Chapter 5
SARS and the Future

On july 6, 2003, the World Health Organization announced that SARS had been contained, as no new cases of the disease had been reported anywhere in the world since June 15. Although the announcement was a relief to many people, medical experts tended to be less optimistic.

For instance, some felt that the disease could easily return. Because SARS is a coronavirus, it may be seasonal like other coronaviruses—such as those that cause the common cold. Michael Osterholm, director of the Center of Infectious Diseases at the University of Minnesota, felt a recurrence of SARS was not only possible, but likely. "I am convinced with the advent of an early winter in the Northern Hemisphere in just six short months," he told Congress, "we will see a resurgence of SARS that could far exceed our experience to date."⁷⁶

Other infectious disease experts concurred, saying that it would only take one case of SARS to spark a new outbreak. And since it was impossible to know whether or not a person with SARS may have been misdiagnosed with some other ailment, an outbreak could come at any time. David Heymann of WHO agreed that it was crucial for doctors to be vigilant, saying, "It's very important countries continue their surveillance for at least the next twelve months."⁷⁷

"I'm a Bit Astounded"

Even if the SARS virus is not seasonal, some scientists are concerned that perhaps the virus may still be at large in China. Because China had been embarrassed by the mishandling of the epidemic, officials there are understandably eager to prove to the world that they can contain the disease. Some have speculated, for example, that in an effort to keep the numbers of SARS victims down, Chinese health officials may have stopped reporting likely SARS cases to WHO.

Another worry is the fact that in May 2003 scientists in China discovered the presence of the SARS virus in a wider variety of animals in food markets in Guangdong Province than previously reported. Originally, SARS was thought to be present in the long-tailed civet cats and rats being sold in food stalls. However, the new findings showed that the virus was also present in raccoon dogs, snakes, wild pigs, bats, badgers, and monkeys being sold as food in the same stalls.

The reaction of WHO officials was one of surprise, because most viruses do not infect such a broad range of animals. "I'm a bit astounded," said one researcher at WHO. "If this virus is present in so many species, it would be a big surprise biologically." He went on to admit that if indeed the findings of Chinese researchers were verified, it "would change the ballgame."⁷⁸

Impossible to Enforce

If it is true that a wider variety of animals carries the virus, it would create a number of new problems. Since it is almost certain that the SARS virus is a crossover from an animal virus, it would mean that there were many carriers of the coronavirus that could possibly infect humans. In that case it is not merely a matter of warning consumers about one or two types of animals, but rather most of the species sold at the markets in southern Guangdong Province. It is believed that the animal virus invades a human host during the handling, slaughtering, or cooking of infected animals. (Researchers do not think that eating animals once they are cooked poses any threat.)

Soon after the link was identified between wild animals and SARS, the Chinese government tried to crack down on the animal markets, banning the sale, capture, transport, or purchase of almost all wild animals—dead or alive. In addition, provincial government officials warned that they would conduct unannounced visits to the markets, restaurants, and ports where the trade in wild animals often occurs. A media campaign began at the same time, urging citizens to "cultivate enlightened and hygienic eating habits, and not eat wild animals."⁷⁹

Yet those who live in southern China say that very little has changed since that time, and animals are as available as ever. In fact, hours after the ban was declared, not only were such animals on sale, but the price had increased, too. For instance, the price of long-tailed civet cats went up from about twenty to more than ninety dollars.

"It's Fun"

The ban has forced vendors to be more careful not to be caught selling exotic animals, and experts say that usually a raid by health officials or police will not catch many. One reporter was in Guangdong Province when rumors of a raid by government officers circulated, and he was amazed at how quickly the exotic animals dealers disappeared. "One woman placed her turtles into a black trash bag," he writes, "slung it over her shoulder and fled. About twenty more hawkers quickly followed, wheeling cart-loads of caged animals with them before vanishing into alleyways and storefronts surrounding the covered market."⁸⁰

Many feel that it will be nearly impossible to enforce the ban, since there is so much money to be made in the markets. They compare the business of selling exotic animals to drug trafficking, insisting that as long as the business is highly profitable, there will always be dealers of such animals. The profits are there because of the demand for such animals, and is not likely to go away.

