Politics and SARS

VICTOR Heiser, an American physician who headed the colonial Bureau of Health in the Philippines for many years, wrote in his autobiography, "An American Doctor's Odyssey," about how he tried to convince a tribal leader in the northern Philippines about the existence of microorganisms.

Heiser brought a microscope, on which he mounted a slide with a "lusty specimen" of amoeba, and explained to the tribal leader: "That's what causes diseases that kill you, but we can kill it." The chief peered into the microscope and retorted, "Well, it might kill a little white man like you, but it wouldn't hurt a great big Apo like me."

That incident happened almost a hundred years ago but in many ways, the "great big Apo" was quite correct. Germs -- bacteria, viruses, protozoa like the amoeba Heiser used -- can be deadly, but politics and power relations will, to a large extent, determine who gets sick and who dies. We certainly see the role of politics in the current outbreak of Severe Acute Respiratory Syndrome (SARS).

Thanks to the work of epidemiologists, scientists who track the spread of diseases by examining records and interviewing people, we now know the outbreak started in China as early as November last year. Unfortunately, the Chinese government suppressed news about this emerging problem, until the infection spilled out over China's borders.

I thought it would be important to share some of the details of what happened, partly to show the amazing medical detective work that can be done by epidemiologists, and partly to show the politics behind diseases. I'm depending mainly on an article by Jan Wong, "How China failed the world," in the Canadian newspaper Globe and Mail (April 7, 2003), supplemented by articles from the South China Morning Post in Hong Kong and The New York Times.

The nightmare started with the initial infection, some time in November last year, of two or three residents in the city of Foshan in Guangdong (Canton) province. Doctors diagnosed the disease as pneumonia but were alarmed because it seemed to be particularly contagious, rapidly infecting the patients' attending physicians and other health staff.

By mid-November, five more cities in Guangdong reported this new disease, with health workers noting how ferocious the disease was. A 10-year-old boy admitted to a hospital in Guangzhou, the provincial capital, was believed to have infected five hospital workers, including an ambulance driver and a doctor who later died. The boy was posthumously nicknamed "Du Huang," du meaning "poison" and huang an "emperor."

Despite all these cases, Chinese authorities kept quiet, fearful that public panic would scare away business investors and tourists. The more the news was suppressed, the more active the rumor mills became. There was talk, and text messages, about bioterrorism. Stores ran out of vinegar as rumors spread that it was a good disinfectant. By February, word about this mysterious illness reached the outside world, with infectious diseases specialists inquiring about what was happening. The Guangdong Provincial Health Bureau had to organize a press conference on Feb. 11, admitting there had been an outbreak but that it was now "under control."

On Feb. 21, Dr. Liu Jianlun, who had been caring for patients with this atypical pneumonia in a Guangdong hospital, traveled to Hong Kong to attend a nephew's wedding. The 64-year-old doctor wasn't feeling well but didn't want to miss the wedding, and also wanted to check with colleagues at the University of Hong Kong about this new disease. He checked in with a high fever and a dry cough, and was given a room on the ninth floor.

The epidemiologists have been able to establish that Liu infected seven other guests at that Hong Kong hotel's ninth floor, perhaps as he and the others were waiting for the elevator. Medical scientists know that the disease is spread when a patient coughs and sneezes, propelling the germs up to a meter away.

Who were infected in that Hong Kong hotel? There were two people from Canada, a Chinese-American businessman, three women from Singapore and a man from Hong Kong.

Johnny Chen, the businessman, flew from Hong Kong to Hanoi, where he began to feel the illness and had to be admitted to a hospital. There, his infection spread to at least 20 health staff, including Dr. Carl Urbani of the World Health Organization (WHO). It was Urbani who realized this strange pneumonia was a serious problem and alerted global health authorities. Chen eventually died of SARS, as did Urbani. Canada, Vietnam, Singapore and Hong Kong now have major SARS outbreaks.

The WHO has been blunt in criticizing China for suppressing the news. If the Chinese had alerted global authorities earlier, experts could have been sent in to help keep the disease under control. Instead, SARS spread out without warning, catching other countries' public health systems off guard. Canada, for example, has a well-developed health care system and yet 10 SARS patients have died, out of some 200 infected.

Contrast that death rate with the United States, where more than 100 SARS infections have now been confirmed but without a single death. The reason is simple: by the time SARS arrived in the United States, health officials were already aware of the disease and were able to issue guidelines to hospitals throughout the country on how to handle SARS. Quietly but effectively, the hospitals were able to treat patients and, just as importantly, to prevent the infections from spreading out too quickly.

What will happen in countries like the Philippines? It'll do well to remember our "great big Apo" and strengthen our body politic so we'll be ready when SARS does arrive.