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Orderlies wheeled the transfer patient into the respiratory department of the Zhongshan No. 3 Hospital on the morning of Feb. 1. He was wheezing and could barely breathe. "I didn't think he'd last 24 hours," recalls Dr. Cao Hong, the department chief. As Cao and a nurse pried open the man's jaws and began an emergency intubation, inserting a pipe down his throat to resume the flow of oxygen, they became victims of what can only be described as the point-blank detonation of a virus bomb. "When we moved the tube down his throat, he started coughing," the doctor says. "His mucus flew all over the place and on our shirts."
The hospital had been notified only one day earlier of a strange new disease sweeping through the province, and had taken some precautions. Both Cao and the nurse wore masks. But the man they treated was no ordinary patient. A seafood dealer, he would become known to Chinese as the "Poison King," the first super spreader of what would later be identified as the SARS virus. The Poison King (Time is protecting his anonymity) recovered, but by the time he went home, he had infected as many as 90 people, including Cao (who has since recovered), the nurse and health-care workers in three different hospitals that treated him. Not only that, it is possible that the highly contagious businessman also gave the virus to a doctor in one of those hospitals who would travel to Hong Kong three weeks later and check into the Metropole Hotel—thought to be the point where SARS first surfaced outside of China. An unknown disease, incubated in China's southern Guangdong province, was loosed upon the world.
Epidemiologists are still trying to trace the arc of the deadly pathogen. Through interviews with health care workers, victims and local journalists in Guangdong, Time has pieced together some of the key events during the opening phases of the outbreak. It's now clear that in early February, while doctors were treating the Poison King, the disease had been spreading through several cities in southern China. Quick action might have slowed it, if not contained it. Certainly doctors and nurses worked bravely against the mysterious threat, caring for victims even as colleagues died of the infection. Yet as health officials raced to identify the disease they faced, official cover-ups and dissembling meant valuable information was withheld not only from the public, but also from the health-care workers who were trying to save lives.
The trail begins in Foshan, a boomtown of garment mills and electronics factories surrounded by farmland. Health authorities there have worked backwards through medical records and traced the outbreak to the first known SARS case, a man in Foshan who showed signs of the illness on Nov. 16. This was a chance to look into the source of the virus, and perhaps confirm researchers' suspicions that it had jumped to humans from pigs or fowl. But neither Guangdong officials nor experts from the World Health Organization (WHO) who interviewed the victim this month managed to elicit much useful information. The man was terrified by the interrogation and wanted to keep secret from family and friends that the illness he contracted in November was SARS. In another disappointment, the WHO team eventually determined that the man probably wasn't the "index patient"—the first known carrier. "I was hoping to find some unusual animal exposure," says Robert Breiman, the head of the WHO. There was none. "It was pretty much run of the mill."
Investigators are still searching for victim No. 1, in part to unlock the mystery of how SARS jumped host species. Also unknown is how the disease hitchhiked to Heyuan city, 200 kilometers from the provincial capital of Guangzhou. On Dec. 15, two patients checked into the Heyuan Municipal Hospital suffering from a pneumonia that wouldn't respond to antibiotics. It quickly spread to five hospital workers. As more patients came in, rumors of a murderous flu spread to the city at large, inciting panic. Crowds gathered outside packed drugstores on Jan. 2 seeking any medicine that might treat flu. "All of a sudden people were flooding in and I didn't know why, but I sold as much antibiotics in a day as I sold last year," says a clerk at the Chun Tang pharmacy. Anxious to calm the populace, the local center for disease control faxed a letter to the Heyuan News at 1 a.m. on Jan. 3, which ran in the next day's paper. The article insisted that "Heyuan has no epidemic virus, we hope residents don't panic." The alarm subsided within days.
That story was the last to appear in the local press for more than a month. Provincial Party leaders, anxious to avoid spreading fear and still unsure what the disease was, barred media from covering what happened in Heyuan—and what would happen elsewhere. Even after doctors from several major hospitals in Guangzhou visited Heyuan and diagnosed patients there as victims of atypical pneumonia, ordinary Chinese were kept in the dark. Su Guoqiang, a 37-year-old who runs his family's seafood restaurant on Food Street in the small county of Beijiao, was clueless when he drove 40 km to a wholesale market in the city of Zhongshan in mid-January to stock up on shellfish and shrimp. More than 20 people there had fallen ill, including 12 at the Zhongshan Traditional Medicine Hospital. As in Heyuan, word filtered out to the city; once again residents, fearing an epidemic, stampeded to drug stores for antibiotics. They even hoarded food and vinegar, which was supposed to purify the air when boiled.
