Chapter 3
Life with SARS

SARS has had a dramatic effect on the way people go about their daily lives in places that have had outbreaks of the disease. Some of these changes have been merely inconvenient, while others serve as frightening reminders of how quickly a disease can turn life upside down—not only for those who are infected, but for healthy people, too.

Clean Tires and Disinfectant

Once the Chinese government realized that it was necessary to openly confront the SARS epidemic, life changed quickly for the Chinese people. Interestingly, China's authoritarian system, which has been widely criticized as repressive, proved to be very useful in fighting the epidemic. "In a country where the government rules by fist," notes observer Kathy Chen, "its orders to fight [SARS] have been carried out in spades."³⁹

For example, the state-run media were required to run public service programs several times each day, informing people how to minimize their risk of infection. Banners were put up in every city and village reminding people to wash their hands and wear face masks, and volunteers were rounded up to staff checkpoints for taking people's temperatures. Chinese officials even decreed that people must disinfect their bicycle and automobile tires each day to kill any germs that might have come home with them.

One man from a town in central China learned how strongly the government felt about containing SARS. Yang Jie, a twenty-two-year-old who worked for a home-improvement company in Beijing, decided to return home for a visit during the height of the epidemic. However, before being allowed on the train Yang had to undergo a thorough physical to make sure that he was not infected with SARS. During the fourteen-hour train trip, railroad workers came through his car several times to spray disinfectant. And when he arrived in his home town, Yang and several other passengers who had boarded the train in Beijing were put into quarantine for a week before being allowed to return to their families.

"Are You Feeling Well Today?"

Travel restrictions were not limited to China, however. At the Singapore airport, all travelers getting off planes—regardless of their point of origin—were greeted by nurses wearing face masks, goggles, and protective yellow gowns cheerfully saying, "Welcome to Singapore! Are you feeling well today?"⁴⁰ The nurses then guided the passengers through high-tech scanners that would beep if a person had a fever of more than one hundred degrees. Anyone setting off the beeper was quickly escorted by masked soldiers to a video-camera–enforced quarantine area.

Singapore was serious about preventing travelers who might have SARS from coming into contact with its citizens. Anyone who balked at being quarantined was fitted with an electronic wristband, and anyone who persisted in trying to escape during the ten-day quarantine period was jailed for six months and fined five thousand dollars. "We do what we have to," explained Singapore's minister of health. "I don't think we've seen anything like this before, and it is a global problem. For now, this is a battle that is being fought with the thermometer and quarantine."⁴¹

In many countries around the world, governments enacted strong restrictions on visitors from a SARS-affected nation. Saudi Arabia simply refused to allow Asians or Canadians to enter the country. Thailand allowed travelers from China, Singapore, and Vietnam to visit, but required that they wear face masks for the duration of their stay.

After Canada experienced an outbreak of SARS, its health ministry requested a ten-day voluntary quarantine from any traveler from a SARS-affected nation. Those travelers were not required to go to a particular facility, as they were in Singapore, but were asked to stay at home, take their temperature every few hours, and to stay in a separate room from anyone else for ten days. By mid-April, there were believed to be at least seven thousand people in Canada under voluntary quarantine.

Life in Quarantine

Some of those in quarantine were relatives and friends of people who had developed SARS. Many spent the required two-week period (the longest time known between being exposed to the disease and showing symptoms of it) at their homes. Besides being told to take their temperatures often and to stay away from their families, they had to resist the temptation of dashing out to do an errand or see a friend.

Thousands of others were put on what was called "working quarantine." Most of these were health care workers who had been exposed to SARS at North York General or Scarborough Grace Hospitals—the two facilities that treated the SARS patients during the epidemic and which later transferred all patients except those with SARS to other hospitals in the city. Those workers at Scarborough or North York who had been exposed were allowed to work their regular shift—wearing masks and protective gear—but afterward had to return home.

