SARS: From China's secret to a worldwide alarm
IHT NYT The New York Times Monday, April 7, 2003 This article was reported by Elisabeth Rosenthal, Keith Bradsher, Lawrence K. Altman, Clifford Krauss, Donald G. McNeil Jr. and Amy Harmon and written by Denise Grady.
Last November in Foshan, a small industrial city in Guangdong Province in southern China, a businessman became desperately ill with an unusual type of pneumonia. Doctors could not identify the germ that was making him sick. Ominously, although pneumonia is not usually very contagious, the four health workers who treated him also fell gravely ill with the same disease.
Now, scientists say, the Foshan businessman appears to have had the earliest known case of severe acute respiratory syndrome, or SARS, which has since become an international epidemic. As of Saturday, more than 2,600 people in 20 countries were reported to have contracted the disease, and 100 had died. The overwhelming majority of cases were in mainland China, with 1,220, and Hong Kong, with 883.
The cause of the disease is unknown, but scientists suspect it is a new coronavirus, from a family of highly changeable viruses that until now have been known to cause only more minor illnesses in people, like colds and diarrhea.
SARS was brewing in Guangdong Province for months but was not revealed by the Chinese government until February, when Beijing began reporting cases to the World Health Organization. The Foshan businessman's case was disclosed just last week, when Chinese officials finally agreed to open their casebooks and hospitals to international specialists. The businessman recovered, but Chinese officials have not discussed what happened to those who took care of him, nor have they said where or how he might have contracted the disease.
The rest of the world did not know much about SARS until March 15, when the WHO issued an alert calling the disease a "worldwide health threat." Since then, fear of SARS has led many countries and corporations to halt tourism and business travel to China, Hong Kong, Vietnam and Singapore, decisions that are expected to cost the region billions of dollars.
Efforts to control the disease in Hong Kong appeared to be making headway last week, but the progress may have been short-lived, as cases jumped sharply over the weekend. There were 41 new cases reported Monday and 42 reported Sunday, up from 39 on Saturday and 27 on Friday. The new cases included doctors and nurses. Two women, aged 68 and 71, died Sunday, bringing the number of deaths in Hong Kong to 23. Health experts say it is too soon to tell whether SARS will turn into a global wildfire or cool down. But scientists insist that the disease must be treated as an urgent public health threat. What worries epidemiologists is that SARS can spread rapidly through the air, via coughing and sneezing, and its death rate of 3 percent to 4 percent is significant, particularly because healthy people are among those who have died.
People of all ages, from children to the elderly, have caught SARS. The illness typically starts like any other acute respiratory infection: with a fever, chills, headache, malaise and dry cough. Chest X-rays tend to show what doctors call "atypical pneumonia" in a lower lobe of a lung. In the following days, a victim may develop difficulty breathing as the pneumonia spreads to another lobe.
About five to seven days after onset, the symptoms improve in about 80 percent to 90 percent of patients and worsen in the remainder. Many of the sickest patients require intensive care, some to the point of being connected to a respirator.
Why some people improve and others die is not known. So far, it appears that the people most susceptible to severe symptoms are those 40 years or older and those who have had a chronic disease in the past. Aside from regular nursing care and help in breathing, there is no effective treatment, and recovery seems to depend on the strength of a patient's immune system.
SARS may have spread at jet speed with air travelers, but fear of the respiratory disease is traveling even faster, hurting businesses and economies around the globe. The disease's economic consequences are still modest in North America and Europe. But SARS is clearly slowing growth in East Asia, which, at least until the last three weeks, had been one of the few regions in the world with briskly expanding economies.
On Wednesday, Morgan Stanley cited SARS in lowering its forecast for economic growth in Asia, aside from Japan, to 4.5 percent this year, from 5.1 percent. The lower estimate reflected the investment bank's analysis that the disease would prevent about $15 billion in business from being done this year, mainly because of less tourism and lower retail sales.
Andy Xie, a Morgan Stanley economist, cautioned in a report that the actual economic effect could be considerably greater. "We believe this medical crisis is the gravest since the 1998 Asian crisis," he warned, referring to a drop in the value of Thailand's currency that set off a series of devastating financial crises across Southeast Asia.
Airlines and hotel chains have been hurt the most by the SARS outbreak. Even the strongest travel companies, like Cathay Pacific, Hong Kong's main airline, are not immune, and the disease may have been the final blow for some already troubled businesses, like Air Canada, which filed for bankruptcy last Tuesday. "We anticipated war; we didn't anticipate this," said Vivian Deuschl, a spokeswoman for the Ritz Carlton Hotel Co., a Marriott subsidiary.
