The Anatomy of an Outbreak

Several travelers met in an elevator in a Hong Kong hotel. Three weeks later, three were dead and the disease they carried had spread around the planet. This is the human story behind SARS and the heroic efforts to stop it.

Part I: Epidemic February 21, 2003

The ninth-floor hallway of the Metropole Hotel in Kowloon, Hong Kong strives for a hushed, expensive formality. The elevator doors are trimmed in dark, polished wood, the carpet is deep green, the lighting discreet. Late in the afternoon, Dr. Liu Jianlun, a 64-year-old kidney specialist and a professor at Zongshan University, on the Chinese mainland, waited with a small group, including six other ill-fated travelers, to ride the elevator to the lobby. Dr. Liu, who had just checked in after an arduous journey, was joined by a Chinese Canadian couple, Kwan Sui-chu, 78, and her husband, who had come to Hong Kong to visit three of their sons. They had wound up at the Metropole because it was free, part of a five-night package offered by the airline. Also waiting for the elevator were four young women from Singapore, including 23-year-old Esther Mok, a former flight attendant whom acquaintances described as a "sweet, cheery girl." Esther and a friend, who had checked into room 901, had come to Hong Kong on a shopping spree.

A 72-year-old Canadian tourist was also on the ninth floor that day, as were a 48-year-old Chinese American businessman in the garment trade and a local man, a 26-year-old airport worker who was visiting a friend.

The elevator doors swished open and the guests filed in, several generations of travelers from distant parts of Asia and North America, suddenly connected more deeply than they could ever suspect. On the short drop to the hotel lobby, a couple of passengers remembered later, Liu began coughing.

Dr. Thomas Tsang, a community medicine specialist, led the team at the Hong Kong Department of Health that traced the paths of the seven people back to where they had crossed that afternoon in the hotel. A painstaking reconstruction of the guests' comings and goings allowed Dr. Tsang and his team to show that the unassuming Metropole Hotel, in one afternoon of a typical day, became ground zero for the worldwide spread of the first major new disease of the century--severe acute respiratory syndrome, or SARS. However they became infected--and Tsang concedes that "we have no way to be certain who bumped into whom"--seven of these unsuspecting travelers spread SARS to the world.

Investigators for the World Health Organization, the public health arm of the United Nations, agree that SARS was spread from the Metropole's ninth floor, but they favor the "hallway incident," in which the elderly doctor may have vomited in the corridor and attempted to clean up the mess himself. Other epidemiologists speculate that what has been called the Metropole supershedding incident was actually a series of individual contacts in public areas of the hotel throughout the late afternoon and early evening.

All agree, however, that this single floor of this Hong Kong hotel was the launching point for a lethal new disease. Hong Kong, with more casualties per capita than any other city, suffered for this distinction, but its doctors and hospital workers, many of whom died while treating patients, left behind a battle plan for the next outbreak as well as a warning for the rest of us. Here is the anatomy of a near epidemic.

Hong Kong is a city of 6.7 million people who live on hundreds of islands connected by bridges and ferries. It is the financial capital of Asia and has some of the highest real estate values in the world. It is among the wealthiest and most crowded cities on earth, with an average population density of 6280 people per square mile. In Hong Kong, and southern China, farmers, merchants and animals live in close proximity, and the region is a breeding ground for new influenzas, many of which sweep through the United States every winter. Not widely known, except to researchers and medical experts, is that most of these viruses originate in birds or animals, jump to humans and then easily spread to the rest of the world through international travel and commerce.

On the same day that Liu and his wife checked in at the Metropole, Dr. Donald Low, chief of microbiology at Mount Sinai Hospital in Toronto, arrived in Hong Kong. Dr. Low had given a speech in Cambodia and had flown to Hong Kong to show his young son the sights. They took a room in a Kowloon hotel near the Star Ferry, which connects that part of the mainland city with Hong Kong Island.

