- - Baoqi Su
Research Center for Bioethics and Dept of Social Sciences,
Peking Union Medical College, Chinese Academy of Medical Sciences, No. 5 Dongdan Santiao, Dongcheng District,
Beijing, 100005, CHINA
Email:
E-mail: subaoqi2005@sina.com
Eubios Journal of Asian and International Bioethics 13 (2003), 108-10.
Beijing has been the worst SARS (Severe Acute Respiratory Syndrome) hit area in the world, where people have experienced and learned a lot from the new deadly disease. Unfortunately, it did not arouse people's attention when the first SARS case was reported in Guangdong province, southern of China in last November, neither did it in the first days' epidemic in Beijing. On April 20, when Darryl (Macer, the editor) was visiting Beijing, it has reported there were 339 SARS cases, an additional 402 "suspected" cases and that 18 people had died from the virus in Beijing. The situation changed dramatically to compare with the former government claim there were only 44 cases with 4 fatalities in the Capital of the day before, and people's normal life turned to an overwhelming panic.
Spring is used to a pleasant season of Chinese people with a high blue sky and a warm sunshine. Around late April and early May, as numbers increased and with news of SARS all the time, could you imagine when the social activities of a city of 14 million population were suddenly brought to a complete halt? People were staying at home and afraid to go outside, with food and water being hoarded. People avoided crowds and minimized all contacts with unfamiliar persons, with a routine of temperature-taking and mask-wearing, meanwhile washing hands frequently for everyone from the kids to the seniors. My work place is almost in the center of the city, with the famous Wangfujing business district nearby, where however streets were deserted and shops were empty.
Also to fight against SARS, cinemas, public libraries have been closed down and the young people were advised to postpone the wedding ceremony to prevent large-scale people gatherings. May First holiday was shortened from seven days to just three days to discourage people from traveling. The worst impact of SARS was that schools, with 1.7 million primary and secondary students had to be suspended from April 24 to May 7, and it was then extended for another 2 weeks to safeguard the health of students until recently the schools have re-opened separately. Ten thousands of people have quit their jobs and tried to escape the infected Beijing. The infected number has been reported far more than 100 cases daily, and being treatments in temporary facilities. People are panicky and jittery as never before has the city had such coverage of a deadly disease. I like many of others took traditional Chinese medicine for a week to enhance my body immune system and to give some psychological comfort while working at home for nearly one month already. However, cases like the one below, has let me start to be scared and think seriously.
A case perspective
The first time, I remembered, that I was completely shocked was when I heard of the news that one of the major hospitals, Beijing University People's Hospital, where one of my best friends works and my families and I frequently visit had been quarantined in the midnight of April 24. There were policemen and security guards standing outside, nobody was allowed to enter or leave. I could not believe what had happened, just as it was announced that the hospital had at least 60 confirmed or suspected cases among nurses and doctors. I started to be scared and ask what had on earth happened in Beijing these days? How could it infect such a wide range of people so silently? Could the government cope with it?
From Hong Kong, Taiwan to Singapore, from Guangdong province, Beijing to Shanxi province, there have been the most dangerous and trembling scenes of SARS epidemics in China and the world. That is that in hospitals large-scale infections happened and numbers of medical staff fell down continuously. What has happened within the People's Hospital? By talking with my friend's families and from the Chinese media I comprehended this, the blood and life founded experiences and lessons, which could never be ignored and forgotten.
On 13 May, Dr. Ding Xiulan died due to the deadly SARS. She was a vice dean of the Emergency Department of the People's Hospital and had unfortunately been infected with SARS in 14 April during the treatment of the patients. She had treated many SARS patients and knew clearly that she could not flee away from it herself too. The state of disease deteriorated quickly, nonetheless she had been transferred to the Ditan Hospital, one of the major infectious hospitals, used a ventilator machine and finally trachea dissection, and she had been sentimentally attached to the life, she at last left her beloved families and work. Meanwhile, in many hospitals there have been more than 90 medical staffs struggling with SARS disease.