Many Chinese eat exotic animals because they believe there are health benefits in doing so. The long-tailed civet cat, for example, is believed to boost a person's immune system, while eating various types of snakes is thought to make men more virile. Giant Chinese salamanders are believed to help one's complexion stay smooth. For most of the food market's customers, however, the biggest draw is the experience of eating something different. "It's fun," admits one. "You point to an item on the menu and ask your friends, have you eaten that? No? Well, I have."⁸¹

Such strong resistance of many Chinese to changing their eating habits has led some scientists to search for ways to lessen the danger of animal-to-human transmission of viruses such as SARS. One University of Hong Kong microbiologist has suggested that long-tailed civet cats be raised on farms, where they could be tested for disease on a regular basis. The slaughterhouses, too, could be controlled by health agencies so that they met approved standards for hygiene and sanitation. Until the sale and slaughter of wild animals is taken out of the hands of individuals, however, the presence of viruses will always be a threat.

SARS and Developing Nations

Another ongoing worry among international health officials is that if SARS does recur, its effect in developing countries will be frightening. Scientists know that patients whose immune systems were already weakened from other conditions were more likely to die from SARS. In fact, more than two-thirds of the deaths in every age category were people suffering from chronic diseases. For many people in developing nations, chronic disease is a way of life.

That means that the more than 30 million HIV-infected Africans are especially at risk. Most AIDS patients in South Africa, which has the highest incidence of the disease, do not get treatment, since the majority of sufferers are poor. State hospitals are overwhelmed with the numbers of people needing care, and often must turn people away. "We are already living a nightmare here," says one South African doctor. "Six hundred people are dying each day from AIDS in South Africa, but if SARS comes into a community, it may be as bad as the 1918 influenza epidemic."⁸²

Worried about the potential for a devastating epidemic in South Africa, the government has set up a twenty-four-hour clinic at the Cape Town Airport so that international travelers can be checked for symptoms of SARS. Each plane arriving at the airport from a SARS-affected country must be boarded by a public health official, who hands out information about SARS and phone numbers to call if a person suspects he or she may be ill.

Although many hail the government's response to SARS as helpful, others say that the biggest danger is not from international travelers but the millions of poor South Africans who have no access to health care or information about the disease. "People now know about SARS, they are worried about the symptoms and those who fly here with the disease will let medical people know immediately once they feel sick," says one South African specialist. "But what about their gardener or maid, who lives in the township [where the poorest segment of the population lives], and goes home that night with a cough?"⁸³

Ripe for an Epidemic

South Africa is one of many places on the planet where impoverished people could be decimated by SARS. Many researchers at WHO were nervous about the consequences of an outbreak in India, whose 1 billion people live in the most crowded of conditions. Since scientists believe that the outbreak in Hong Kong's Amoy Gardens housing complex was caused by feces of a person with SARS, the likelihood of a major outbreak in India—where only one-fourth of the citizens have toilets—is very strong.

Many nations of the world are also hampered by impoverished, almost nonexistent health care systems. In India, for example, most people have no health insurance, so sick people often wait a long time before going to the doctor. And doctors are scarce—in 2000 it was estimated that in India there were only five doctors for every thousand people, and only one small health center for every eighty thousand people. "The danger is extremely great," says one Indian university professor. "Over time the health system has become weaker and weaker."⁸⁴

Some health care systems are so impoverished that they lack even the basics necessary to treat someone with SARS—or any other contagious disease. Kenya, which is one of the better-equipped African nations, has only ten respirators in the entire country. The Philippines, which spends only 2 percent of its annual budget on its citizens' health, cannot even afford to buy gloves and masks for its emergency room technicians. Few disagree that SARS—or any contagious respiratory disease—could kill thousands, or tens of thousands, in such countries before it was through.