Low read the front-page stories in the South China Morning Post, the main Hong Kong newspaper, which featured news about a mysterious new form of avian influenza, type H5N1. Bird Flu Scare Escalates With Second H.K. Case, read one headline.

None of this was shocking to Low. Bird flus are not uncommon in Hong Kong, but even mild eruptions can scare the wits out of health authorities. The most recent appearance of an H5N1 bird flu, in 1997, killed six people and caused the slaughter of 1.5 million chickens--every one in Hong Kong--because the birds were the direct carriers of the virus to humans. Hong Kong public health officials have grown adept at containing new bird viruses before they cause even greater havoc by spreading internationally. Yet any new avian flu in Hong Kong shoots a bolt of fear, as well as professional interest, through the world's public health experts.

Low pointed to the newspaper and said to his son, with a scientist-father's exuberance, "Here we are, right in Hong Kong, and this is going on. Isn't that kind of cool?"

Patient Zero

Liu had spent three hours on a bus with his wife, traveling from Guangzhou, the capital of Guangdong province, in mainland China, when he arrived in Hong Kong for his nephew's wedding.

For the occasion, Liu had taken a much needed break from treating patients for a mysterious, highly infectious new pneumonia. WHO was already worried about this disease, as was the Hong Kong Department of Health, which had noted an upsurge in demand for white vinegar, a traditional sterilizing agent used in southern China.

Liu had been ill for a time back home but was feeling well enough to take the bus trip. A few days earlier, when he had first become feverish, he'd worried that he had come down with the mystery disease that had killed or seriously sickened so many others. His lungs had looked fine in a chest X ray, however, and the day he arrived in Hong Kong, he felt healthier. He shopped, did a little sightseeing with his brother-in-law and had a long lunch with his Hong Kong relatives. A hotel concierge remembers that Liu and his wife arrived at the Metropole around 5:30 P.M. They checked into room 911.

The hotel was busy; 90 percent of its 478 rooms were occupied. The Metropole's rooms are clean but hardly fancy, and the neighborhood is a mix of expensive and rundown buildings. The Lius' window provided a view of a Shell service station, an aging high-rise apartment building with laundry hanging from the windows, and a YWCA.

Liu missed the wedding banquet the next day. In the morning, he felt terrible, with a fever that made him shiver violently. He had trouble breathing. His lungs were inflamed, his muscles ached and he had a blasting headache. Around noon, he checked out of the hotel and into Kwong Wah Hospital. By the time he reached the hospital, Liu was experiencing respiratory failure and was immediately placed in the intensive care unit. The hospital staff also put him in isolation in the unit, and they threw on masks, gowns and gloves whenever they dealt with him. They were leery of the new bird flu as well as the mysterious pneumonia festering in southern China, which Liu told the staff he had been treating. At this point, many medical people assumed the two diseases were the same.

Liu refused to believe he had the new disease until the Kwong Wah doctors showed him the telltale white patches on his chest X rays, which indicated lung damage. The doctors tried antibiotics and a few powerful antiviral medications. But Liu kept slipping. Soon his breathing gave out and he had to be put on a ventilator. To keep him from ripping the tube from his throat, the doctors sedated him into unconsciousness.

For nurses, intubation--placing a breathing tube in a patient's throat--is one of the most dangerous procedures, even when the patient is unconscious. The patient may struggle and cough, forcing infected liquids from his or her lungs. Despite their precautions, five nurses and a doctor at Kwong Wah Hospital were infected by Liu.

By this time, the six other Metropole guests Liu had encountered had become infected and were infecting others. The Hong Kong health department tracked other guests who had been at the hotel the same time as Liu but on different floors. Eight other cases turned up.

Chan Y.P., Liu's 53-year-old brother-in-law, who had spent 10 hours sightseeing and shopping with the doctor, quickly came down with symptoms. Almost immediately, he had trouble breathing. He was admitted to Kwong Wah Hospital, where Liu remained unconscious.

