The Politics of Disease

The language of epidemiology, the study and prevention of the spread of infectious diseases, is steeped in the metaphor of blockade. Doctors and scientists develop "barrier" nursing techniques and try to erect "ring fences" within society to corral a dangerous microbe, preventing it from jumping between people and countries. But one of the lessons learned by Hong Kong, the city hit hardest by the deadly epidemic of Severe Acute Respiratory Syndrome (SARS), is that it does no good to slam the ring-fence gate after the killer has left the pen.

Prompt action by local health authorities can nip an outbreak in the bud, saving lives and billions of dollars. "When you confront new diseases and they begin to travel widely, you have to do everything you can to try to stop the transmission," says World Health Organization (WHO) spokesman Dick Thompson. "Maximum efforts in the beginning are justified." Although doctors and scientists decline to point fingers, it's increasingly clear that the Hong Kong government failed to recognize the potential threat when SARS first surfaced and downplayed its impact to avoid panic and bad publicity. As a result, the virus slipped into the general population—and the number of Hong Kong victims continues to rise steadily. There were 26, 27 and 39 new cases reported on April 3, 4 and 5, respectively, bringing the total number since the outbreak began to 800, with 20 deaths. Far from being contained, the disease appears to be gathering steam. "I don't think we should pack our books and go home early," says Dr. Stephen Ostroff, chief epidemiologist for the National Center for Infectious Diseases at the Centers for Disease Control and Prevention in the U.S.

The advance of the epidemic in Hong Kong stands in marked contrast to the situation in Singapore, another Asian transportation hub hit by SARS last month. Health authorities in the Lion City have all but declared victory over the disease. Although six people have died—the latest fatality coming April 4—just 26 Singaporeans of 101 who were infected remain in the hospital and the rate of new cases has fallen to about three a day. "It will take at least another week or two to be certain that the epidemic is close to ending," says Dr. Osman David Mansoor, a WHO scientist. "But there's no doubt the disease is being controlled here in Singapore."

Local health officials credit the full-court press they clamped on the virus. Those measures included quarantining more than 1,500 people who had close encounters with SARS victims, confining them to their homes under threat of heavy fines; closing all schools, and medical screening for all travelers entering the city. When new cases were discovered, a team of 100 "contact tracers" tracked down not only patients' immediate families, friends and neighbors but also their office colleagues and favorite food hawkers, and placed them in quarantine, too. Anyone suspected of having SARS is transported to the hospital in an ambulance.

This ring-fence approach, isolating suspected victims and painstakingly retracing their steps in the days before they fell ill, "showed us that infection control works," says Dr. Balaji Sadasivan, Singapore's Minister of State for Health and the Environment. It paid another dividend: authorities got an early warning that most victims were getting sick after visiting hospitals with known SARS patients. "The moment we realized hospitals were the most dangerous place, we designated Tan Tock Seng [Hospital] as a SARS-only hospital and shut it down to all other patients," says Sadasivan.

Hong Kong's response, by comparison, has been marked by what appear in hindsight to be tardy half-measures. As in Singapore, Hong Kong's outbreak started at a medical facility—the Prince of Wales Hospital, where nearly 100 patients and staff rapidly began falling ill beginning March 8. But even after it became clear that a potentially deadly mystery illness was loose in the wards, visitors and outpatients came and went freely for several days, despite mounting evidence that the disease could be highly contagious.

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Among the patients was an unidentified local man who was admitted to Ward 8A—where the hospital had sequestered pneumonia patients—with a suspected case of SARS on March 15. Test results indicated the man, who suffered from kidney disease, had the flu not pneumonia. He was discharged. In fact, he had SARS, and health officials now think that when he later visited family in the Amoy Gardens apartment complex, he passed the disease to his brother and sister-in-law—sparking a virulent outbreak among residents. Some 250 people in the apartment complex came down with SARS, giving the disease its first major beachhead in the general population.

Under increasing public pressure, Hong Kong officials on March 28 announced that all public schools would be closed. Special quarantine laws were also invoked. But authorities stopped short of immediately shutting potential victims in their homes, as Singapore had done. Instead, they were told to report daily to designated clinics for monitoring—meaning suspected SARS carriers were actually being required to venture out among the masses.