A warm and sunny May day would normally be a profitable and pleasant one for all manner of businesses. But the storm raging over the increasingly widespread epidemic of severe acute respiratory syndrome (SARS) has enveloped the entire island of Taiwan in a mist of anxiety and tragedy. Ambulance sirens wail all around, and normally cackling schoolchildren now have their smiles obscured behind protective masks. On the subway system, passengers cast suspicious looks at those around them, alert to signs of anything out of the ordinary, and there is a prevailing fear of becoming the next mass transportation victim to be infected by SARS as had previously happened to passengers on trains and inter-city buses.

A virus brought over from the Amoy Gardens apartment complex in Hong Kong caused a massive "cluster" transmission at Taipei's Hoping Hospital, and the epidemic has spread out from there, with one health care bastion after another falling to the invader. The photo was taken on the fourth day after the sealing off of Hoping Hospital. (photo by Jimmy Lin)

Thank your unlucky SARS

To briefly recap the epidemic in Taiwan, the first case appeared in late February, when a Taiwanese businessman named Chin, who had been infected with SARS in mainland China, returned to Taiwan. He was immediately admitted to National Taiwan University Hospital for treatment, and was subjected to a strict quarantine. By mid-April, although there had been sporadic cases of SARS in persons coming back from mainland China, Taiwan continued to maintain a spotless record of "three zeros": zero deaths, zero community transmissions, and zero cases of Taiwanese taking the disease abroad. Citizens remained in a state of blissful optimism.

But this optimism did not stand the test of time. Early in April, a woman from Taipei named Tsao went to southern Taiwan to visit her mother-in-law who was in hospital there. On her return trip north, she became infected by SARS, probably a result of being in the same rail car as an infected individual from the Amoy Gardens housing project in Hong Kong (where dozens of people had come down with the disease). Ms. Tsao went to the Hoping Hospital to see a doctor, and although the hospital was on the lookout for possible cases and immediately transferred her to a better equipped teaching hospital, in the brief time that she had spent in Hoping-less than one hour-her presence set off a chain reaction with explosive results.

Starting on April 15, virtually every day there were new cases of medical staff and patients at Hoping showing high fevers, and with the hospital failing to take timely measures to more strictly isolate affected persons, the virus spread quickly and could not be contained.

On April 25, Hoping Hospital was hurriedly sealed off. On April 29, Jenchi Hospital, not far from Hoping, was also forced to close. Chaos and uncertainty reigned, until, fortunately for everyone, former Taipei City Bureau of Health director Yeh Chin-chuan came forward to take command on the front lines, and the situation was stabilized. Nonetheless, the damage had already been done, and today more than 60 staff members from Hoping Hospital are still locked in a life-and-death struggle against the virus in a situation that can only be described as tragic.

Fighting an epidemic is much like fighting a war. There were initially shortages of protective masks and thermometers as citizens grabbed every chance they could to buy them, and some health care professionals had nothing more useful than raincoats to wear in approaching infectious SARS patients, suggesting that the government was not well prepared.

Seal everything!

In early May, when it appeared that the epidemic had been brought more or less under control in Taipei City, there was a wave of cases of SARS in individuals with no known history of contact with infected persons. On May 10, an elderly person living alone in an apartment in the Huachang Public Housing Project in Taipei's Wanhua District was discovered to have passed away at home several days previously, and two women living in neighboring apartments (one of whom died shortly thereafter) were apparently infected. The entire community was quickly sealed off, with more than 700 persons subjected to compulsory quarantine, making this the first community in Taiwan to be sealed as a result of a SARS outbreak. Fortunately, an investigation showed that there had been no infection of the water system or of shared public facilities at the project, and after intensive disinfection, the neighborhood was released from quarantine. The entire sequence took five days.

With the situation at hospitals out of control and the penetration of the virus into the community, on the day that Huachang was sealed off the World Health Organization listed Taipei along with Beijing, Guangdong, Shanxi, and Hong Kong as an area of high incidence of SARS transmission. Suddenly, "sealing up Taipei" became a hot topic of discussion.