Liu died March 4.

His brother-in-law struggled and died two weeks later, on March 19.

When Dr. Liu died, the world had no idea that SARS even existed. In fact, the mysterious pneumonia from southern China didn't even have a name. But in Hanoi, Singapore, Toronto and Hong Kong, the disease was about to change lives forever.

Hanoi

Johnny Chen was a young, fit garment merchandise manager based in the Shanghai office of the Gilwood Co. of New York City. He arrived in Hanoi from Hong Kong on February 24 to make sure a local contractor correctly installed zippers and other components in a shipment of blue jeans. The order was set for delivery in April. He and colleagues from the small firm checked out the jeans factory, which was outside Hanoi, then returned for a night on the town.

The next day, Chen, who had been staying in a guest room above the Gilwood office in Hanoi, woke up feeling under the weather. At lunch with his co-workers he said he was having chills, but he thought if he turned in early that night, he'd get rid of the bug.

The next morning, though, the normally genial Chen was seriously sick. He called a doctor, who prescribed rest. When his colleagues returned from another trip to the factory, Chen was feverish and in trouble. They checked him into the Hanoi French Hospital, the relatively new, well-staffed private hospital that is favored by expatriates in the Vietnamese capital.

Chen's attending physician, Dr. Olivier Cattin, was confused by Chen's symptoms, particularly the trouble that Chen was having breathing. Dr. Cattin had heard of the bird flu outbreak in Hong Kong, which he thought might be associated with the pneumonia in southern China, where Chen had been on a business trip before stopping in Hong Kong. After seeing no improvement for two days and still unable to identify what was making Chen sick--and with two hospital staffers now suffering similar high fevers, dry coughs and breathing problems--Dr. Carlo Urbani, a WHO specialist in Hanoi fighting parasitic diseases in schoolchildren, was called in to consult. Dr. Urbani loved fine wine and opera and was a first-rate photographer--"a great enthusiast," says Dr. Aileen Plant, an Australian international health expert who joined the Hanoi WHO team in mid-March. Extremely popular in the Hanoi medical community, Urbani was widely respected as a diagnostician. He was also the sole WHO physician in the city.

Urbani called the WHO regional office in Manila and talked to Dick Thompson, a WHO spokesman in the communicable-disease section who happened to be manning the phones there. "He thought they had identified an unusual case of pneumonia," Thompson recalls. Next, Urbani spoke with two WHO investigators in Beijing who were trying to figure out whether the southern Chinese mystery disease was actually type H5N1 avian flu--or something much worse. They asked Urbani to send tissue samples from Chen. Hearing rumors of a new plague in town, commercial airlines refused to carry the material. The U.S. embassy chartered an airplane to take the tissue samples out of Vietnam. The samples tested negative for bird flu, however. And the symptoms still didn't fit. "We didn't know it was a virus," says Thompson, "didn't know how to treat it, didn't know what the course of the disease was except that it was looking bad. It was attacking health care workers."

Over the next two days, 10 hospital workers got sick with the disease. Urbani told his boss, WHO Hanoi director Pascale Brudon, "Look, there's a real problem here." The two redoubled their efforts at infection control and called for more WHO infectious disease experts to come to Vietnam. Urbani and Brudon also contacted the Vietnam public health authorities to warn them of the virulent new infection in the Hanoi French Hospital. Urbani quickly closed an entire wing of the hospital where the infection was centered. Still the disease continued to spread. Two days later, as WHO disease experts arrived in Hanoi, Urbani called Dr. Klaus Stöhr, the virologist in charge of WHO's influenza program, to warn him that he was "losing control" of the French Hospital.

With more WHO doctors now on the scene, Brudon convinced Urbani to take a break from his nonstop days at the hospital to attend a medical meeting in Bangkok. Urbani felt fine, though exhausted, when he got on the plane. By the time the plane arrived, however, he was ill. He immediately checked into a Bangkok hospital, not realizing that he would never get out.

