Regional Affair

The

fleet of ambulances from the China-Japan Friendship Hospital started their engines last Monday and dispersed into Beijing's smog-filled traffic. Inside the vehicles was a deadly secret: 31 coughing, shivering hospital workers who had caught severe acute respiratory syndrome (SARS) from their patients. Riding alongside were nurses who recoiled at each contagious breath their dangerous charges exhaled. As the white vans took a leisurely tour of the Chinese capital, a team of experts from the World Health Organization (WHO) walked into the China-Japan Friendship Hospital, hoping at last to gain a more accurate sense of the scope of Beijing's mounting SARS crisis. Instead, they were presented with deceptively uplifting news. The hospital had only two suspected SARS patients on view. Especially encouraging, as those ambulances were meandering around Beijing, it appeared that no medical staff were confirmed to have contracted the virus.

Across China's capital last week, similar shadow games were taking place to obscure the depth of Beijing's SARS outbreak. A doctor at the People's Liberation Army No. 309 Hospital told TIME that 46 confirmed SARS patients were dragged out of their beds last Tuesday and moved to the Zihuachun Hotel on the hospital grounds—just before the WHO team visited. At the People's Liberation Army No. 302 Hospital, where two infectious wards had previously been filled to capacity, only a handful of patients remained in their beds while WHO team members met with hospital officials. Throughout the week, Beijing authorities continued to report the city's SARS caseload at 37, even though a doctor who used to treat top Communist Party cadres told TIME that an internal Ministry of Health report put the number of confirmed patients at 200 to 300 cases. Says one doctor at the China-Japan Friendship Hospital: "I can't tell you any details because I don't want to lose my job. All I can tell you is that the government's handling of this matter is absolutely irresponsible."

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As international outrage over such dissembling intensified, China's top leaders were forced to address this health and public-relations fiasco late last week. "We have clearly told the government the international community doesn't trust your figures," says Henk Bekedam, China representative for the WHO, which could have added Beijing to its travel-advisory list, alongside Guangdong province and Hong Kong. The WHO then estimated the capital's SARS patients at 100 to 200—five times more than the government acknowledged—based on hospital visits and other data. On Friday, state media reported that China's new President, Hu Jintao, had met the previous day with the Politburo's Standing Committee and that those present were "explicitly warned against the covering up of SARS cases."

It was a dramatic policy shift and a long-awaited sign that Beijing may finally be ready to address SARS as a dire health threat that cannot be contained by a policy of secrecy and prevarication. But fears remain that this move has come far too late—and that the virus is already spreading to China's vast interior, where hospitals are ill-prepared to deal with such a costly and complicated epidemic. "I'm most concerned about the provinces," says the WHO's Bekedam. "[They have] neither the financial resources nor the human resources to deal with SARS."

IN FAR-FLUNG SHANXI PROVINCE, WHICH has reported more SARS cases than anywhere in mainland China except for Guangdong, Beijing's latest directives, including one stipulating that all needy SARS victims receive subsidized medical care, have yet to make a difference. In the sooty provincial capital of Taiyuan, where the average monthly income is just $60, the family of an infected student surnamed Han has had to fork over $240 in medical fees for four days' care. "The government has underinvested in health in the last 20 years, leaving it to individuals to pay the bills," says Bekedam.

Like their big-city counterparts, provincial doctors have also succumbed to political pressure to conceal information about the dangers of the virus. At a secret meeting last Wednesday overheard by a TIME reporter, Dr. Zhang Hanwei, the director of the Shanxi Provincial People's Hospital in Taiyuan, began his speech by berating the 40 or so embattled doctors gathered before him. Other regions afflicted by SARS were reporting only a 4% mortality rate. But Shanxi, then with an official tally of 82 cases and 7 deaths, was reporting an 8.5% death rate. "The government is very unsatisfied with these numbers," Zhang said. "Our provincial leaders are very angry." Then he announced a new policy measure called the "Three Nos," which he said came straight from the Communist Party's Publicity Department, China's top propaganda office: no talking to the media about the nature of SARS; no talking to the public about doctors' personal experiences treating the disease, and no communicating with the WHO about anything to do with SARS, should the international medical experts visit Shanxi province. And, with that astonishing warning, the meeting was over.

The reality is that SARS patients are overflowing from Taiyuan's threadbare hospitals. With nearly 40 confirmed cases filling up one quarantine ward at the Shanxi Medical University No. 1 Hospital, another makeshift isolation section had been set up in the back of the hospital. Many of this ward's rooms have as many as five suspected SARS patients squeezed into them, their coughs wafting freely through screens into the corridor. Family members can intermingle with patients, and some relatives are not even wearing masks.

It was into this sorry isolation ward that 20-year-old Shanxi student Han was admitted last week, accompanied by his sister and her boyfriend, who came to take care of him. The boyfriend, surnamed Liang, remembers asking a nurse for a mask to wear around the crowded ward, but he was curtly told to go out and buy his own because the hospital had no money to provide extras. More worrisome, Liang had dozed overnight in a chair next to five relatives of a man who was dying of SARS. By last Wednesday, all five family members had come down with the disease. "We relatives have to stay in that room without any protective measures, all day and all night," says Liang, who has not yet developed symptoms. "It's very dangerous, but we have no choice if we want to take care of our family."

So packed are some Taiyuan hospitals that they have been turning away patients. One relative of a SARS victim at the Shanxi Medical University No. 1 Hospital was shocked to hear nurses, citing overcrowded conditions, refusing to admit more SARS patients. "It is really bad that the government doesn't care about ordinary people's lives," he says. Other patients are avoiding hospitals completely, because they don't have the funds to pay for expensive SARS treatment, thereby raising the chances that the disease will continue spreading into China's interior.

