Newsday - April 20, 2003
Laurie Garrett, Staff Correspondent

And economic disaster looms.

Hong Kong, which has a population of about 7.3 million people, faced the Easter holidays having counted more than 1,350 cases of SARS, or severe acute respiratory syndrome. The number of deaths has reached 81 - 12 of them reported yesterday, the highest daily toll so far. And the traditional days of holiday travel and reunions with family members on mainland China find the local populace hunkered down, worried not only about the epidemic and their prospects for survival, but also for the economic future of their city.

The Easter weekend is usually a time of mass migration, when more than 300,000 travelers cross the border to China's Guangdong province - and tens of thousands of mainland Chinese cross into Hong Kong for nightlife, theme parks and shopping. It's a ritual soon followed by "Golden Week," when millions of Chinese travel all over the nation and to Hong Kong to celebrate the single-largest holiday of the year - workers' day on May 1.

Easter weekend has seen a huge drop in travelers - fewer than 150,000 are estimated to have ventured in either direction - an occurrence greeted by mixed emotions: A sigh of relief joined with concern over the tourist money that is going unspent. And as May Day approaches, hope that Chinese travelers will visit and spend their yuan is tinged with the fear that they actually might. For though the Chinese currency would be welcome, the virus that appears to have gotten its start on the mainland is not.

It's a tough balancing act. The government and people are watching the death toll mount as the stock market falls, even as they try to maintain a sense of hope and determination to beat this mystery disease. In the end, tiny Hong Kong knows that no matter how thoroughly it scrubs - houses have been well bleached - and how efficiently its doctors act to control local spread of the virus, in the end the island's fate is inextricably bound to that of mainland China, home to 1.3 billion people. And cooperation between authorities in the two areas has just begun. Health experts in Guangdong and Hong Kong first officially shared expertise and insights on Friday.

Hong Kong officials are cautious when describing relations with their mammoth neighbor with whom they were reunited in 1997, careful to avoid questions about the virus' origins, or the possibility of a Chinese government cover-up of true SARS tolls there.

"We have to look forward, rather than trying to pin blame," said Dr. C.H. Leong, chairman of the Hong Kong Hospital Authority. It was a tactful response, offered during an interview in a shopping mall as he took a break from round-the-clock efforts to manage Hong Kong's medical response. He dodged questions regarding mainland China's outbreak.

His stance is typical among Hong Kong's political leaders. Their balance of fear and hope is made more precarious by a distrust of the government to the north - which must be leavened by their need for scientific cooperation with health authorities there.

"One heart, One mind: Together we will beat SARS," a group of prominent, well-masked physicians promises in a regularly broadcast television ad here, sponsored by the government. Every commercial break carries messages of reassurance, coupled with advice on how best to scrub down the home, wear a mask or protect children from the virus. Travelers arriving at Hong Kong International Airport are greeted by signs declaring, "This is life - Hong Kong!"

But on Friday, Hong Kong's leader, Executive Secretary Tung Chee Hwa, labeled SARS "a disaster for Hong Kong" and admitted his government had responded too slowly to the initial outbreak. Yet he exuded cheer as he said the situation has changed - and called for every resident to join in a national day of scrubbing. Yesterdayfound a virtual army of scrubbers and moppers deployed across the city. Government officials were out in force, inspecting such sites as subway cars and the Telford Plaza, a multilayered shopping mall next to the Amoy Gardens housing complex, site of a severe SARS outbreak. Shoppers, most in masks, were scarce.

"The biggest issue for us is restoring faith in the MTR," Phil Gaffney, operations director of the Mass Transit Railway subway system, said as he watched riders use newly installed spraying devices that cover hands with disinfecting alcohol solution. "We're seeing 20 percent less people per day," he said. "That comes to half a million fewer people."

The bright stainless-steel seats, straps and floors of the subway cars were antiseptically clean, and the few passengers avoided holding onto straps or poles, lest they come in contact with germs.

Throughout the Telford mall, women in brightly colored uniforms and rubber gloves wiped escalator handrails with bleach, rubbed alcohol over Easter-bunny displays and swept antiseptic mops along the shining floors. Inspectors made the rounds of housing complexes, searching for construction, hygiene or plumbing flaws that might promote spread of the virus.