On March 12, the day after Urbani entered the hospital, WHO released a global alert announcing the new disease that Urbani had isolated. Three days later, WHO first used its choice of name for the disease: SARS.

At the request of his wife, (continued on page 138) (continued from page 70)Johnny Chen, who was comatose, had been returned to Hong Kong by air ambulance. He was placed in isolation in Princess Margaret Hospital, which specializes in infectious diseases. He died on March 13, hooked up to a ventilator, with tubes sticking out of his once muscular body. By the time of his death, Chen had, directly or indirectly, infected 63 people in Hanoi, including seven of his colleagues at the garment company. Five of the victims died.

One was Urbani, who died in Bangkok on March 29, the day after he was finally intubated. "We all thought he was going to get better," says WHO spokesman Thompson. "I remember a big argument he had with his wife toward the end about whether he should have kept going back to the hospital." His widow, Giuliana Chiorrini, quoted his reply: "If I cannot work in such situations, what am I here for? Answering e-mails, going to cocktails and pushing paper?"

Toronto

When Kwan Sui-chu and her husband took the long flight back to Toronto on February 23, she was already desperately ill. In Toronto, she saw her family doctor, who merely prescribed an ordinary antibiotic. She never went to a hospital, and she died at home on March 5--the first SARS death in Canada. No one in the country had an inkling of the terrible new disease that had been unleashed.

Kwan lived in a townhouse with her husband, a son, his wife and their newborn baby. During the 11 days that her illness festered and grew, Kwan infected many of her closest relatives, including one son who, when Kwan was suffering her final respiratory failure, followed a paramedic's instruction over the telephone to give her mouth-to-mouth resuscitation. Another son, 43-year-old Tse Chi-kwai, would bring SARS into Toronto's hospitals.

Tse was admitted to Scarborough Grace Hospital with what looked like pneumonia. Tse spent a night in a corner bed in the emergency room's observation ward. There, two other patients, including Joseph Pollack, 76, contracted the disease. More than a dozen hospital staffers began to come down with symptoms. Before he died, Pollack infected his wife, Rose, 73. Before she died, Rose had sat in a hospital waiting room next to the leader of Bukas Loob Sa Diyos, a predominately Filipino Roman Catholic prayer group. At least 30 members of the prayer group became infected, and three died.

Soon, more Toronto health care workers began to get sick. Some doctors and nurses were unaffected; others had sat next to an infected person for only a moment or had removed their masks and briefly touched a virus-laden finger to their eyes--and wound up dead. "With other infections, you'd get away with that 99 times out of 100," says Dr. Low, who had been in Hong Kong during the outbreak. "With this one, you might get caught." He had treated SARS patients in Canada but was not infected. Christel Clark, an emergency room clerk at Scarborough Grace, wasn't so lucky. She apparently contracted the disease from a patient when she handled his insurance card.

Dr. Allison McGeer, director of infection control at Toronto's Mount Sinai Hospital, had her own experience with SARS, though she describes her case as mild. SARS usually has two components--one is the lung disease, the other is severe gastrointestinal problems, including cramps, nausea and relentless diarrhea. Even as she tried to regain her strength, Dr. McGeer continued to compile information on the epidemic from her laptop and her phone.

The Toronto outbreak continued for months and had a powerful resurgence in May. In all, more than 150 cases developed--about half of them in health care workers--and more than 25 people died. In April, Toronto was placed on a WHO travel advisory, panicking many would-be tourists and business visitors.

Despite their enormous personal losses, the Kwan family came under fire. "People treat us like monsters. They say we eat like rats and live like pigs," said Ms. Tse, a daughter, who would use only her family name when speaking to the Toronto Globe and Mail.

