The Red Plague

Cheryl Miller

How China bungled SARS

In Guangdong, a southern province of China, there are thousands of wild animal markets, selling every possible kind of creature: snakes, raccoon dogs, civet cats, monkeys, otters. These markets cater to the southern Chinese love of yewei, or “wild-flavor” cuisine, which features such exotic fare as camel hump, dried tiger penises, and bear bladders. For many, yewei was the perfect symbol of China’s newfound wealth; the Chinese would even call the period of economic boom in the South “the Era of Wild Flavor.” Businessmen would gather at one of the province’s many Wild Flavor restaurants to nosh on various delicacies, all reputed to make their consumer fan rong or “prosperous.”

But, as Karl Taro Greenfeld writes in his history of the SARS outbreak, yewei was also a symbol of China’s vulnerability — its markets and restaurants becoming the breeding ground for a deadly new virus that would infect more than 8,000 people and kill over 800. Based in Hong Kong, Greenfeld was the editor of Time Asia when the outbreak began. He was an experienced reporter, having covered the Asian “miracle” economies of the early 1990s in two previous books. With The China Syndrome, Greenfeld provides both a fascinating glimpse of life in modern-day China and an account of a pandemic averted that has all the suspense of a good thriller.

In Guangdong, Greenfeld writes, the virus had found the perfect home. Known to scientists as “the birthplace of influenza,” Guangdong had been the starting point for two of the past three flu pandemics. With the rapid industrialization of the province, immigrants from all over China were flooding the cities looking for work. They crowded tenements, living three or four people to a room. Life in these places was so transient that roommates sometimes didn’t even know each others’ names, which would later make it more difficult for health workers to identify and quarantine the infected.

The public health infrastructure was badly strained. In the city of Shenzhen, many residents did not even have running water. Newly privatized hospitals were starved for funds, leading many to cut back on preventative care and supplies. At the height of the SARS crisis, some medical staff still needed to pay for their own gloves and masks to protect against the virus.

Add to all this the unusual opportunity offered by the wild animal markets for a virus to attack. These markets were left practically unregulated; so were the restaurants that served up various yewei delicacies. When asked, the director of the Wild Animal Protection division at the Guangdong Forestry Bureau admitted that the department did not keep track of the licenses it provided to the Wild Flavor restaurants. The director then provided Greenfeld with a list of animals that were forbidden from being sold at the markets. Every animal on the list — except for panda — was available.

Walking through the markets, Greenfeld was overwhelmed by a powerful musky odor — the combined smells of the flesh and waste of hundreds of caged animals. “Each of these creatures, destined for the banquet table, had a host of indigenous viruses that it shed by the millions, in feces, blood, sweat, saliva and tears,” Greenfeld writes. These unsanitary conditions provided what infectious-disease reporter Laurie Garrett would call “a microbial swap-meet.” And at one of these markets, Severe Acute Respiratory Syndrome (SARS), a rapidly mutating coronavirus found in civet cats, would make the leap from animal to man.

The virus could not have found a country less prepared. Initial cases were simply ignored. Respiratory illnesses are common in China, and few patients even consulted a doctor. A trip to the hospital could cost a month’s wages, leaving the infected to rely instead on traditional healers and indiscriminate quantities of antibiotics, which are sold over the counter in China. Local hospital directors and provincial authorities, afraid to lose face with their superiors, decided to wait and see if the outbreak subsided before notifying the Chinese government.

When it became clear that the “atypical pneumonia” tearing through hospital wards and cities was not just another seasonal malady, frightened health workers began to petition the government for help. It responded by issuing what it called “the Three No’s”: doctors should not share information about the virus with the media; they should not contact other medical workers; and they should not alert international bodies, such as the World Health Organization (WHO).

The Three No’s were a recipe for disaster, and Greenfeld’s title, The China Syndrome, is as apt a moniker for the Chinese government as it is for SARS. The Chinese regime’s secretiveness and paranoia was as deadly as the disease itself, as the government sought at every turn to cover up any news of the epidemic killing hundreds of its own citizens. The authorities feared that news about SARS would create public unrest, possibly interfering with the March 2003 transfer of power within the government and with the celebration of the Chinese New Year. “Look at what happened in Hong Kong, where everybody’s scared and wearing a mask,” a senior aide to Shanghai’s vice mayor told a Time Asia reporter. “We don’t want everyone to get panicked like that for no reason and destroy our economy.”

To prevent any possibility of “instability,” the authorities labeled all information about the disease “top secret.” The state-controlled media were forbidden from reporting on SARS beyond repeating the government’s denials about its presence. Although China’s leaders knew that SARS was highly contagious, they prohibited the release of memos to hospitals on how to protect medical workers against the disease. That decree made hospitals killing zones, as doctors unwittingly spread the virus by intubating the infected and handling patients without proper protection. At just one hospital, over fifty members of the staff were infected with SARS. When the Chinese authorities finally allowed a WHO team into the country, government operatives stashed patients in hotels and ambulances to hide them from the foreign doctors.

As impressive as Greenfeld’s reporting is on the clumsy and destructive machinations of the Chinese Communist government, he fails to apply the same level of scrutiny to the other players in the SARS drama. It is disappointing to find that a reporter so gimlet-eyed can also be so credulous of the conventional wisdom. This misplaced credulity manifests itself in Greenfeld’s breathless admiration for the United Nations and his accompanying vehement disapproval of the Bush administration. That he would feel so is not altogether surprising. Greenfeld is completely candid — though a bit disconcertingly — about how he resented the Iraq War for overshadowing his big story. And many WHO officials served as sources for his book, making it more likely that the U.N. agency would be cast in the best possible light.

