How to Shut Down a Country and Kill a Disease
China’s response to SARS a decade ago was effective but brutal. Is there a better way to stop the spread of Ebola?
With every passing day the absence of a powerful international response to West Africa’s Ebola epidemic allows the horror to grow, pushing the nightmares in Liberia, Sierra Leone, and Guinea closer to the catastrophic worst-case scenario forecasted by the U.S. Centers for Disease Control and Prevention: an estimated 1.4 million cumulative cases, with 980,000 dead, by Feb. 1, 2015 — a prediction so dire as to be impossible to imagine. For Liberia and Sierra Leone, the dire augury translates to this: In the absence of radical measures to stop the virus’s spread, the two countries could witness a combined 10,000 new cases per week by the time Americans sit down for Thanksgiving feasts, and they could see some 14 percent of their populations perish by Easter.
What is to be done?
A dramatic new study from a team of Virginia-based researchers dissects the current rates of the spread of Ebola and the likely impact of various strategies for controlling the epidemic. The results are deeply sobering. First, the virus is spreading very fast now, with each infected person in Liberia and Sierra Leone passing Ebola on to, on average, 2.22 others. And contrary to the experiences in 20 past Ebola epidemics (in which the majority of cases were transmitted in hospitals or during funeral preparations), the virus is now primarily spreading in the general population through everyday activities. This means that the strategies that were used to successfully control past Ebola epidemics — cleaning up the hospitals, quarantining infected souls within those newly sanitized facilities, and stopping traditional funeral practices — will not have the same significant impact in the current catastrophe. Therefore, according to these researchers, even if there were a miraculous treatment available right now, it would barely make a dent in the epidemic.
The Virginia researchers concluded: “[F]or at least in the near term, some form of coordinated intervention is imperative. The forecasts for both Liberia and Sierra Leone in the absence of any major effort to contain the epidemic paint a bleak picture of its future progress, which suggests that we are in the opening phase of the epidemic, rather than near its peak.”
None of the currently available tools and strategies for countering the epidemic will actually beat Ebola in 2014, perhaps even in 2015. But there is one strategy, the Virginia disease-modelers say, that will dramatically reduce the scale of the epidemic if it is aggressively implemented immediately. The plan: Find every single person who is infected and all of their close contacts and then “remove infected individuals from the general population and plac[e] them in a setting that can provide both isolation and dedicated care.”
Such a course of action is unprecedented in modern times. Not since the great influenza pandemic of 1918 have epidemic-fighters found themselves with such a scanty toolbox, unable to douse viral flames. The fire, it seems, will be an inferno. But in a sense, at least in this strategy, the drastic quarantine proposed is like the deliberate burning of hillsides so as to remove woodland fuel out of the path of a more massive, unwieldy forest fire.
The only modern outbreak forced to draw from a tool kit somewhat of this nature occurred in 2003. The necessity of resorting to draconian methods in this case was the result of government blundering and obfuscation. The virus was SARS (severe acute respiratory syndrome). And the place was the People’s Republic of China.
Lessons From a Dark Time
Like Ebola in 1976, SARS for millions of years was a bat virus never previously known to infect human beings. Also akin to the Ebola situation, people were exposed to SARS through an intermediary species — with Ebola it’s typically primates that eat or fight with bats. SARS spread from bats to civets, which were consumed as a Cantonese delicacy. The patient with the first known human case of SARS staggered into a southern Chinese hospital in November 2002, and subsequent cases spread across Guangdong province during December of that year and into January 2003. The Chinese chose not to report the epidemic, and it went unnoticed outside the Chinese mainland until an ailing traveler from Guangzhou staggered into Hong Kong’s Metropole Hotel (since renamed the Metropark Hotel), where he infected fellow guests, all staying on his floor — who probably were infected via his floor-level elevator button — who then went on their respective journeys to Singapore, Vietnam, and Canada.
From mid-January to April 2003, the World Health Organization (WHO) led a goliath battle against SARS in 29 countries, creating unprecedented systems for rapid global sharing of scientific and medical information, and, one by one, wrangled each outbreak under control. But the WHO knew that SARS had originated and spread inside mainland China and that people with the disease were hospitalized in Beijing — points that the government of Jiang Zemin denied. China was in transition, awaiting formal endorsement from the National People’s Congress of its newly designated leader, Hu Jintao. The lame-duck Jiang government and the Communist Party feared that any disturbing news could upset the transition process — the first in recent Chinese history to unfold without violence or a targeted political bloodbath.
So it wasn’t until after the late-March National People’s Congress session and its formal installation of the Hu government that China’s leaders would consider divulging what many in Beijing already knew — that SARS was widespread in the capital and that hundreds of patients were secretly said to be hidden from public view. In early April a surgeon from the People’s Liberation Army, Jiang Yanyong, secretly passed documents to Time magazine reporters that proved the authorities were rounding up SARS patients and secretly treating them in military facilities. Jiang told Time that physicians were “forbidden to publicize” the SARS deaths “in order to ensure stability.”