Singapore

On February 25, Esther Mok left the Metropole Hotel and returned to Singapore. Four days later, Mok and two of the other Singapore women came down with symptoms and were admitted to local hospitals. Since no one thought she had anything more serious than pneumonia, Mok was allowed to receive visits from her family and members of her church. Her father, Joseph, her mother, Helen, and her pastor at the Faith Assembly of God Church, Simon Loh, became infected. So did Mok's uncle, grandmother and brother.

On March 25, Mok's father died in Tan Tock Seng Hospital, and the next day her 39-year-old pastor was dead--the first two SARS deaths in the city. Loh, who had a wife and two small children, had gone to pray for Esther Mok after her aunt asked him to. His death shocked other clergymen in Singapore, and church attendance plummeted. Many congregations canceled Sunday school and confessions.

The first week of April, Mok's mother died. A few days later, her uncle was also dead of SARS. A nurse tending Mok caught the disease and passed it to a patient in the intensive care unit, who spread it to 25 other patients. One of those patients took the illness to yet another hospital when he was transferred, infecting another 35 patients. Dr. Ong Hok Su, a 27-year-old medical officer from a cardiac unit, died. His mother, a doctor herself, took care of him, contracted SARS and died in intensive care.

The other two women who had traveled to Hong Kong infected no one and would quietly recover. When it became clear that Mok was infectious, however, her anonymity was sacrificed for the public good. Health officials named Mok, hoping to encourage anyone who had been in contact with her to seek medical attention.

Long after Mok had recovered from SARS, hospital officials kept her isolated in Tan Tock Seng Hospital to protect her from the public and reporters. Only her sister was allowed to visit.

The Singapore government didn't do much else to protect Mok's reputation, however. In its fear-fueled war on the disease, officials called highly infective SARS patients superinfectors and occasionally spoke as though Mok had deliberately spread the disease. "Esther Mok infected the whole lot of us," Lim Hng Kiang, Singapore's health minister, said in April. Although Mok hardly intended it, nearly all of Singapore's SARS cases and deaths can ultimately be traced to her being in the wrong place at the wrong time.

Like Drowning on Dry Land

In Hong Kong, on March 1, a week after Dr. Liu had stayed overnight at the Metropole, the 26-year-old airport worker who had been visiting a friend on the ninth floor was admitted to Hong Kong's Prince of Wales Hospital. Tests showed that his lungs were in trouble, but he appeared to have conventional pneumonia. In a tragic case of bad luck, the hospital staff used a standard treatment--a drug introduced by an atomizer called a jet nebulizer. For seven days, the device spread the new virus aggressively throughout the hospital ward. As a result, every attending doctor, nurse and medical student--along with every nearby patient--would contract the disease. It was the start of the massive Hong Kong SARS outbreak.

Doctors and nurses at Prince of Wales began to show symptoms of the disease by March 5. Dr. Gregory Cheng, chief of hematology, the first Hong Kong health care worker to become infected, remembered how the disease felt in the beginning: "high fever, chills, feeling very cold, shaking from the inside, and muscle ache." Some of his colleagues were so relentlessly tired that "just brushing their teeth, those people would run out of breath and be completely exhausted afterward."

For others, the course of the disease was far worse. For terminal patients, SARS means a slow and progressively painful death, like "drowning on dry land," as one news report put it.

In some cases, the disease quickly turned severe without apparent reason, forcing the patient to intensive care and the awful ventilator tube. That happened, Dr. Cheng said, to about 10 percent of the SARS cases he saw. "Once you need ventilation, the outcome as a whole is generally poor," he added.

As doctors and nurses from other specialties volunteered to replace their sick colleagues in the now isolated SARS wards, the Hong Kong health department, at a late-night briefing on March 19, released its report linking the spread of SARS to the chance meeting of international travelers at the Metropole Hotel. It presented a glimmer of hope: SARS seemed to be spread by person-to-person contact--most likely by viruses suspended in droplets, as from a sneeze--and not as airborne particles that could have wafted around the hotel through the air-conditioning ducts, as influenzas can. That can be a much more dangerous proposition in public health terms. If the virus survived only in relatively big droplets, it meant that one had to be within roughly three feet of an actively infective person to catch the disease. This made the classic quarantine a promising weapon with which to battle the disease and perhaps eradicate it.