But it is no easy feat to block the virus from moving around. On a normal day before being sealed, Hoping and Jenchi hospitals saw about 1000 patients, and if you add to that family members and visitors, the number of people who should have been placed under home quarantine was well over 12,000. But the Taipei Municipal Government simply didn't have the resources to fully monitor such a large group. A small number of persons, feeling ill but unaware that they had SARS, went to hospitals, and now the news is that there has been a large cluster of infections at Chang Gung Memorial Hospital in Kaohsiung.

The epidemic has spread to even the most remote locations in Taiwan, and the number of cases island-wide whose source of infection cannot be clearly traced is growing every day. There have also been numerous cases that have been reported only after the patient has died.

Even more worrisome is that Taiwan's leading medical institution-National Taiwan University Hospital-confirmed after a long period of rumors that there had been hospital transmission. About 250 medical personnel (10% of the staff) were placed under quarantine, and the emergency room was closed for two weeks for intensive disinfection. It was just around this time that the cluster outbreak occurred in Chang Gung Memorial Hospital in Kaohsiung, putting that hospital on the verge of being sealed off.

Moreover, when news of the cluster outbreak at Chang Gung came out, many patients there snuck away and re-registered at other hospitals, spreading the illness to Kaohsiung Medical University and Tainan County Medical Center. The situation in southern Taiwan, in the words of Lee Ming-liang, vice convener of the Executive Yuan SARS advisory committee, is "probably going to get worse, we just don't know how much worse."

The nation's military has mobilized troops equipped for chemical warfare to disinfect streets in hopes of bringing the epidemic in Taipei's Wanhua District to an early end and restoring normalcy there.

SARS breeding grounds

How is it that the epidemic has spread so fast in Taiwan? Hospital transmission has undoubtedly been a major source of infection. As of May 23, medical professionals accounted for 40% of the 1500-plus suspected and probable SARS cases. That figure increases to nearly 90% when you add in persons infected in hospitals as a result of working as janitorial staff, providing private nursing services, coming for treatment, or visiting an inpatient.

In fact, because Taiwan did not immediately arrange for any specific hospital to handle all SARS cases, many different hospitals have been forced to accept SARS patients. Although there are now ten designated SARS hospitals, even these may have to transfer patients to large medical centers with better facilities and more complete respiratory equipment when the condition of these patients worsens. Taiwan Hospital Association President Kimma Chang finds this situation galling.

"SARS is highly infectious in any closed space with a high degree of interpersonal contact, which means that hospitals are among the most dangerous places!" says Kimma Chang. Based on current operating procedures, almost all hospitals, from the level one teaching hospitals (NTUH and Veterans General Hospital) to mid-sized institutions such as Cathay, Shin Kong, and Mackay, have been forced to accept from ten to over 100 SARS patients. The result of scattering patients for treatment has been that no place is free from risk.

Since these hospitals do not necessarily have adequate resources to defend against the virus, the result is that it is very possible that these hospitals will be taken out of action by SARS.

With every hospital trying to protect itself, patients are being bounced around from facility to facility, and the end result is that the bigger hospitals end up overwhelmed anyway. At NTUH, where there was a cluster outbreak at the end of May, for example, vice-superintendant Chen Ming-fong complained just before the outbreak that "the medical staff accounts for only 3% of the national total, but we've taken more than 80 SARS patients, which is more than 40% of the national burden."

Chen added that though the epidemic had been under way for nearly two months, the Department of Health had not established fixed procedures for handling suspected cases. Because NTUH does not have enough up-to-standard isolation rooms with negative pressure equipment, and was refused in its efforts to transfer patients to other hospitals, some suspected SARS carriers have to be left in makeshift quarantine in the emergency room. Under such circumstances, how can you talk about blocking the spread of infections?

And now that the virus has also invaded southern Taiwan, the major hospitals there are in the same boat as NTUH.

Current research suggests that SARS does not hit many children or infants, but nursery schools are still taking protective measures in order to put parents' minds at ease.

