April 14, 2004
Quarry Bay, Hong Kong, China
3,750 Infected, 369 Dead
THERE WERE SIXTY-ONE NEW CASES IN HONG KONG ON THE ELEVENTH and two more deaths, forty-nine newly infected on the twelfth, forty-two on the thirteenth, forty on the fourteenth, and forty-two the next day, with nine fatalities. That day, Ka-Kui Kwok, one of our production staffers, won about two hundred dollars in the office pool by predicting that there would be forty-one newly infected—the office infection pool was structured like The Price Is Right: you had to be under the number; one over and you would be out of the money. I was always optimistic and tended to lowball the guess, choosing in the twenties. We never established an office pool on the number of fatalities. The WHO would later report, “the case fatality ratio of SARS ranges from 0% to 50% depending on the group affected, with an overall estimate of case fatality of 14% to 15%.”
A 15 percent case fatality ratio is frighteningly high. Marburg, one of the strains of Ebola, among the most lethal viruses ever to cross the species barrier, has a case fatality ratio of 20 percent. Measles kills just .2 percent of those who are infected in the developed world and 2 to 10 percent of children in the developing world. Malaria, which remains one of the globe’s worst scourges, killing more than a million people a year, has a fatality rate of under 3 percent. Smallpox killed about 30 percent of those who contracted it. SARS, then, was a world-class killer.
By mid-April, SARS in Hong Kong had taken on a certain rhythm. Most of those who did not need to stay in Hong Kong had already departed. And many of those who had departed, like my downstairs neighbors, decided to convert their trips into permanent relocations. For those of us who stayed, there was almost nothing to do in the evenings. Nightclubs were closed. The Rolling Stones had canceled their two scheduled shows in Hong Kong, as had DJ Shadow and Santana. My actor friend told me, “even the Russian hookers have all left town.” Rather than drive home, I would stop in at the American Club in Tai Tam for dinner. The buffet, of course, had been shuttered. The swimming pool was drained. The children’s play area was closed. The staff was masked. It began to look, I realized, as if Hong Kong, and indeed much of the world, was still subscribing to the miasma theory of disease, the Victorian view that “foul air” was somehow to blame for the outbreak.
Indeed, Hong Kong instituted rigorous disinfecting and scrubbing, as if litter-free streets would ward off disease. Bow-tied chief secretary Donald Tsang led “Team Clean,” while Betty Tung, wife of beleaguered chief executive Tung Chee-hwa, donned more protective gear than most hospital workers as she toured Lower Ngau Tau Kok housing estate to pass out hygiene kits. Newspapers immediately slammed Tung for wearing the protective gear that ICU doctors were finding in short supply. And what protection did face masks actually provide? One’s eyes, perhaps the best conduits for virus particles, were still exposed. Newspapers were filled with advertisements selling “antibiotic incense” and health-giving tonics—“Boost your immunities!” and, my favorite, “For Bountiful Lungness.”
I would sit by myself in a booth at the American Club, eating my chicken vindaloo. Yet I was, in my own small way, succumbing to the same hysteria. We are, even at the best of times, bombarded by advertisements for pharmaceuticals that list symptoms to be alleviated. Every day, we read in newspapers about research indicating that too much of this or not enough of that will result in cancer, heart disease, or some other chronic illness. We are warned to vaccinate our children and ourselves, to take vitamins, to eat a balanced diet, to exercise—all in the name of warding off illness. The pharmaceutical-industrial complex encourages mild hypochondria. And the more recent development of the businesses of holistic medicine, New Age pharmacology, health food, organic food, vegan restaurants—it is all, at its most basic, about warding off sickness. Wheatgrass. Folic acid. Echinacea. Vitamins C, D, E, B12. Zinc. Fish oil. We are fortified by a host of supplements intended to keep us fit. The first sniffle, fever, cough, chest pain, ache, or rash, and many of us are off to have it divined by our physician—or healer or masseuse or dietician—as a possible symptom of impending illness. And if he or she does not prescribe something to banish the symptom, we feel as if we have been cheated.
And here, into these vast cities, these communities of hypochondriacs, comes an actual, real disease, a genuine reason to worry and panic. No wonder folks started disinfecting their houses with the government-recommended one part bleach to ninety-nine parts water. They had to do something.
Among my precautions was a completely unscientific decision to eat almost nothing while in or around my office besides Chicken McNuggets. I shied away from using the office kitchen; I had once seen the cleaning lady, a well-meaning woman with a cheerful grin who spoke a dialect that no one seemed to understand, wipe a table, the counter, and the basin around the sink, and then, with the same damp cloth, reach under her shirt and wipe her armpits. Part of our office’s “Team Clean” program was to have this woman on duty every day, all day, which didn’t inspire confidence.
