The Next SARS

This article first appeared in the February 2004 issue of Toronto Life

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On February 18 of last year, Kwan Sui Chu, a 78-year-old Toronto woman, checked into Hong Kong’s Metropole Hotel. She was there celebrating Chinese New Year with her brothers. Dr. Liu Jianlun, a professor of respiratory medicine in Guangzhou, a city in southern China, had travelled to Hong Kong to attend a friend’s wedding and was also staying at the Metropole. On February 21, Liu and Kwan were waiting for an elevator in the lobby when Liu coughed, the proverbial fluttering of butterfly wings that unleashes a tidal wave.

Liu had been exposed to an atypical pneumonia that had surfaced in southern China a few months earlier, and now Kwan was exposed. She had lived in Canada for a decade but didn’t speak English. An avid gardener, she communicated with her Scarborough neighbours using gestures and smiles. She flew back to Toronto on February 23, and on March 5 she died at home.

Though no one knew it at the time, she was the city’s first SARS fatality, the beginning of a daisy chain that connected thousands of Torontonians, from janitors to clothing salesmen to neurosurgeons. Two days later, her son Tse Chi Kwai, a 43-year-old garment worker, was admitted to Scarborough Grace Hospital with a dry cough and fever. Tse was given drugs and oxygen and kept overnight in a room with two other people.

One of them was 76-year-old Joseph Pollack, a salesman in the garment district, who had an irregular heartbeat and was waiting for an intensive care bed. He and Tse lay side by side for 24 hours. That day—March 7—the World Health Organization activated its global response network, a confidential request for assistance that went out to 110 government agencies, including Health Canada. On March 12, the WHO issued a global alert for atypical pneumonia. The next day, Tse Chi Kwai died at Scarborough Grace.

Joseph Pollack was discharged but soon returned with symptoms typical of the new disease, severe acute respiratory syndrome. On March 16, he was taken to Grace by Greg Bruce, a paramedic. Bruce, a big man with a boyish face and a crewcut, had grown up in Scarborough. After dropping off Pollack, he heard on the news that another SARS case had been confirmed. He realized it was the man he’d just transported. Two days later, watching the Leafs on TV, Bruce developed fever and a pain in his legs. He checked himself into Scarborough Grace, where he was diagnosed with flu and sent home. He had three children—aged 12, nine and two months—and, worried about infecting them, he put himself into quarantine in his bedroom. Two days later, much sicker, he returned to hospital; again he was sent home, though the hospital was aware that he had come into contact with a probable SARS case. That day, March 21, Joseph Pollack died.

At this point, little was known about SARS; its genome sequence was still unmapped, the mode of transmission unclear. These uncertainties were set against the certainty in the medical community that a pandemic—a virus with global reach—will arrive some day. Was SARS it? In March and April, it was a candidate. Dr. Robert Webster, a virologist at St. Jude Children’s Research Hospital in Memphis and a world authority on influenza, has noted that there are thousands, possibly millions, of viruses out there. “We don’t even know they’re there until we disturb them. SARS is probably just a gentle breeze of what one of these big ones is going to do some day.”

The pandemic, epidemiologists agree, will likely be a form of the influenza A virus. When there is a significant, spontaneous change in one or both of its surface proteins, no one will be immune, because it will be a completely new virus. There were three such antigenic shifts in the last century—in 1968, in 1957 and in the devastating Spanish flu of 1918. According to Dr. Allison McGeer, head of infection control at Mount Sinai Hospital, “SARS was practice for the pandemic”—a vivid dress rehearsal for the inevitable.

Information became the dominant trope in the SARS months—the quality of it, the quantity, what it meant, what effect it had. The way information moves through a population is analogous to the way a virus operates. The story mutates; certain versions are selected for advantage, meaning they have audience appeal. They are picked up by more outlets, delivered to more homes, exposing more people. What tends to die quickly (the unselected mutations) is pure information, often statements made by anonymous doctors. In Toronto, the frequent updates were welcome because they had pragmatic value. But there was little sense of the human element. The victims were in quarantine, and families were hesitant to talk, wary of the stigma. There was no human face to associate with the disease, no focus for public grief. Initially, there weren’t even any names. There wasn’t a narrative, just information.