Peggy Dawson, a twenty-nine-year-old nurse who works at Scarborough Grace Hospital, was put on working quarantine, though she says that to the best of her knowledge, she was not exposed to anyone with SARS for the period in question. "However, there were other members of the staff," she said, "who could have been exposed, from people who clean the floors to physiotherapists and respiratory therapists. We all share the same cafeteria, come in through the same entrance. It's a contact of a contact, and that's why we are all under quarantine, the entire hospital."⁴² Dawson says that every day she worried that she would develop symptoms. "Every time I put the thermometer in my mouth," she admitted, "I'm praying that there isn't a change." She has remained healthy, but says that even though she is out of quarantine she still worries that an epidemic—SARS or something else—will happen again. "It has really changed the face of nursing," says Dawson, "and changed the face of health care forever."⁴³

"It Feels like Being in Prison"

Quarantine was often far different for people in Asia. Shortly after it was discovered that more than 250 residents of the large Hong Kong housing complex, the Amoy Gardens, had become infected with SARS, health officials descended on Block E of the complex and bused the 240 remaining residents to quarantine facilities.

Many of the evacuees were angry, however, for they say that their temporary lodging seemed far more conducive to the spread of disease than their housing complex. The facilities to which they were taken were rundown resort settlements, which were cramped and filthy. One woman says that she spent the first morning in quarantine disinfecting her cabin's toilet with bleach—only to be told that several families would be sharing bathrooms during the quarantine. Said the woman, "It feels like being in prison."⁴⁴

In the eastern mainland province of Zhejiang, SARS patients were quarantined in a government office building. Not only were those quarantined angry at the lack of facilities—no beds, for example—but nonquarantined residents staged violent protests at the use of those buildings. Breaking windows and smashing furniture, townspeople were furious that such buildings were used, calling the quarantine a danger to everyone. They worried that after the quarantine ended, germs would remain in the buildings, endangering citizens. Insisted one protester, "They shouldn't have hospitalized patients in the government building, which has no medical facilities and professional staff."⁴⁵

Reminders Everywhere

Though SARS patients and others quarantined were most affected, daily life—even for healthy people—changed drastically during the SARS crisis in China and other Asian countries. For children in Singapore and China, it meant that school was canceled until the threat of infection had passed. For parents of very young children, it meant babysitting services, daycares, and preschools were closed, too. That presented a problem for people who had no older children or other family members to watch their young children while they went to work. In Singapore alone, more than six hundred thousand young children were affected by the closing of child care services.

There were daily bulletins on radio and television that gave the totals of new infections and numbers of deaths for the day. In these bulletins parents were strongly urged not to take their children to public places such as the zoo, playgrounds, or shopping malls. One woman says that it was especially hard on children who were celebrating birthdays during this time. Parties had to be canceled. It was probably for the best, she says, since no one felt like celebrating.

Lest anyone forget—even for a moment—that there was a dangerous disease in the area, there were constant reminders everywhere one looked. "Security officers stationed at the driveway of our apartment building were stopping everyone," one woman says, "even cabdrivers, to take their temperatures."⁴⁶

In Singapore, every business person was stopped before entering a downtown building and, before using the elevator, had to fill out a health evaluation form. People were afraid of buses and trains because of the threat of touching a contaminated door or seat. Instead of relying on public transportation as is usual in most Asian cities, people opted to ride their bicycles—a decision that created massive traffic jams.

Bambi and Teddy Bear Masks

More than anything else, however, it was the presence of face masks that served as a constant reminder of the threat of SARS. People rushed to medical supply stores to buy them, hoping to keep airborne germs away from their noses and mouths. In Hong Kong, stores were selling more than one thousand masks each day—some people were buying hundreds at a time. When only a few were left on store shelves, shouting matches often broke out among customers.

On street corners, vendors tried to capitalize on the frenzy. On a Singapore street, a vendor sold turquoise masks with pictures of Bambi or a teddy bear on them. They appealed to parents whose small children did not like wearing face masks. "My kids don't want to wear them," said one mother as she bought two of the Bambi masks. "With cartoons on them, they might change their minds."⁴⁷

Masks seemed to be everywhere SARS was. They were worn by bank tellers, flight attendants, and waiters. Even on television, talk show hosts (and their guests) wore masks, too. But the mask-wearing has brought up some new issues of etiquette that have never been considered before. For example, business people debate whether masks make their clients more or less afraid. Should one remove one's mask when meeting someone for the first time? And since touching and handshakes are frowned upon in the age of SARS, how best to greet a valued customer or client?

