Chinese SARS poster
SARS (severe acute respiratory syndrome) is a deadly pneumonia-like disease that appeared in China in 2002 and spread across China and into Southeast Asia and North America in the winter and spring of 2003, killing several hundred people, scaring many more and disrupting economies and travel plans around the globe. SARS was given its name by the World Health Organization (WHO) after it was first reported to the organization by an Italian doctor in Vietnam.

SARS is caused by a corona virus, which is also connected to about a third of all cases of the common cold. The SARS corona virus is very deadly, killing almost 10 percent of the people who get it. About half of those who have died form it so far are over 65. As of October 2004, 8,098 people had gotten SARS and 774 people had died from it. Higher death tolls had been listed. Investigation found some of the deaths on these lists were the result of other causes.

China has been accused of covering up the SARS outbreak during its early stages. It is widely believed that if the Chinese authorities had been more aggressive fighting the disease, more forthcoming with information and had invited the World Health Organization to infected areas, SARS would more likely have been isolated and contained in its early stages before it was allowed it to spread. and hundreds of lives could have been saved.

Websites and Resources

Good Websites and Sources on Disease in China: The Chinese Center for Disease Control and Prevention ; Center for Disease Control on China CDC World Health Organization on China ; Wikipedia article on Public Health in China Wikipedia ; Rare Diseases in China , Lancet Article ; Burden of Disease in China pdf file ; AIDS-HIV: Article on AIDS in China ; WHO China Office Report on AIDS ; China AIDS Info China AIDS Medica Project ; SARS : CDC Paper on Origin of Sars ; SARS Map ; SARS Book Stanford University ; Influenza and A/H1N1 Flu: Flu in China ; Paper on Flu and Ducks ; Paper on effects of Flu Pandemic in China ; Bird Flu: Avian Influenza Info ; WHO Avian Influenza Reports ; Flu in China ; Bird Flu Center; CDC on Bird Flu

Good Websites and Sources on Health in China: Center for Disease Control on China CDC World Health Organization on China ; Wikipedia article on Public Health in China Wikipedia ; Short UNICEF Article on Health Issues in China ; On Health Care in China: Health Care in China, an IBM pdf file ; Pape on Chinese Helat Care from the 1990s ; Library of Congress Country Studies Paper on Chinese Health Insurance ; Ex-Pat Report ; China Health Care Blog Asia Health Care Blog


SARS Symptoms and Treatment

SARS victims develop a sudden, very high fever and suffer infections and damage in their lungs. Symptoms included chills, headaches, and muscles aches. Those with severe cases develop a dry cough and have trouble breathing. There is no effective treatment. Drugs that work on similar diseases don’t work of SARS. About 10 percent to 20 percent of SARS patients need a ventilator. The virus also affects the digestive system. Some victims suffer from severe diarrhea. Some carry the virus but show few symptoms.

One man who had the disease told the Los Angeles Times, he felt sick and had a fever and stayed home from work. When his fever rose to 102̊ F he checked with a doctor who sent himhome with some flu medicine. When his temperature rose to 104̊ he went to the emergency room of a hospital but was discharged after nothing turned up on a chest X-ray. After that he had severe diarrhea and his fever persisted he visited the same emergency room.

The SARS victim began getting nervous when he was switched to intensive care and the patient next to him died and the dead man’s relatives began screaming with grief. “There were a few days when I felt I wasn’t going to make it. I though I might die, too.” Finally after 12 days the fever broke and he recovered.

SARS can be transported like cold virus through the air on exhaled vapors or by touching surfaces that have come in contact with these vapors. SARS is cairned mostly on relatively large mouth-emitted droplets that generally no more than 1.5 meters. If they were carried on smaller droplets that could be carried further through the air the disease could have spread much more than it did.

Origin of SARS

The first known SARS case appeared in November 2002 in Foshan, a gritty southern Chinese city, near Guangzhou (Canton). Health officials became alarmed in January when it began appearing in cities around Guangzhou such as Shunde, Heyuan ad Zhongshan. By early February there were 305 cases and five deaths in Guangdong.

Some people think that SARS may be a disease that jumped from animals to humans, possibly in a market where wild animals are sold to be eaten. One of the earliest victims, who died in December 2002, was a seller of snakes and birds who worked at a market in Shunde, a small city about an hour from Guangzhou. Among the other early victims were food handlers, chefs and their families.

Describing the animal market in Shunde where the victim worked, Elisabeth Rosenthal wrote in the New York Times, “In hundreds of cramped stalls among the stink of blood and guts, wholesale food vendors tend to veritable zoos that will grace Guangdong Province’s tables: snakes, chickens, cats, turtles, badgers, frogs...And, in summer, sometimes rats, too...The cages are stacked, one on top of another, in cages that serve as seats, card tables and dining quarters for the poor migrants who work here. On a recent morning, near stall 17, there were beheaded snakes, disemboweled frogs and feathers flying as a half-alive headless bird was plunked into a basket.”