The effort was reminiscent of the early 20th-century sanitarians' movement in New York City, in which armies of health crusaders invaded tuberculosis-plagued neighborhoods to cleanse the germs away. As it was then, these acts had more to do with public morale and the international reputation of the region than with actual biological control of the virus.

The World Health Organization, which has for more than a month advised travelers to avoid Hong Kong, has "to take into account the general measures we are taking here in Hong Kong," Dr. Yeoh Eng-kiong, secretary for health, welfare and food, said yesterday in a news conference.

"I'm sure it's going to be over soon. I have every confidence that we have excellent doctors," said Chung Ying Si, manager of Mak's Noodle Shop, speaking from behind a bright-green face mask. "We just have to grit our teeth and get through this. We are a city of life - we always have been. But this has made me gloomy because this fear is not what we are about. Hong Kong people are very hospitable."

But it's not easy being hospitable when everybody is wearing face masks. Many people fear a casual brush against a stranger or handshakes from old friends.

In farewell, Chung shakes hands with a reporter, albeit cautiously, after explaining that his nearly empty won-ton soup shop is known the world over, especially among Japanese and American tourists, and usually can only be entered after long waits in a lengthy queue.

The eatery's financial plight is mirrored throughout the city. The Stanley Street Camera Shop - usually besieged by tourist bargain hunters - sold only one camera on Friday, the manager said. The centrally located Hair Magic Salon posted a sign in Cantonese on its front door: "Because of [SARS] . . . we have disinfected the whole premises, and every staff member is wearing a face mask. Every customer will be given two free face masks."

And even as new understanding offers reason for hope - as Hong Kong's sophisticated scientists gain understanding of SARS and how it is spread -the balance is tipped by uncertainty over what isn't known.

An example comes from Dr. Yuen Kowk-yung, head of the microbiology department at Hong Kong University. He's played a pivotal role in identifying the new coronavirus, helping to determine its genetic sequence and finding ways to treat SARS patients. The speed with which scientists the world over discovered and genetically deciphered SARS has amazed observers.

But, Yuen said, though the virus is "a classic coronavirus in its genomic topography," or organization, its actual RNA sequence is bizarre. Of known coronaviruses, he said, its closest cousin is the mouse hepatitis virus, but that relationship is not a close one. Most of the genes in the SARS virus have only 10 percent in common with the mouse virus; one of the genes has 30 percent of its RNA in common with the rodent microbe's RNA.

"That is almost nothing, 30 percent," Yuen said, noting that such a disparity raises more questions than it answers: Where did the virus come from? How does it work? Why is it so contagious, and so virulent, in humans?

Last week, Erasmus University scientists in Rotterdam, the Netherlands, infected two primate species - Asian macaque monkeys and African chimpanzees - with SARS, producing pneumonia in the animals that mimics the human disease. That discovery may make it possible, Yuen said, to systematically delete genes or parts of genes from the virus, use those strains to infect macaques, and thereby figure out which genes are responsible for the various symptoms and transmission. But the process will be long and tedious, he warned.

Yuen, who helped treat the first SARS case identified in Hong Kong early last month, witnessed the so-called "super spreader" effect, in which an ailing individual seems to infect many others. So far, no super spreader has been seen in the United States, though, in addition to Hong Kong, outbreaks of SARS in Canada, China, Vietnam and Singapore have been traced to such individuals. Yuen says that there is no evidence super spreaders carry different, more virulent, forms of the virus. Most Hong Kong super-spreader incidents can now be explained by a different phenomenon - amplification.

In early March, one SARS case, involving a physician from Guangdong who fell ill during a visit with Hong Kong relatives, swiftly expanded at the Prince of Wales Hospital, eventually involving nearly 200 people. That outbreak, Yuen said, "was directly related to the use of nebulizers."

People with asthma, bronchitis and other chronic lung ailments commonly go to the hospital for inhaled medication, using devices called nebulizers. Prince of Wales Hospital had a large outpatient facility in which dozens of patients would sit, breathing through nebulizers. Yuen and his University of Hong Kong team have found that when these patients inhaled their medications, they exhaled air that was literally sprayed with force, infecting doctors, nurses and patients.

"The nebulizers acted as amplifiers" of a handful of SARS cases, Yuen explained, swiftly spreading the virus through the hospital.