Learning Lessons

One of the most important aspects of the SARS crisis is that it has shown the weaknesses in the health care systems around the world. If the disease returns, as many researchers believe it will, it is important that governments and health agencies learn from the mistakes that were made during the 2003 outbreak of the disease.

For one thing, it is clear that honest, prompt, accurate reporting of the disease is vital to containing it. China's coverup of its first cases directly led to the worldwide spread of SARS. Barry R. Bloom, the dean of the Harvard School of Public Health, says that it is pointless for any nation to use deception when it comes to a virus like SARS. "In infectious diseases, it helps no one to either deny you have a problem, or to be dishonest in reporting it," he says, "because if you do, and you do have spread, you are going to get caught."⁸⁵

But inaccuracy can be just as devasting as deceit, and China is only one of several nations where botched diagnoses allowed SARS-infected patients to spread the disease. In Toronto, an investigation of health officials' handling of the SARS crisis there found a lengthy list of mistakes that worsened the city's epidemic. One of the most flagrant errors was the misdiagnosis of patients. Although many exhibited symptoms of the virus, doctors sent them back into the community, assuring relatives that the patients did not have SARS. As a result, relatives and health care workers became infected.

"It's the Dumbest Thing in the World"

Toronto's health officials say that one lesson they learned from their experience with SARS was the woeful state of their patient-tracking system. As Toronto's outbreak worsened in April and May, the public health system was overwhelmed by the task of keeping track of thousands of people who had been exposed to the virus and were at risk of developing SARS, as well as the many people in quarantine.

Because of underfunding, the public health office had to rely on a paper-based tracking system—far more time-consuming and prone to errors than a computer-based one. The tracking system was so inaccurate, for example, that some people who were at risk for developing SARS were never called and warned, while others were called several times. Two families were not called until after their relatives had died of SARS.

One health official defends her office, saying that they worked as hard as they could with an antiquated system. She describes how hard it was to keep track of so many individuals:

Someone takes the file. Where is the file? Okay, well, you look that way and I will look this way. It's the dumbest thing in the world. I can't believe this is the state of affairs. It's amazing to me that we have been able to manage the way we have, given that degree of inadequate support on these central functions with basic technology.⁸⁶

"The Crossroads of the World"

Another lesson of the SARS crisis was how important a part Hong Kong played in the epidemic, and how vulnerable to disease the region is. Hong Kong lies at the very edge of southern China, a region that is historically where many flu viruses and other potential epidemics begin. There are an estimated 4 million border crossings from southern China into Hong Kong each month by people who may very well be carrying a number of germs.

Hong Kong is also vulnerable because the crowded, heavily populated conditions in the city make any contagious disease difficult to control. There are many housing projects like the Amoy Gardens, and a broken sewer pipe or a faulty ventilation system could easily spread a virus to hundreds of thousands of people within a few days. Doctors agree that in the SARS epidemic of 2003, Hong Kong was fortunate to keep the number of infections at 1,755 and the death count at 295.

Finally, Hong Kong's role as the busiest air travel hub in all of Asia is another reason the region is such a worry to infectious disease experts. With seventy airlines in operation there, there are almost unlimited opportunities for the virus to spread anywhere on the planet. "Hong Kong is at the crossroads of the world, certainly," says one WHO official. "It's not only susceptible to many diseases coming in, but also to exporting diseases, and they travel around the world."⁸⁷

Police and Health Officials

WHO officials are convinced that health agencies throughout the world would be wise to see how Hong Kong was able to contain the spread of SARS, given its high vulnerability to contagious diseases. It was successful, say experts, because once Hong Kong's public health department realized the danger, it began a thorough tracking of all personal contacts of each SARS patient who had been seen in a hospital there.