Civets and SARS

There is circumstantial evidence that SARS originated with civets, nocturnal mammals closely related to mongooses The SARS virus and corona viruses found in humans are 99.8 identical to the SARS virus and corona viruses a found in Himalayan, or masked, palm civets, racoon dogs and hog badgers sold for foodat the market in Shenzhen, China. Researchers also found antibodies to the virus in the blood of 20 wild animal traders and 15 workers who slaughter the animals. .

Although this evidence is good it is not conclusive. And even if it is true it does not offer any clues on the how the disease may have passed from civets to humans. The SARS virus is found in booth civet feces and human feces. Some heath officials speculated that the disease was spread to humans by contaminated civet feces.

Around Guangzhou, civet meat is eaten in a stew as a winter time delicacy said to be rich in yang, an energy source that helps keep one warm. The meat is also braised, roasted and added to soups. The animals are served at restaurants, sold at markets and raised in breeding farms. Small-time civit breeders earn $200 a month, considerably more than the could earn from farming.

Links between Asian bats and the SARS virus have also been found.

Spread of SARS From China to Hong Kong and the World

The spread of SARS on a global scale began in Hong Kong in late February 2003 when a Chinese doctor with disease passed it on to 10 others while attending a conference in Hong Kong. Hong Kong lies just 80 miles from Guangzhou, and near other places where the disease began. Each day more than 400,000 people cross the busy border between Hong Kong and China.

On February 21, a Chinese doctor and a professor of respiratory medicine, who had treated people with SARS in the Guangzhou area, came to Hong Kong to attend a nephew’s wedding even though he had a fever. He stayed on the ninth floor of the Metropole Hotel in Hong Kong, where he infected at least 16 people---including a woman from Toronto, another Canadian and an American businessman on his way to Hanoi and three young women from Singapore---who spread the disease internationally. The Chinese doctor was treated at the Prince of Wales hospital in Hong Kong, setting off a huge outbreak there.

The Toronto woman returned home and infected her son and at least five health workers. Within weeks 140 people had the disease in Toronto. The three Singapore women became ill when they returned home and were each treated at separate hospitals. Two of them didn’t infect anyone. But the other, Esther Mok, infected at least 90 people. She survived. Among those that died were her mother and father.

The American businessman was treated at the Vietnam French Hospital in Hanoi, where he spread the disease to 20 health care workers, including Carlo Urbani, an Italian doctor, who was the first to report the disease to the World Health Organization. Urbani ordered a number of preventive steps to be taken, but ended up dying of the disease. On March 15, the WHO issued a worldwide alert for a new diseases, which it called SARS.

Afterwards, cases of SARS started popping up around the globe. The were a number of cases in the United States. Places like Finland and Poland had small outbreaks. Altogether 30 countries were affected. SARS gained momentum through March and April and peaked in early May. The disease was spread widely by so called “super carriers” who transited the disease much more than most of those who had it. All of the cases in Toronto were traced to the woman who had visited Hong Kong. A number of victims were health care workers who contacted the disease from patients.

Impact of SARS

SARS had a worldwide impact on trade and the travel industry. Worldwide demand for oil was affected to such a degree that members of OPEC held an emergency meeting. Even international flights to places in Europe and Japan, where no cases of SARS were reported, were affected. The outbreak is estimated to have cost the global economy $50 billion largely because of cuts in travel and trade from Asia.

In countries affected by the disease, growth declined, export-oriented companies saw their orders drop; small businessmen, shop owners and market vendors saw their sales and incomes plummet due to lack of business. Particularly hard hit were airlines, hotels are other business in the tourism trade.

In countries affected by the disease, people were scared to go out. They didn’t go shopping, eat at restaurants, or attend movies. Vacations were canceled. People avoided places with the disease. Some chose to socialize over the phone rather than in person. Many wore masks whenever they went out. The custom became so widespread that wearing masks became a fashion statement, with Hello Kitty and Betty Boop versions selling particularly well.

Health care workers were particularly affected by SARS. In Hong Kong, they made up a forth of all cases. Of these 55 percent were nurses and 15 percent were doctors, some of whom died. People were taken off the SARS watch list if they went two weeks without showing symptoms.

Combating SARS

Poster encouraging people
to wear a face mask
Because there was no effective treatment for SARS the strategy to fight it consisted primarily of isolating people with the disease quickly and quarantining anyone that came in contact with them. Tracking down people SARS was another top priority. Passengers at airports arriving from affected countries were screened. Some had their temperature taken with a special strip of tape applied to their forehead. Other were checked with an infrared device that picked up heat. In some countries offices were set up to follow rumors of people with suspicious, high fevers or other symptoms of the disease. Following rumors turned out to be an important element in the fight against SARS

To prevent themselves from getting SARS, health care workers were required to wear goggles, multiple layers of masks, gloves and uncomfortable, waterproof, full-length body suits. As a precaution against spreading it, they were quarantined and in some cases prevented from seeing their own families. Those that were allowed to be with their families often wore masks at home, ate separately and used different bathrooms and bedrooms than other family members.

