Thursday, Mar 27, 2003
I understand this old Chinese curse better now than I ever have. Two weeks ago I was sure that I would be in China right now, with Karen and almost 20 family members and friends of family, but it wasn't to be.
When the news about SARS broke out a week from last Sunday, I was concerned, but not overly so. I was glad that it was still a week until our trip, so that informed analyses would have time to replace sensationalism and we could make an informed choice as to the outcome of our trip.
As the days rolled on, and three cases in Hong Kong became 12, then 50, then 260, I grew more and more concerned. Cases had turned up in Canada, the disease was blossoming in Hanoi, and 12 nations had people with atypical pneumonia, all recent visitors to affected areas, under observation and isolation.
I raised the issue to a few people who were going on the trip, and some were concerned. My cousin, a doctor, assured us that the dangers were minimal, and that if he was taking his one-year-old son along, then it should be clear that in his informed decision there was no substantially increased danger.
Each day I'd check Google News to find out the latest on the virus investigation and spread. On the night before I was supposed to fly to Los Angeles to catch a flight to Tokyo then Beijing the next day, I did a lot of soul searching.
While cases had been cropping out in several areas connected to Hong Kong, the Chinese Ministry of Health claimed that there were no cases in China outside Hong Kong, and released a report about 305 cases (with 5 fatalities) that occurred from November to February in Guangdong province. They claimed that that outbreak was under control, and hadn't spread beyond Guangdong.
Considering that there is more personal traffic between Hong Kong and Beijing and Shanghai than several places with documented cases, it seemed questionable that Mainland China was somehow free from disease.
The New York Times published a piece discussing how infection rates are considered 'state information' and are controlled by the government. In the previous Guangdong outbreak, the government-controlled media was specifically prohibited from broadcasting information about the new disease or its spread. Investigators from the World Health Organization who came to Beijing were not allowed to travel to Guangdong province to conduct their own assessment of the current state of the disease.
Backing out of the trip is no small deal. Magnanimously paid for by my uncle, it probably cost about $6,000 per person. Though it sounds like we could get an 80% refund on the last minute cancellations, due to the outbreak and war policies, that's not certain. I had a lot of thinking to do, and family politics, like it or not, would play a major role.
As the infection numbers grew daily, so did my concern. Family members who claimed it was no big deal were still purchasing N95-level face masks for protection on the trip. On Thursday, word came that two people had died of SARS in Beijing. Two cases and two fatalities wouldn't concern me overly much, if not for the knowledge of the extent to which the Ministry attempts to hide this information. Sure enough, it turns out that the doctor in the medical hospital who told the French press about the fatalities was fired the next day.
Speaking with my cousin (doctor) Thursday night, I heard a few rationalizations as to why the disease wasn't a concern: First, the current risk seems to be equivalent to that of driving in China, an admittedly more hazardous activity than driving in the US. Second, the virus appears to require close contact for transmission, and the large majority of documented transmissions were between relatives or to hospital workers. Third, in response to my concern that we'll be in Shanghai for several days after the virus has a chance to go through an additional four or five incubation cycles, I was told that either the virus is non-contagious enough to be avoidable, or it is virulent enough that it will eventually reach all corners of the globe (like the Spanish Flu of 1917) so it doesn't matter whether exposure happens in China or in my home town.
Most of my family had already made a firm decision to go, and they had put their fears to rest, bolstered by these arguments. I didn't make a significant effort to try and persuade others to the validity of my views, since it was clear that I wouldn't be able to convince others to consider alternate plans at this late date, and trying to would likely only make a tense situation worse.
Having heard the arguments as to why SARS is no big deal, I still had significant reservations. Any infectious risk assessment is based on three factors: How many carriers there are, ease of transmission, and risk groups.
The number of carriers right now in Beijing and Shanghai is unknown. Today the Ministry of Health admitted that their report on the November-February outbreak was incorrect. There were over 600 cases, not 305, and there were at least 31 fatalities, not 5. Meanwhile, the Ministry continues to deny that there is any outbreak in other mainland areas, even though several SARS cases in other countries are in travellers who only visited Shanghai or Beijing. Without government support, we can't hope to know how large the outbreak in Beijing and Shanghai is, or how far it will spread amongst an uninformed populace over two weeks. In the absence of concrete information, I prefer to err on the side of caution.
On transmission vectors, the statement that documented cases of transmission are heavily weighted to personal acquaintances and hospital personnel is misleading at best. Documented cases always favor these groups because they are easier to document. Most cases at this point have no documented transmission vector, so saying that those that are identified tend to be of the type that are easier to identify is a meaningless tautology. As it turns out, as cases are being investigated further, several cases of in-aircraft transmission have been documented, along with the hundreds of cases with no identifiable source. 'Casual contact' is a completely ambiguous term, especially when it seems to cover the contact between a hospital worker and a patient known to be contagious. One patient infected 40 hospital workers in Honk Kong last week, even after it was known that he had a communicable disease. While proximity was certainly a factor in transmission, many of these hospital workers used barrier systems (face masks, gloves) when interacting with the patient, and the fact that they came down with SARS means that the means of transmission goes beyond casual contact.
Lastly is risk groups. Viral infections, especially non-airborne infections, are social diseases, in that they spread through social groups (healthcare workers, families, communities, etc.). As it happens, in the current outbreak, a high percentage of the cases in the last two weeks have been among travellers. Those cases of non-familial and non-hospital transmissions have all taken place within the social group of 'traveller'. People are being infected in hotels and airplanes. This makes some sense because the traveller comes in to contact with so many more people on a given day than someone following their regular daily routine. This localization of infection should be kept in mind when weighing total documented cases against a population in order to estimate risk. In this case, the population of greater Beijing isn't as relevant as the population of travellers in the city.
In the end, it came down to the fact that this is an emerging disease, with an unknown but growing infected population in the areas we were travelling, unknown transmission vector, unknown treatment, in a country that deliberately hides cases of the disease by transferring them to military hospitals and ordering doctors not to discuss them. In 1975, 85,000 Chinese were killed by a broken reservoir, and it went unreported for 23 years. In 1995, China finally revealed that 694 people died in a cinema fire 18 years earlier. Yesterday China announced that the November-February infections in Guangdong Province were 790 with 31 dead, not 305 with 5 dead. Even now they won't allow health officials into the province to assess the situation.
In short, vacations are supposed to be relaxing, and it wouldn't be relaxing to spend two weeks in a land with a rapidly spreading disease and a government rushing to stop the spread of information instead of disease. I believe that there is a middle ground between an epidemic that poses virtually no statistical risk of infection and one that will sweep the entire world. I believe that there are cases where travel to specific areas should be curtailed during times of local epidemics, and I believe that this is one of those times. Within days they'll likely know the causative agent, and soon after a test, and an ideal course of treatment. For now, none of those things is confirmed.
I dearly hope that none of the 20 in the group that went anyhow gets sick. If one of them catches SARS then many likely will. If one gets sick with anything else requiring a visit to a hospital, they'll find an overtaxed system and waiting rooms filled with parents worried about their coughing children (as reported). A stuffed up nose and red eyes is enough to convince ticket agents not to allow a passenger on their flight home.
All in all, I was very much looking forward to the trip, and I hope those that went have a fantastic time. It wasn't right for me and my sensibilities, even if it was for others. I know they'll be happier without a nervous Kevin spreading his paranoia, and I hope that they accept that I had to go my own way.
Throw in the Iraq War and the fact that South Korea moved to Defcon 2, their highest point in 12 years, in concern for a preemptive North Korean strike, and you truly have interesting times.
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