May 1, 2003
Jianguomenwai, Beijing, China
6,310 Infected, 452 Dead
WHAT WAS GOING ON IN SHANXI WAS A MICROCOSM OF THE FIGHT against SARS across the country. China’s mobilization had been to total war footing, and the disease was held in check through measures that might be possible only in a dictatorship. “The fact that China is still an authoritarian state was certainly an important factor in containing SARS,” David Heymann would tell me later. “They were able to put resources and assets to work at a level that a democracy might not be able to do. When there is an infectious-disease outbreak, one of the hardest issues for public health officials is imposing quarantine or asking questions that could, in a strict constitutional sense, run up against civil liberties. China did not have these problems.”
If you weren’t a native son or daughter of a certain village, you would have a hard time even passing through that village. Lower-level officials, especially toward the end of April, seemed to be manning every roadblock and bus station, checking IDs and Hukous to ensure the provenance of each voyager. The scenes reminded me of those sheriffs at the California border turning away Okie trucks in The Grapes of Wrath. There were many cases of floating people—the migrant workers who crowded the cities—being turned away from hospitals and dying at train stations or bus terminals while other migrants cleared a swath around them.
Chinese train stations, in the best of times, can be packed with sweltering mobs of migrants embarking or returning from long journeys. During the season of SARS, which, I believed, signaled an end to the Era of Wild Flavor, the stations were even more crowded than usual as the entire nation seemed to be on the move at once.
Yet the vast rafts of virus that were supposedly being set adrift with these migrants never appeared.
And when cases did appear, the central government’s relentless propaganda campaign made sure every doctor and hospital in the country now knew the protocol: suspected cases had to be isolated, and all their contacts traced and monitored for symptoms; and health care workers were required to maintain the highest standard of infection control. As local hospitals throughout remote provinces such as Shanxi and Hebei began to implement these measures, the greatest threat to the planet, that a newly emerged virus would achieve endemic transmission in one of the poorest regions on earth, appeared to have been curtailed. The strict infection-control measures first advocated by Zhong Nanshan and his fellow clinicians in Guangzhou would prove bluntly effective against the virus. It was a reversion to pre-antibiotic-era hospital protocol; infection-control chiefs—usually senior nurses—enforcing strict protective gear and clothing dress codes. In Singapore, such thorough measures were employed almost from the start, and hence that city-state’s early success in ring-fencing the disease. “You had to become religious about it,” says Dr. Lim Suet Wun, chief of Tan Tok Seng Hospital. “That meant zero tolerance for any deviating from the protocol.”
It has been decades since doctors and nurses practiced this sort of infection control. During the nineteenth century, a routine visit to the hospital could result in grave infection and possibly death. In the maternity hospitals of Paris, for example, the death rate for delivering mothers was a staggering one in nineteen, prompting newspapers to dub a typical lying-in hospital a House of Crime. Women, understandably, were terrified of hospitalization. Louis Pasteur, among others, had insisted that what killed women with so-called child-bed fever was “you doctors, who carry deadly microbes from sick women to healthy ones.” Yet Pasteur was always more obsessed with finding microbes than merely interdicting them.
Joseph Lister, a Glasgow surgeon in the 1860s, had been the first to introduce the concept of antisepsis into operating suites. He noticed that if he applied carbolic acid to the wounds and surgical incisions of patients, they would not develop infection. Lister would take this further, having carbolic acid sprayed into the air of operating theaters. Despite the resulting foggy atmosphere and the frequent dressing changes required, antisepsis caught on. Later, this was modified to the concept of asepsis, or sterilizing all instruments and objects that would come into contact with a patient’s wound. Asepsis eventually replaced antisepsis, as it was obviously more efficient and less unpleasant for the doctors and nurses. This marked a paradigm shift in the quality of health care. Lister’s asepsis was the first successful break in that chain of infection. Hospitals went from being among the deadliest options for someone in need of medical care to actual houses of wellness. In the hundred years from 1800 to 1900, the single greatest advancement in medicine may have been the movement to sterilize operating theaters. In that period immediately prior to the invention of penicillin, the West had the cleanest hospitals in the history of the world.
The advent of penicillin as the first of the “miracle drugs” in the early twentieth century made vigilance against infection less of a priority in hospitals. Why take such aggressive measures against infections and bacteria if most of them could be so easily killed with antibiotics? As a result, infection-control measures at hospitals around the world underwent a gradual deterioration as doctors relied more and more on antibiotics, forcing pharmaceutical companies to invent new drugs faster than the bacteria could mutate into antibiotic strains. (It is in part because of this relaxed vigilance that hospitals in the United States and Canada are plagued by staphylococcus infections.) With the current outbreak, institutions around the world were exposed for having less-than-perfect infection control. “Hospitals emerged as the main amplifiers of the disease,” says K. Y. Yuen.