On April 20, under pressure from the WHO and the foreign media, the Hu government formally admitted the presence of SARS and told the Chinese nation that a deadly virus lurked in its capital.
I was in Hong Kong and mainland China during the SARS epidemic while covering the epidemic for Newsday, and what follows is how the enormous nation of 1.3 billion people stopped what could have been a genuinely calamitous pandemic.
Once the Chinese government admitted to the existence of SARS in Beijing, it simultaneously announced, in hopes of limiting movement, the cancellation of China’s biggest holiday, May Day, when millions of Chinese travel to visit families or join in national celebrations. But authorities failed to appreciate how Beijing residents would react to the dual SARS and May Day cancellation announcements — texted rumors raced across mobile phones, hinting that behind the cancellations were dark plans to use the epidemic as a pretext for rounding up dissidents, students, and illegal migrant workers from rural parts of the country. Wild rumors spread anonymously in mass-texted phone alerts, prompting masked students to grab what they could in haste, stuff bags, and race to train stations. As dawn broke on April 21, a mass migration commenced, and within a week some 250,000 students, migrant workers, and SARS-fearing citizens fled Beijing, mostly by train. I watched them cram into train cars, most wearing face masks, fleeing to every corner of the vast nation. Within days, more than 4 million migrant workers fled urban centers across China, returning to their rural homelands.
said in a press conference. “Forty percent of new cases are in our control, under medical observation or in quarantine. For the rest of the cases, we do not know who they are or how they got infected.”By the time May Day rolled around, leaders knew that their failure to close off airports, trains, buses, and highways had hemorrhaged SARS-carriers across the vast geography of China. What had been a focused set of outbreaks was now an epidemic, generalized across the vast country. And inside Beijing on May 9, officials acknowledged that most of the spread of SARS was unexplained and outside the control of authorities: “Apart from hospitals there are other sources of infection in society,” the city’s top epidemiologist, Liang Wannian,
The government had no choice: Health officials had to assume that their entire nation was infected, and any hope of stopping SARS rested with implementation of a national strategy of control.
Like Ebola, SARS was only contagious once individuals had developed symptoms. In the case of SARS, those symptoms were fever, difficulty breathing, uncontrolled coughing, and severe fatigue. As is the case with Ebola today, the technology tool kit for dealing with SARS was bare: There was no vaccine, no direct treatment, and no rapid diagnostic test that could be performed outside a laboratory. The primary weapon in China’s war on SARS was the thermometer.
Another striking parallel between the Ebola outbreak and SARS: ravaged health-care systems. Liberia, Sierra Leone, and Guinea are struggling to combat Ebola with health-care systems so abominable that they are virtually nonexistent. As Liberian President Ellen Johnson Sirleaf wrote in the Washington Post this week:
In Liberia, a country that never before had an incidence of Ebola, we were utterly ill-equipped and unprepared…. Having worked its way through the cracks in our fragile health infrastructure, Ebola has effectively brought health care to a halt in Liberia, as people avoid seeking medical attention. There is nowhere to go. So, with the malaria season setting in and routine immunization programs stopped, even when this outbreak is over we must prepare for other diseases to take hold. Yet, with Ebola having claimed the lives of 96 of our health workers and infected more than 209 others, recovering is going to be hard. This is a huge hit for a country that had barely 50 doctors to care for a population of 4.4 million at the start of this outbreak.
China was similarly ill-prepared to handle SARS, having allowed its rural health infrastructure to nearly collapse. According to China’s 21st Century Economic Herald, the country’s leading financial magazine, between 1991 and 2000, the proportion of government funds subsidizing health declined from 12.54 percent to 6.59 percent, social funds declined from 6.73 percent to 3.26 percent, and the proportion of health expenses paid out of pocket by the rural poor rose from 80.73 percent to 90.15 percent. The system was so broken and lacking in credibility that most rural Chinese did everything possible to avoid clinics and hospitals.
“The biggest fear of the peasant is being sick,” 74-year-old Zhang Shulin of the village of Longwangtoucin, located about an hour’s drive from Beijing, told me, “because the government won’t pay for it. A cold costs 100 yuan.”
“One hundred! Are you crazy?” chimed in neighbor Pao Wenying. “If you go to the hospital for one day, it costs 2,000! So we usually don’t go see doctors when we are sick.” Average annual per capita income for rural Chinese in 2003 was a mere 2,366 yuan.
If SARS got into the awful rural medical facilities, officials knew, it would spread like wildfire. Any solution would require shunning the existing health system altogether. “Public health is a national security issue now,” one top official told me on May 13, 2003 on condition he not be identified, “because the lack of decent public health has the potential to destabilize the entire society.”