The harm is not confined to the travel industry. Business has plunged at stores and restaurants in heavily affected cities like Hong Kong, Singapore and Toronto, as well as in places that are inaccurately perceived as affected, like the Chinatowns in New York and San Francisco.
Hardest-hit have been retailers in Hong Kong. Customers have simply stopped going into the store of Peter Chan, who sells bronze and ceramic Buddhas and horse statues in a store across the street from the 156-year-old Man Mo Temple, where clouds of incense billowed last week as Taoists prayed for an end to the disease.
"I have been working in this field for more than 20 years," Chan said, "and I have never seen such a bad situation before, not even after 9/11." Electronics companies have struggled to stay in touch with their operations in China, which has become one of the world's largest producers of computers and wireless local area networks.
One big worry is that, as hospitals - in Hong Kong in particular - become flooded with SARS patients, the quality of medical care overall will decline. The U.S. State Department said that part of its reason for offering free tickets out for nonessential diplomats and their families was "concerns over our ability to obtain suitable medical care."
Adding up all these disparate effects has proved a guessing game for economists. A few, like Stephen Roach at Morgan Stanley, predict that SARS could make the difference in tipping the world into a recession if the war in Iraq also becomes prolonged. No one is certain what causes SARS, but a microbe known as a coronavirus is the chief suspect, most likely a new strain that originated in Guangdong Province.
Coronaviruses take their name from their appearance under an electron microscope: a circular, crownlike shape with protruding spikes. Until now, these viruses were thought to produce only minor illnesses in people, like colds, diarrhea and other intestinal disorders. In cats, dogs, chickens, pigs and cattle, coronaviruses distinct from the human ones cause severe and often fatal illnesses.
All coronaviruses have an extraordinary ability to capture stray bits of genetic material from related viruses and weave them into their own genomes, a feat biologists call recombination. Such natural recombination favors the creation of new viruses, and in theory could turn a benign microbe into a biological time bomb. For a virus already inclined to morph into new identities, there could be no better environment than southern China. The region is known to be one of the world's great incubators of new viruses, particularly influenza. Though coronaviruses are not related to influenza, scientists say coronaviruses could easily take advantage of the same conditions that make southern China the birthplace of new flu strains.
The region is populated by millions of farmers living on small plots of land in close quarters with their pigs, ducks, chickens and other livestock - an ideal setting for microbes to be passed between species and for viruses to swap genetic material.
Gene swapping is not the only way a new coronavirus can emerge. Another possibility is that an earlier version of the virus, one that did not cause severe illness in people, underwent a genetic mutation that made it more virulent. It is also possible that an animal virus "jumped" into humans. Such jumps are known to occur, sometimes with severe consequences.
Coronaviruses became the chief suspect in SARS when scientists used a device called a gene chip, or a microarray, to scan tissue samples from disease victims. The chip is a glass slide containing bits of genetic material from about 1,000 viruses. If the tissue sample contains genetic material from any of those viruses, it will stick to the corresponding bit on the slide.
When tissue samples from SARS victims were scanned, the slides indicated matches with coronaviruses not only from humans, but also from turkeys and cows. That suggests a strain that has never been seen before. In November and December, outbreaks of the mysterious disease cropped up again and again in cities in Guangdong Province, including Zhongshan and Guangzhou. By January, local doctors were investigating what they suspected was a new kind of atypical pneumonia. But the Chinese government said nothing of the panic in Guangdong.
Finally, on Feb. 9, the WHO received its first report about the disease from China. Before the end of the month, cases had popped up in Hong Kong and Hanoi, and in March one infected traveler from Hong Kong caused an outbreak that led to seven deaths among more than 150 suspected and probable cases. By early March, the disease had begun to spread explosively among hospital workers in Hong Kong and Hanoi.
By mid-March, it was clear that a highly contagious disease was poised to begin spreading around the world. Officials at the health organization realized they had to take drastic action, even though that action might have a devastating impact on travel, tourism and commerce in Asia and elsewhere. "Hong Kong is an international airline hub," said Dr. David Heymann, the organization's executive director for communicable diseases. "We had to let other countries know that this was coming. "And we had to let passengers know what the disease was as well, so that if they got it they could tell their doctors and get themselves isolated."
On March 15, WHO took a highly unusual step in issuing the global health alert, describing the new disease and where it had been found.
Last week, after months of international pressure, a team of WHO experts was finally permitted to go to Guangdong. But until the past two weeks, health officials in China not only were unwilling to share their data, but also denied that the four-month-long pneumonia outbreak affecting Guangdong had anything to do with SARS.