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SARS in China

STANFORD UNIVERSITY PRESS

Contents

Preface.............................................................................................................................viiContributors........................................................................................................................ixIntroduction: SARS in Social and Historical Context ARTHUR KLEINMAN AND JAMES L. WATSON............................................1Part I. The Epidemiological and Public Health Background1. The Epidemiology of SARS MEGAN MURRAY...........................................................................................172. The Role of the World Health Organization in Combating SARS, Focusing on the Efforts in China ALAN SCHNUR.......................313. SARS and China's Health-Care Response: Better to Be Both Red and Expert! JOAN KAUFMAN 53Part II. Economic and Political Consequences4. Is SARS China's Chernobyl or Much Ado About Nothing? TONY SAICH.................................................................715. SARS and China's Economy THOMAS G. RAWSKI.......................................................................................1056. SARS in Beijing: The Unraveling of a Cover-Up ERIK ECKHOLM......................................................................122Part III: Social, Moral, and Psychological Consequences7. Psychological Responses to SARS in Hong Kong-Report from the Front Line DOMINIC T. S. LEE AND YUN KWOK WING.....................1338. Making Light of the Dark Side: SARS Jokes and Humor in China HONG ZHANG.........................................................148Part IV: Globalization and Cross-Cultural Issues9. SARS and the Problem of Social Stigma ARTHUR KLEINMAN AND SING LEE..............................................................17310. SARS and the Consequences for Globalization JAMES L. WATSON....................................................................196Notes...............................................................................................................................205Index...............................................................................................................................235

Chapter One

MEGAN MURRAY

In mid November 2002, a middle-aged businessman from Foshan, China, was hospitalized for an atypical pneumonia. He eventually recovered from his illness, although not before infecting four of his health-care attendants. Later, this patient would be recognized as the first detected case of SARS in the world.

Little concrete information about the spread of the disease emerged from China over the next few months, but in mid February, the World Health Organization was notified of an outbreak of a respiratory illness involving 305 cases and causing 5 deaths in Guangdong province. Even at the time of this report, it was clear that many of the cases had occurred among the health-care workers who had cared for infected patients. What was not apparent until much later was that food handlers working in Guangdong's busy markets were also heavily represented among those who became ill with the mysterious illness.

This was not the first time a new respiratory infection had emerged from southern China. In 1957, a new strain of influenza appeared in Hunan, China, which spread throughout the world and led to the Asian flu pandemic of that year. That strain persisted until 1968, when it was supplanted by yet another influenza strain that emerged from southern China and rapidly moved to Hong Kong before disseminating around the globe. Since then, several new variants of flu have arisen from the same region, most recently, an avian strain of influenza A that emerged in 1997, killing large numbers of poultry before it spread to humans, and that resulted in at least six deaths among the eighteen cases reported. Despite fears that this highly virulent avian strain might lead to a worldwide pandemic, there was fortunately no person-to-person spread of this virus. All of those who became ill had some connection with the live chicken markets in Hong Kong, and no further human cases were reported after influenza was brought under control in its avian host through mass slaughter of poultry.

With the last three influenza pandemics all originating in southern China, many researchers have wondered why this area has been the breeding-ground from which these new virus strains have emerged. Influenza A is widespread in nature and can be found in a range of animal hosts, including birds and pigs. Most influenza researchers believe that avian strains of influenza A acquire mutations that enable them to cross the species barrier and go on to infect humans and then spread among them. Although these mutations are rare events, southern China is home to an enormous poultry industry; the sheer numbers of birds on these farms means that there is ample opportunity for the population of viruses to grow and for one of these multitudinous virus strains to undergo a rare mutation.

Given this history, the Chinese authorities immediately suspected that a new influenza strain was the most likely culprit responsible for the mysterious respiratory infection spreading in Guangdong. However, tests for influenza quickly came back negative. Given recent events in other parts of the world, the Chinese also sought and ruled out suspected agents of bio-terrorism such as anthrax and plague, organisms that can cause respiratory symptoms. To complicate matters further, several different common and not so common respiratory pathogens were found in the respiratory secretions of at least some of the infected; these organisms included human meta-pneumovirus and chlamydia, a relatively common cause of atypical pneumonia among young people worldwide.

All of this remained a fairly local problem until February 21, 2003, the day on which a 65-year-old physician from Guangdong checked into a room on the ninth floor of the Metropole Hotel in Hong Kong, already symptomatic with the infection for which he had been treating people back at home. Although the doctor had little contact with others in the hotel, twelve guests staying on the same floor were eventually diagnosed with SARS. Among them were a Chinese businessman who traveled on to Hanoi to become the index case of the outbreak there, a Singaporean woman who was hospitalized soon after her return to her native city, an elderly woman from Toronto who went home to expose her large family in Canada, and a group of others who were admitted to Hong Kong hospitals, where they spread the disease to many of the hospital staff to whom they were exposed. Another one of these cases was a young man who was treated for a week in a Hong Kong hospital with a jet nebulizer that aerosolized his respiratory secretions, thus disseminating the virus throughout the hospital environment.

Although it was not clear how these people became infected at the Metropole Hotel when they had no direct contact with the doctor, it was clear that this cosmopolitan setting had provided the opportunity for the virus to infect travelers who would go on to spread the disease throughout the world. Through this seeding, subsequent local epidemics occurred in Hanoi, Singapore, Toronto, and Hong Kong with transmission to hospital staff and patients a major route of subsequent spread. The Singaporean woman was ultimately linked to...