In January 2004, China okayed human testing for a SARS vaccine made from a dead sample of the virus. Beijing said that tests using the vaccine on animals had been effective. In April 2004, researchers at the National Institute of Allergy and Infectious Diseases in Albany, New York announced it had developed an experimental gene-based SARS vaccine that was effective on mice.

SARS in China

20080311-sars image mclc.jpg
Effects of wearing a face mask
SARS killed 349 people in China in 2002 and 2003. Around 5,500 people got the disease. Most of the cases were in Guangdong and Beijing with cases also reported in Shanghai, Shanxi, Inner Mongolia, Hunan, Sichuan, and Guangxi. News of SARS appeared in Hong Kong, Taiwan and Thailand before much news came out of China even though the disease originated in China. By the time the government finally released news about it SARS had spread all over China.

During the SARS outbreak growth in China slipped by three percent. Countries around the world slapped restrictions on Chinese crossing their borders. Chinese students were banned from universities in the United States. The border between Russia and China was closed. Many airlines canceled fighting going into China.

Opportunists sold products purported to ward of SARS, hand lotions that purportedly boosted the immune system and herbal teas with ingredients such forsythia and honeysuckle. Companies worked overtime to produce enough bleach and disinfectants to meet demand. The price of some herbal medicines increased tenfold. The People’s Liberation Army released a whole line products, including vehicle-mounted clothes washers designed to disinfect contaminated clothing.

Inaction and Cover Up of SARS in China

China was criticized for not doing more to stop the SARS outbreak and not releasing information about the disease in a timely fashion. Officials at the World Health Organization (WHO) were angry that more wasn’t done to determine the source of the SARS virus and study how it was transmitted between animals, including humans, in the early stages if the outbreak. After a number of cases were reported in the early stages of the outbreak, it seemed like that numbers of cases were tapering off. But that was not the case.

Authorities in Guangzhou province and Beijing covered up the disease after it first appeared in each of those places by under reporting or failing to reported SARS as the appeared in hospitals. The government reacted the way it did, some analysts have suggested, because it believes that maintaining social stability has precedence over the well being of individuals. Doubts were raised about the humanity of the government. There were even some calls for political reforms

Jiang Yanyoung, a high-ranking military doctor and Communist Party member, blew the whistle on SARS cover-up and in the process became a folk hero in China. In a letter addressed to top leaders, which was also released to the international news media, he reported that many Beijing hospitals, including the one he worked at, were under reporting the number of SARS cases they had.

After the news of cover up came out, the government broke a pattern of never admitting mistakes and publically apologized for failing to inform the public about the disease earlier. Officials that were involved in the cover up---including the health minister and the mayor of Beijing---were sacked.

Later Jiang and his wife were detained and placed under house arrest. Jiang was forced to undergo brainwashing study sessions and wrote a daily “thought report” after asking the government to reappraise the Tiananmen Square pro-democracy protests.

Combating SARS in China

SARS prevention poster
Once the government decided to do something about SARS they pulled out all the stops. Roadblocks were set outside infected areas. Men in white smocks, masks and goggles fanned out across the nation with disinfectant spray. People with even the slightest hint of a possibly of carrying the disease were quarantined to their homes. Fines for spitting were raised and enforced. Harsh punishments were set for anyone who broke the SARS restrictions

In the early stages of the SARS outbreak people stocked up on disinfectants and avoided public transportation. As the crisis worsened streets emptied, restaurants were closed and entire neighborhoods and factories were quarantined. An effort was made to prevent millions of migrant workers from returning to their hometowns. Employers of migrant workers were told not to fire them even with business slacking off and offered tax breaks and other financial aid.

Schools, libraries and other public buildings were closed. Additions were quickly added on to hospitals to accommodate extra sick people. In the rural areas, villagers set up barricades to keep out people suspected of having the disease. The Chinese government threatened to execute anyone who caused death or injury by deliberately spreading SARS and suggested it might apply this policy to SARS patients who violated quarantine orders.

Studies later showed that government overreacted in some cases and quarantined too many people. Other measures---including the suspension of foreign adoptions and marriages between foreigners and Chinese---had dubious effectiveness. Chinese were allowed to marry other Chinese.

