Even in remote China, SARS arrives in force

Joseph Kahn
The New York Times
Tuesday, April 22, 2003

HUHHOT, China Meng Chunying felt the beginnings of a nasty head cold on the morning of March 18. But Meng, an Air China flight attendant who often flew the Hong Kong-Beijing route, never made the connection with an outbreak of pneumonia that she thought was long since under control.

A few days and a few flights later, Meng, feeling listless and feverish, flew to Huhhot, the chilly, wind-swept capital of the Chinese region of Inner Mongolia, to rest at home with her family.

Though the illness, an atypical pneumonia called severe acute respiratory syndrome, or SARS, first appeared in southern China last November, local doctors did not figure out that Meng, 27, was Inner Mongolia's first case until early April. By then it was too late to contain the damage.

Meng infected her mother, her stepfather, her brother and her doctor, who subsequently gave it to another patient. Meng also passed SARS to Li Ling, her husband of three months, who had attended her in the hospital for days, holding her hand and sharing bottled water and steamed dumplings. Shortly thereafter, Li became one of Inner Mongolia's first SARS fatalities.

"We were told atypical pneumonia was finished in February," Meng said through tears at the Huhhot Hospital, where she has mostly recovered. "I never imagined that this kind of tragedy would fall on me and my family and take away the person dearest to me." In China, as in much of the world, SARS has until now been a disease of big cities, places like Beijing, Hong Kong and Guangzhou, whose medical schools are full of experts and whose hospitals can offer advanced treatment for a disease that can require weeks of intensive care. But for public health experts, the real nightmare was this: What if SARS traveled to less developed regions in China's vast hinterland? Now it has happened. In recent weeks, SARS has arrived in force in places like northern Inner Mongolia and northwestern Shanxi, a poor, parched coal mining province, which has had the largest outbreak outside the major cities with well over 120 cases, provincial health officials said. Inner Mongolia has had 25 cases officially, though the number of patients being treated in at least five places around the sprawling region appears to be significantly higher. China has become a society on the move, where people from the remotest provinces travel routinely for work and pleasure. But planes and trains also allow a potentially lethal germ to hitch a ride to communities where health care has fallen far behind transportation links. China's economic transition has brought airports to the smallest cities, but it has forced local hospitals to make do with far less government support. "We are getting help from the authorities, but it is a terribly difficult situation," said a doctor at the Provincial People's Hospital in Taiyuan, the capital of Shanxi. The hospital had to buy and borrow a cache of ventilators for what has become the largest SARS ward in the provinces. The rapid spread of the disease explains why the Chinese authorities reversed themselves and canceled Golden Week, a weeklong holiday starting May 1 that officials had been promoting for months to help stoke tourism and higher consumer spending. The disconnect between China's mobility and its medical care also shows the terrible gamble China's government made - and lost - when it suppressed information about SARS in February, apparently so that bad news would not sully the parliamentary session in March to appoint new government leaders.

Around the time that President Hu Jintao and Prime Minister Wen Jiabao were taking on their new titles at the National People's Congress, SARS was extending its reach to at least nine provinces. With a blackout on reporting about the disease in the state-controlled press, patients knew little. Doctors were unprepared for outbreaks, despite the fact that SARS had emerged in the southern province of Guangdong four months earlier and was by mid-March raging through Hong Kong. "We did not even have the proper masks. No one had any idea how to deal with this disease," said Zhang Wei, a doctor in Huhhot, describing confusion when the first SARS cases reached Inner Mongolia. "We had four people die here one after the other before the officials realized we had a serious problem." In Taiyuan, an edginess hangs in the air at the ramshackle Shanxi Provincial People's Hospital, over a battle whose outcome is still uncertain.

Taxi drivers, whose red cabs boast signs proclaiming "Newly Disinfected," refuse to pick up people who emerge from the hospital gates. Passers-by haul huge bags of medicinal herbs and plants - a concoction that the provincial government has announced can prevent SARS.

The object of the nervousness is a squat glass and concrete building that sits behind a locked fence at the very back of the hospital: It is home to several dozen patients with SARS, some sick enough to be on ventilators. Through a large plate-glass window doctors and nurses, clad in bright blue head-to-toe protective garb, can be seen scurrying through the halls, the white coats that used to be the armor of their profession hanging limp by the door. The chronically underfunded Health Department had to round up expensive tools to fight SARS: large stocks of protective gear, fancy masks that cost $3 each, as well as oxygen tanks and ventilators. Doctors and nurses, some quarantined in the SARS wards, work 10-hour shifts. The first case from Taiyuan was diagnosed in early March, in a jewelry merchant who had returned from Guangzhou, the SARS epicenter. He infected close to 30 patients, including his mother and father. The father died in mid-March in a hospital in Beijing.

Even as provincial doctors worked hard to contain the first outbreak, the virus slipped back into the province in the lungs of other travelers. In late March an official from Taiyuan's Qingxu District had an oral ulcer treated at People's Liberation Army No. 301 Hospital in Beijing - a place that secretly housed SARS patients. A week later, back home in Taiyuan, he developed the disease and it began racing through Qingxu District. A third outbreak started after a man who collected the body of a relative who died at Beijing's Youan Hospital returned to Shanxi and discovered he had SARS. SARS has also begun to show up in even poorer areas, hitchhiking with sick patients like a dental resident at Provincial People's Hospital who got infected and took SARS home to the southern city of Linfen. Some expect the problem to get worse before it gets better. Jiang Cheng, a local pharmacist, said that there were far more cases than had been so far reported. "It has already spread to other parts of the province, especially in the south," he said. "That's because it's more developed there and people travel around a lot." Meng, the flight attendant who inadvertently infected members of her family, traveled regularly to both Guangzhou and Hong Kong, and she heard about the outbreak in Guangdong in February. But, following the government's propaganda line, Air China assured employees that the outbreak was purely local and "under control." On March 15, Meng was working on Flight 112 from Hong Kong to Beijing. Among the passengers she served that day was an elderly man who looked pale and wan and asked for water so that he could take some pills. (Hong Kong authorities in late March rushed to track down travelers on that flight after as many as nine members of a tour group took ill after flying to Beijing).

Meng first felt sick three days later. She visited an Air China medical clinic, but no one warned her about SARS, she said. "We work hard and get tired all the time, so we're used to it," she said. Had she known she had a highly infectious disease, she said she would never have returned to Huhhot.

But it was there that she developed a high fever, and there that she sought help. She described the Huhhot Hospital as "completely unprepared," initially putting her into a room with patients who had different diseases. Only in early April did doctors diagnose her SARS.

When her husband, brothers and stepfather took ill, the hospital staff panicked and refused to treat them, Meng said, adding that the hospital manager eventually relented.

The disease had spread to health workers by then. At the nearby Huhhot Chest Hospital, the main treatment center for lung diseases, SARS infected half a dozen medical workers. Frightened staff members refused to work, leaving the hospital critically shorthanded. Huang Qi, the vice general manager of the chest hospital, worked day and night in the SARS ward, even wheeling dead bodies to the "peace room," or morgue.

Huang was subsequently diagnosed with SARS. The disease has roamed far in this northern region, as far north as Hulunbuir, an area near the Russian border known for its grassy steppes.

And in the west, a medical worker for the state-owned railroad system named Li Song, who was sent to Beijing for training in March, brought SARS home to the remote town of Linhe.

An isolation ward at the Ba Meng Hospital there now houses at least 13 patients, including Li, his mother and father, and the nurse who first treated them.