Cab drivers in Hong Kong and Singapore found that because they wore masks, they were losing business. As a result, many opted not to wear them and left their windows open instead. Too, there was the issue of comfort; the most effective masks are form-fitting, and they can cause discomfort when worn for hours at a time. They are also hard to breathe through when exercising or doing strenuous work. One American visitor to China felt that the mask was more trouble than it was worth. "I wear my masks most places," he said, "but it's uncomfortable because it's humid here, and in a restaurant when you're trying to eat, it's just impractical."⁴⁸

Fear Among Health Workers

While the constant worry about SARS was hard on almost everyone, it was especially troubling for health care workers. They were the ones most at risk, and in the early weeks of the disease, it was doctors and nurses in mainland China, Hong Kong, Vietnam, and Toronto who were infected more than any other group.

Because of the shortage of healthy emergency workers in Toronto, Canadian physicians contacted doctors they knew in the United States and asked for help. As a result, about three hundred American doctors agreed to come to Toronto. The Canadian government issued temporary medical licenses to the Americans (physicians are normally allowed to practice medicine only in the country from which they received their medical license.)

One of the American doctors who traveled to Canada says that the atmophere in the Toronto hospital where she worked was both angry and frightened. So little was known about SARS—especially how it was transmitted—that health workers felt vulnerable even with protective gear. The healthy members of the staff were burned-out because they had to work more shifts to cover for their colleauges who had caught SARS or who were in quarantine. Many were working double or even triple shifts. "They're not getting enough sleep, they struggle with putting on their protective gear," said the chief of infectious diseases at the University of Toronto, "and they are worried about getting infected themselves."⁴⁹

"Mommy, Are You Wearing Your Mask?"

Trish Perl, one of the American doctors who came to help in Toronto, noticed right away that there was a strange atmosphere at the hospital, with everyone wearing layers of protective gear—even in the staff lounges. Some moved to the other end of a meeting room when a doctor who had cared for a SARS patient walked in. "It was eerie—like you were on Mars or on a new planet," she says. "You sit in meetings, everyone around the table is wearing an N-95 [high-quality face] mask."⁵⁰

Perl was struck, too, by the number of doctors and clinical workers who are so afraid of SARS that they cannot—or will not—deal directly with patients with symptoms that might be SARS. For example, she noted that some would not deal with anyone with a fever of more than one hundred degrees, or who suffered from a dry cough. One radiologist stayed in his office with his door closed and refused to have any contact with X-ray technicians. The only X-rays he would read were those slipped under his door.

Perl admits that she was fearful before she traveled to Canada, since she was unsure of how bad the situation was. Like other physicians, she was concerned about the many health care workers who had become infected—even though they had taken precautions. "As I was hugging my little girl on leaving, I thought, 'What am I doing?'" Perl remembers. "'Is this a smart thing to do?' I was very scared at first; I didn't know what I was getting into." And when she talked to her children on the telephone, she was not surprised at what they wanted to know. "They would say, 'Mommy, are you wearing your mask?'"⁵¹

Hungry Ghosts

SARS has not only changed the routine for doctors and hospitals, but for the families of the victims of SARS. For instance, the disease has forced a change in the cultural rituals associated with death. In China, for example, people are expected to remain with a dying family member. A family vigil, known as you zi song zong, is considered extremely important to ensure that after death, the spirit is happy. However, when SARS spread to Hong Kong, doctors began to realize how vulnerable family members and other visitors were as they sat with an infected patient. By the end of March 2003 most hospitals in Hong Kong prohibited visits by family members. This meant no vigils, and families were upset.

Vigils are important for more than support for a dying loved one. Many Asian people believe that it is important to note the expression of a person's face at the moment of death. Families believe that a person who dies with open mouth or open eyes dies trying to communicate something important. To have a loved one die in such distress can produce guilt within a family that can last for many years. The spirits of those who have died with such unfinished business are called "hungry ghosts," and are greatly feared. "People who have died an early death—from a disease or other natural causes—are considered dangerous," explains anthropologist Joseph Bosco. "They've got every right to be angry at the world, because they were cheated out of their lives."⁵² And because of the hospitals' need to keep family members separated from the dying SARS patients, people do not know the emotional state in which their loved ones died.

