Living in a Hot Zone
Time Asia April 7, 2003 / Vol. 161 No. 13 BY JIM ERICKSON
Asia's killer virus has the region on edge. Jim Erickson looks at the outbreak's medical and economic repercussions
The pathology department at the University of Hong Kong is one of the few places on Earth where you can stare death in the face. In the department's lab, a transmission electron microscope capable of magnifying an image up to 150,000 times is being used to view a never-before-seen virus that researchers now believe has killed at least 55 people worldwide and infected more than 1,500. Illuminated on a green phosphorescent screen by a beam of electrons and viewed through an optical device that resembles an upside-down periscope, the virus—this particular specimen had been taken from a relative of a Chinese doctor who was the first victim to die in Hong Kong on March 4—looks every bit the alien matter that it is. "There are the little buggers," says Dr. John Nicholls, a pathologist at the University of Hong Kong, leaning aside so a TIME reporter could take a look. Magnified 100,000 times, the organisms are fuzzy black balls that fill the screen and look like the burrs that stick to your pants during a hike through the woods. You can just make out the little hooks sticking out of the viral body—telltale characteristics that help classify the pathogens as members of the coronavirus family.
Coronaviruses, so called because of their spiky crown of protein globules, are generally not mortally harmful. They are a pest to livestock and in humans are responsible for more than one-third of common cold cases. But the bugs on Nicholls' slide have, for reasons researchers have just begun to investigate, mutated into something far deadlier: a rogue virus that triggers a killer pneumonia recently labeled Severe Acute Respiratory Syndrome (SARS). Since news of the first SARS cases escaped mainland China a month ago, health authorities around the planet have been in a state of high alert, fearful of a worldwide outbreak of a highly contagious and untreatable disease. Last week the disease continued to go global, affecting more than 15 countries, as infected individuals jetted from hot zones to other parts of the world, passing along their unwelcome baggage through sneezes and coughs. Most worrisome, the disease doesn't look like it will die out anytime soon: Thomas Tsang, consultant in community medicine at Hong Kong's Department of Health, says he expects to see as many as 50 new cases a day over the next few weeks—just in the territory alone. LATEST COVER STORY SARS: How Dangerous Is It? What Else Is Out There? Tracking a Deadly Virus April 7, 2003 Issue IRAQ Bush: Sticking To His Guns Strategy: Flawed Assumptions POW: Taken By Surprise
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CNN.com: Top Headlines SARS, which is believed to be a form of atypical pneumonia, has already claimed some high-profile victims, including a World Health Organization (WHO) doctor who came into contact with patients in Hanoi and succumbed on Saturday. Secretive Chinese health-care authorities—the disease is suspected to have first surfaced last November in the southern Chinese province of Guangdong—now admit that the country has far more cases and in more places than previously acknowledged. Last week they put the toll at 806 cases and 34 deaths, a statistic that many mainland doctors say still underplays the disease's real effect. In Canada's Ontario province, where 35 people have been stricken and of whom three have died, access to medical facilities has been severely restricted and officials ordered thousands of people to self-quarantine. In Singapore and Hong Kong, schools were ordered closed and governments invoked quarantine laws not used for decades to isolate those who might be carriers. Nearly 1,700 Singaporeans are now confined to their homes. Explained Hong Kong's Chief Executive Tung Chee-hwa in announcing tougher measures to curb the spread of the disease: "Hong Kong is currently facing its most serious contagious disease threat in 50 years."
Drastic steps are being taken in part because so little is known about SARS. Scientists have only begun to deconstruct the virus' DNA to find out where it originates from, how it kills and, crucially, how to counteract it. According to the WHO, the coronavirus, while it can spread quickly, is actually less contagious than the average influenza virus. But once inside a human host, it can be virulent. The pathogen causes high fever and creates an "inflammatory storm" as the body's immune system attempts to fight it off, says one doctor, causing lung tissue to swell and, in the final, brutal stages, suffocating the host. Nguyen Thi Bich, 44, a nurse at Hanoi's French Hospital, where nearly 60 SARS cases have been traced, contracted the disease and was hospitalized for three weeks. "The fever felt like having red ants in my body," she says. "Sometimes I felt my body was about to explode." She was lucky and recovered. But Bich's friend and colleague, nurse Nguyen Thi Uyen, died of SARS. Although the virus appears to attack indiscriminately, once contracted its effects are generally more harmful in the elderly or those with pre-existing medical conditions. "On a scale of 1 to 10, [the disease] is a 12," says Dr. Sydney Chung, dean of the medical faculty at the Chinese University of Hong Kong. "The outcome is that a significant proportion get very ill and end up on a ventilator."
