The Return of SARS?

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m their onset in any community, infectious diseases quickly become political as well as medical crises. During the Middle Ages, the appearance of the plague in a European city was more likely to result in a pogrom against Jews, or burnings of suspected witches, than any rational public-health response. More recently, when HIV began its slow burn through the U.S., it was several years before then President Ronald Reagan even mentioned the disease publicly. The appearance of a probable new SARS case in the southern Chinese city of Guangzhou late last month reminds us that the story of this disease's emergence, and now possible re-emergence, has also been, in many ways, a triumph of politics.

In February and March, when SARS began to spread outside of Guangdong province, where it first infected humans in late 2002, the Chinese central government made a series of politically motivated decisions that allowed the disease to gain deadly footholds in Beijing and elsewhere. Several Chinese officials have told me that a consideration in covering up—or, as one put it, "not mentioning"—the disease was the timing of the plenum of the National People's Congress, which convened in March. The country's top law-making body was then rubber-stamping the selection of a new President, and an unseemly new infectious disease could have been seen as besmirching heaven's mandate. This was a political decision that cost human lives.

The World Health Organization (WHO) also played politics—as a U.N. body must—but in this case it was in the service of public health. The international laboratory network it established took the lead in identifying the infectious agent. Its communicable-diseases team issued travel advisories that forced governments to take the threat seriously. Local WHO offices forged high-level relations with public-health officials and used SARS to achieve a partial opening of China's health-care and scientific communities. The WHO's political savvy contributed to curtailing the first outbreak.

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But this fresh case, a 32-year-old TV journalist recovering at Guangzhou People's No. 8 Hospital, has reminded us again that diseases can be political infections. This past week has seen an almost comically confusing fusillade of "it's SARS", "no it isn't" or "maybe it is" stories. Can a person be "slightly exposed" to SARS, as the WHO stated late last week? Sure. But doesn't that mean this is a SARS case? Judging by two positive antibody results taken from samples sent to Hong Kong last week, the Guangzhou patient was almost certainly exposed to SARS or a coronavirus genetically very similar to SARS. But the WHO has been reluctant to say so, and that has begun to rankle some Chinese health officials.

Ever since this case surfaced, Guangzhou health authorities have treated it as SARS. The hospital has isolated the patient. Clinicians have taken appropriate infection-control measures. Guangzhou hospitals are the most experienced in the world at treating SARS. Guangzhou laboratories, however, are not up to the same standards, and that has led to suspected lab contamination as a possible cause for the positive tests that initially suggested this was a SARS case. Some Guangdong officials interpret as disrespectful the WHO's unwillingness to confirm their labs' findings. The WHO, which has no laboratories of its own and relies on collaborating institutions, has been unclear as to why it is delaying its diagnosis. It is, however, acting as if it is the only organization in the world allowed to confirm a SARS case. At what point, though, will waiting for a WHO diagnosis cause a critical delay? The work of responding to individual cases and making diagnoses must ultimately be the responsibility of local governments.

Yet the implications of the current case are so troubling that the diagnosis has been taken out of local hands. Unlike the previous laboratory-based SARS infections in Taiwan and Singapore, the patient in this instance had no known contact with the virus. The pressing question is where did this infection come from? "If this is SARS," says Huang Wenjie, director of respiratory diseases at Guangzhou General Military Hospital, "that means it is out in the community, and this may be a seasonal disease." One that, in all likelihood, won't be eradicated any time soon. The WHO is awaiting another series of antibody tests and will probably confirm the case this week, in a joint press conference with the Ministry of Health, rather than leave it to the Guangdong health officials who have been working the case. That will be a matter of protocol—the WHO as an international organization believes it should appear with its counterparts at the national, rather than the local, level. Yet the ill will engendered among local Guangdong officials might make them less eager to collaborate with the WHO the next time a possible case appears. The importance of maintaining this relationship in Guangdong goes beyond SARS to include other agents that might cross the species barrier—possibly avian influenza or some other novel zoonotic disease. Local officials and the WHO have to maintain a warm dialogue. The world's health depends on it.