Where atypical is the norm

Moreover, "Taking care of SARS patients is very difficult and dangerous work," says Kimma Chang. Each time a medical professional enters/leaves an isolation room, he or she must put on/take off a protective "space suit" and two layers of gloves. Because caregivers must keep N95 masks on for long periods of time, they develop skin allergies and rashes on their faces. And whenever it is necessary to take a throat culture or insert a tube into a patient having trouble breathing, the result is often that the patient begins violently coughing or spewing saliva. Considering that one drop of saliva can contain more than 100 million viruses, no matter how professional or careful health care workers may be, there is still a risk of infection.

During the early stages of the epidemic in Hong Kong, it was said that "three health professionals go down for every patient cured." But now there are virtually zero transmissions among caregivers in that city. In contrast, Taiwan still lacks enough protective suits, masks, and portable oxygen tanks, with the result being that many health care workers are resigning to protect themselves. It appears that Taiwan has not given sufficient attention to training its medical professionals for epidemics, or to protecting them in the event.

On the other hand, with large medical centers ordered to accept SARS patients, other people in need of medical care, no matter how serious their condition, are afraid to come to the hospital at all. Thus each hospital's natural functions are paralyzed, and the needs of the larger public sacrificed, which could have very serious side effects on the nation's health.

Yet, says Kimma Chang, even though inpatients stay away, ordinary hospitals still take a steady flow of non-SARS outpatients and emergency cases each day, putting more people at risk. For example, if a kidney patient comes in with a fever, it could be diagnosed as the standard urinary tract infection, for which the patient will be sent to the nephrology department. When the hospital finds out this is a SARS "fish that has slipped through the net," then a whole group of doctors and nurses has to be quarantined, so that the shortage of personnel is made even worse.

It is especially disconcerting that the SARS virus appears to have mutated often in Taiwan. Many SARS victims have not shown the classic phenomenon of pulmonary infiltration in the early stages. Moreover, the transition period from spring to summer is when people suffer most from allergies and colds and germs are especially active, so it is no wonder one hears of so many misdiagnoses.

The first civil servant to die of SARS, an office chief in the Highway Bureau surnamed Chou, went to the NTUH emergency room because he felt ill and thought it might be SARS. Unexpectedly, he was twice sent home by doctors, and it was only on his third visit that he was admitted as an inpatient. He died of the illness not long thereafter. Similarly regrettable incidents have occurred at Chang Gung Memorial Hospital in Kaohsiung and at the Department of Health's Taitung Hospital, testifying to the difficulty of diagnosing the illness in its early stages.

People feel constantly threatened when taking mass transportation, shopping, or working. When will this nightmare end and life get back to normal?

Designated hospitals

Kimma Chang suggests: "Rather than having every hospital become a 'SARS hotbed,' why not follow the example of Singapore? There they require that people with fevers call a special hotline, after which patients are picked up by ambulance according to a computer generated priority system and taken to a specially designated hospital. Then they undergo meticulous screening and diagnosis at the designated hospital to determine whether they are in fact SARS cases, whether they need to be kept for observation, or whether they need to be treated in a negative-pressure isolation room."

Chang notes that Singapore's designated SARS hospital has separate floors for preliminary diagnosis, suspected cases, probable cases, and serious cases, and is provided with the best possible equipment for quarantine and treatment. On the one hand this minimizes the risk of the disease spreading more widely, and on the other patients know that they will be able to rest easy and get the best possible care there, and don't have to, as they do now in Taiwan, get moved around from place to place.

Of course, it is asking a lot of any hospital to be a designated SARS hospital, and it is a rather terrifying prospect for the staff there. For this reason all hospitals should contribute to the staffing of the special facility in rotation-time spent caring for patients, a 'vacation' in quarantine, and then a return to their original hospitals. Staff must also be provided with the best possible protective gear and financial bonuses, so that the sense of anxiety felt by caregivers can be reduced to a minimum.