Almost immediately, another deadly puzzle presented itself--a new SARS outbreak in Amoy Gardens, a towering, middle-class housing complex in the Kowloon Bay section of Hong Kong. A 33-year-old man with chronic kidney disease had picked up SARS while being treated in Prince of Wales Hospital. He then paid several visits to his brother, who owned an apartment in block E of the complex. However, investigators couldn't account for the infection, in short order, of more than 300 people in the complex--a quarter of all cases in Hong Kong--most of them in block E. The man hadn't been wandering around the building, and only a fraction of the residents had had contact with a SARS patient or had been to the mainland recently. The first terrible thought was that SARS could be spread by means other than droplets or that it could survive for long periods on doorknobs, elevator buttons and the like--or worse, that the virus had mutated.

On March 31, moved to extremes, Director of Health Margaret Chan put all of block E into isolation for 10 days, the generally accepted incubation period. Residents were ordered to remain in their apartments and were given three free meals a day, medical testing and help in disinfecting their rooms. No one could leave without an OK from a medical officer. To the relief of public health officials, the cause was found to be a plumbing problem that had allowed the virus to spread in droplets. The virus hadn't mutated and it didn't have another transmission method.

It was a messy affair. Before block E was isolated, 113 families packed and left to stay with friends and relatives. The health department enlisted the Hong Kong police department to help round them up before they spread the disease further. During the hunt, seven members of the force came down with SARS.

Part II: Containment Pieces of the Puzzle

In early March, Dr. Stöhr picked up his phone in Geneva. On the line was an anxious Margaret Chan. "Klaus, we have a problem over here," she said. "We have an outbreak in a hotel." In the first week of March, a parade of doctors, nurses and aides at Hong Kong's Prince of Wales Hospital had begun getting sick from what was clearly an extremely virulent disease. Chan and her epidemiologists were tracing contacts, the most important first response to any sort of infectious disease. E-mailed reports from public health officials in Canada and Singapore would finally make the link to the Metropole Hotel. "That first rang a bell," said Dr. Tsang.

At the same time, health care workers at the Hanoi French Hospital were falling ill. And by March 13, Toronto already had two SARS deaths, and sick hospital staffers in the city were being admitted to their own hospitals. Another case was quickly isolated in intensive care in Vancouver.

Then, at 2:30 A.M. on March 15, Dr. Michael Ryan, director of WHO's Global Outbreak Alert and Response Network, got a phone call from the Singapore Ministry of Health. Singapore had also had an outbreak of a mysterious new disease in its hospitals, and authorities there had just learned that a Singapore doctor who had treated one of these patients was on a plane that had just left New York. The doctor, who could easily be highly infectious, was heading home and had a stopover in Europe. The Singapore authorities had only the doctor's name, however. "Not the flight number or even the airline," Dr. Ryan recalled.

"What we saw at the beginning were a few puzzle pieces," says Stöhr. And then the number of those pieces quickly grew. In the week before March 15, when WHO issued a rare travel advisory, it had received more than 150 reports internationally of a strange new pneumonia.

On the same day, when the Singapore doctor's plane touched ground in Frankfurt, German quarantine officers were there to meet it. The doctor and two companions were taken off the plane and placed in isolation; the other passengers were examined and advised that they might have been exposed.

With an alacrity that has startled even public health investigators, doctors, nurses, epidemiologists and other investigators around the world fought back even before they knew what they were fighting. "The overall level of knowledge that people assembled in SARS is extraordinary," says Marc Lipsitch, an epidemiologist at the Harvard School of Public Health. "To have such a large health emergency and to be able to do successful contact tracing in Hong Kong, Singapore, Canada and Vietnam is a very impressive thing."