“One can argue that the SARS situation positively affects the power of President Hu Jintao,” Sonny Lo, a professor of politics at the University of Hong Kong, told me on May 17, 2003. “In the long run, President Hu will even reinforce his power base if SARS dies down. But if SARS worsens, Hu will be in trouble. Then we will observe whether there will be a backlash against the current leadership.”
The stakes for the new Hu government could not be higher.
The Communist Party and Authoritarian Public Health
From Beijing, the Chinese Communist Party and State Council in 2003 could exercise unlimited power over the rest of the nation during a crisis, and there was no real danger of popular resistance. Severe orders were issued.
First, rumor-mongering about SARS was declared a crime, punishable by a range of means, including execution. Chinese Communist Party Premier Wen Jiabao announced on May 13 a series of laws and punishments, and the first to be charged under the edict was a traditional-medicine physician named Li Song, of the small Inner Mongolian town of Linhe.
Prosecutors argued that Li’s actions during March and April led to the infections of 102 people in Linhe, including 23 fellow health-care workers, and to the deaths of his father, mother, and wife. Li’s crime was a brief but violent outburst in a Linhe hospital, during which he attacked doctors for refusing to dress his dead father in appropriate funeral garb, out of their fear of contracting SARS. Li was scheduled for execution; his ultimate fate is still unknown. Other heads rolled after Li’s, though few were publicly revealed.
Second, fever-check stations were installed at every transport hub, airport, truck stop, and site of public congregation in the country by May 10. In addition, every hotel, theater, hospital, and school conducted mandatory fever checks routinely through non-contact thermometer devices. On any given day in Beijing, I was subjected to more than a dozen fever checks, typically at the entries of buildings or after being pulled over along a roadway by police. Fever stations were staffed by local health departments’ personnel alongside visible authority figures — uniformed police or soldiers.
Meanwhile, the most dramatic construction effort I have ever witnessed unfolded.
On Beijing’s outskirts, in an unpopulated area, the government erected a 1,100-bed quarantine hospital with its own sewer-treatment system, water supply, and electricity supply — all built in just six days. I watched in astonishment as isolation rooms, complete with negative air pressure to prevent the virus from spreading to health workers, appeared almost as if by magic. Crew members toiled around the clock, creating from prefab modules a world-class infectious diseases hospital in less than a week. Anybody presenting with a fever at check stations in Beijing was masked, packed into an ambulance, and deposited in the new isolation facility. There were no human rights, civil liberties, or even tests to confirm SARS infection — a child might have strep throat, but his cough and fever were all police needed to drag him out of his mother’s arms and haul him away to the SARS quarantine hospital.
The homes and families of fever patients were then quarantined by police. Residents had no right of refusal, and quarantine violation could be “prosecuted” immediately with the firing of a policeman’s pistol. Health authorities brought food and supplies to the quarantined households daily, examining each of the residents for SARS symptoms while they were there. Any fever or coughing would result in immediate transport to the isolation wards.
This strategy was implemented the same way across the entire country, with hospitals that seemed to sprout up overnight and hundreds of thousands of people placed in isolation for their fevers. (The Chinese government never released an actual tally of the numbers of its citizens detained, forcibly hospitalized, executed, or imprisoned in relation to the SARS epidemic.) As I drove across the country, repeatedly pulling over to undergo mandatory inspections at police-manned fever stations, I feared something might make my temperature rise, putting me in a dreaded isolation ward. I popped aspirins several times a day as a precaution — a provision that could foil temperature-based surveillance. I recall in early May 2003 pulling into a highway checkpoint in the mountains of Shanxi to find a long line of 18-wheeler cargo trucks held in position by an armed officer. The truck drivers were a surly but obedient lot, submitting to fever tests and nervously watching health officials dressed in full PPE (personal protective equipment) spacesuits spray their truck cabs with disinfectants. Despite the gravity of the situation, I couldn’t help but laugh, imagining how a similar group of American truck drivers would behave, rifles hooked in their cabs, hearing CB radio warnings from other drivers, and demanding that the cops get the heck out of their way.
By July 6, 2003, China officially declared its SARS epidemic over (a declaration certified by the WHO), and the country eagerly set out to socialize, making up for months of mandatory or self-imposed epidemic isolation. The Chinese government has never revealed how much this radical approach to epidemic control cost, how many people were placed in mandatory confinement or treatment, what percentage of them actually turned out to have SARS, and how many individuals were imprisoned or executed for violating rumor-mongering or quarantine edicts. My Council on Foreign Relations colleague Yanzhong Huang estimated in 2004 for the U.S. Institute of Medicine that China lost nearly a full percentage point in GDP during SARS and that the mass-control effort, including the construction of instant hospitals, cost $1.1 billion to the central and local governments combined. The effort “worked,” in that it brought China’s epidemic to a halt. But the social and economic costs were exorbitant, and the model could only be repeated in an authoritarian setting.
