Lessons From SARS: How to Deal With the Coronavirus — and Our New Normal

What I learned about outbreaks from surviving a pandemic

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AtAt the end of March 2003, I was sitting on the sofa of a borrowed studio apartment in Hong Kong, wondering if I was going to die.

It was the spring of SARS. The outbreak, which had originated in late 2002 across the border in the neighboring Chinese province of Guangdong, had been growing throughout the month. In Hong Kong, where I had been working as a reporter for TIME magazine for nearly two years, there had been a burst of cases at one of the city’s main hospitals. There were smaller outbreaks in cities like Singapore, Taipei, Beijing, and Toronto. By the middle of the month, the World Health Organization (WHO) had issued a heightened global health alert over the respiratory illness, which didn’t yet have an official name. Worst of all, on March 30 an explosive outbreak in Hong Kong’s Amoy Gardens apartment complex sickened more than 200 people and fueled fears that the SARS virus — which up until then had mostly spread in health care settings — was now active in the community. And if the SARS virus could spread easily in public through the air like the flu, what could stop it? Which is how I found myself on that couch, worrying I was going to die in Hong Kong.

An outbreak looks and feels very differently as it is unfolding than it does in hindsight, when the cases have been closed and the virus contained.

Looking back 17 years later, I can see those fears for what they were: ridiculous. The Amoy Gardens outbreak, which marked the high point of SARS hysteria, turned out to be the result of a fluky set of epidemiological coincidences that hinged on the apartment complex’s faulty plumbing system. There was never again a large-scale community outbreak of SARS on that scale. A couple of weeks later international scientists managed to isolate and identify the pathogen that was causing SARS, and I found myself at Hong Kong’s Queen Mary Hospital, staring through an electron microscope at the spiky coronavirus that was the cause of all this trouble. By the end of April, the outbreak was halted in a number of affected cities and the number of new cases in Hong Kong was plummeting fast. By July 5, the WHO declared the SARS outbreak contained. It was all over.

SARS has obvious parallels to the ongoing coronavirus outbreak, and not just because both originated in China and were caused by pathogens of the same viral family. The differences matter too, from the nature and virulence of the virus to the major technological and geopolitical changes that have occurred since 2003. But perhaps the most important lesson — as the outbreak in Wuhan exceeds the total number of SARS cases and the WHO finally declares the situation a global health emergency — is this: An outbreak looks and feels very differently as it is unfolding than it does in hindsight, when the cases have been closed and the virus contained. Which should give us some comfort as global alarm rises over the new coronavirus, while also reminding us of just how hard it is to know what will come next.

The reason why the Amoy Gardens outbreak was so frightening was that it seemed to mark a drastic shift in just how contagious the SARS virus was. SARS already appeared, true to its name, severe. At the time nearly 60 people had died from SARS, out of more than 1,600 cases, but even those who survived were often hospitalized for weeks, with many requiring mechanical ventilation to breathe (a treatment that inadvertently helped spread the disease in hospitals before doctors realized what they were dealing with). If SARS could spread easily among the public, as the Amoy outbreak seemed to indicate, the effects would be truly devastating. Think hospitals overwhelmed by patients gasping for breath, requiring the rationing of ventilators and forms of emergency care. Hence the fear.

Unlike SARS, the novel coronavirus — or 2019-nCoV as its officially called, for 2019 novel coronavirus — seems to have been fairly contagious in public from the earliest stages of the outbreak, which is why the case numbers have piled up so quickly. But like SARS, in the middle stages of that outbreak, we don’t really know how contagious the new coronavirus is yet. As science writer Ed Yong pointed out in an excellent article in The Atlantic, scientists have come up with a range of figures for the virus’s infectivity, characterized as its R0 — the average number of people each infected person will in turn infect. The higher the R0 — and most early estimates for the new coronavirus fall between 2 and 3 which is theoretically the more contagious a pathogen will be and the more difficult it will be to control an outbreak. But R0 is an average that can hide all kinds of variation, including the possibility that some sick individuals may infect large numbers of people, while the vast majority infect very few.

Such people, known as super-spreaders, played an important role in the SARS outbreak — though again, that wasn’t something we knew for sure in the middle of it. Though SARS ultimately had an R0 around the same range as the early estimates for the new coronavirus, that number was inflated by super-spreaders like Liu Jianlun, a doctor from Guangdong who introduced SARS to Hong Kong in late February when he infected over a dozen people at the city’s Metropole Hotel. Had every SARS patient been as infectious as Liu, community explosions like what happened at Amoy Gardens would have been far more common, and the outbreak might have been impossible to fully contain. But they weren’t, especially once doctors put in place infection control methods that essentially halted transmission in hospitals, which reduced the virus’s R0 number below 1. Ultimately, save for the super-spreaders and flukes like Amoy Gardens, SARS wasn’t a terribly transmissible virus — though again, that wasn’t clear until the later stages of the outbreak.

