March 10, 2003
World Health Organization China Headquarters, Dongzheminwai, Beijing, China
1,069 Infected, 119 Dead
KEIJI FUKUDA AND HITOSHI OSHITANI HAD RUN INTO THE BRICK WALL that too often characterizes the recalcitrant Chinese bureaucracy. “We left those meetings feeling there was a lot we wanted to know and a lot we didn’t understand,” said Fukuda. “More troubling, we left meetings with the sense the Ministry of Health wasn’t really engaged with this as an issue.” Concerned at their lack of progress in Beijing and the possibility that the outbreaks in Hanoi and Guangdong were related, Fukuda and Oshitani both decided to depart from Beijing. “If we can’t visit Guangdong,” Oshitani complained to WHO Beijing chief Bekedam, “there’s no point staying in Beijing.” Bekedam reluctantly agreed that Oshitani and Fukuda could be more useful in the field. He assured Oshitani that he would continue to seek an audience with China’s vice-minister of health.
Within the WHO, there was a divergence of opinion on how much pressure should be brought to bear on the Chinese government—or, indeed, if applying pressure was the right tactic. Oshitani and Bekedam, with Heymann conferenced in, considered bringing Gro Brundtland, the director-general of the World Health Organization, to Beijing to meet directly with Minister of Health Zhang Wenkang. However, it was decided that such grandstanding could end up hurting their cause more than helping it.
The leading figure in promoting a more conciliatory approach was Alan Schnur, the WHO’s second-in-command in Beijing and an eleven-year veteran of working with the Chinese government. The Boston-born, Brooklyn College–educated Schnur had great faith in the technical abilities of his Chinese counterparts and had come to the conclusion that, somehow, this outbreak had become elevated into a policy matter. “All we could do was explain to them that this was a global matter, an urgent matter,” Schnur said in a later interview, “but we knew they couldn’t make any decision.”
Schnur had a remarkably long face, like Munch’s Scream without the hands, and his patience was almost a physical attribute, as tangible and present in any conversation as Oshitani’s sighs of agitation or Fukuda’s crisply cut-off consonants. Schnur could wait for hours, days if necessary, for the right moment at which to make a suggestion or observation. He had learned from years of working with the Chinese government on tuberculosis and polio outbreaks that you can’t bludgeon Chinese bureaucrats into submission. They are the civil servants who are most skilled in the world at warding off unpleasant tasks. At any rate, Schnur knew, the threat to a Chinese bureaucrat from above was of a different magnitude than the threat from an international agency like the WHO. Better to unleash a deadly virus upon the world, a Chinese bureaucrat might reasonably conclude, than become the scapegoat purged for letting the foreigners know about it. Later in the outbreak, reporters covering the World Health Organization press conferences would view Schnur almost as a collaborator with the Chinese government, never realizing the role he had played in building up a relationship that allowed for what little contact there was between the WHO and the Ministry of Health. Still, by March 10, Oshitani had become increasingly frustrated with Schnur’s approach.
He was joined in his impatience by the WHO’s David Heymann and Klaus Stöhr. As early as March 4, they considered placing a travel advisory upon China, an unprecedented proscription that could set off an international diplomatic row. In a meeting at the Ministry of Health on March 6, Bekedam and Oshitani for the first time actually mentioned to ministry officials the possibility of a travel advisory—such an edict would cause tremendous international embarrassment for the Chinese government and certainly cost the country billions of dollars in lost investment and tourism. “I don’t think they understood the consequences at that stage,” Oshitani would later tell me. “Some of the officials still thought they could cover up and the disease would be gone in a few weeks.”
At least one Ministry of Health official whom I spoke with privately would insist that ministry officials didn’t appear to be engaged because they had been told to view this outbreak as a closed matter. “This came from quite high up in our ministry. That’s why in our meetings with the World Health Organization, we were emphatic that the outbreak was over but could not give them satisfactory scientific explanations of the etiology, epidemiology, or virology of the outbreak. We did not have that information, and once we were told that the outbreak was officially ‘closed,’ we could not secure cooperation at the provincial level.” The official went on to say that it had become, in effect, a political rather than a medical issue.
When I asked him if a tactical decision had been made to stall and hope that the outbreak would burn itself out, he responded, “We retreated into thinking like that because we had other plans in place. It is not a satisfactory position to take from a public health standpoint. But consider that the information we had from Guangdong indicated that whatever it was, they had reached the narrow part of the epidemiological curve. So the world can’t accuse us of malfeasance.”
“But the virus was already in Beijing at that point,” I pointed out.
“Nobody knew that,” he said.
“And what about Hong Kong?” I asked him.