The situation in China's other provinces is not much better. In Sichuan province, which sends millions of migrant workers to Guangdong—where the disease is thought to have originated last November—an official of the local center for disease control told TIME that at least two migrant workers had died and six more were confirmed to have the disease. In a troubling precedent, a SARS-infected migrant worker who rode a long-distance bus back home to Sichuan was quarantined in the same ward with all his fellow travelers—increasing the chances they would catch the virus from him, if they hadn't already.

Meanwhile, up north in the windswept autonomous region of Inner Mongolia, Liu Shutao, the careworn deputy director of the region's health department, openly frets over 19 confirmed and 13 suspected SARS cases. "We are very concerned with the spread of this disease," says Liu from a hotel in the regional capital of Hohhot, where he has been meeting day and night with local officials and experts from Beijing. While Beijing continued to suppress information, Liu and his health team conducted their own painstaking detective work to figure out how SARS arrived in their remote province. After weeks of investigation, they deduced that two local stewardesses who flew from Hong Kong to Beijing on a March 15 Air China flight first brought the disease to Hohhot. On March 17, the pair began running high fevers, and when their symptoms had not abated 10 days later, local doctors suspected they might have SARS. But the cases could not be officially confirmed, because one of Beijing's conditions for diagnosing SARS is that the patient had to have been in close contact with another person with the virus. Yet Air China repeatedly denied that there were any SARS suspects on that March 15 flight.

By the time a Ministry of Health investigation found on April 11 that there were indeed two SARS victims on that plane, it was too late. One of the flight attendants had infected her husband, her mother, her father and her brother, as well as an elderly male patient in the room across the hall, who in turn infected his wife and two sons. The doctor caring for the stewardess also came down with the virus. But, again, until April 11 none of those cases could be confirmed as SARS, because the link between the stewardesses and the sick airplane passengers hadn't been confirmed by reluctant airline officials. Indeed, as of last weekend, a press statement on the Air China website continued to insist that "at present, no flight-crew members have been infected." Other cases were brought to Inner Mongolia by two families who visited relatives at Beijing's People's Liberation Army No. 301 Hospital in early March, infecting at least six people in the cities of Baotou and Fengzhen. Yet it wasn't until April 12 that Beijing publicly announced that the No. 301 hospital had treated any SARS patients, meaning that the Inner Mongolian victims had no warning about their exposure to the deadly virus.

Even in more-developed places like Hong Kong and Beijing, hospitals have had to scramble to create discrete infection wards and procure enough respirators to treat SARS. Economically laggard cities like Hohhot simply can't muster the resources as quickly. "Facilities at Beijing hospitals pale in comparison to those at American hospitals," says Jia Xueyi, a deputy director of Inner Mongolia's propaganda department, "and facilities at Hohhot's hospitals pale in comparison to hospitals in Beijing."

The hope now is that Beijing's high-profile policy shift late last week will quickly have a tangible impact, and not be seen merely as a PR ruse designed to limit damage to China's prestige and economy. But in the provinces, faith in the country's leadership has already been hurt as the outbreak has been allowed to spread virtually unchecked. "How can we trust Beijing when they lied to us for so long," asks a respiratory specialist surnamed Ma from the western province of Gansu, who is now reviewing recent pneumonia cases in his hospital to see if any of them could have been SARS. "Even though this disease started in our country, we are behind everyone else in the world in trying to treat it." Other doctors from China's interior share his sense of betrayal and distrust. Asked about Shanxi's official death toll of just seven people, one doctor stationed outside a grim isolation ward stared at a TIME reporter and laughed: "Seven? That's complete fiction. Try maybe 20."

Meanwhile, hobbled by a lack of candid information about the disease, many doctors are unclear about the best treatment methods available to them. At the Inner Mongolia Thoracic Hospital, located in a squalid part of Hohhot in front of a garbage dump, a doctor eagerly opens an express-mail package sent by a colleague in Beijing. Inside it are pages of SARS research from the University of West Virginia, which points to antioxidants as a possible treatment for the mysterious pathogen. "Our preventive measures aren't sufficient," he says. "Beijing sent us instructions about how to prepare for this disease, but before we had time to get ready, the disease was upon us."

Thankfully, most city residents seem cognizant of basic SARS symptoms, because of an extensive—if belated—publicity campaign. Elementary and middle schools have been closed in Taiyuan, while taxis in both Taiyuan and Hohhot have been disinfected, as have many trains and buses. But information quickly runs dry in the grasslands village of Badian, just a 40-minute drive from Hohhot. There, Mrs. Guo says she's heard of SARS but is mistakenly convinced there aren't any cases in Hohhot.

Despite health authorities who appear committed to openly reporting SARS cases, the region remains susceptible to an outbreak of this treacherously elusive disease. Only 50% of Inner Mongolian residents use the local hospital system, according to the regional health department. Instead, medicine is dispensed by tiny, ill-equipped clinics or a ragged team of barefoot doctors, who often have little more than an elementary-school education. Wei Guo, a second-generation barefoot doctor in the village of Shuiqu, says he knows what to do if he encounters any SARS cases. He will prescribe a popular traditional remedy called banlangen, a dose of antibiotics and perhaps an herbal tonic that promotes a patient's yin to counter an imbalance of yang. With much of the nation depending on such ill-informed care, the killer virus looks set to spread even further into China's underdeveloped interior.