As you moved out from the centre, the information became less necessary—and so, less interesting. With international coverage, what has the best chance of survival is an image: furniture floating down the streets of a flooded town, the detritus from a tornado, that epochal clip of the twin towers collapsing. In Toronto, television news showed a deserted Bloor Street, with a voice-over describing lost sales. The economic impact was devastating but untelegenic. The damage was all offstage.

There was already a sense of quarantine—the last vestiges of winter hibernation—but it was heightened by the absence of tourists, the cancellation of concerts and conventions. The American Library Association held its annual convention here in June, but organizers offered to refund half the prepaid expenses if members stayed home, and many took the deal. I was there on book business, wandering the deserted acreage of the convention centre. People reminisced about New Orleans, where it had been difficult to move because of the crowds. Some booths weren’t occupied; the chairs, tables, bunting and books had all been delivered, but the exhibitors had failed to arrive. “See what the media have done,” a publisher said to me, gesturing to the empty space.

Without a memorable image, the foreign media focused on the besieged city angle, which contained an element of self-fulfilling prophecy. In the United States, where three 24-hour news stations compete viciously for market share, the war with Iraq coincided with the emergence of SARS, so initially there was little coverage. But the war was relatively short and dull, and the cameras turned toward the epidemic, which was conveniently located in a place where hotel rooms were suddenly cheap. The American reporters wanted hyperbole, said Dr. Donald Low, the microbiologist at Mount Sinai Hospital and the University Health Network who became a familiar face during the crisis. Even the normally sedate BBC was looking for bodies in lime pits.

As Low pointed out, “The fear outside Toronto was much greater than within.” The impression was one of Old Testament plague, and even some of Low’s medical colleagues had misgivings about coming to Toronto. The disease was progressing much faster than the medical literature, so initially doctors were getting their information from the media as well.

Studies of epidemiological behaviour show that a population reacts most fearfully to the unknown. There is a pattern for diseases like necrotizing fasciitis (flesh-eating disease), Creutzfeldt-Jakob (mad cow) and AIDS: the initial dread and stigma gradually subside, replaced by perspective and caution. The genome sequence for SARS was mapped within 11 weeks of the outbreak (with HIV, it took almost a decade), and the constant news in Toronto was, if not encouraging, then at least normalizing.

But for those outside the city, the unknown qualities of the disease sparked greater dread, a dread exacerbated by the fact that Canada itself was unknown. The Japanese didn’t discriminate between Banff and Toronto, and tourism evaporated. Irish businessmen cancelled meetings in Edmonton. Americans’ celebrated knowledge of Canadian geography hurt businesses in British Columbia.

In his novel White Noise, about an undisclosed “toxic event,” Don DeLillo writes: “In a crisis, the true facts are whatever other people say they are. No one’s knowledge is less secure than your own.” In a crisis, rumours thrive. In China, it was rumoured that SARS could be prevented by boiling white vinegar. The practice resulted in several cases of carbon monoxide poisoning from people using charcoal fires in their apartments. There was a rumour that SARS was carried by rats. A British astronomer speculated that SARS had come from outer space. During the plague in London in 1665, it was rumoured that cats and dogs were carrying the plague, and they were ordered destroyed by the city government. An estimated 40,000 dogs and 200,000 cats were killed. The result was fewer natural predators for the rats that were spreading the disease. Rumours are viral, moving quickly through the population, reliably communicating unreliable information.

At the other end of the spectrum is the way information moves through a bureaucracy, which is slowly, and tainted by self-interest. Chinese authorities had been aware of a new virus as early as November 2002 but actively suppressed any dissemination of that information. In Toronto, Dr. David Naylor, head of the National Advisory Committee on SARS and Public Health, said that dysfunctional relationships among public health officials contributed to the crisis. The communication between various departments and officials was criticized as obscure, inconsistent, incoherent and untenable. Front-line workers complained of a lack of information. There wasn’t a coherent public communications strategy. There was no central body, like the U.S. Centers for Disease Control and Prevention in Atlanta, that administered information, no general in what is loosely, but accurately, called a war.

Greg Bruce’s fever rose to 40 degrees, and he didn’t respond to Tylenol. He was too weak to drive, so his wife took him back to Grace. Their baby was in the back seat. Bruce’s chest X-ray showed abnormalities, and this time he was admitted, then transferred to an isolation unit at Mount Sinai.