But McDonald’s, I figured, had to be among the most sanitary dining establishments in Hong Kong. And Chicken McNuggets, I reckoned, were probably the most sterile items on their menu. The chickens were fed an antibiotic-rich diet while raised on factory farms; they had to pass inspection by the Hong Kong Department of Agriculture and Fisheries; and they were slaughtered in industrial pens and then chopped, breaded, and bagged on mechanized assembly lines—untouched by any potentially virus-infected human beings. After they were delivered to the franchises, they were then deep-fried in oil heated to over 350 degrees, enough, I guessed, to kill almost any living organism or active virion. The McDonald’s staff in Hong Kong wore rubber gloves, and, throughout the process, from slaughter to preparation, the nuggets never come into contact with potentially virus-bearing human flesh. I ate at McDonald’s every day for lunch during SARS season: nine McNuggets and a Diet Coke. I lost eight pounds.
The SARS Diet.
I would throw the cardboard McNugget packaging away, light a cigarette, and then, some afternoons, take a pair of binoculars and survey Jordan, Kowloon Bay, and Lower Ngau Tau Kok. There, in the distance, was Amoy Gardens. Local authorities had begun gathering rats and cockroaches from the apartment complex to see if they carried a viral load. Hong Kong’s Department of Health determined that of eighty-three rat specimens, six samples from droppings and two samples from throat swabs had been found to be positive for SARS. Rats, the study charged, could serve as mechanical carriers for SARS even if they themselves were not infected. Partly as a result of this investigation, Amoy Gardens became notorious for poor hygiene and pest infestations. Yet how different could that complex be from any of a thousand others in Hong Kong?
The prevailing hypothesis as to what had triggered the outbreak at Amoy Gardens, announced at a Department of Health press conference later that week, would be that virus-laden feces had been aerosolized by a cracked fourth-floor drainage pipe. Feces, of course, are proven viral carriers, as any particles that don’t find a cell to infect are passed through the intestinal system; a single gram of human feces may contain up to one billion virus particles. This sewage pipe crack found at Amoy Gardens, according to the Department of Health investigation, “emitted droplets carrying contaminated sewage into the light well every time a toilet was flushed.” The droplets would then be sucked into tenants’ apartments via “dried-up U-traps”—the same sort of curved pipe that is beneath most sinks. That U-shaped pipe beneath a floor drain, when filled with a barrier of standing water, serves to keep insects, vermin, and viruses from reaching the bathroom. At Amoy Gardens, these drains had long dried out, so that when tenants turned on their bathroom exhaust fans, the fans created a vacuum, hoovering up droplets of virus-laden feces that would either infect the tenant of the apartment or pass through the fan and back into the light well, becoming a finer, more aerosolized virus-feces cocktail. One of the more recently noted symptoms among SARS patients was stomach-cramp-inducing diarrhea, causing up to twenty watery bowel movements a day. Thus, each infected tenant at Amoy Gardens would use the toilet often, flush frequently, and, in doing so, send another viral load down the pipes to be aerosolized and blown back up the light well—and into other tenants’ noses, eyes, and mouths.
As I sat in the press conference where E. K. Yeoh announced these findings, I found a few factors confusing. Didn’t this mean that the disease had basically gone airborne?
“No,” Yeoh insisted. “It had been ‘aerosolized.’”
I don’t know if anyone in that conference room found this to be a reassuring differentiation. It also did not explain why so many other residents of Amoy Gardens, those who didn’t live in Block E but in entirely different buildings, had become infected. Were the virus-laden feces really being blown that far afield?
Yes, we were told, it was possible that the bathroom exhaust fans had created an upward “plume effect,” shooting virus-laden feces droplets up out of the top of the building, like a Roman candle of microscopic shit.
The secretary of health assured us that the cracked sewage pipe would be fixed and that U-pipes would be filled with water, preventing any microbial travel through the drains.
ON APRIL 12, THE MICHAEL SMITH GENOME SCIENCES CENTRE IN British Columbia, Canada, had announced that it had sequenced the entire SARS coronavirus genome, a crucial step toward understanding the virus. The SARS coronavirus, Caroline Astell, project leader at the Michael Smith Genome Sciences Centre, would tell me, was “the largest RNA virus we’ve ever seen.” Every organism on earth, besides a few viruses, stores and deploys its reproductive instructions by DNA, or deoxyribonucleic acid, the familiar double-helix “code of life,” rendered in Ping-Pong ball and pipe cleaner models in high school biology classrooms around the world. RNA, ribonucleic acid, is generally used as a messenger to carry genetic instructions. A few viruses, such as the SARS coronavirus, instead store their genes as RNA. DNA is far better suited than RNA to serve as a storage medium for genetic information. The “double” part of the helix can, in effect, check on the work of the genetic machinery as it replicates itself, “correcting” most errors, i.e., mutations, as they occur. Viruses with their genetic code stored as RNA instead of DNA lack this proofreading ability to check on their own reproduction. As the nucleotides of a next-generation virus are assembled according to information stored on the viral RNA, there is a far higher chance of an error occurring. Adding volatility to the process is the fact that RNA is a more reactive polymer than DNA, which means that there is more likelihood that any part of the genome may become altered because of the presence of foreign chemicals or proteins.