In recent years it's become clear that the world faces great danger from new or manufactured diseases that can easily spread through air travel. Even before SARS, WHO had been constructing a better global disease network. One component of the network was an agreement among the best laboratories on the planet to cooperate, not compete, in times of need. The new system, noted Ryan, had undergone some tests during smaller outbreaks, but before SARS, it hadn't had a "major road test."

Now, with a cascade of reports arriving in Geneva, WHO investigators realized they had a major trial of their new system at hand. "We've had killer outbreaks of new diseases before, like Ebola," Dr. David Heymann, WHO executive director for communicable diseases, told the Associated Press, "but they have never spread internationally. If this system had been in place when AIDS occurred, we might not have had the AIDS expansion that we had."

Seemingly local triumphs had big impacts. Dr. McGeer, of Mount Sinai Hospital in Toronto, had difficulty getting the local coroner to perform an autopsy on Tse Chi-kwai, the first patient to die in a Toronto hospital. Coroners are often reluctant to investigate what seem, as in this case, to be ordinary pneumonia deaths. McGeer persevered, however, and in an impressive leap for the worldwide public health effort, tissue from that autopsy would be used by the Michael Smith Genome Sciences Center, in Vancouver, to decode the virus' genome. From that, the SARS coronavirus was identified, and the search for protective and curative measures began.

Urbani, in Hanoi, had kept trying to ascertain whether he was dealing with a truly new disease even as he treated patients, most of them fellow health care workers, no matter the obvious infectiousness around him. "On March 5, 6, 7, 8, 9 and 10, he went to the hospital every day," says Dr. Plant, who volunteered to take the place of Urbani among WHO Hanoi investigators after he fell ill. Urbani's work alerted doctors around the globe.

In Vancouver, for example, the British Columbia Center for Disease Control began sending doctors e-mails that warned of strange influenza symptoms or a possible new avian flu. When a 55-year-old patient who had been on the 14th floor of the Metropole came to Vancouver General Hospital on March 13, he was in a mask and in isolation within an hour. This quick action spared Vancouver a SARS outbreak. Other WHO investigators pressed the Beijing government to open the real books on the new disease.

Hong Kong excelled in medical detective work, often in dangerous conditions. The authorities set up medical check stations at the city's borders, turned all available government resources--including police computers--toward tracking people who'd had contact with SARS patients and urged anyone who thought they were ill to come in for treatment without penalty.

Singapore applied a more draconian hand. There, on March 21, the Ministry of Health produced an Infectious Diseases Act that forced anyone found to have had contact with a SARS patient to be quarantined and monitored by web-cams installed in their homes or, if they started to wander, by electronic wristbands. If that didn't keep potential SARS patients home, jail terms would be applied. On May 4, the first offender was publicly named and charged with violating the Home Quarantine Order.

No visitors were allowed in Singapore hospitals. Thermal scanners, to check people's temperatures, were widely installed. Virtually everyone in Singapore who dealt with the public carried badges that listed the time of their last temperature check, since fever was one of the first symptoms. And to stop contamination from one hospital to another, doctors were threatened with revocation of their medical licenses if they worked in more than one hospital.

Not all episodes were heroic. Residents of neighborhoods in mainland China rioted when they learned that SARS patients might be quarantined in local buildings. Several U.S. universities, including the University of California in Berkeley, announced attendance restrictions at graduation ceremonies and/or in summer programs for students and parents from SARS-affected countries, whether or not they exhibited symptoms. "It was shocking and quite stupid," says Howard Markel, director of the Center for the History of Medicine at the University of Michigan. "I always worry about scapegoats in an epidemic." And hospital workers in Taiwan's Chang Gung and Ho Ping hospitals quit when they became convinced that mistakes in recognizing SARS were responsible for the fact that 90 percent of Taiwan's SARS patients were hospital workers.