Cold and Empty

Because people were unsure of how SARS was spread, families had a great deal of difficulty finding funeral parlors that would accept a SARS victim's body—and even those refused to hold traditional funeral services. Throughout Asia, funerals are almost always held with the body displayed, but the threat of SARS changed that. Funeral directors, worried about spreading the disease from the dead body to funeral guests, insisted on using a framed photograph of the deceased, instead.

Another funeral custom that has been suspended because of SARS is the ceremonial "water buying," in which a family member—usually the oldest son or male relative—purchases water with which to wash the dead person's face. This symbolic ritual is extremely important to many Asian people—so much so, says one funeral director in Hong Kong, that "among the older generation in Hong Kong, the greatest insult would be to say, 'When you die, I hope you have no sons to buy you water.'"⁵³

Not surprisingly, the funerals for SARS victims tend to be sparsely attended, which is disappointing to grieving families that need the support of others. One woman says she felt terrible when only a handful of her husband's friends showed up for his funeral. "I felt the atmosphere was cold and empty," she says. "I was broken down spiritually and psychologically."⁵⁴

The Psychological Toll

As months went by in SARS-affected countries, many learned that there were often psychological effects on residents. In Hong Kong, for example, many people complained of feeling mentally fatigued each day. There was no comfort of routine. There were no concerts to attend, no social get-togethers with neighbors.

Many people found that the sources from which they had always drawn strength were missing. For some it was religion, and there were noticeable changes in churches in Asia and Canada. In Singapore, for example, the Catholic Church suspended confessions in private confessional booths—instead offering general forgiveneness to their parishioners. Toronto churchgoers were asked not to dip their hands in holy water or to share wine at communion.

Others in SARS-affected regions missed the support they normally received from their families. Since many foreign business people in Asia had moved their families to other continents in an attempt to avoid SARS, they weathered the ordeal without the comfort of their spouse and children. Karl Taro Greenfield, a Time magazine reporter living in Hong Kong, says the experience was not just a medical threat but one that affected people's spirits. "The quesions raised alter the rhythm of life itself," he noted. "Do you dare dine communally, as is the custom here in Hong Kong? Is it safe to work out at the gym? If you do work out, is it advisable to take a shower in the clubhouse afterward? Do you kiss your children?"⁵⁵

One man said that people put a huge importance on daily radio and television bulletins about SARS, hoping to hear promising news about the disease. "Every evening, the Department of Health releases the numbers of new infections and fatalities," he said. "If the numbers are lower than yesterday, we cling to the hope the worst is over. If there are more new cases and deaths, we shudder."⁵⁶

Psychiatric Study

For people who have survived SARS, the psychological toll has been documented. In a study of 150 SARS patients in Hong Kong, it has been found that 45 suffered from psychiatric problems when they were discharged from the hospital. The problems have ranged from anxiety and mild depression to episodes of posttraumatic stress and severe panic attacks. Some doctors suggest that the psychiatric problems may stem from a reaction to the steroids and other drugs given in the hospital, but no one is certain.

Health care workers who survived SARS, experts say, tend to be more fearful than before they were infected, and that as a result, they have not returned to their jobs as quickly as predicted. "We're finding that [because of the psychological factors] it takes quite a long time for some people to get back," says one Toronto doctor, "even if they haven't been that badly infected."⁵⁷

One key factor that experts believe is contributing to the psychological problems of survivors is the stigma that is attached to them by society. Many patients found that employers were not willing to have them return to work because they believed the survivors remained a high risk for infecting others in the workplace. One Hong Kong woman was fired after refusing to sign a vow to break up with her boyfriend—a health care emergency worker.

Not only recovered patients, but also many doctors, nurses, friends, and relatives of patients have been ostracized, too. One Hong Kong woman who lives at the Amoy Gardens residence was shunned not only by friends but by her own family—even though her area of the housing complex was not affected by SARS or the quarantine. The fear of SARS was so strong that neither her mother nor her eight brothers and sisters would see her, and she was treated as an outcast at work.

Her experience is not uncommon; in fact, Hong Kong's minister of health finally reacted to the lack of empathy by the public toward people remotely affected by SARS, urging people to be less fearful and more compassionate. Even so, by June 2003, the Hong Kong Equal Opportunities Commission had received thirty-eight complaints of SARS-related discrimination, and officials believed there would be more filed within the month. Because so little was understood about the disease, those who had been infected and had survived often remained on society's periphery.