He shook his head. “We never considered Hong Kong. It has to do with old thinking, political thinking as opposed to epidemiological thinking. Once the virus crosses the internal border, it becomes a political matter.”
Once it became clear that the WHO would not get down to Guangdong or Fujian from Beijing, it was decided that working through Hong Kong might be more fruitful. Fukuda had worked there during the avian influenza outbreak of 1997 and was well connected with local public health officials and the medical community. As for investigating the possibly related Hanoi outbreak, Oshitani, the holder of a diplomatic passport, could fly to Hanoi without having to secure a visa.
Fukuda boarded a Monday-morning Dragon Air flight and landed in Hong Kong on Monday afternoon, taking a taxi from Chek Lap Kok to the Empire Hotel in Kowloon, just a few hundred meters from the Metropole. When he called his old friend Margaret Chan, Hong Kong director of health, she told him he should plan on staying for a while.
“Keiji, I have two dozen infected health care workers at Prince of Wales Hospital,” she explained in her patrician trombone of a voice. “Atypical pneumonia from China. It’s here, Keiji, it’s here.”
THE FIRST RESPONSE TO AN EPIDEMIC IS USUALLY DENIAL. WHEN smallpox appeared in the Roman Empire in A.D. 189, the initial impulse of local prefects was to issue edicts attributing the recent mortalities to an unhappy Jupiter or a vengeful Mars, or to make public pronouncements suggesting that fellow Romans had fallen ill owing to natural calamities, common grippe, or even a poisoned barrel of wine. From the perspective of a head of state, a mayor, a governor, or any ruling body, infectious disease remains among the hardest issues to manage. You can’t legislate a virus out of existence, nor can you order a stricken populace to be healthy. There is almost no calamity, save starvation or siege, that can so quickly reduce a city to panic and despair. Yet very often the populace is as guilty of denial as are those ruling it.
In the face of impending doom, there will always be that segment of society that persists in wishing away the problem or pretending it doesn’t exist. That was the case in London during the Plague of 1665, in Philadelphia during the great influenza outbreak of 1918, and even in San Francisco’s gay community during the earliest days of AIDS, when some homosexuals argued that AIDS was not a new disease but rather a bogeyman conceived by puritanical doctors and conservative politicians seeking to put an end to the promiscuity of the seventies.
Why should China’s Mandarins have behaved any differently? When confronted with an infectious disease, they initially downplayed the danger and assumed a tacit policy of wishing the microbe back into whatever species from which it had jumped. What did they really have to go on, a few hundred cases in a nation of over a billion? “Human lives just aren’t as valuable in China,” says Guan Yi. “They don’t see these matters the same way a politician might in the West.” Indeed, with infectious-disease outbreaks a far more common occurrence in China than in, say, the United States, it is on one level understandable how China’s minister of health, Zhang Wenkang, could have initially downplayed the threat posed by a respiratory infection thousands of miles from the capital. And if it hadn’t jumped international borders, then the outbreak would indeed have remained a minor medical curiosity, a matter that respiratory specialists in Guangdong would reminisce about when they finally retired.
At the beginning, this was a very small outbreak. “They had never dreamed it possible that our little town should be chosen out for the scene of such grotesque happenings,” wrote Albert Camus in The Plague. “A pestilence isn’t a thing made to man’s measure; therefore we tell ourselves that pestilence is a mere bogey of the mind, a bad dream that will pass away.” What China’s public health Mandarins failed to recognize was that all disease outbreaks start small. In fact, they tend to start with just one case or a coeval cluster of cases. In denying the severity of the threat, and even the existence of the disease itself in Beijing, China’s governing officials were acting in character, both national and political. For that season was even more unsettling than usual, as a political transition was taking place in Beijing on March 15, with Jiang Zemin handing over the title of party secretary to Hu Jintao at the National People’s Congress. In a country that has never had a peaceful succession since the Communists took over in 1949, such an event required that a docile media present a united, peaceful, tranquil, and healthy China. “Why didn’t the government act faster?” asked Zhong Nanshan. “Look at what was going on in Beijing on March fifteenth.”
Even if there hadn’t been a new leader being appointed, I wonder if such crisis management was even in the arsenal of a Communist Party devoted primarily to its own preservation. How does admitting that there is a new killer disease in the provinces contribute to the state’s paramount goal of stability? As long as the state controls the means and modes of the message, then why tell the story of a killer disease? Because an infectious disease, especially one that has achieved human-to-human transmission, will not, as a rule, just go away.
There were those in the Chinese medical hierarchy, such as Zhong Nanshan, who were arguing for greater disclosure and insisting that information be more widely broadcast. As the world would soon discover, if everything that was known inside China had been shared with the world just a few weeks earlier, hundreds of lives would have been saved.
Denial kills, as surely as any microbe.