Identifying and isolating cases is only the first step, however. The second step is isolating all those with whom they have come in contact.

Stay put!

Theoretically, except for a small number of "superinfective" individuals, in general SARS is not that infectious. "Only about 4% of people living with SARS victims actually get SARS themselves," says Chen Chien-jen, a member of the Academia Sinica, who took over the job of minister of health only in mid-May, right in the heat of the crisis.

But this does not change the fact that those who have been in contact with a SARS victim are the highest risk group, and should be quarantined, and this policy must be rigorously executed without exception. Success in this endeavor depends to a large extent on the public-mindedness of citizens and their willingness to obey the law.

Before the disease began to spread widely, many citizens did not take the home quarantine rules seriously. Fortunately, as waves of new infections have struck, people now increasingly accept the logic of the policy of "isolating oneself to protect others." When the Huachang housing complex was sealed, there was little protest or complaint, despite fears that quarantined individuals might lose their jobs or that their children would fall behind in school. Beginning on May 20, a "telecom monitoring system" was launched for the 12,000 category A people (i.e. persons who had been in direct contact with a known SARS case) to prevent them from "sneaking around" and posing a risk to society.

Regrettably, even as the country was getting tough on domestic quarantine, in mid-May a doctor from Mackay Memorial Hospital caused an international incident when he showed SARS symptoms while in Japan. Assuming that he only had the flu, he took some cold medicine and finished his travel itinerary, only later discovering that one of the patients he treated in hospital later died as a probable SARS victim. Japan was furious and Taiwan had to issue a formal apology.

While the furor caused by this particular incident has cooled, it highlights the need to raise awareness and civic-mindedness among medical professionals and citizens as a whole, and raises issues of balancing individual rights against public safety.

Not a very catchy field of study

Stepping back for a moment from the immediate struggle at hand, objectively speaking what advantages and disadvantages does Taiwan have in coping with a situation like the present one compared with those countries which are now fighting the same epidemic?

"Our weaknesses are in fact a product of our original strengths," says Twu Shiing-Jer, minister of the ROC Department of Health. Over the past half century, Taiwan has successfully eradicated various communicable diseases like smallpox, cholera, malaria, and polio, and its accomplishments in the field of public health are widely recognized.

But the downside of having conquered these illnesses is that the number of patients is constantly falling, so most young doctors prefer to specialize in growth fields like illnesses of advanced industrial societies or problems of the elderly. Virology, bacteriology, and epidemiology are considered "sunset subjects." The result is that there has been no one to take the baton from the previous generation, and gatherings of specialists in these fields can be mistaken for meetings of a senior citizens group.

Moreover, various specialized medical centers that formerly carried the ball for epidemic illnesses-such as the hospitals dedicated to tuberculosis, leprosy, and even sexually transmitted diseases-have been compelled by market forces to close or restructure. Though the general hospitals that have replaced them have state-of-the-art facilities, they do not have an adequate number of negative pressure isolation rooms with independent climate control. And while several teaching hospitals have invested heavily in electron microscopes for studying viruses, these have not been used or maintained in so long that they have become useless.

With little experience dealing with epidemics, today's officials, hospitals, and citizens have let their guard down. During the enterovirus epidemic in 1998, there was a major controversy because the government delayed notification of the threat. While this is not the case with the SARS epidemic-there are press conferences almost every day at every level of government from the premier down to local government officials, as well as at all major hospitals, so that there is considerable information available-SARS has still had an impact of unprecedented scope, with related issues that include the quarantine of over 10,000 people, sealing of hospitals and neighborhoods, closing of schools, creation of dedicated facilities, proper use and distribution of masks and protective clothing, and economic aid to affected industries. One official admits, "We are all improvising as we go," hoping to find the best approaches through trial and error.

Shared fate across the strait?

Since there is currently no medication to treat SARS, the only effective strategy is to keep people away from affected areas, to isolate infected persons, and to not give the virus any chance to find new hosts so that it dies out naturally. But given the state of the epidemic in mainland China, this could be a problem.

