Fever Pitch
The fastest way for a government official to become a victim of severe acute respiratory syndrome (SARS) is to do too little to prevent the killer disease from spreading. Perhaps that's why Taiwan's President Chen Shui-bian is portraying himself as a front-line crusader in the fight against the SARS virus. Chen told local reporters that he received a phone call on April 22 from a friend, a local health-care official, warning him that Taipei Municipal Hoping Hospital was covering up an outbreak of SARS among its patients and medical staff. Chen dispatched investigators from Taiwan's Center for Disease Control (CDC); within hours, the island's most serious cluster of infections since SARS first appeared here in March was exposed. The hospital was quarantined within two days and, 14 days later, shut down entirely—but not before 120 people caught the disease, 20 of whom have since died. "This is the medical equivalent of war," said Chen, who refuses to show fear by wearing a surgical face mask in public.
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Unfortunately, it's a war that Taiwan may be losing. Elsewhere, there were strong signs last week that the SARS epidemic was running out of steam. Toronto was removed from the World Health Organization's (WHO) list of travel danger zones, and a WHO official said it appeared the disease was waning even in hard-hit Hong Kong, where the number of new infections had fallen to just a handful a day. But the fever is spiking in Taiwan. Since the Hoping Hospital outbreak, the number of SARS victims has soared from 28 to 308, a 91% increase in just three weeks, while the number of deaths from the disease has leapt from zero to 35. Taiwan now has the third highest number of cases in the world, behind mainland China and Hong Kong, and enough to earn a WHO travel advisory. The epidemic also claimed Taiwan's first political casualties: Twu Shiing-jer, Minister of Health, and Chen Tzay-jinn, director of the CDC, resigned over criticism they were too slow to implement strict infection-control measures in hospitals.
The sudden viral surge has been a setback for Chen's administration. Until last week, politicians had been patting themselves on the back for keeping the disease largely at bay. Officials were only too happy to compare their handling of the outbreak with the situation in mainland China, where authoritarian bureaucrats initially tried to cover up the existence of the disease, only to see the number of infections explode—mistakes that cost the mainland's top health official and the mayor of Beijing their jobs. "Because we had avoided what happened in Hong Kong and China we thought we had avoided an epidemic," says Chen Chien-jen, an epidemiologist who replaced Twu as Health Minister. "But now we have to be humble and admit that perhaps we were careless."
Although it's not clear why the virus has suddenly taken hold, there are clues. Until recently, 80% of Taiwan's SARS victims contracted the disease abroad. Many were Taiwanese businessmen returning home from mainland China. But nine out of 10 of the newest casualties have been infected through contacts within the island's well-regarded medical facilities, suggesting that, despite quarantine rules and other anti-SARS measures, health-care workers let down their guard, resulting in the first significant spread of the disease on the island.
In recent weeks, at least eight hospitals have reported possible transmissions inside their wards; two Taipei hospitals, including Hoping, were closed. At a hospital in Taiwan's second largest metropolis, the southern city of Kaohsiung, authorities were considering quarantine measures after five people came down with SARS. Most alarming was an outbreak at the island's most prestigious medical research facility, the National Taiwan University Hospital (NTU), a regional leader in SARS treatment. The hospital has reported 10 confirmed cases of hospital transmission since May 10, of which six are medical staff, and closed its emergency room on May 12. That rocked the confidence of a populace that had previously been willing to believe that everything was under control. "When I heard the reports about what happened in NTU I felt the situation was more serious than the government was telling us," says Elaine Chiang, 25, a shop assistant in Taipei. "I haven't taken my mask off since."
Under international pressure, Beijing on May 3 finally allowed two WHO investigators to visit Taiwan, but they were barred by WHO headquarters in Geneva from contact with Taiwanese government officials. "They are not even allowed to talk to our officials from the Department of Health," complains Yu. "They are here to observe and compile information which, so far, they have only used to slap a travel warning on us."
Nevertheless, Taiwan had plenty of information at its disposal. To compensate for the WHO's inability to send help, the U.S. on March 16 sent a team from its Centers for Disease Control and Prevention to liaise with the island's government health officials. The government could have relayed information about protocol to help prevent hospital transmissions, which have been commonplace wherever the virus has struck—yet hospital administrators in Taipei say they received no data. "Everything we know, we learned from the Internet," says Lee Yuan-teh, superintendent of the NTU.
Moreover, Taiwan's initially low infection rate may have had more to do with luck than sound government policy. Authorities have been slow to put in place a national action plan to combat the virus, forcing local governments and individual hospitals to improvise. Taiwan at first also refused to impose health screening at immigration checkpoints as other places have done, and its quarantine measures were more lax than those seen in affected zones such as Singapore, which has successfully contained the disease.
Some critics say politics played a role in Taiwan's sclerotic containment efforts—specifically, that a hostile relationship between President Chen and the mayor of Taipei, Ma Ying-jeou, made coordination difficult. Rivals for much of the past decade, Ma unseated Chen in Taipei's 1998 mayoral election, sending him into the political wilderness until his upset presidential victory in 2000. The relationship between the two plummeted to new lows during the recent mayoral race, with Ma and Chen trading insults throughout the campaign.
Joseph Wu, Chen's deputy secretary-general, pointed out that some of the hospitals suffering the worst outbreaks are under the direct control of the local Taipei government. But he acknowledged Chen's Cabinet ministers "should have reacted more quickly to the situation and been more decisive in telling hospitals what to do." Indeed, the island's Health Minister may have been sacked partly because he failed to heed calls by the city government to declare SARS an infectious disease, which resulted in complacency among medical staff.
Now, the Chen administration is taking control. A Cabinet-level anti-SARS task force has been hastily assembled, the military has been called into action to help disinfect Taipei's streets and hospitals and strict quarantine measures have been imposed in the capital with stiff fines for violators. Still, some worry that the disease is gathering momentum and bureaucratic reaction times remain too slow. A foreign health-care specialist, who declined to be identified, notes that more than 100 suspected SARS cases in Taiwan have yet to be reviewed by epidemiologists—meaning the number of victims might be substantially higher than the official tally. "Clearly there are major structural and organizational issues that need to be addressed," the specialist said.
The strain is beginning to show on the face of Chen Chien-jen, the new Health Minister. He says he was "cautiously optimistic" a week ago that the virus could be contained within a month. Now, with a map of Taiwan in his hands that shows victims in every region of the island, he is not so sure. "I can no longer be confident it won't spread farther," he says. "I even had to admit that to my own President." Armed with that information, it may not be too much longer before President Chen, too, is seen wearing a face mask.
With reporting by Joyce Huang and Donald Shapiro/Taipei
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