Posted Sunday, April 27, 2003

TRYING TO COPE: A nurse and a resting SARS patient in a hospital in the city of Guangzhou


The truest sign of fear is the sound of silence. In Beijing, a city whose freeway-size avenues usually over-flow with packed buses and armies of bicycles, there are no traffic jams anymore. Restaurants and shopping malls resemble abandoned movie sets, their windows shuttered and doors chained shut. The scenes of calm mask a quiet frenzy. Beijing's residents learned last week that contrary to previous government denials, the city is harboring hundreds of SARS patients. In response, millions have gone into self-imposed seclusion, withdrawing into their homes in an attempt to protect themselves against a disease that has officially claimed about 48 lives in the capital and may have killed untold numbers more. Many of those who venture outside wear protective masks and head straight to the supermarket, to stock up on necessities such as salt, oil and instant noodles, as if preparing for a siege. Police officers man checkpoints around the city, spraying down buses with disinfectant solution. Elementary and middle schools are closed for two weeks; some universities have refused to allow students to leave campus. The most bustling places in town are the railway stations, where frantic citizens jostle for a ticket out of town.

"I'm very worried about getting on a train with so many people," says a university student, waiting for a train back to his hometown of Changzhou. "But I'll do anything to get out of Beijing. It's simply become too dangerous."

In the six months since SARS first emerged in China in the southern province of Guangdong, the virus has sickened an infinitesimal percentage of the population. But nearly everyone, it seems, is afflicted with fear. What began as a mysterious, remote illness has become a national crisis of confidence that is threatening to cripple the Chinese economy and shake the ruling Communist Party to its foundations. The central government attempted last week to blunt mounting outrage over reports--first detailed in TIME and TIME's Asian edition--that health authorities had systematically underreported the number of SARS cases in China and willfully deceived representatives of the World Health Organization (WHO) on their visits to Beijing hospitals. On April 20, the national Health Minister was fired in the most public sacking of a government minister on account of malfeasance since the Communists seized power in 1949. The mayor of Beijing was fired on the same day, and the government revised its count of suspected SARS patients in Beijing from 37 to 339. By the end of the week, that number had doubled.

On Wednesday, in the most aggressive attempt yet to contain the epidemic, Beijing officials ordered the quarantine of all offices, hotels, restaurants and residential buildings that may have been visited by infected individuals. At Peking University's People's Hospital, the quarantine orders left some 2,000 healthworkers and patients isolated and at the mercy of the rampaging virus. At least 70 doctors and nurses and 20 patients at the hospital were already carrying the disease. In an effort to prevent the disease from spreading, Beijing has begun touting a soon-to-be-finished facility dedicated to SARS victims; wards are being constructed out of the same makeshift material usually used to house migrant workers.

The government's scramble to atone for its early stonewalling managed to spook the public even more. In villages on the outskirts of Beijing, terrified citizens have set up blockades to bar outsiders from entering. The capital is buzzing with paranoid rumors, for instance that the government is on the verge of closing all public places. "I know this is probably a rumor," says Yu Jun, 32, as he stocked up on supplies at a grocery store. "But right now I'd rather believe rumors than what the government tells me."

There is reason to suspect that Chinese health authorities are continuing to cover up the extent of the crisis. Government sources told TIME that the country's leaders are so terrified of a SARS outbreak in Shanghai, the country's densely packed commercial center, that they have ordered bureaucrats there to preserve the city's "SARS-free" reputation at any cost. "All I have been told is that we must maintain the image of Shanghai as a place without a SARS problem," says a Shanghai health official. The government admitted to two confirmed and 15 suspected cases in the city, but local doctors--who say they have been threatened with dismissal if they speak to foreign journalists--are voicing doubts about that figure. A doctor at the Shanghai Contagious Diseases Hospital told TIME that there were more than 30 suspected cases checked into his hospital alone. In a press conference last Friday, visiting WHO experts said Shanghai had agreed to reform its accounting methods to international norms, which will mean a "substantial increase" in the city's suspected caseload.

