A Case Study

Sha

nghai likes to play by its own rules. But the city's unilateralist approach to severe acute respiratory syndrome (SARS) puzzles a senior hospital administrator from Shanghai's Huangpu district. A month ago, visiting experts from the World Health Organization (WHO) said Shanghai would relax its superstringent standards for diagnosing suspected SARS patients to conform with international norms. That should have caused the city's tiny caseload of suspected SARS patients to increase substantially. But just a couple of days after the WHO's announcement, the hospital administrator was curtly informed by local health-bureau officials that the standards would not be changed. Then, last week, after the Ministry of Health had further broadened the national standards, he was again called in for a meeting with local health officials. "They said Shanghai was still being allowed to stick to the old standards," recalls the doctor. "They said Shanghai was an exception and that was agreed to by the Ministry of Health." That means that before classifying a patient as a suspected SARS case, the Shanghai Municipal Health Bureau requires that person to have either traveled to a SARS-infected area or had known contact with a SARS patient—in addition to the classic symptoms of high fever, cough, lowered white-blood-cell count and suspicious spots on a chest X ray. The rest of China may be hewing to new regulations that don't require verification of exposure, but Shanghai has decided instead to protect its most important asset: its image.

While other Chinese commercial centers from Guangzhou to Beijing have been devastated by the pneumonia-like illness, China's financial capital has so far reported only 11 suspected cases and seven confirmed ones—of the latter, two have died and one is an American who was released from hospital late last week. By contrast, in Beijing, where officials announced last week that people who intentionally spread SARS could face the death penalty, there are more than 2,400 cases, of which more than 140 have died. Maintaining Shanghai's SARS-free reputation has become an all-encompassing obsession for this proud city. After all, an innate superiority complex makes it easy for many Shanghainese to believe their city will somehow evade the virus. A massive publicity campaign on SARS-prevention measures has helped, too, successfully quelling the large-scale panic striking many other Chinese cities. Restaurants may not be packed as usual, but life swings on in Shanghai.

Yet as the weeks roll by and the promised adjustment to Shanghai's suspected SARS caseload hasn't materialized, a restive undercurrent has many beginning to wonder how a city of 16 million could be so lucky as to have just a handful of SARS patients. Residents aver that they aren't worried yet; nevertheless, face masks and vitamin C are in short supply. "I don't think anyone believes there are hundreds of cases being hidden here, like in Beijing," says a Shanghai respiratory-disease specialist who, along with other doctors in Shanghai, has been forbidden by the local propaganda department to talk with the foreign media about SARS. "But if Shanghai people lose trust in the way the health bureau is classifying SARS cases, they may also lose trust in the whole government. That would be a real crisis."

The opaqueness of Shanghai's suspected SARS caseload could be the kind of numbers game that dents that faith. The hospital administrator from Huangpu district says he was told the WHO did not oppose Shanghai's decision to keep its old diagnostic standard. But a WHO spokes-person in Beijing denies that is the case. "If Shanghai's still using the old standards, they're contravening national regulations," says the spokesperson. Indeed, the WHO has been expecting Shanghai's suspected SARS caseload to increase, but instead it has remained flat since April.

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Ostensibly, that's good news for a city obsessed with maintaining its bill of good health. "My stocks are going up because Shanghai has escaped SARS," says Xie Lingzhen, as he scans the stock ticker at a local retail brokerage. "Other places in the world have been affected, but our future will continue brightly." To show just how serious Shanghai is about keeping the virus at bay, the municipal government earlier this month mandated a limited quarantine on anyone coming from a SARS-infected area—a policy that runs counter to Premier Wen Jiabao's vow last month not to implement any extreme quarantine measures. But Shanghai's quarantine policy has not been rigorously enforced, as dozens of visitors from Beijing and Hong Kong continue to disperse into the city without a trace. Still, locals seem to think that Shanghai can beat the bug. "Shanghai is much cleaner than other places in China," says janitor Shen Xianzheng. "Everyone knows that Beijing is very dirty and dusty, and that's why so many people there got SARS."

Life in Shanghai isn't all business as usual, however. More than half of the city's industrial output derives from foreign investment, but international businessmen haven't been showing up to sign new deals. Luxury hotels, usually overbooked at this time of year, have just 30% occupancy; several top hotels have been temporarily shuttered, including the venerable Peace Hotel, one of Shanghai's historic landmarks. Many jittery expats have sent their families home, while the much anticipated Women's World Cup soccer championship, for which matches had been scheduled in Shanghai this fall, has been moved out of China. And in a tacit admission that even the most careful of cities can't always escape, Shanghai is building extra SARS wards on the outskirts of town, in case there's a sudden overflow of patients.

Nevertheless, local bureaucrats emphasize that SARS isn't a homegrown problem, reiterating that all of Shanghai's SARS cases to date have been "imported." All 11 suspected cases have an "epilink," meaning each person either visited a SARS-infected region or had contact with a SARS patient, according to a doctor on the SARS-consultation board of Shanghai's Center for Disease Control. But that's a tautology: because local doctors are still following the old diagnostic standard, no one without an epilink can be designated as a suspected SARS case, much less a confirmed one. And proving that epilink can be very difficult. Two of Shanghai's confirmed SARS patients, for instance, reportedly lied about having come from Beijing. Consequently, they were kept for a few days in a normal fever emergency ward, where they were not as stringently isolated as they might have been at the hospital designated for suspected SARS patients. Says a frustrated Shanghai doctor: "If someone lies about where they've been, there's no way you can screen every SARS patient with 100% accuracy."

In other cases, it's the government that has been shading the truth. By early April, a businesswoman who traveled to afflicted Guangdong province had brought the disease back to Shanghai and was admitted to the Contagious Disease Hospital. For weeks, she was Shanghai's only confirmed SARS case. Yet, at the same time, medical staff at the hospital said there were two other SARS patients in the isolation ward—the woman's elderly father and a man from Guangdong province. When asked why the other two were not part of the official statistics, one hospital worker theorized that the father wasn't counted since he was an ancillary case to his daughter and the Guangdong man didn't need to be tallied because his symptoms weren't very serious. Two weeks later, the father was finally counted as a SARS patient. He has since died. "You can hide suspected patients," says the Shanghai respiratory-disease specialist, "but it's hard to hide deaths." Shanghai has to hope this death will be one of the few exceptions to its own rules.