There Must Be a Better Way
As the Virginia researchers found in their study, the current epidemic in Liberia and Sierra Leone (if not also Guinea) has reached a stage akin to that which followed China’s April 20, 2003, announcement and subsequent mass disbursement of SARS by fleeing students and migrant workers. The epidemic has spread across nearly every nook and cranny of the two African countries and into every social setting. The health infrastructure has disappeared entirely. In its place stands nothing more than Ebola care centers with little to offer ailing virus victims. Public faith and trust have eroded; wild conspiracy theories and rumors are rampant.
Although Liberia’s President Johnson Sirleaf has recently rejected dire forecasts for her country’s Ebola fight, she is pushing legislation granting her the power to shut down press and broadcasters that spread false rumors. The language of national security has been invoked, questioning the very survival of the state. Food prices across the region have soared some 24 percent over the last two months, and starvation looms. The economies of the affected countries are in tailspins, and the World Bank and IMF predict much worse financial and trade hardships. The IMF now forecasts continentwide economic gloom, thanks to Ebola.
“Across West Africa, a generation of young people risk being lost to an economic catastrophe as harvests are missed, markets are shut, and borders are closed,” Johnson Sirleaf said in a BBC “Letter to the World” on Oct. 19. “The virus has been able to spread so rapidly because of the insufficient strength of the emergency, medical, and military services that remain underresourced.”
The treatment approach to limiting Ebola’s spread is failing, as even a recent surge in international support hasn’t come close to matching needs and patients are still being turned away from overcrowded facilities. The U.N. office that is coordinating the global response recently issued a detailed strategic plan and budget requirements — so far only about a third of the money has been provided. Among the worst scofflaws is Canada, which initially promised CA$35 million in support for the U.N. effort and, has to date, delivered a mere CA$4.3 million.
The U.N. strategy, portions of which would be executed by a variety of agencies and international responders, focuses on identifying people who are infected with Ebola through the classic public health method of contact tracing. The highly labor-intensive tactic starts with getting the names of individuals who had close contact with each known Ebola sufferer, finding every one of them, separating out those who have fevers or other symptoms of the disease, and monitoring the others over time. Nigeria successfully prevented an Ebola epidemic in its country by using this technique, monitoring more than 1,200 contacts for 42 days and limiting the disease’s death toll to eight individuals. Of course, the scale of Liberia’s, Sierra Leone’s, and Guinea’s epidemics is orders of magnitude larger than Nigeria’s. Effective contact tracing would entail tracking down and monitoring tens of thousands of people.
The United Nations’ strategic plan, which was originally drawn up more than a month ago, reckoned that the cost of effective contact tracing would be just under $190 million. The epidemic has grown enormously since the plan was drawn up, and with each day of inadequate financing, the effort falls further behind. Contact tracing costs are just a small part of the big strategy, which envisioned providing medical care not only for all Ebola victims, but also for the thousands of people no longer able to obtain routine treatment for everything from malaria to auto accidents — a total price tag of just under $1 billion in September.
Isabelle Nuttall, director of the WHO’s global capacities, alert, and response effort, told reporters, “We cannot underestimate the importance of contact tracing,” and she warns that the affected countries lack the capacity to execute such tactics, as do most of their African neighbor states. At the most basic level of epidemic control — counting the numbers of sick, dead, and recovered disease victims — all three countries are failing miserably and officially reported tolls delivered to the WHO are universally believed to be gross understatements. But there is no clear agreement about just how far off the numbers are — twofold? Threefold?
In lieu of effective contact tracing and humane isolation with treatment, the countries have resorted to quarantines of entire geographical areas and neighborhoods within their capital cities. The tactic has had a chilling impact on food production, trade, and the movement of supplies. And unlike in China’s SARS situation, where authoritarianism bred compliance, outrage and resistance have often emerged. Sierra Leone shut down the country for three days of mandatory quarantine of all citizens in a drastic effort to find the infected and halt the spread — it failed.
If the world cannot manage to muster promised monies and mobilize far more personnel and equipment to confront the epidemic, the governments of Sierra Leone, Guinea, and Liberia may be compelled to implement strategies as severe as China’s SARS endgame, dragging thousands into isolation without respect for their rights or civil liberties, and even at gunpoint. The world must not compel such hellish action. The less odious, more humane alternative of building quality treatment centers on a scale to actually absorb thousands of needy patients and provide meaningful care that improves survival and thus lures Ebola sufferers out of hiding could still work today. It is hugely expensive, and it demands thousands of skilled health workers and support staff from all over the world. But in the absence of ample aid, three nations that nobly came back from the horrors of civil war into their dawns of democracy may be forced backward into an Ebola authoritarian horror.