Hong Kong has the unfortunate distinction of being the epicenter of the SARS outbreak outside of mainland China. The first known case to die outside the mainland was in the territory, and nearly 500 people have contracted the virus since then. Just last week, 310 new cases came to light. Still, that's just a fraction of Hong Kong's 7.3 million population, and in fact, the SARS mortality rate isn't very high—fewer than 4% of those who have contracted the disease so far have died. But the limited death toll belies the much wider impact SARS is having on the city's economy and psyche. Indeed, in Hong Kong there seem to be two contagions at work: one is the virus, which is transmitted when a person comes into contact with pathogen-laden droplets; the other is fear, which has spread swiftly through the community, stoked by sentiment that the territory's beleaguered government hasn't done enough to stem the disease's spread.
Until last week, Hong Kong's health officials had downplayed the threat of the virus to avoid public panic. To ease fears, government officials announced that cases appeared to be confined mainly to the city's Prince of Wales Hospital, which received more than one-quarter of the territory's total infections and where more than 100 health-care workers had contracted the disease in the facility's cramped wards. But on March 23, after Dr. William Ho, chief executive of Hong Kong's Hospital Authority, was admitted to hospital with atypical pneumonia, fear of a major outbreak began to seize the public consciousness as the disease spread beyond the Prince of Wales Hospital. By Saturday, more than 100 residents of a Kowloon housing estate had come down with SARS. A branch of the Bank of East Asia was shut down when an employee contracted the disease. The Central Library was closed. On March 28 alone, 58 new cases were confirmed.
Hong Kong now looks like a city under threat of biological-weapons attack. Almost overnight the streets have filled with people wearing surgical and industrial face masks, as if shopping malls and subway stations had suddenly morphed into vast hospital wards. Convenience-store clerks, shopkeepers, bus drivers and even TV talk-show hosts are wearing masks, the latter while on camera. Doctors say the devices can hamper the spread of the disease by corralling coughs and sneezes and by preventing people from touching their noses and mouths. Even transit companies and political parties are handing masks out on the street by the thousands, helping calm citizens who are searching for any incremental advantage over this little-known stalker. Naturally, in this most economically minded of cities, street hawkers are price gouging, charging several dollars each for tissue-thin masks sporting pirated cartoon characters such as Pokémon and Hello Kitty. "Forget about Scud missiles and smart bombs, we could all die if someone with the disease merely coughs," Shirley Li, a Hong Kong resident, told Reuters when explaining why she makes her son wear a mask in public.
The hot-zone atmosphere has unsettled natives and expatriates. Keesler Cronin was already jumpy when she recently took her nine-year-old son to a doctor because he had a sore throat. "Everyone in the office had masks when we got there," Cronin says. But that scene wasn't as bad as what the doctor had to say: "He said, 'If you have the means to leave Hong Kong, I would pack your family and get out of here for a month.' It put the fear of God in me." At Yiu Him House, an apartment complex in northern Hong Kong where several people have been diagnosed with SARS, cleaners last week scrubbed down staircases, elevators and lobbies with disinfectant. A resident who identifies herself only as Mrs. Man eagerly discussed Hong Kong's hottest conversational topic—the different kinds of masks and their prices. "It's good that they're cleaning the building more," she said through a thin paper mask. "One night I saw that they hadn't cleared the garbage, and the next day some people here got atypical pneumonia. You can't be too scared. I'm quite scared, but there's nothing I can do."
Visitors, too, are feeling jittery. "I usually shake hands with everyone when I meet them," says Raynald Denis, a fashion retailer from Montreal who was in Hong Kong and the mainland on business last week. "But on this trip I tried to minimize all contact." Although Hong Kong has not been declared off-limits by the WHO, some governments have issued travel advisories cautioning against visiting destinations with known SARS cases. The Canadian government said it might ban flights to Hong Kong, Singapore and Hanoi if the situation worsens. The Rolling Stones rock band canceled their much-anticipated pair of concerts in Hong Kong. Another major local event, the Hong Kong Rugby Sevens, went ahead but without teams from Italy, France and Argentina, which all stayed home because of the SARS outbreak.
Citizens of overcrowded Hong Kong were hypersensitized to the threats of a rogue virus long before AIDS or the movie Outbreak. The regional transportation hub and trading entrepôt borders Guangdong province and has long been associated with the outbreak of new diseases. The city even has a disease named for it—the Hong Kong flu, which killed 700,000 people globally from 1968-1969, infecting 30% of the world's population in less than nine months. Since 1997, local health authorities also have been periodically quelling eruptions of the avian flu, which is one of the few deadly diseases thought to directly jump from birds to humans. No surprise, then, that Hong Kong's vigilant residents were calling for a comprehensive battle plan against SARS long before their bureaucrats belatedly announced their anti-SARS blueprint on March 27. Parents who have school-age children and local lawmakers accused the government of being complacent and keeping silent about SARS to protect the already fragile economy. But Selina Chow, a legislator and chairman of the Hong Kong Tourism Board, maintains that officials have had to be careful not to start a panic. "We are not just dealing with the scientific containment, we're also dealing with the psychological effect," she says. The decision last Thursday to close local schools for a week and monitor 1,080 people who had close contact with SARS victims "is not due to a scientific need but rather is a move to calm the worries of parents. It's come to a point where, strictly speaking, some of the measures are not for medical reasons."