Not only did public health workers do the tracking, but police officers helped, too. All family members or friends who had been in contact with a person infected with SARS were found and confined to their homes. Some worried that this zealous tracking partnership might be an infringement of civil liberties, but most health care workers in Hong Kong and elsewhere were pleased with the system—and other nations have taken note. "I'm convinced that the way that the health authorities, the Department of Health and the police department have begun to work together on this outbreak will not only be copied in future outbreaks here in Hong Kong, but in cases throughout the world," said one WHO official, "because it's a very important marriage of databases."⁸⁸

Is the World Ready?

Hong Kong is not the only place where strategies have been mapped out in the event that SARS returns. In the United States, where only a handful of confirmed cases were verified, health officials have taken inventory in various cities, making certain that there are enough respirators and other tools needed to care for victims. Many experts say that even before the SARS outbreak worldwide, the United States was already fairly organized for a large outbreak of some infectious disease. The terrorist attacks of September 11, 2001, had alerted the nation that its procedures for a bioterrorist attack needed to be shored up.

The anthrax scare, as well as the heightened nervousness about the use of the smallpox virus as a weapon, created an urgency throughout the medical community. As a result, communications between hospitals and public health authorities have been in a constant process of improvement, and readiness is the number one priority. Hospitals need to be equipped to handle "surge capacity," which is the sudden influx of hundreds of new patients at one time. By 2004 city hospitals are expected to be ready to handle as many as fifteen hundred emergency patients in a single day.

In the United States, many doctors and public health officials have been impressed with the sense of cooperation between hospitals—which often compete for business. Emergency rooms at various hospitals have begun cross-credentialing patient information so doctors have access to information about patients no matter at what facility they receive care. The cooperation has saved hospitals money on supplies, too. "We're talking about buying [supplies] in bulk, in economies of scale," says one Dallas physician, "with everybody participating. Everybody is anteing up."⁸⁹

New Tools to Fight SARS

If or when SARS does make a comeback, scientists are banking on new tools with which to fight it. Although experts predict a vaccine will not be available until at least 2006, there are other things that could be valuable in saving lives. One would be an accurate test for SARS. Tests at the current time are not accurate unless a patient has been infected for at least twelve days. In that time, that patient will have infected dozens of other people.

However, in July 2003 one Swiss drugmaker announced that it had developed a test that could diagnose even a tiny trace of the virus in a patient's bloodstream. Although the product first needs to be clinically assessed, doctors say that such a test would be extremely good news. Another test being developed by the Public Health Research Institute is rapid, too. It uses tiny beacons of DNA with a light-emitting molecule at one end. When the beacon senses a bit of the genetic makeup of the virus, the molecular light flashes.

As yet, there is not a surefire drug to cure SARS, but some progress has been made. Doctors know, for example, that a combination of the antiviral drug Ribavirin combined with an AIDS drug called Kaletra has great promise. Ribavirin tries to damage the virus, while Kaletra cuts the virus's ability to replicate itself. Doctors in Hong Kong have said that they will use a combination of the drugs if SARS returns. However, some doctors are less enthusiastic. They point out that there is a risk to using the drugs, for they may cause red blood cells to break down, and in some patients, that would ultimately interfere with the body's ability to fight off disease.

One very promising study by the University of Massachusetts Medical School is looking at producing antibodies, which are normally made by the body as it fights an infection. If antibodies could be produced in a laboratory, there might be a way to give an injection to a patient to fight SARS, or to healthy people to prevent it. The director of the study says she is optimistic that such a vaccine is possible. "We're pretty convinced," she says, "that if you give the right antibody to the right folks at the right time, you can be pretty effective in shutting down an outbreak."⁹⁰

Looking Ahead

Though such promising improvements are reason for medical authorities to be hopeful, they know that SARS may very well reappear before drugs or tests are completed. If there is another outbreak, doctors fervently hope that it occurs within a pool of people that has access to good medical care. With prompt, accurate reporting, experts believe that they can halt the spread of SARS before it becomes an epidemic—again.