Rose Pollack had been infected by her husband. In the waiting room at Scarborough Grace, she sat beside an 82-year-old Filipino man named Eulialo Samson, who worked as a janitor at a Toronto hotel. Samson spent half of each year in Manila and half in Toronto. He was diabetic and had an injured knee, and doctors wondered if his leg would have to be amputated. But he was also feverish and having trouble breathing. He didn’t know he had SARS, didn’t know the disease existed, and he tried to remove the oxygen mask and tear out the IVs.

One of Samson’s granddaughters, Maria Conception Samson, a 34-year-old events planner, visited him in Scarborough Centenary, where he’d been placed in isolation. Maria has a pretty face, round and open, and a sense of drama regarding her family’s contact with SARS. Her grandparents had taken care of her for a few years in the Philippines while her parents established themselves in Toronto, and she was close to them.

Maria’s 78-year-old grandmother, Gregoria, was also infected and admitted to Grace. Maria spent time with her there, pressing a plastic rosary into her hand, telling her stories. “And the doctor’s telling me we’re going to move her into isolation,” Maria says, “and they’re not really equipped for SARS. So I sat down with the infectious diseases nurse, and I told her when someone gets sick, the whole family comes together. Obviously, we were all infected.”

Eulialo Samson was the turning point in a disease that, until then, had been contained within the hospital system. This was the nervous moment for medical professionals, when it looked as if SARS would spread to the community, the epidemiological equivalent of a jailbreak. There were 22 members of the Samson family in Toronto. Maria explained the situation to them; everyone was quarantined. “We waited to get sick,” she says. Within a few days, Maria developed a fever. She packed a bag, called an ambulance, put on her coat and a surgical mask and waited in her living room. An ambulance took her to Sunnybrook. She was diagnosed with SARS.

“I can’t breathe,” she recalls. “It hurts here and it hurts there, and I can’t breathe.” The slightest touch was excruciating. “I remember going into this room with machines everywhere. It was dark, and then it’s all glass, so it looks like there’s more machines. And I’m thirsty and I’m hungry, and my stomach is burning. I’m surrendering myself to God. I’m not making deals, I’m not crying. I’m thinking stupid things like should I clean my apartment? I’m thinking, how are they going to pay for the funeral? You know, like my soul will go with or without a box. I always wanted to be cremated. I wanted to be rolled in a really expensive bag of weed and have everyone smoke me. My grandfather’s just died, my grandmother’s on life support, my father’s in ICU, six other members of the family are in the hospital, and I’m worried my mom will get sick.”

Maria was isolated in a critical care room for two weeks, medicated, hooked up to a ventilator. No visitors were allowed. She saw only the heavily protected doctors, nurses and interns. She was too weak to read, to concentrate. She thought about her breathing, taking oxygen into damaged, shrunken lungs, pushing it out, looking for another breath, thinking that if just two successive breaths go wrong, she’d die. She thought about death and talked to her departed grandfather, asking what it was like in heaven.

After Gregoria Samson died, Maria spoke to her, and to the deceased aunt she was named for. “I asked her if I still looked like her. I was looking forward to seeing them, to be reunited with them.” She asked questions of the dead: “How soon can I become an angel? What do I have to do? I wanted to know if I could watch over my little sister, who is 23. Can you only watch them, or can you intervene? If I could be an angel really quickly, then I could watch everybody at the same time, and then I’d have to tell my sister I’m an angel without scaring her.”

Maria drifted in and out of sleep and dreamed that Jon Bon Jovi was a close friend. “He came with his kids to my house; it was getting late and they should be going home, and I said to leave the kids. And they did. I’m in God’s hands. I believe in heaven—I do. Maybe not in the Church, but there’s a heaven.”

Initially, Eulialo Samson couldn’t be buried; the cause of his death was still being determined. “I was talking to him,” Maria says, “and I don’t know if he was listening. I just figured ghosts can hear everything. And I said, ‘I wish I had money to give to the family so you could have a really nice casket. A nice casket and a nice hat. I wish we were more organized and we could put together one of those funerals like you see in the movies—where everyone sings and there’s, like, gospel singers, doves flying in the air.’ And I said, ‘I’m sorry, I wish you could go in style.’”