Su returned home from his shopping trip running a fever. Having read nothing about a mystery illness in his area, he assumed he had a cold and never thought to visit the doctor. When his temperature still hadn't fallen by Jan. 20, he checked into his local hospital. Three days later, as his breathing failed, medical staff transferred him to Zhongshan No. 2 hospital in Guangzhou.
Although the delegation of Guangzhou doctors had earlier determined the Heyuan outbreak was atypical pneumonia, the information was not widely disseminated. Su's doctor at Zhongshan No. 2, Li Jianguo, didn't know what he was dealing with. "I felt this was a new disease but I didn't know what," says Li. Eight days later, Su died—but not before passing the disease to his younger brother, Su Qingshan. He has recovered, but he is angry his family wasn't informed of the outbreaks. "If the media had covered the disease earlier, do you think we would have waited four days to go to the hospital?" he asks. "We thought it was just a normal cold."
Behind the scenes, bureaucrats were becoming alarmed as the number of infections climbed into the hundreds, prompting government officials to begin notifying anxious doctors of the new disease. Following an investigation into the Zhongshan outbreak by the Guangdong provincial health bureau, a bulletin went out to doctors in Guangzhou on Jan. 28. It was an accurate summary of the facts then at hand: an atypical pneumonia was spreading especially quickly among hospital staffs and showed "characteristics of epidemic disease." Officials recommended isolating patients who showed symptoms, and urged hospital staffs to wear masks and to sterilize areas where patients were treated. "Doctors recognized early that they had a problem and tried to deal with it head-on," says Breiman of the WHO. "It was an appropriately timed response."
Through February, as they groped in the dark for a treatment, doctors at the army-run Zhujiang Hospital in Guangzhou tried regimes for several established diseases that show similar symptoms—other well-recognized forms of atypical pneumonia such as Legionnaires' disease, chlamydia pneumonia and mycoplasma pneumonia, which are caused by bacterial infections. They tried steroids to reduce inflammation in the lungs—swelling of airways due to a runaway immune response is how SARS kills—and antibiotics to stem the spread of bacteria in the respiratory system. Nothing worked (reseachers later determined SARS was caused by a virus, not bacteria).
On Feb. 28, the Zhujiang Hospital finally received a memo from Beijing identifying the new disease as mycoplasma pneumonia—a cause the doctors had already ruled out. "Many of us thought differently but kept silent," says a doctor at Zhujiang Hospital. Better communications, he says, would have helped doctors understand what they faced more quickly. "Only a small group of people knew how bad it was, and no media was covering it," says Cao, who treated the Poison King at Zhongshan No. 3 Hospital. "We didn't react quickly enough."
The silence was broken, briefly, when Guangdong Province's new party chief, Zhang Dejiang, allowed health officials to hold a Feb. 11 news conference announcing the disease for the first time. During the event, staged to avoid further panics like those in Heyuan and Zhongshan, officials said the outbreak was under control. Huang Qingdao, the leader of the provincial health bureau, announced 305 cases and five deaths. When journalists asked him why he hadn't reported the Heyuan outbreak faster, Huang said "it was fine not to tell the public" about the disease because he wasn't legally required to do so. The government did not release updated statistics on the outbreak for another month.
Guangdong newspaper editors who chaffed at the blackout thought they had the green light to publish after the news conference. They had plenty of material—journalists had been working on the story all along. "We told our reporters to write their stories and hold them for the day we could run them," says an editor for a major weekly in Guangzhou. A raft of articles quickly broke, some of them raising questions about the way the government handled matters. The Xin Kuai Daily even ran a long interview with a local professor, Cai Lihui, who noted that after the 2001 attacks on the World Trade Center, and as anthrax letters passed through the U.S. postal system, the U.S. government released as much information as it could. By contrast, he said, "the way the government has dealt with atypical pneumonia shows its inability to deal with a crisis." Two weeks later the government reimposed the media ban, which stayed in place until March.
By then the Poison King had passed through three hospitals, the Zhongshan Hospital No. 2 and No. 3 and the Guangzhou No. 8 People's Hospital, infecting up to 90 workers. After a recovery that doctors consider miraculous, they discharged him in late-February. On his way out, he knelt before them and presented a thank-you banner. According to the WHO, none of the people who caught the disease from him then re-transmitted it to anyone else. But researchers are still trying to determine if a retired nephrologist named Liu Jianlun who worked occasionally at the Zhongshan No. 2 Hospital had contact with the super spreader. They do know that Liu began showing flu symptoms on Feb. 16, running a high fever. Five days later he visited Hong Kong to attend a wedding and checked into the Metropole Hotel. There, he is believed to have infected several people who then began the widespread transmission of SARS around the world. Liu died on March 4. At last count, SARS has killed 116 people and infected 2,890 worldwide.
- Matthew Forney / Guangzhou
- How did a deadly virus find its way from southern China to the rest of the world? TIME traces the path of the contagion