Yet Greenfeld’s biases are often contradicted by his own reporting. In one chapter lambasting the Bush administration for questioning the United Nations, he describes the WHO as “indispensable,” a “sterling example” of the U.N.’s importance to global order. As for those nasty “Republican politicians,” their criticisms of the U.N. are merely excuses meant to hide their real objective to rid the world of “an unwanted obstacle to Pax Americana.”

In the same chapter, however, Greenfeld explains that the WHO had been downgrading its infectious disease-fighting abilities since the 1970s, shifting its resources instead to combating behavioral problems such as smoking and obesity. The WHO’s Global Outbreak Alert and Response Network, meant to identify emerging outbreaks and coordinate government and agency responses, consisted of a mere three-person staff, which basically just monitored already existing networks such as ProMED. “In most cases,” Greenfeld writes, “the WHO would find out about an outbreak only after it had already run its course.” And this is the world-class organization that is going to protect us from a global pandemic?

Even when it became clear that China had lied about the extent of the epidemic, the WHO put off holding a press conference about the disease, hoping instead that the Chinese government would come clean on its own. The U.N. agency also put off placing a travel advisory on China and Hong Kong, worried that this would cause a diplomatic row. At one point, it almost seems as if the WHO was complicit in Beijing’s cover-up. When Susan Jakes, a Times Asia reporter, leaked to a WHO official a memo by a Communist Party doctor describing the cover-up — proof of the conspiracy the WHO had been investigating for months — she was initially rebuffed. The WHO representative was concerned — not that the spread of SARS in China might unleash a global pandemic, but that Jakes’s story would “unnecessarily offend the Chinese government.”

Moreover, Greenfeld does not mention the most troubling example of the WHO’s timidity in working with the Chinese: Taiwan. This omission is troubling, particularly in light of Greenfeld’s glowing account of the WHO’s work in Vietnam. In just six weeks, he reports, thanks in large part to the quick thinking of the Italian parasitologist Carlo Urbani, the WHO was able to contain the virus in Vietnam. Its work in Taiwan, though — as Steven Menashi has described in these pages [“The Politics of the WHO,” Fall 2003] — was not nearly so laudable. While the WHO was assisting Vietnam, Taiwan was forced to wait seven weeks for the Chinese government to permit a WHO team to enter the island. In the meantime, the WHO refused Taiwan’s request to listen in on its weekly video conferences or to join its information-sharing network on SARS. The WHO would not even acknowledge the outbreak of SARS in Taiwan, believing instead the Chinese government’s claims that the island was disease-free.

In the end, as the WHO itself concedes, it was mere luck that kept SARS from raging out of control. Had SARS become airborne, it could have killed many thousands. Moreover, just as the Chinese government finally began to respond to the crisis, the virus mysteriously disappeared, perhaps because of the seasonability of coronaviruses. As one former WHO official put it, “SARS is the pandemic that did not occur.”

The world was lucky in another way, too. It was a few extraordinary people who helped expose the cover-up, forcing the Chinese authorities to cooperate with the WHO. Greenfeld singles out his Time Asia staff, in particular Susan Jakes, and two Chinese doctors, Guan Yi and Jiang Yanyong.

A virologist at the University of Hong Kong, Guan worked day and night to identify the new mystery disease. Twice, he smuggled samples from infected patients out of China — an act for which he would have been tried for treason had he been caught. And it was Guan’s work in identifying the virus’s host which convinced the authorities to close down the wild animal markets, helping to prevent another outbreak.

Jiang was the aforementioned Communist Party member and military doctor who gave Susan Jakes the memo she offered to the WHO. When a fellow doctor told him about the terrible illness that was killing his staff, Jiang began calling hospitals, trying to get a count on the number of people infected. The news was horrifying: there were sixty patients at just one hospital, even though the government maintained that there were only twelve cases in all of Beijing. Jiang decided that he must inform the public, knowing all too well the potential cost of his heroic actions. Labeled a “class criminal” during the Cultural Revolution, he had been sentenced to hard labor at a prison camp for political detainees. His wife urged him to keep quiet, but Jiang refused: “This is bigger than me, or you, or China,” he would tell her. “I have to tell the world. This could be a disaster for all of mankind.”

The disaster averted, Greenfeld asks whether China has learned from its mistakes. The evidence is not encouraging. Although the mayor of Beijing and a few ministers of health lost their jobs, the Chinese Communist Party continues to suppress information about anything — no matter the consequences — that might cause “instability.” Indeed, some government officials, Greenfield writes, “believed that the real lesson of SARS was to engage in more effective cover-ups.” When SARS reappeared in 2004, Chinese authorities tried just that, arresting any journalist who reported on the new infections. That same year, Guan Yi was charged with revealing “state secrets” after he spoke out about the recent outbreak of avian flu in Guangdong. His laboratory was closed down. The wild animal markets, which Guan exposed as the breeding ground of the virus, have been reopened.

And the other SARS hero, Jiang Yanyong? In 2004, he wrote a letter denouncing the Tiananmen Square massacre. Jiang felt guilty, he said, for not speaking out at the time, when he treated the Tiananmen victims. The government, alas, felt no such guilt. Chinese authorities put Jiang under house arrest and forced him into a “reeducation” program. That same year Jiang was awarded the Ramon Magsaysay Award — sometimes called the “Asian Nobel Prize” — for his work in publicizing the SARS outbreak. So the Communist Party forced him to write a letter stating that he didn’t deserve the prize. Though eventually released from house arrest, he reportedly remains under government surveillance. All this prompts Greenfeld to raise the question: Given the personal and professional risks of speaking the truth in illiberal regimes, “Who will be so brave next time?”