Though not a reliable storage medium, RNA does provide an interesting survival strategy for a virus. All viruses go through a very rapid duplication cycle. A single RNA virus can produce ten thousand copies of itself in six hours; a human being might reproduce, perhaps, every eighteen months. Hence viruses, even more stable DNA viruses, are evolving much faster than we are.
An RNA virus accelerates that already quickened process. As the RNA replicates one strand of itself, it averages one mistake per ten thousand nucleotides copied. Such instability means that once an RNA virus has entered a cell and successfully begins to create copies of itself, it is producing numerous mutated versions, with differences ranging from just a few nucleotides to dozens or perhaps hundreds. The vast majority of these genetic changes—perhaps 99.9999 percent of them—are inconsequential or unsuccessful, or they create a virion that is not successfully “active.” Occasionally, however, because of the tremendous rate of mutation, an evolved virus will emerge, one that it is actually better suited to its cellular environment. It might have different spike proteins or a slight variation of peptides that enables it to bind more efficiently with a host cell, making the disease it causes more infectious or contagious.
The SARS coronavirus, it turned out, had nearly thirty thousand nucleotides—a nucleotide is a specific combination of purine or pyrimidine, a sugar molecule, and phosphate; genes are the sequences spelled out by groups of these nucleotides—making it the largest RNA virus ever recorded. While genome size does not automatically correlate with mutability, it is a depressing fact that RNA viruses do mutate more rapidly than DNA viruses, and that this was a very large RNA virus. “SARS is a big, big boy,” said Kathryn Holmes, who literally wrote the book—or at least the relevant chapter of the book Field’s Virology—on coronaviruses. Viruses from the coronavirus family had previously been known to cause only mild infection in humans; along with rhinoviruses, they are a major culprit for the common cold. They were traditionally so unthreatening that the 2,629-page Harrison’s Principles of Internal Medicine, the world’s best-selling English-language medical textbook, devotes just a page and a half to them. Yet coronaviruses that infect animals can undergo troubling mutations. For example, a coronavirus that caused gastroenteritis among pigs mutated in the late 1980s into porcine respiratory infection. Another coronavirus that was the cause of shipping fever among calves became the reason for dysentery among adult cattle. Perhaps it had been a mutation—a random set of genetic tumblers clicking into place—that had allowed this particular RNA virus to become so infectious among humans at Amoy Gardens? Even more alarming, virologist Stephen Tsoi and a team at the Chinese University of Hong Kong were conducting research indicating that the SARS virus, as it rolled through humanity, was mutating and could become increasingly pathogenic, causing disease of greater severity. His team would take the genomic sequence from the earliest cases in Hong Kong, which were very similar to those in Guangdong, and find that there were already significant changes occurring in later strains taken from Singapore and Toronto. These mutations, he noted, were occurring primarily in the spike protein of the virus, precisely the means by which the virus attaches to a cell receptor. Perhaps what had occurred at Amoy Gardens—the emergence of new symptoms, the apparent greater infectivity—was that sort of mutation.
I thought back on the images I’d viewed through John Nicholls’s electron microscope at the University of Hong Kong: viruses budding by the hundreds around the membrane of an infected cell; other cells collapsing and breaking apart as the SARS virus finally cannibalized all the proteins and genetic material it could. As the cell literally broke apart and fragmented like a torpedoed ship—the process described in textbooks as “lysis”—thousands of viruses would then be released into the host. Lysis is the virus’s crowning achievement, the moment at which it has successfully commandeered everything of value in the cell: all those virus particles, each potentially carrying three mutations (ten thousand nucleotides times three), heading off to infect more cells.
Yet here was E. K. Yeoh, assuring us that aerosolized SARS coronavirus was not airborne SARS coronavirus.
Oh, how we clung to that fine semantic point. “Airborne” meant that it was everywhere, all the time. That if you rode in an elevator a few minutes or even hours after someone who had it, then you would probably inhale it. “Aerosolized” meant that you had to be in the elevator at the same time as someone who carried it, that you had to inhale his infected mucus particles. “Aerosolized” meant there was hope. If we scrubbed, cleansed, and disinfected, were valuable members of “Team Clean,” kept our N-95 masks strapped on tightly, and were diligent about fever checks and avoiding virus-laden feces, then we had a chance. “Airborne” meant we didn’t.
I went home. I filled my U-pipe. Six inches of standing water in a U-shaped drainpipe to keep the world’s microbes at bay.