SARS in Beijing

Beijing was perhaps hit harder by SARS than any other place. There were 2,531 cases and 191 deaths. The disease all but shut down Beijing. At its peak, the streets and many buses and trains were empty. People stocked up on disinfectant. Marriages were postponed. The May Day parade in Tiananmen Square was canceled. Schools closed for 1.7 million children, many of whom where not allowed to go outside by their parents.

Hospitals and dormitories where the disease had appeared were quarantined and strict rules were implemented to make sure no one left. “Building bosses,” “door watchers,” and other informers were told to report cases of people who looked sick. Roadblocks and checkpoints were set up on roads leading out of Beijing. One family told the Washington Post they were stop 20 times on a 600 miles trip from Beijing to Nanjing and then assaulted by men in maska and white smocks, who quarantined the house where they were staying.

Not everyone complained. One American art dealer told the New York Times, “Beijing was wonderful during SARS. Romantic, beautiful. The sky was clear, for once. Everything shut down. There was no smog, or dust or traffic jams. No tourists. No cars.”

SARS Elsewhere in China

The most cases outside Beijing were found in Guangdong (the southern province where Guangzhou is found) and the northern province of Shanxi. In the Guangzhou area, animal markets were closed down. In Shenzhen a man was diagnosed of having SARS after he attended a wedding with 940 guests. All 940 guests, including all 508 inhabitants of a village, plus all the employees who worked at the wedding, were tracked down and quarantined.

In April riots broke out in the town of Chagugang near the northern coastal city of Tianjin over rumors that a local school would be turned into a ward for SARS patients from Tianjin. Cars were overturned, construction equipment was smashed and a hospital was raided. Tianjin had seven death and 149 cases of the disease.

SARS is Contained and Then Returns in China

Another SARS prevention poster
In July, 2003, the WHO declared that SARS had been contained around the world after no new cases had ben reported for three weeks. The disease disappeared almost mysteriously as it arrived. The most effective means of controlling it seems to have been the quarantines and isolation.

In December 2003 SARS returned. A 32-year-old man came down with it in the Guangzhou area The man lived in a house with some rats. The case was mild and he survived. Some believed there may have been a connection between the disease and the rats. There were four other cases. Of these, one had contact with civet cats---a waitress that worked at a restaurant where wild animals were served.

This time the government was better prepared and ready to take action. The patients were quickly quarantined. Travelers and health care workers were screened. Hotels required patrons to have their temperatures taken before they checked in. Travelers at train stations and bus terminals had their temperatures checked with ear thermometers.

In April 2004, two confirmed cases of SARS and four suspected cases were announced. The victims were believed to have contacted the disease through a lack of safeguards at the National Institute of Virology, a laboratory in Beijing where research on SARS was being done. Again, the government acted quickly. Five hundred people were quarantined. They were mostly people who had come into cotact with the victims.

One victim died---a woman who got SARS from her daughter, who in turn got from a nurse at the laboratory. A researcher at the laboratory passed SARS on to the nurse. She in turn infected her roommate and then her mother (the one who died), father and aunt when she visited her home town in Anhui. Most of people who were quarantined either came in contact with the nurse in Beijing or Anhui.

Civet Cat Culling Campaign

In early January 2004, as part of the anti-SARS campaign, the government ordered the slaughter of all palm civets, hog badgers and racoon dogs in the Guangzhou area. Thousands were killed but many escaped because the were hidden by owners and animal traders. Chinese health officials in goggles, white smock and masks raided markets and breeding farms and seized animals that were killed by electrocution, boiled to death or drowned in disinfectant and then incinerated. A campaign to get rid of rats was also launched.

About 10,000 animals were killed, In addition to the cull, roadblocks were set up to make sure no one was smuggling animals out of the region. People who worked in the animal markets where civets were sold had their blood tested, sometimes several times. Those who hid animals were threatened with fines of up to $12,000.

The measure came eight months after palm civets, hog badgers and racoon dogs at a Guangzhou market had been found carrying a virus almost identical to SARS. Instead of acting quickly them, suspicions were raised about the quality of the data. Not long after the civet cull the ban on selling civets was lifted and markets were again filled with the animals. Many scientists believe the killing of all these animals may do more harm than good. Little is known about SARS and its transmission and studying these animals may provide some insights into the disease. There was little evidence that killing animals provided much help.

The SARS outbreak brought attention to the consumption in civet cat in Guangzhou Even after the SARS outbreak business was good at the First Village of Wild Food restaurant in Guangzhou. One customer who was eating civet cat told the New York Times, it tastes “very good, very good.” When asked if was worried about SARS he said, “It’s no big deal.”

Image Sources: Landsberger Posters and Ohio State University

Text Sources: New York Times, Washington Post, Los Angeles Times, Times of London, National Geographic, The New Yorker, Time, Newsweek, Reuters, AP, Lonely Planet Guides, Compton’s Encyclopedia and various books and other publications.

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© 2008 Jeffrey Hays

Last updated April 2010

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