Yet WHO authorities remain pleased with how SARS has been nearly contained, despite the renewed round of infection in Canada in May and the storm of disease running through China. A remarkable level of international cooperation has bloomed, and WHO honchos have been quick to take advantage of it, particularly in light of the initial intransigence of the Beijing government. At the end of May, WHO drafted new regulations, subject to member nations' expected approval, to strengthen future efforts. Under the proposal, each country will have public health contacts who are available 24--7. WHO will no longer be dependent solely on a country's official version of a disease outbreak, as it was for so long with China. And the organization will be specifically authorized to bring the weight of world opinion against a member country if, in a crisis, that country refuses access to WHO health investigators.

SARS remains a dangerous and mysterious disease. McGeer notes that "the mortality rate from SARS is the same as from invasive group A streptococcal disease," a group that includes such ruthless illnesses as toxic shock syndrome and flesh-eating disease. According to the experience in Hong Kong, more than half of SARS patients over 60 will die. Worse in some ways, its pattern of infectiousness makes SARS an extraordinary threat to health care workers in hospitals and in private medical offices--patients are most infectious after they are in health workers' care.

"It's been 50 years since working in a hospital has been a dangerous thing to do from an infectious disease perspective," says McGeer. "In most of the developed world, we're already having almost a crisis in staffing our hospitals and health care systems. People looking to go into nursing and medicine are going to think twice about it now, when they're faced with such an obvious risk."

Fifty years ago, health care workers faced the threat of getting smallpox while working in North American hospitals. In the Forties and Fifties, while most Americans had been vaccinated against the disease, many people in developing nations had not, so hospital staffs encountered people who had picked up smallpox overseas. SARS poses a similar menace--what's known in the health trade as recurrent introductions. Many people forget that even the great influenza pandemic of 1918, which killed at least 20 million people around the world, came in repeated waves in 1918 and 1919, the second wave being the most deadly. And the 1918 flu had a mortality rate of only one percent among healthy adults.

SARS, says McGeer, "is obviously a worse disease than that."

Aftermath

In early May in Hong Kong, SARS hangs like a shroud over the city. The frontline doctors still work 18-hour shifts in SARS hospital wards, and locals have just learned that even recovered patients may be permanently weakened by lung scarring. But the city has begun to recover from weeks of fear. Masks are coming off, even on the trains and trams.

Christine Loh Kung-wai, chief executive and founder of Civic Exchange, an independent, nonprofit Hong Kong think tank, has been analyzing decisions made during the first months of the SARS crisis by the Hong Kong Department of Health and the independent Hospital Authority. "The strength of the system is the natural instinct of Hong Kong not to hide," she says. She agrees that Hong Kong has been faulted for not realizing soon enough the enormity of the SARS problem. And she has publicly criticized uneven infection-prevention policies and inadequate stocks of protective clothing in the public hospitals. Yet it was Hong Kong that first contacted WHO, she points out, when the new pneumonia showed up. "Nobody ever tried to hide anything," she says.

Meanwhile, on Ashley Road in Kowloon, in Ned Kelly's Last Stand, which claims to be Asia's oldest jazz club, the leader of the three-piece band, Colin Aitchison, says, "This is the worst Hong Kong has ever had it financially. But people aren't dropping dead in the streets. The medical people are the best. Everybody in town thinks so. We're going to beat this damn disease."

Across the harbor at the Amoy Gardens, a young couple, their arms full of groceries, are moving back into their apartment, to the clang and clatter, around the corner, of a Taoist priest appeasing the spirits. "I'm a little bit afraid," the husband admits Then he shrugs his shoulders and goes in.

At the Metropole Hotel, another modest but optimistic moment arrives. Two young female backpackers, no doubt attracted by the rock-bottom prices, are checking in for the night.

The mystery pneumonia from southern China didn't even have a name.

Urbani called WHO to warn that he was "losing control" of the French Hospital.