The extended Samson family were members of the Bukas Loob Sa Diyos Covenant community, a Catholic charismatic group. On March 28, several of the family, including members who had visited Eulialo in hospital, had gone to a mass that was attended by 500 BLD members. Thirty-one people from this one source were listed as probable SARS cases. A BLD member from Philadelphia attended the mass and returned home, infected. On April 12, all 500 were ordered into quarantine. Maria’s father worked at City Hall on the 19th floor; 100 of his colleagues were also put in quarantine.

To this point, every infected person could be linked, like characters in the book of Genesis, but now there was a danger of losing track. A 46-year-old nursing assistant named Adela Catalon went to the Philippines and developed symptoms there. She died in Manila, starting a chain of infection that reached 10 people. There were other outbursts of infection—in North York and at Sunnybrook Hospital.

For a virus to escape into the general population means not just a quantitative change but also a qualitative one. “The essential nature of viruses is to mutate,” says Low. The mutations that change a virus are those that offer an advantage. Mutation happens only when the virus is transferred to another host. If it is contained within a relatively small population, it has difficulty evolving. With a global pool of slightly more than 8,000 people, there was little evolution of the SARS virus. Its homogeneous nature suggests that it had only recently made the leap from animals to humans, with the civet cat being a possible host. “We expect over time it will change,” Low adds. “That’s why you want to contain it, because it will learn how to be a more effective virus.”

The coronavirus that is SARS has changed from its earliest analyses, but it hasn’t changed much; it is still a clumsy adolescent. It has a halo of protein spikes that latch onto cells, and it regenerates every few hours or so in vitro. It can survive on an inert plastic surface for 48 hours, can live in human feces for four days, can withstand the cold for three weeks. Despite its survival skills, Low suspects that SARS will not make it as a major disease, that its career will be more like monkey pox than influenza. “Monkey pox was stopped in first generation,” he says. “Every year in Africa, it comes back—there’s a small outbreak, but it’s contained and disappears.”

Once a virus reaches a certain stage of evolution, the battle between it and mankind becomes an eternal chess match. The flu vaccine given out every year is different from the previous year’s because influenza mutates to battle each new assault. It remakes itself to increase its chance of survival. Influenza is a sophisticated, battle-hardened virus that claims hundreds of thousands of lives annually. As one epidemiologist says, “We’re only here for the viruses.” Humans are mere vehicles.

“Epidemiologists have been telling governments for a while that we will be facing new and emerging viruses, that world pandemics are coming,” says Dr. Raymond Tellier, a microbiologist at the Hospital for Sick Children. Tellier adopts the tone of many health professionals, vacillating between indignation and resignation. “And for all those years, governments have been cutting budgets.”

The reasons for the coming pandemic are various. In his chaotic office, Tellier lists them on his fingers: “The increase in human population, increased densities, diminishing socio-economic conditions, increase in air travel, massive population displacement due to wars, the encroachment of humans into new ecosystems, the change in global weather. It’s a given that we’ll see emerging infectious disease.” Perhaps SARS will return in a more potent form, or perhaps it will be a new virus altogether, one that emerges from apes or dogs or pigs or birds—some latent bug waiting for its chance at the big time.

If SARS was practice for the pandemic, Toronto was the practice field. It was the Western focus for the disease, the perfect host. But why? Why not Chicago or Vancouver or Jacksonville? Toronto’s vaunted multiculturalism ensures regular traffic with hundreds of nations, and it’s a travel hub; 26 million passengers came through Pearson in 2002. Globalization is a factor: an exotic animal market in Guangdong Province is only hours away. And our medical system has been in a state of underfunded decline for many years, poorly prepared for any outbreak. But we were also hit with bad luck: two of the early SARS victims were so-called “super-spreaders,” who passed the disease along with particular efficiency.

