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The language of epidemiology, the study and prevention of the spread of infectious diseases, is steeped in the metaphor of blockade. Doctors and scientists develop "barrier" nursing techniques and try to erect "ring fences" within society to corral a dangerous microbe, preventing it from jumping between people and countries. But one of the lessons learned by Hong Kong, the city hit hardest by the deadly epidemic of Severe Acute Respiratory Syndrome (SARS), is that it does no good to slam the ring-fence gate after the killer has left the pen.
Prompt action by local health authorities can nip an outbreak in the bud, saving lives and billions of dollars. "When you confront new diseases and they begin to travel widely, you have to do everything you can to try to stop the transmission," says World Health Organization (WHO) spokesman Dick Thompson. "Maximum efforts in the beginning are justified." Although doctors and scientists decline to point fingers, it's increasingly clear that the Hong Kong government failed to recognize the potential threat when SARS first surfaced and downplayed its impact to avoid panic and bad publicity. As a result, the virus slipped into the general population—and the number of Hong Kong victims continues to rise steadily. There were 26, 27 and 39 new cases reported on April 3, 4 and 5, respectively, bringing the total number since the outbreak began to 800, with 20 deaths. Far from being contained, the disease appears to be gathering steam. "I don't think we should pack our books and go home early," says Dr. Stephen Ostroff, chief epidemiologist for the National Center for Infectious Diseases at the Centers for Disease Control and Prevention in the U.S.
The advance of the epidemic in Hong Kong stands in marked contrast to the situation in Singapore, another Asian transportation hub hit by SARS last month. Health authorities in the Lion City have all but declared victory over the disease. Although six people have died—the latest fatality coming April 4—just 26 Singaporeans of 101 who were infected remain in the hospital and the rate of new cases has fallen to about three a day. "It will take at least another week or two to be certain that the epidemic is close to ending," says Dr. Osman David Mansoor, a WHO scientist. "But there's no doubt the disease is being controlled here in Singapore."
Local health officials credit the full-court press they clamped on the virus. Those measures included quarantining more than 1,500 people who had close encounters with SARS victims, confining them to their homes under threat of heavy fines; closing all schools, and medical screening for all travelers entering the city. When new cases were discovered, a team of 100 "contact tracers" tracked down not only patients' immediate families, friends and neighbors but also their office colleagues and favorite food hawkers, and placed them in quarantine, too. Anyone suspected of having SARS is transported to the hospital in an ambulance.
This ring-fence approach, isolating suspected victims and painstakingly retracing their steps in the days before they fell ill, "showed us that infection control works," says Dr. Balaji Sadasivan, Singapore's Minister of State for Health and the Environment. It paid another dividend: authorities got an early warning that most victims were getting sick after visiting hospitals with known SARS patients. "The moment we realized hospitals were the most dangerous place, we designated Tan Tock Seng [Hospital] as a SARS-only hospital and shut it down to all other patients," says Sadasivan.
Hong Kong's response, by comparison, has been marked by what appear in hindsight to be tardy half-measures. As in Singapore, Hong Kong's outbreak started at a medical facility—the Prince of Wales Hospital, where nearly 100 patients and staff rapidly began falling ill beginning March 8. But even after it became clear that a potentially deadly mystery illness was loose in the wards, visitors and outpatients came and went freely for several days, despite mounting evidence that the disease could be highly contagious.
Under increasing public pressure, Hong Kong officials on March 28 announced that all public schools would be closed. Special quarantine laws were also invoked. But authorities stopped short of immediately shutting potential victims in their homes, as Singapore had done. Instead, they were told to report daily to designated clinics for monitoring—meaning suspected SARS carriers were actually being required to venture out among the masses.
Another glitch was timing. The quarantine measures did not go into effect until March 31, three days after they were announced. That lag proved crucial. In the interim, SARS cases at Amoy Gardens soared from seven to 213, and before a lockdown could be implemented there, 113 families living in the complex packed their bags and fled. Instead of separating them from the rest of the city, health officials lost track of them.
A few days later, authorities tightened up, sending remaining Amoy Garden residents to fully fledged quarantine facilities at four local summer camps and resorts. About half of the families who fled the complex had been located by the end of last week. But the Hong Kong Police Department is still tracking down the remaining 45 families. In some cases, they've yet to even learn the names of the missing residents.
Some question why Hong Kong, with its sophisticated medical infrastructure and experience with similar outbreaks—the city effectively contained a deadly avian-flu epidemic in 1997—was caught off guard. Local radio talk-show host Albert Cheng puts it bluntly: "The government wanted to show the foreign press that Hong Kong is not in crisis and that everything is under control."
Medical experts decline to fault the government, pointing out that it was dealing with a disease not seen before and that the situation was fast moving and fluid. Hong Kong's top health official, Secretary of Health, Welfare and Food Dr. Yeoh Eng-kiong, says officials "were as forthcoming as possible with as much information as we honestly had." He adds, "we did try our best."
By failing to keep SARS in check, Hong Kong is now a city full of fearful, surgical-masked citizens—and a city that is an international pariah. On April 2, the WHO issued an unprecedented advisory, warning against travel to Hong Kong and the nearby southern Chinese province of Guangdong because of the risk of contracting SARS. Airlines are slashing flights to the city as travelers stay away. Hong Kong businessmen were even barred from attending a major watch-and-luxury goods trade fair in Basel, Switzerland, unless they submitted to intrusive health checks, sparking a diplomatic row. Says Christine Loh, a former Hong Kong legislator who now runs Civic Exchange, a political think tank: "The importance of getting it right in terms of Hong Kong's image is critical, and this is where we've been messing up."
It's not hard to see why it's crucial to halt the spread of SARS, and not just for health reasons. The economic toll could be devastating. Some economists predict that the hit to Hong Kong's travel and retail sectors will drag the city's 2003 GDP-growth rate down by one-fifth or more, a loss of more than $1 billion. Last week Stephen Roach, chief economist for Morgan Stanley, said SARS is "just another nail in the coffin" for the global economy, which is already stumbling from the Iraq war. He predicts a worldwide recession will begin this year.
Of course, denial and disease often go hand in hand. Other countries have been slow to acknowledge that SARS had penetrated their borders. Hong Kong's response looks positively proactive compared with that of China, where the disease first appeared and which still has the most cases by far, at 1,220. For months, national and provincial authorities kept a lid on publicity surrounding the mystery ailment and refused to share patient information with international health organizations.
Now that SARS has become a global scourge—and the WHO is warning people not to travel to China—Beijing's denial may be ending. In an unusual admission last week, the director of the Chinese Center for Disease Control, Li Liming, apologized for "poor coordination" between medical departments and the mass media. "We weren't able to muster our forces in helping to provide everyone with scientific publicity," he said.
More importantly, after more than a week of waiting, Beijing granted permission for five WHO epidemiologists to travel to Guangdong, the cradle of SARS. They're still not getting all the cooperation they say they need, such as direct access to hospitals and patients. But WHO officials say they are hopeful that by studying the outbreak at its source, they will be able to contribute to the growing body of scientific knowledge about the disease—and perhaps stop it in its tracks, for good.
- Jim Erickson / Hong Kong
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