He has a point. In China during the season of SARS, there was only one superspreader outside of a hospital setting: the dialysis patient who lived at Amoy Gardens. Sterilization protocols had been relaxed in part because those respiratory ailments that do show up in modern hospitals are not viewed as serious threats. Measles, for example, is a virus against which almost every health care worker is vaccinated. And common influenza strains will cause at most a few days’ discomfort; often, those health care workers who are likely to come into contact with influenza patients will have been vaccinated as well. Most common chest infections can be knocked out with doses of antibiotics. With SARS’s arrival, however, hospitals were forced to consider a respiratory ailment that was highly infectious and deadly, an opponent that had not stalked hospitals in decades. “We’ve never seen a disease that spread like this before,” says Aileen Plant of the World Health Organization team in Hanoi. “Millions of people turn up every day in developed countries with infectious but minor illness. You never expect anything like this. We had to think about infection control from the point of view of a respiratory illness that spread this rapidly in hospital settings.”
What worked was old-fashioned Florence Nightingale–style proscriptions: protective layers of masks, goggles, gloves, galoshes, and gowns. Sealed wards. Quarantine. Ventilation. This was not Nobel Prize–winning medicine. Yet it was effective. One of the ironies of SARS was that hospitals with less-sophisticated climate-control systems fared better than those with modern air-conditioning. An open window with a fan blowing outward to ensure reverse pressurization was the most effective way to safely disperse the virus. “We noticed that ventilation was essential,” says Zhong Nanshan, “that fresh air seemed to curtail the spread. That was before we knew this was a virus.” These are methods from a bygone era, yet they were the only procedures that slowed down SARS. Those rural Chinese hospitals with open windows would turn out to be viral dead ends.
And the layering and sealing of the body from patient effluvium was a commonsense approach that turned out to be the only effective course. You protected yourself out of fear, yet that was what worked. It has been half a century since a disease outbreak had caused big-city hospitals to take these sorts of measures; virtually no doctors alive today have had to work in these conditions. Yet it was nineteenth-century medicine that was defeating the twenty-first century’s first pandemic. The battle was being fought one hospital ward, one patient at a time. It was the medical equivalent of trench warfare. There were no cures, no magic-bullet treatments. You did what you could for the patient, provided what symptomatic relief you could, and, in a sense, let the disease run its course. Since there was nothing that was proven to be effective at killing the virus itself, the disease made exhausting demands on health care workers. Doctors and nurses were forgoing seeing their families for weeks at a time. “I felt like we went two months without sleeping,” said Joseph Sung of Hong Kong’s Prince of Wales Hospital.
Yet in a pitched battle between this newly emerged virus and some of the best medical facilities in the world, the virus almost won. This was not supposed to happen. Infectious diseases are supposedly a thing of the past. Since World War II, no modern city had been brought to a halt by an infectious disease, and now, here were a half dozen in Asia and another in North America that had been reduced to panic because of a novel respiratory tract illness. The season of SARS could be viewed as either an anachronism or a harbinger. Unfortunately, scientific evidence suggests that it was an indicator of outbreaks to come and that we had better learn as much as we can from its emergence.
AMONG VIROLOGISTS, THIS LATE-SPRING LULL IN SARS ACTIVITY looked suspiciously like the seasonality that is a trait of most coronaviruses. Scientists are not sure why some viruses become more “active” or “infectious” in colder weather. It might be as mundane a reason as people being huddled together indoors during the winter months, resulting in greater proximity of hosts; or it could have to do with lower relative humidity in cold temperatures. “At the clinical level,” says Malik Peiris, “we could see what was working. As hospitals adopted greater infection control, we saw the chains of transmission starting to break. But there was always a nagging question about seasonality. It was getting warmer, and coronaviruses had been shown to react to the climate changes.”
Just as influenza had a season, perhaps SARS did as well. Hong Kong, Guangdong, Beijing, and Shanxi were still WHO no-go zones, yet there was a cautious optimism; for the first time, we could see more recovered SARS patients being discharged than new cases being admitted.
It had been only six weeks since the WHO’s first Global Advisory. We now knew what this thing was. We knew what it did. We even knew, albeit through prophylactic measures, how to stop it.
We still had no idea where it came from.