Personal View: China in the grip of SARS
Authors: Therese Hesketh
Journal: BMJ (2003)

At a press conference on 20 April the Chinese minister of health admitted that there had been failings over the SARS (severe acute respiratory syndrome) epidemic: the situation was more serious than had been admitted previously. Along with the mayor of Beijing he was promptly fired. But the speech had had the desired effect: public health action had finally been galvanised.​galvanised.




Figure 1



A dubious measure?

T HESKETH




I live in Zhejiang, a coastal province halfway between the two Chinese epicentres of the disease, Guangdong and Beijing. Here following the press conference, the government immediately held an emergency meeting. By the next morning a whole raft of measures was in place. All cinemas, theatres, and karaoke bars were closed. All public training courses and meetings and all school outings were cancelled. All buses, trains, taxis, train stations, bus stations, airports were to be disinfected. The May Day holiday was cancelled.

But there was much more: at 7 am we were handed a leaflet about SARS prevention at the gate of our compound. This included advice about regular hand washing, warnings about crowded places, and the dangers of nose picking. It advised that masks should be 16 layers thick and changed every four hours. At our sons' school chaos ensued as 600 children were having their temperatures taken before being allowed into class. They would have their temperatures taken twice daily until further notice. Any recording over 38°C would result in the child's immediate removal to hospital.

By 9 am our residential compound had been disinfected, and we had been offered free disinfection of our apartment. Masks and thermometers were sold out by mid-morning. Supermarkets were busy with people stocking up to batten down for the duration. Usually jam packed buses had plenty of spare seats as people took to bikes as a safer option.

The next day I was scheduled to go to Yunnan province in the south west of the country. The trip necessitated six flights in a week. On the outward journey around 20% of passengers were wearing masks, and a health declaration had to be completed before boarding each flight. At two hotels I had to take my temperature before being allowed to check in. On the return journey mask wearing had increased to over 80%, health declaration forms were required before departure, on arrival, and in one case during the flight as well. In addition, passengers' temperatures were taken in-flight. At the local airport in Zhejiang infrared imaging was in use. But with just one camera for all domestic flights, the crush of passengers probably just increased the potential for SARS transmission.

The China SARS story is instructive in a number of ways. Firstly, as many commentators in China and elsewhere have pointed out, the failure to acknowledge the problem earlier has almost certainly resulted in a more widespread epidemic. The government is painfully aware of this, and the high profile sackings (almost unknown in China, except in cases of corruption) demonstrate just how seriously the mistakes are regarded. Though there have been significant moves towards greater transparency over the past decade in areas regarded as sensitive by the Chinese, the SARS secrecy debacle is certain to accelerate this process.

Secondly, it demonstrates that once China has decided to mount a campaign it can do it with speed and aggression over a vast area, in a way that must be the envy of many other countries. The public health network allows for rapid dissemination of information down to the grassroots. Provincial level health bureau staff have been dispatched in great numbers to the countryside to ensure that all appropriate preventive measures are being taken and to ensure that identified cases are managed correctly. Even in remote rural Yunnan, health workers I spoke to knew about SARS. In a township hospital a doctor told me he wasn't afraid of SARS, because he had ribavirin (at a cost of 5 US cents per tablet) to treat it. He would isolate any case immediately, and treat free of charge.

While many of the preventive measures are of dubious effectiveness—all that disinfection, and all those schoolchildren taking their temperatures, for example—frightened people find all the activity reassuring.

Finally, China needs to change the name of this disease. Currently SARS is called fei dian xing fei yan, which translates as atypical pneumonia. I believe that at least some of the earlier under-reporting, which has proved so damaging, was related to failure to realise that this was a new form of pneumonia, and not just a more severe form of atypical pneumonia, for which the causative organism is frequently not isolated. This new disease needs a proper Chinese christening.