Still, Hong Kong's health precautions have stopped short of those of ultra-cautious Singapore. There, nearly 1,700 people have been quarantined—they can't leave their homes, and if they do they may be fined up to $5,650. Teacher Melanie Young, who may have been exposed to SARS by a five-year-old student, was cooking dinner for her husband and two children on March 24 when officials from Singapore's Ministry of Health knocked on her door. They delivered quarantine papers stipulating that she and her kids could not venture outside under any circumstances—not even to buy groceries—for 10 days. During that time she was to check the family's temperature daily and "observe good hygiene." It was the first time Singapore had ever invoked its Infectious Disease Act. "I was surprised but I accepted this," Young says. "I take this seriously, especially when it comes to my children." Indeed, precautions are being taken everywhere. The body of Simon Loh, a Singaporean pastor who died from SARS on March 26, was double-bagged and the casket was hermetically sealed before his cremation. At the 39-year-old's funeral, the first five rows closest to the coffin were empty. The pallbearers wore rubber gloves.
In Hong Kong the economic toll of the outbreak is rising, despite the efforts of government spin doctors. Some 300 Hong Kong workers for U.S. computer maker Hewlett-Packard were sent home last week after an employee came down with SARS. Two important economic sectors—tourism and retail—are expected to be hit hard, hurting an economy already wounded by prolonged deflation and by the effects of the Iraq war. According to investment bank Morgan Stanley, Hong Kong could lose $256 million in tourism revenue over the next two months. Local tour guide Carmen Li hasn't gone to her office for four days—most of her bookings have been canceled, as tourists stay clear of the infected territory.
Potentially more dangerous is the impact on local spending. The city's usually crowded haunts—malls, karaoke bars, movie theaters, nightclubs and restaurants—are eerily devoid of traffic. Tommy Cheung, a lawmaker who represents Hong Kong's restaurant industry, says there has been a 10-15% drop in the local dinner business recently. Yu Pang-chun, chairman of the Hong Kong Retail Management Association, reported last week that sales among his association members were down more than 10% compared with the same period last year. That translates into a $50 million-a-week loss in revenue for the city's retailers. The outbreak "is going to have a much greater impact on psychology and consumer confidence than the chicken flu," says Tai Hui, an economist at Standard Chartered Bank. Overall the SARS effect could cut Hong Kong's GDP growth by 0.4 percentage points this year, according to Deutsche Bank economists.
Business owners are trying to cope. "We are anticipating a 30-50% drop in the near future, and there isn't much we can do about it," says Alex Chan, chief of the retail division of a regional chain of jewelry stores. "We have our staff cleaning the floors and the show windows every hour." Its employees wear gloves and sterilize jewelry before customers try pieces on, but the company has stopped short of instructing staff to wear face masks. "I think wearing masks will scare off customers," Chan says.
Economists say losses will be contained if the SARS outbreak—which is not yet widespread enough to be considered an epidemic—burns out. The prognosis is unclear. Thanks to swift and pervasive e-mail communication and unprecedented collaboration among scientists and doctors worldwide, rapid progress is being made on the research front. Last week, pathologists at the University of Hong Kong scored a breakthrough when they announced the probable SARS culprit was a mutated coronavirus. Their finding, which controverted earlier research that pointed at the paramyxoviridae family of viruses, was confirmed by the U.S. Centers for Disease Control and Prevention in Atlanta. Still, it's possible that paramyxoviridae, which causes mumps and measles, might play a role in the disease. In the meantime, the identification of the coronavirus has made it possible to come up with diagnostic tests for the disease.
There is other good news. The coronavirus currently is not believed to be airborne, meaning that it can't float through the air like a mushroom spore. Instead, it can only be passed by direct contact with an infected person or with an object they have touched. And, while the number of cases is rising, the toll is not increasing exponentially. Steps such as those taken in Hong Kong and Singapore can strangle the outbreak before it reaches epidemic proportions. "We've come a tremendous distance since three weeks ago," says Chung, the dean of the medical faculty at the Chinese University of Hong Kong. "We know a lot more about the disease, the diagnosis and treatment." There is still no sure cure—antibiotics are useless against viruses—but patients in Hong Kong are responding to broad-spectrum, antiviral drugs combined with doses of steroids to reduce inflammation. "Patients are getting better," says Chung. "The majority are now recovering." But Chung quickly adds that the coronavirus has already spread through the Hong Kong community and is making inroads elsewhere. "I think this disease is going to be with us for a long time," he says. The world now has a new viral enemy to contend with, and its deadly capacity is only beginning to be understood.
Reported by Ilya Garger, Neil Gough, Carmen Lee and Bryan Walsh/Hong Kong, Kay Johnson/Hanoi, Daffyd Roderick/Toronto and Genevieve Wilkinson/Singapore