News of a widespread Shanghai cover-up would further devastate the credibility of the national government and perhaps threaten the political future of China's new President, Hu Jintao. Until its attempts to come clean last week on the situation in the capital, the Hu government's approach to dealing with SARS had been both craven and ineffectual. After the disease surfaced in China's southern Guangdong province in November, party leaders quashed media reports about its existence, fearing the public would stay home during the Chinese New Year holiday rather than spend money that could spur the economy. By early March, when the government convened the National People's Congress to inaugurate a new slate of senior leaders, doctors and members of China's state-controlled media say they knew about the growing crisis but were prevented from reporting it. "We had stories ready to run," says a journalist in Guangdong. "But before the Congress, we couldn't publish them, and after the Congress, the government didn't want to alarm the people."

The depth of the misinformation campaign became clear in early April, when Health Minister Zhang Wenkang scoffed at WHO warnings against travel to southern China and declared, "It is perfectly safe" to visit the country. An official familiar with leadership briefings says senior leaders must have known they were spreading false assurances, but "the pressure to say everything is under control is enormous." Still, the veil of secrecy unraveled. In mid-April, as the government stuck to its claims that the disease was under control, current and former health professionals in China revealed to TIME that authorities were suppressing the number of suspected cases and had ordered doctors to adhere to requirements for diagnosing SARS that are more stringent than those applied anywhere else in the world. As TIME reported in its April 28 issue, state-run hospitals in Beijing moved dozens of SARS patients out of wards just before WHO inspectors arrived. In one situation, 31 patients at the China-Japan Friendship Hospital were loaded into ambulances and taken for a tour of the capital; WHO experts who visited the hospital were then told it had only two suspected SARS cases.

Stung by the torrent of criticism of his government, Hu finally decided to act. He and Premier Wen Jiabao warned their satraps to report SARS cases factually or face punishment, and authorized a massive media campaign to educate the masses about the disease--an almost revolutionary policy shift for a leadership structure that feels more comfortable with obfuscation than openness. On Wednesday, Hu appointed Wu Yi, a tough-talking former Trade Minister, to take over responsibility for the government's fight against SARS. Some China watchers believe that the public clamor for transparency may create an opportunity for Hu, a career bureaucrat with liberal tendencies, to push for the kinds of sweeping political reforms that party elders have long resisted. "This is his chance to grab the support of the people and stand up on his own," says Bao Tong, a former senior party official who was purged after the Tiananmen Square uprising in 1989. "China can keep living in a black box, or it can live in the sunshine. If he can't take advantage of this situation and move into the sun now, then when?"

He doesn't have much time. Some China watchers predict that former President Jiang Zemin, who continues to exert influence over the party, will try to shove Hu aside if the government fails to contain the epidemic and China's economy stumbles. There's little cause for optimism on either count. Citigroup economists have lowered the projected growth rate of China's economy this year from 7.6% to 6.5% as a result of the SARS scare. Meanwhile, the virus is picking up steam in the impoverished hinterlands, where public awareness of the risks of SARS is limited and hospitals lack the resources to treat an outbreak. In Shanxi province, just southwest of Beijing, eight patients have died, and overcrowded hospitals are turning patients away. Locals have begun to express openly their disgust with official denials of the size of the epidemic. Says the relative of one victim: "It is really bad that the government doesn't care about ordinary people's lives." No matter how long it takes for China to overcome SARS, that's an indictment from which the country's rulers may never recover.

--With reporting by Matthew Forney/Guangzhou and Susan Jakes and Huang Yong/Beijing


The emergency room at Toronto's Scarborough Grace hospital was, as usual, overwhelmed and understaffed when a man arrived the night of March 7. The triage nurse who first looked at Tse Chi Kwai, 43, immediately escorted him into the E.R. "He had a fever and a cough, and he was having a hard time catching his breath," says Jane Eckersall, 26, the principal nurse who treated Tse that evening. "And he looked scared." Tse had reason to be. On March 5, his mother died at home after suffering what had been diagnosed as a chest infection. A day before her death, Tse had come down with the same symptoms she had, and now the mysterious illness seemed to be spreading to the rest of his family.