What about the new coronavirus? The picture is incomplete, but less encouraging. The sheer number of cases that have piled up in a fairly short period of time would seem to indicate that the virus spreads more easily in the community than SARS did. On January 30, the Centers for Disease Control and Prevention (CDC) confirmed the first case of person-to-person spread inside the United States, as a person who had been in Wuhan and returned to Chicago transmitted the virus to another individual. It likely won’t be the last. And while the new coronavirus has racked up almost as many cases in several weeks as SARS did over the course of more than six months, doctors are almost certainly overlooking milder cases in the heat of the outbreak, which means the true case count is likely higher. “If it gets so expansive then it’s not going to just disappear the way SARS did,” Dr. Anthony Fauci, the head of the National Institute of Allergy and Infectious Diseases, said in a podcast posted by the medical journal JAMA. “I think the next four to five weeks are going to be critical. It’s either going to start peaking and go into a downturn, or it’s going to explode into a global outbreak.”

The infectivity of a virus helps determine how widespread an outbreak will become, but just as important is how deadly it is. And the early indications are that the new coronavirus is milder for those who contract it then SARS was. With 170 deaths out of around 7,770 confirmed cases as of January 30, the new virus has a mortality rate below 3%. That’s high for a respiratory virus — seasonal flu kills around 0.1% of those it sickens — but it’s lower than the roughly 10% seen during SARS. And while again, any estimate made during the midst of an outbreak is uncertain, it’s more likely that number falls than rises, as doctors uncover milder cases that were initially missed. Those who have died have been elderly and/or suffer from preexisting health problems — the same population that tends to be most vulnerable to the flu.

In some ways, we’re also readier to respond to a new outbreak than we were 17 years ago. Advances in genomics helped scientists rapidly sequence the genetic structure of the new coronavirus, which in turn sped the development of diagnostic tests and candidate vaccine strains, even as the outbreak is still at full tilt. It took months after the SARS outbreak officially began before the virus was isolated and sequenced. The Chinese government has been, if far from perfect in how it has handled the new coronavirus, more open than it was during SARS when months of cover-ups on the local level directly led to the virus spreading into Hong Kong and then globally.

Disinformation — and there’s no other word for it — matters because trust matters during an outbreak. Trust might be the most important ingredient of a successful outbreak response.

But the world also has new vulnerabilities that didn’t exist back in 2003. China is far more connected to the rest of the world via travel and business links than it was 17 years ago, which means both that it’s easier for the new coronavirus to spread internationally and that any economic damage in China from the outbreak won’t be contained there. China under President Xi Jinping is even more authoritarian than it was in 2003, increasing the chances that ordinary citizens could be hurt as the government institutes unprecedented responses like the effective quarantining of tens of millions of people in and around the heart of the outbreak. In 2003, brave Chinese citizens like Dr. Jiang Yanyong spoke out against the government’s cover-up. Jiang told my colleagues at TIME’s Beijing office that Chinese officials were hiding SARS patients from the WHO, in an effort to minimize the scale of the outbreak. Instead of being lionized, though, he’s been in and out of house arrest in the years since, and it’s difficult to imagine someone making the same choices to speak up today in Xi’s China.

And then there’s another new contagion: social media. In 2003 there was no Facebook, no Twitter, no Reddit, and hardly any smartphones worthy of the name. Information about the outbreak still mostly moved via the mainstream media. In 2020, that is… not exactly the case. Influencers and hucksters have used social media to spread hoaxes about the origins of the coronavirus outbreak, its severity, even supposed treatments. Promoters of the pro-Trump conspiracy theory QAnon have been urging their supporters to stay safe from the virus by ingesting what is essentially bleach. (Do not do this.)

This disinformation — and there’s no other word for it — matters because trust matters during an outbreak. Trust might be the most important ingredient of a successful outbreak response. People need to trust public health officials that the information they’re receiving about a virus is accurate, and ultimately, we need to trust each other. Perhaps that is the ultimate lesson of SARS. Even during the darkest days of that outbreak, there was trust in what international health officials were doing to try to stop the spread of the virus — and ultimately, that trust was rewarded. Is that still possible today, in a media ecosystem contaminated by disinformation, cynicism, and racism? The answer to that question will help determine how we remember the coronavirus outbreak of 2020.

The coronavirus outbreak is rapidly evolving. To stay informed, check the U.S. Centers for Disease Control and Prevention as well as your local health department for updates. If you’re feeling emotionally overwhelmed, reach out to the Crisis Text Line.

Journalist, author, dad. Former TIME magazine editor and foreign correspondent. Author of END TIMES, a book about existential risk and the end of the world.

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