SARS was a grim illustration of how, when the pandemic comes, globalization will co-exist with the new medievalism. Thousands of Torontonians were quarantined last spring, either voluntarily or by order of the board of health. Tens of thousands more stayed home by choice, avoiding subways, theatres and restaurants. In May, I went to a normally bustling restaurant with a friend for a late dinner. The definition of a city is people (Statistics Canada defines an urban area as having a density of at least 400 people per square kilometre); the point of a city is people. Sitting in an almost empty restaurant makes you pine for absent fellow citizens: the celebrated, the boring, the maddening, the too-loud, too-beautiful, eccentric, the witty failures, all those extras who make up the urban film. I was reminded of a piece I had read about Mick Jagger shopping at a clothing store while it was closed to the public, a celebrity perk that carried a taint of sadness. We were becoming celebrities without a public.

And it was Mick we turned to for deliverance. The Rolling Stones—those slight, adolescent bodies and famous heads—arrived at the end of July and said it was good to be here. It was good to be anywhere, Keith said, recycling the old George Burns line. On a small platform in a tent in Downsview, they exchanged kind homilies with the press. It was dark when they took the stage, that wide blue sky given up for a more suitable black. There was a large screen in the backstage area, which was several acres of asphalt, tents, abandoned buildings and compounds. Here, a few thousand people milled about, segregated from the 400,000 who pulsed unseen on the other side of the barriers. There were politicians, film people, celebrities, the police chief. There was a 300-pound man with a shaved head, moving rhythmically in small steps, and an impatient, sleek, 50-year-old man in expensive loafers with his teenaged sons in tow, his backstage passes a favour that would have to be returned in the future. There were desiccated, middle-aged career rock monsters in leather jackets, chain-smoking and bored; Justin Timberlake with his mother; and a pale teenaged girl on a stretcher, her eyes blank, her navel ring shining under the lights.

Around the corner, past the forklifts jockeying for position and the limousines and the roadies moving like burly dancers, there was the sunburned crowd, chanting, swaying, presenting bare breasts. In a crowd, Elias Canetti noted, man is freed from the burden of hierarchy. Life is a process of establishing hierarchies and maintaining distance, but this breaks down in the crowd. When it is large enough and dense enough, everyone becomes equal—they have the same amount of space, the same voice. The crude symbolism of the crowd, peaceful and joyous, probably had a greater effect around the world than generally thought. The still-potent celebrity of the Stones ensured that the image was seen everywhere: a city joined together in that limitless Canadian field, defying contagion, dancing to the music. Here was an image with viral promise.

As the Stones wrapped up their frantic set, I joined the throng moving for the exits, leaving a carpet of more than two million water bottles on the field. We filed to the Downsview subway station without incident and were politely herded onto waiting trains. A man sat by himself, shirtless, obese, sunburned so badly he almost glowed, in the first stages of a terminal hangover. At the other end of the train was another man, also shirtless and with an emergency room sunburn, wearing a baseball cap with an AC/DC logo. They glimpsed one another briefly through their respective hazes. What went through their minds? Look at that fat idiot? Oh, my brother? One of the side effects of both plagues and Woodstock-size concerts is the chance for the city to see itself in a way it rarely does. We are faced with our limitations, our capacity for heroism and compassion, our sunburned optimism.

Like her husband, Rose Pollack died of SARS. Greg Bruce, the ambulance driver, recovered from the disease. Maria Samson lost three family members. In all, 251 people in Toronto were diagnosed with probable SARS, and 44 deaths were recorded. Worldwide, 8,098 people were reported infected, and 774 died. Statistically, you had a better chance of being the victim of a car accident or a homicide. You certainly had a better chance of dying from the flu, a disease that kills up to 1,500 a year in Canada. But the flu is a known quantity; we grew up with it, experience its wrath annually. It kills mostly the elderly and the ailing. Flu season arrives in Canada in late fall. But people still socialize, shake hands, kiss, cough—which is one of the reasons the flu is such a success.

Computer models for influenza pandemics are complex, because the human population doesn’t mix randomly. As of late 2003, the Canadian contingency plan hadn’t produced projected figures, but California, which has a similar population, predicts 9.9 million ill (out of a population of 34 million), 386,000 hospitalized and 168,000 dead. The World Health Organization has its own estimates, which are more conservative. The projected statistics allow for vast margins of error, and they differ widely. Even figures for past pandemics are hazy: for the Spanish flu of 1918–19, the WHO estimates that between 20 and 40 million died. The only certainty is that it will arrive and it will be devastating.