On 5 April, the first high suspected SARS patient Qing, a 64 year old female was arranged in a custodian room, opposite another room containing a variety of diseased patients, under the treatments by the same group of the nurses and doctors. Its Emergency Department is one of the busiest in Beijing, but its narrow structure for patients' conveniences in ordinary days was not adept for this severe acute respiratory infectious disease. After a patient with a cardiac muscle blockage who had been moved to the ordinary ward from the Emergency Ward was diagnosed with SARS it brought a disaster to this ward with 11 nurses and doctors' infections. The same thing happened to the Department of Neurological Medicine, which had found 2 doctors and 1 nurse's infections. The number of new patients was still increasing, and accompanying nurses and doctors were continuously infected. Even though the hospital had tried all kinds of methods to deal with it, which is not the assigned SARS hospitals but had difficulties to move the all patients in time, it was already too late. It is not set aside to treat SARS patients but it has finally 93 medical staffs confirmed or suspected cases itself.
Ethical and social considerations
Mend the fence after a sheep was lost
China has an old adage, which says it is not late to mend the fence after a sheep was lost. When SARS disease first appeared in Beijing in January 2003, the government withheld the information to avoid the flow of tourists from coming to a complete halt. In the early April the government continued to cover up the news and keep people in the dark about the severity of the spread. However after hundreds of people became infected and under intense international pressure the government started to take SARS more seriously and to report the true situation on 20 April.
In my opinion, the first reaction of the government's ignorance of the severity of this new disease could be understood. In fact, when SARS emerged in Guangdong province during the first months of the year, the disease did not gain anybody's attention from Beijing. However, it indeed has done more harm than good to try to conceal the real numbers. When the "official SARS figures" of Beijing increased more than nine-fold overnight, it brought people a big panic. Suddenly everyone needed to check the body temperature and show an ID to enter the work place and home community. All strangers are suspected, while illogically, friends and family are assumed to be safe, even though most cases of transmission are through close contact.
Darryl Macer, my former supervisor, has argued that most people do not have a simplistic view of science and technology, and can often perceive both benefits and risks (Macer, 1994). People have expressed dissatisfaction or anger over the earlier government covering up of SARS, which hindered control efforts and resulted a wider infected range. However, after the Health Minister and Beijing Mayor were sacked and the government took active and practical actions to fight SARS, now the people have become more trusting and supportive of the government. It is very helpful to publicize the everyday data not only for the public awareness, but also for the clinical diagnoses and treatments and pursuing international collaborations.
Only by telling the real situation to the public is there a chance to block SARS, so far mostly an urban disease, from spreading to the countryside, where the majority of 1.3 billion people live with a shortage of doctors and hospitals. By the national media all the time, farmers know that the disease can kill and they should to take methods to protect themselves and their communities.
"Angels in white"
As mentioned above, the large-scale infections and numbers of medical staffs being continuously infected has been the most dangerous features of SARS. Medical staff are called the "angels in white", who work in the front line of SARS breakout, who are fighting in the war on SARS days and nights.
National-wide, 20% of those infected are medical workers who fell ill while treating others. They are rescuing the dying and treating the sick in disregard for their personal safety. There have been a lot of heroic deeds that can move us to tears. In April in Guangdong hospitals, nurse Ye Xin and doctor Deng Lianxian died after contracting the viruses on duties, after they had been working in the front line so many days without even one day's good rest. We regard medical workers as heroes, while most of them just simply considered that they are just doing their duties. Many of them are teenagers, new married, months old baby's mothers, living with old parents, however, almost all of them could not go back home for months and the only contacts are by telephones. Did they fear of SARS? What did support them to work in the front line of the disease? In-depth interviews to the nurses and doctors should be explored in the future study.