Lee Ching-yun, a professor emeritus at National Taiwan University medical school, who is known as "the father of epidemiology in Taiwan," says with a sigh that Taiwan has really been too intimate with the mainland. Even in mid-May, there were many travelers back and forth. In fact, as of May 20, more than 25,000 Taiwanese had returned to Taiwan from seriously affected areas like Hong Kong and Guangdong; fortunately, there have been no reports of any infections as a result.

Indeed, the epidemic seems to be nearing its end on the mainland. Meanwhile, the number of cases in Taiwan continues to climb. Is there no end in sight?

"There's no need to be pessimistic," says Chen Hour-young, a researcher at Taiwan's Center for Disease Control, which is in charge of monitoring the virus. No matter how much a coronavirus mutates, it is still just a type of cold, and as everyone knows, the number of cold sufferers drops dramatically as soon as summer arrives. So we can likewise expect the SARS virus to chill out.

You've had it... maybe

Chen Hour-young says that the three main indicators for whether an epidemic will spread are weather, antibodies, and pathogens.

The SARS virus' level of activity and lifespan both markedly decline at temperatures over 35 degrees Celsius or humidity over 60%. This is especially the case in well-ventilated spaces, where the virus will die in less than half an hour under these conditions.

Antibodies are another reliable indicator of an epidemic. SARS may be frightful, but the fact is that some people are unaffected by a virus no matter how ferocious it may be, and will not become seriously ill.

Look for example at the enterovirus-71 epidemic in 1998. Because this type of virus had not existed in Taiwan for a long time, most children lacked natural antibodies, and the epidemic left 78 children dead and more than 400 others impaired for life. But three years later, a survey by the Center for Disease Control showed that 68% of 15-year-olds had antibodies to enterovirus-71, indicating that many people had caught the virus but never even realized it.

With such precedents, will SARS turn out the same way? Former CDC director Chen Tzay-jinn points out that while at present the death rate from SARS is about 10-20%, this could be a serious overestimate. Because there is as yet no comprehensive system for testing for antibodies, the national infection rate-the number that experts are most interested in-remains a mystery. "Since we don't really know how many people have been infected nationwide, how can we calculate the rate of fatalities?"

Chen says that in Guangdong, where strict quarantine measures have not been taken and public health resources are inadequate, the epidemic has apparently begun to naturally slow down on its own. Does this mean that most people have been mildly infected and their bodies have produced antibodies, so that the virus cannot find any "fresh" victims without natural defenses, and therefore is retiring from the field?

All-out prevention, normal life

As for tracking pathogens, often they can be traced through so-called "intermediate hosts." For dengue fever, for example, every summer the health authorities conduct a search for areas with high numbers of the kinds of mosquitoes that carry that illness as a clue to which areas are most at risk.

Unfortunately, with SARS being passed directly from one person to another, a lack of intermediate hosts means a lack of indicators for monitoring, warning, and quarantine. At present it is widely believed in the medical community that after this first appearance by SARS, in which it has taken 600 lives worldwide, it could very well become a localized illness that periodically resurfaces in mini-epidemics. If this is the case, then Taiwan, which is a high-risk area, urgently needs to construct an effective system for monitoring and studying epidemic illnesses, so that when the next one hits we will be ready.

With great uncertainty still surrounding the epidemic, should Taipei be "sealed up" and everyone put under quarantine? Should Taipei really shut down all businesses, schools, and public venues and halt all commercial activities to create a "vacuum" for ten days in order to bring the virus down? Faced with conflicting demands and advice, former CDC director Chen Tzay-jinn borrows the advice of Singapore senior statesman Lee Kuan-yew: "Full-scale prevention, normal life." He hopes that citizens will remain calm and not act irrationally.

While disease is indeed frightening, if the critical factors can be identified and the policies based on this identification rigorously implemented, then the harm caused by SARS will be kept to a minimum. Let us hope that when the tide of SARS recedes, the Taiwan society that surfaces will be a more coherent, more tolerant, and more mature one.