Last summer, in the uncertain lull, some medical professionals predicted that SARS would return in the fall, that it would mimic the behaviour of influenza. “But SARS is in no way, shape or form like influenza,” says Low, “either in transmission or in what it is able to do.” SARS didn’t return, but the A/Fujian flu arrived, the worst influenza virus in at least a decade. After several mild years for flu, many children lacked immunity to this virulent strain. At year’s end, there were predictions of more than 75,000 deaths in North America from A/Fujian, another harbinger. “It’s been more than 30 years since the last pandemic,” said virologist Robert Webster, “and we’re overdue.”

The mortality rate for SARS in Toronto was about 17 per cent, but in the event of a pandemic, that figure would be much higher. The limited resources of even a newly funded medical system, the finite number of intensive care units, would mean that many people would be unable to receive the necessary care. And there would be no hope of outside help, because in a pandemic there is no outside. Everyone is affected. Every city becomes a walled city, a city state.

During the 1665 plague in London, the aristocracy fled to the country, followed by merchants, lawyers and the clergy. Before long, even the poor were trying to escape, but the Lord Mayor ordered the gates closed. After a few months, Londoners were dying at a rate of 6,000 per week. Countries refused to trade with London. Letters from Londoners were heated or scraped in an attempt to kill any pestilence. And those citizens who did flee were shunned, the way travelling Torontonians were regarded with suspicion (or, in the case of Malaysia, refused entry). The stigma attached to SARS was still potent enough that by the end of September, the Toronto Star was able to identify only about half of the 44 victims.

“Plagues are invariably regarded as judgments on society,” Susan Sontag wrote in AIDS and Its Metaphors. In the Middle Ages, plagues were associated with evil. In 1866, a cholera outbreak prompted this New-York Daily Times judgment: “Cholera is especially the punishment of neglect of sanitary laws; it is the curse of the dirty, the intemperate, and the degraded.” AIDS, in Ronald Reagan’s scripted wisdom, was nature’s revenge on those who had offended her. How was Toronto judged during the days of SARS? The city was dangerous, careless and ill managed, a judgment given human form by Mayor Mel Lastman’s appearance on CNN, a desperate salesman with a Nixonian sheen.

The fragility of cities is one of the lessons of the new century. The bombings of the World Trade Center showed the devastating effect of terrorism, a handful of men destroying lives and wounding the world’s largest economy. Hong Kong suffered 299 SARS deaths, its personal bankruptcy rate rose 74 per cent, and retail sales dropped 50 per cent. The worldwide cost of SARS was estimated at $30 billion (U.S.). The economic cost to Toronto was placed loosely at $1 billion. Both cities initiated advertising campaigns to bring tourists back. The Hong Kong Tourism Board took out four-page ads in Canadian newspapers and ran television spots that declared Hong Kong “the culture that celebrates life.”

Ontario has had a particularly bleak look at the new medievalism. One untracked blip on the electrical grid in Ohio and 50 million are left in blackness. For a week or so, electricity reverted to being a mysterious, miraculous event that few understood. There is tainted water, tainted blood, tainted beef. Everything is suspect. Influenza is an Italian word meaning “influence,” and the disease was originally thought to be delivered by the heavens to the unworthy.

We have ourselves, as well as the stars, to blame for recent tragedies. Mismanagement and the short-term goals of governments exacerbate the problems. While recommendations from the Naylor report are laudable (including an injection of $700 million into the health care system), similar proposals have been put forth several times in the past decade. “The business model for medicine doesn’t work,” says Tellier.

That business model now extends to the research of the SARS virus. The British Columbia Cancer Agency, which first outlined the genetic makeup of the coronavirus, applied for a patent, claiming the commercial rights to the genetic sequence. The U.S. Centers for Disease Control and Prevention submitted patents on their own findings, as did the Hong Kong team that first identified the virus. Several biotech companies filed patents for drugs. It is legally possible to patent the virus itself. “If you are the first person to isolate a virus,” says New York patent attorney Jim Haley, “you are entitled to claim that. The virus may be old, but the isolation is new.”

Isolation is what SARS gave us and what the pandemic will bring. It’s the dominant feature of any plague; we are left alone with our mistakes, our symptoms, our dead, ourselves.

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This spring, Don Gillmor will receive the 2020 National Magazine Award for Outstanding Achievement.