On the other hand, what should we do for the "angels in white", and what is their autonomy? In Beijing, SARS wards are so overburdened, although the government has summoned 1, 200 military doctors and nurses form other provinces to help. The majority of the fatigued medical staffs, in particular in the earlier stage, have faced shortage of protective clothes and other materials in the hospitals and the immense psychological pressure. However, was the government aware it, and if so, to what extent? Aren't we doing enough to ensure our well being and their autonomy? What should we do to release pressure of the "angels in white" when the phone is the only means of communication with the outside world, who have relatives and friends too? Ethical principles teach us to do good to others while avoiding doing harm. However, medical staffs, especially nurses, while fighting with the disease have to battle the social stigma associated with the virus too, as they were separated in public, so were their children in schools.
Scientific challenges and social transitions
It is recognized that SARS virus first emerged in Guangdong province, southern of China in last November and has since spread to other parts of the country, Hong Kong, Beijing and more than 25 other countries around the world. The virus that causes severe acute respiratory syndrome is a newly discovered coronavirus, a relative of a common cold virus, has no effective therapy. It is spread by droplets from sneezing and coughing, and may be transmitted by touching objects such as elevator buttons too. At present early diagnosis and quarantine are essential and maybe the only way to halt the spread of SARS. Scientists are still trying to discover its source. Did SARS virus jump species from other exotic animals to infect human beings? If SARS was an animal virus, did it mutate to cause a new human virus? Or did the virus come from a common could virus, and mutated into a new deadly form? These are the questions that scientists are trying to answer. However, the challenges that Chinese people are facing are not merely issues mentioned above.
Many scientists assume that SARS virus may have originated from exotic species of animals. The search of the sources of SARS has been mainly focused on the Guangdong province of China, where the world's first case reported and people used to handling and eating the wild animals. If it was finally proved true, what should our Chinese people think of with the dietetic cultures of putting wild animals on the markets and the plates in some areas? Could eating wild animals easily transfer a virus from animals to human beings? And if doing so do our human beings violate animals' lives, as Dena Hsin also writes in this issue of EJAIB? When could the scenes of selling dogs, cats, snakes, rats, frogs and so on disappear from some of the Chinese markets? How should we human beings get along with the other species in the nature?
There is no proof that dogs or cats can spread SARS, but some local authorities has claimed that domestic animals are a threat and have forbid them to go to outside anymore. Some people have abandoned or killed their pets for the fear of SARS. I was afraid to bring my dog outside, that it would be taken away by authorities and killed these days. However, I would also never give my dog up, who has brought me a lot of joy. Even though within the SARS panic now, could people then violate animals' rights? I do think it is necessary for the government to cope with SARS, as well as other aspects of people's life more practically and wisely. It is very important to become a bioethical mature society.
Another important issue that arisen from the outbreak of SARS is the international collaboration of health care. Within the three months since SARS spread from China to more than 25 countries around the world, more than 7,900 people have been infected and 660 of them have died. It is not a China, Hong Kong, Taiwan, Singapore or Asian crisis, but a global crisis. Establishing a global health care system is critical to fight the disease as SARS, HIV, BSE, cancers, cardiovascular diseases and so on in both developed and developing countries. Absolutely, Chinese government and people have obtained significant benefits and encouragements from others by global cooperation between scientists, public health officials and the coordination of the World Health Organization (WHO) while fighting in the war on SARS.
Beijing has never before been subject to such blanket coverage of a deadly infectious disease, and before SARS, it was full of optimism and opportunity with a rapid economic growth and having won to host the 2008 Olympics. Yesterday the Health Ministry reported just 12 new infections (May 21, 2003), the lowest level in more than a month. Nonetheless, calm has been restored and schools reopened in Beijing. We all wish this would end in Beijing, in China and in the world soon. Let us give our best wishes to people who are still struggling with SARS and those who are accompanying them, the "angels in white" in the world.
Reference
Macer, DRJ. Bioethics for the People by the People (Eubios Ethics Institute, 1994).