January 3, 2003
Guangzhou Number Three Hospital, Guangzhou, China
48 Infected, 9 Dead
DENG ZIDE, DIRECTOR OF INFECTIOUS DISEASES AT GUANGZHOU Number Three Hospital, had just completed morning rounds with several residents when he stopped in at the third-floor Clinical Department offices to see if he had missed any calls. A nurse handed him a message from the Provincial Bureau of Health, which read, simply, that he was to appear at the bureau at 2:30 P.M. The message ended with an ominous instruction: “Bring a packed suitcase.” The forty-two-year-old specialist showered in the doctors’ changing room, slipped into a dark suit and black shoes, and walked back to his apartment in the complex behind the hospital. He sat down to a quick meal of pork, rice, and cabbage before throwing a change of clothes, a gown, gloves, a mask, and goggles into a small duffel bag and heading fifteen minutes by taxi across Guangzhou to the Department of Health.
He arrived at the fourth-floor meeting room a few minutes early and found several other respiratory doctors and epidemiologists all in a similar confused state as to why the meeting had been called. They took seats on wooden chairs around a conference table on which stood a dozen bottles of mineral water and paper cups. He Zhaofu, the deputy director of the Provincial Department of Health, entered the room, greeting them all and curtly thanking them for coming. As the ranking official in the room, he could dispense with anything but the most perfunctory of pleasantries; yet since this was a gathering of medical professionals and not political appointees, some courtesy was still required. The men in that room were among the most prominent physicians and scientists in the whole Pearl River Delta. Along with Deng Zide, there was Huang Wenjie, the chief of respiratory diseases at Guangzhou General Military Hospital. Next to him were three Guangdong CDC epidemiologists, led by Lou Hwei Ming; and opposite that team was Xiao Zhenglun, vice-director of the Guangzhou Institute of Respiratory Diseases.
The department had received a fax, He Zhaofu explained, from Heyuan Number One Hospital, which was four and a half hours by car northeast of Guangzhou. The director of the hospital had written under the subject line “Heyuan People’s Hospital Fax to Guangdong Health Department on January 2, 2003” that two patients had been admitted on “December 15 with serious pneumonia of unknown causes. These two patients were transferred to Guangzhou Military General Hospital and Guangzhou Institute of Respiratory Diseases as their conditions deteriorated.” He Zhaofu went on to say that the first patient had been admitted with fever, muscle aches, and a faint crackling sound in the lower left lung. Nothing surprising there, of course, since it was early winter, and respiratory ailments were common during the dry season. He Zhaofu continued reading aloud: “In a few days, every medical staff member who had been in close contact with these two patients developed similar symptoms. Three were in critical condition. At present, six medical staffers have been hospitalized. None of the patients have responded to conventional treatments.”
While none of the doctors in this room yet knew of the mysterious deaths throughout the province that had followed this similar litany of symptoms, for Huang Wenjie of Guangzhou General Military Hospital, this sounded like an institutional cry for help disguised as a procedural document. No director of a local hospital was going to lose face by admitting to his bosses in the provincial capital that he could not handle a local health care crisis. For the director to be relaying his worries up the chain of command meant that something frightening, or at least very strange, had to be occurring in that picturesque city. But for Huang Wenjie, there was something else discomfiting about the fax. One of the patients had been transferred to his hospital—without any indication given that this was an extraordinary case. He remembered that his hospital had admitted a pointy-eared, chubby-cheeked fellow with a thick neck and a crew cut who had lost consciousness in the ambulance on the way to Guangzhou. The patient’s accompanying charts indicated that his high fever and lung infection had been treated with broad-spectrum antibiotics yet had shown no sign of abating. Upon his admission at General Military Hospital and settling into bed 93, his respiratory rate reached three times the normal level even while he was lying still. Despite that labored breathing, he could not maintain 90 percent blood oxygenation. In other words, he was taking deep, frequent breaths, but no oxygen was reaching his bloodstream.
“That patient,” Huang Wenjie said. “He came two weeks ago. A very strange case.” What he did not reveal was the mild sense of betrayal he felt at belatedly receiving this information. The patient had been a mystery to Huang Wenjie. At first, he had assumed he was dealing with a typical pneumonia case. But the patient’s rapid deterioration, combined with his unresponsiveness to any therapy, had left Huang Wenjie, a forty-two-year-old career military medical officer, struggling to come up with a diagnosis. “Pneumonia” is actually a catchall term, a roundup of symptoms rather than an explanation of the causative agent. It describes, broadly, virtually any infection of the lungs—viral, environmental, or bacterial. In the vast majority of cases, the cause is bacterial, and the patient responds to some sort of antibiotic therapy. Only in a case when the patient does not respond to standard antibiotic treatments does a clinician worry about identifying the causative agent.
In the case of the twenty-seven-year-old from Heyuan, there had been no effective course of therapy, and the patient’s condition deteriorated so rapidly that within a day of his admission, he no longer recognized his own family. This sort of severe pneumonia was rare among healthy young men. But still, in China, one case was unlikely to rouse anything but passing interest. Most doctors relied instead on rotating medications until the right dose and drug finally knocked out the microbe that was causing the disease. (In the West, among most clinicians, the treatment would be much the same. If they can cure the patient without knowing what has ailed him, seldom will doctors bother to find out the actual microbial agent.)
Now Huang Wenjie discovered that the doctor and nurse who accompanied this patient from Heyuan had themselves fallen ill with this mysterious affliction and were hospitalized in critical condition.
Xiao Zhenglun from Guangzhou Institute of Respiratory Diseases then spoke up and reported that on December 22 he had accepted from Heyuan Number One a forty-one-year-old owner of a small trading company. He had no previous history of disease, but upon admission he had almost immediately gone into acute respiratory distress syndrome (ARDS), despite the antibiotic treatment he had been given. For the doctors of Guangzhou Institute of Respiratory Diseases, such a case was unusual only in its resistance to the usual treatments. The patient’s condition, again, was curious but did not seem particularly noteworthy. Even when the patient was put on a ventilator and lost consciousness, the doctors at Guangzhou Institute were not alarmed. But on December 27, a chest X-ray showed an almost complete whiteout of the lungs, meaning that huge amounts of mucus had effectively blocked off large patches of the lungs, preventing them from functioning.
“How many of these cases are there?” both Xiao and Huang asked after listening to the briefing.
“We don’t know,” He Zhaofu told them.
He detailed their assignment: they were to head to Heyuan immediately and find out what was going on. For every man in the room, this was the first time he had ever been sent on such a mission. Deng Zide had never before heard of an epidemiological investigation of this sort, not for a respiratory ailment. It had to be a truly terrible disease if the Department of Health was rounding up a high-level team to investigate it. “And you”—He Zhaofu indicated Xiao Zhenglun with a quick glance—“are the team leader.”
The thickset doctor with a shaggy comb-over stood up and gathered his suitcase. He followed the other men out the door, into the elevator, and down to the parking lot, where a white Jinbei van with a red medical cross over the front grille stood idling. They piled in, arranged themselves so that there were two men on each bench seat, and talked about what there was to eat in Heyuan.