague in India to BSE in Britain.
Such new infections have always been with us. The difference is that 21st century humans offer them unparalleled chances to spread: two million people a day cross international borders, an unstoppable tide of human movement allowing versatile microbes - the corona-virus thought responsible for Sars belongs to a group of viruses that mutate unusually rapidly - to leap thousands of miles within hours.
'In historical times, these would have been local outbreaks that would not have spread, but cosmopolitan life means there is a route out,' said Professor Ian Jones, virologist at the University of Reading. 'If you were on a ship years ago and were sick you would go to the sick bay. Nowadays you get off a plane and you may feel awful but you haven't been isolated until it's too late.'
Hong Kong offered the virus an almost uniquely fortuitous mix of crowded living conditions and a huge pool of international travellers to export it.
Prophetically, the city was singled out as an example of how a new pandemic might start in a report by Prof Donaldson last year, Getting Ahead of the Curve. An outbreak of 'bird flu' in Hong Kong - where a virulent chicken virus infected a child sparking a human outbreak - was halted only by the slaughter of 1.6 million birds. The report added: 'Further newly emergency infectious diseases are inevitable. It is essential to expect the unexpected.'
Like bird flu, Sars is thought to have jumped the species barrier from either birds or pigs to humans, probably in rural China where humans and animals co-exist closely. Most 'jumpers' simply do not take: it is homo sapiens' bad luck that the new coronavirus, another form of which causes breathing difficulties in premature babies, did.
With a safe, clinically available vaccine up to seven years away, the best answers 21st century medicine can now offer are the old-fashioned remedies that helped eradicate smallpox - swift diagnosis, identifying contacts of the infected person, isolating them until they recover - and the knowledge that Sars will almost certainly not be the last such outbreak. 'We get new infections every year or so. Our expectation is that new things will continue to crop up,' says Watson.
But one of the nastiest stings in the tail of Sars is that in a globalised economy, it may infect human wealth just as much as human health.
Rod Eddington, the chief executive of British Airways, should have been in a good mood as he travelled in his chauffeur-driven car from home near Maidenhead to Heathrow last week. After a series of desperate disasters for the airline industry - foot and mouth, the 11 September atrocity, and two wars in the Middle East - the fall of Saddam finally looked set to trigger a much-needed rush of renewed bookings.
Then the 6.30am radio news bulletin announced that Sars had claimed another three lives in Hong Kong, a premier business destination. To make matters worse, it was his industry that was spreading the killer disease. 'This is the worst crisis the aviation industry has seen. It has been two years of non-stop bad news, and now this,' he said last week.
Passengers trooping off flight Air Canada 848 from Toronto yesterday, some wearing facemasks, will have given him little cheer. 'I had a head cold and I was scared that if I coughed in London, they would take me to court and lock me up,' said Sean Rogers, 24.
The old economists' axiom about recession is that if America sneezes, Europe catches cold: but this time it is Asia sneezing and the rest of the planet who may soon be sniffling over falling stock markets. The Bank of Canada has already slashed its economic growth projections for this year, while the City has revised down forecasts for China.
In London's normally bustling Chinatown, no reservations were required last week. One restaurant manager said a couple chomping noodles in the corner were his only clients during one of his busiest periods. In Toronto hotel occupancy is down to 30 per cent. 'You can clear a subway car with one cough,' says health worker Michael Greenway. 'Some people think it's the black plague. But it's not. It's like a bad case of the flu.'
One British health worker recently returned from the Far East was left shaking his head over the behaviour of a fellow passenger during a brief stopover in Singapore. 'He got off the plane wearing a surgical mask, and then asked where he could go for a smoke,' he added. 'A cigarette is a lot more likely to kill him than Sars. Now what does that say about our assessment of risk?'
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