Tse had SARS, from which he died on March 13, and he was about to set off a chain reaction that would infect 138 Ontario residents, leave a total of 20 dead and force more than 10,000 people into quarantine over a four-week period. How could the situation in Toronto--a center of advanced medicine--have gone so wrong so quickly? Bad luck explains most of Toronto's tale, but not all of it. As a TIME investigation has found, medical staff members early on missed key opportunities that, if taken, might have drastically slowed the spread of the disease.

The story begins with an elderly Toronto couple who spent 10 days in Hong Kong. Kwan Sui-chu, 78, and her husband began a visit to the city on Feb. 13 and stayed one night at the Metropole Hotel. Kwan almost certainly had a chance encounter there with a retired Chinese nephrologist named Liu Jianlun, who, it turns out, had SARS. After her return to Toronto on Feb. 23, Kwan passed the disease to members of her family, including her son Tse. At Scarborough Grace, he was placed in a corner bed of the E.R.'s observation ward. Next to him was Joseph Pollack, 76, who had been complaining of an irregular heartbeat. That night Pollack almost certainly got SARS, as did another man in the room, a coronary patient whom authorities refer to as Mr. D., 77. Both Pollack and Mr. D. would infect many others.

Could the spread of SARS in Toronto have been stopped that first night? Tse spent almost 24 hours in Scarborough Grace before he was placed in isolation. Says Dr. Sandy Finkelstein, who was on call that day: "His mother had died of a respiratory illness, and his background was Asian, and until proven otherwise, that's tuberculosis in my book. At which point I put him in the isolation room." Finkelstein also told the rest of the family members to isolate themselves, which they did. But he did not order the isolation of any of the patients and healthworkers with whom Tse had already been in contact. Should he have done so? "No," says Dr. Andrew Simor, a microbiologist and a member of the team coordinating Toronto's SARS response. "At that point there was no concept of how infectious (Tse) was."

If there had been, Pollack and Mr. D. might have been treated differently. After leaving the hospital, Mr. D. returned to Scarborough Grace complaining of shortness of breath. He probably had SARS by then, but because no one had connected him to Tse, he was sent to cardiac care before being transferred to York Central Hospital, north of Toronto. Mr. D. was finally linked to SARS on March 28, the day before he died. York Central was then shut down, and more than 3,000 staff members, patients and visitors were isolated. "In hindsight," says Dr. Allison McGeer, a Toronto infectious-disease specialist, the transfer of Mr. D. to a previously uncontaminated hospital "was the worst miss of the early days of the investigation."

Pollack was found when authorities started to trace people who may have been exposed to Tse. By that time he was already on his way back to Scarborough Grace with a burning fever. Pollack was isolated, but the E.R. staff apparently didn't check his wife Rose, 73. She was getting sick too. (Both would soon die from SARS.) When she took her husband into the E.R.'s waiting room, she sat near a man who was accompanied by two sons; all three were members of the 500-strong Toronto chapter of a largely Filipino Roman Catholic group, the Bukas-Loob Sa Diyos (B.L.D.) Covenant Community. The sons may have infected 30 other members of the B.L.D. Worse, B.L.D. members would expose an unknown number of people outside their circle to possible infection. On April 12, for example, one of the sons who had been at Scarborough Grace went to a conference in Montreal attended by about 450 people, including many from New York State.

Is SARS under control in Toronto? Authorities claimed last week that it was. Still, many questions about the handling of the outbreak remain. Don't put them to Carol Tough, a Scarborough Grace nurse who had to care for eight of her colleagues leveled by SARS and then spent 10 days isolated from her family. "I'd like to see someone else have done a better job," says Tough, defending the staff. "Walk a mile in our shoes and then tell me what you would have done different. And all the time you're wondering, When is it my turn?"

--By Steven Frank; With reporting by Daffyd Roderick, Cindy Waxer and Leigh Anne Williams/Toronto