Similarly, Dr. Sarah Liao, Hong Kong's secretary of environment, transportation and works, announced Friday that government agencies had found an amplifier that explains the outbreak in a Kowloon apartment complex, Amoy Gardens, where so far 321 residents have contracted the disease. A kidney patient who underwent dialysis at Prince of Wales Hospital in early March got infected there with SARS, and during a visit with his brother in Amoy Gardens suffered severe diarrhea. Yuen's group proved that SARS can be passed in human feces.

Liao said that the plumbing construction in Amoy Gardens acted as an amplifier, spreading the virus through sections that shared plumbing with the one occupied by the kidney patient's brother. Investigators figured out that the toilet drain pipes from each bathroom went to large vertical pipes, or stacks. Separate pipes, feeding into the same stacks, were supposed to carry away water that had dripped onto the floors or shower of the bathrooms. Developers put a U bend in the floor drain pipe, intending it to hold enough water to form a block against a backflow. But the U pipes were usually dry, because apartment residents used water frugally. So vapors from the waste stack could flow backward, carrying contaminated droplets into bathrooms.

This explanation provided little solace, because such plumbing configurations are common in this city. Residents' associations demanded this weekend that authorities check their plumbing. Yesterday, Liao, an environmental scientist, posed for the media, studying the pipes and sewer systems of two buildings next to Amoy, offering praise for recent plumbing alterations made by building managers.

Yesterday Eng-kiong, Yuen and medical colleagues announced progress in solving some mysteries about SARS treatment. On Friday a small team of Hong Kong physicians, led by Dr. Loretta Yam of Pamela Youde Eastern Hospital, visited Guangzhou and compared notes with their counterparts on the mainland. They discovered, Yam said, that the Chinese had stumbled on the same course of therapy as had doctors in Hong Kong, with the same outcome: 95 percent survival.

The approach involves treating patients with a powerful combination of high-dose, intravenous Ribavirin, an antiviral drug, and a steroid. The Ribavirin "isn't perfect", Yuen said, but when used in very high doses does seem to slow the virus' ability to reproduce. The steroid blocks the patient's immune system.

That anti-immune system effect may seem paradoxical, but Hong Kong physicians say the most distressing damage to patients' lungs is not produced directly by the virus, but, as Yuen put it, by "an immune system gone mad," that chews up infected lung cells, causing pneumonia. Patients with the poorest medical prognosis are those of all ages who have underlying medical conditions that affect their immune systems, such as diabetes, heart disease and old age.

Yesterday Dr. Yu Wai-cho of Princess Margaret Hospital said residents of Amoy Gardens "seem to suffer a more acute, severe form of the disease, which is something we cannot yet explain." For the other roughly 1,000 cases, age has become the most important factor in predicting outcome. In Hong Kong, only two patients of 539 under age 34 have died, compared with a 28.6 percent death rate in patients older than 75. Recently there has been a surge in severe cases in young adults, and the death rate in 35-54 year-olds has reached almost 4 percent. But half had underlying chronic ailments, which put their immune systems out of kilter. Overall, nearly 70 percent of Hong Kong's SARS deaths have been in people with underlying chronic ailments.

The Hong Kong team is struggling to find a way to save the 5 percent who die, trying such things as protease inhibitors used to treat HIV. The top goal is to save lives, Eng-kiong said, and number two is to slow down the progression of the disease.

Slowing the outbreak is something Hong Kong desperately needs. The city has only 400 intensive-care-unit beds. Now, 1,200 patients are hospitalized with SARS, 15 percent of whom need intensive-care attention at some point. If the epidemic continues to grow - and there are no signs it is slowing - SARS patients could fill every ICU bed.

"But we are at capacity now," Leong said. Hong Kong's Hospital Authority is using 3 million masks a week, Leong said, compared with 10,000 per week before SARS. The authority just purchased 600,000 disposable protective gowns. And more than 600 health-care workers are living in voluntary isolation, staying in hospital dorms. The outbreak's stress is threatening large-scale burnout.

Leong believes his planning will enable the city to handle up to 3,000 SARS patients. If the epidemic grows beyond that, or establishes a permanent hold, Leong says the system, and the city, will be severely challenged.

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