Experts Say China Has Greatly Underestimated Virus Cases

The New York Times

By ERIK ECKHOLM April 16, 2003

BEIJING, April 16 — Chinese authorities have significantly understated the prevalence of severe acute respiratory syndrome in Beijing, international medical investigators said today. Cases are possibly now in the range of 100 to 200 rather than the 37 that were officially reported on Monday, they said.

"My guess is that we are in the 100 to 200 range now," said Alan Schnur, an infectious disease expert from the World Health Organization's Beijing office who led the expert team on the outbreak, known as SARS.

"We are not talking about a wild, out-of-control outbreak," Mr. Schnur said, noting that the city has a population in excess of 13 million.

"But the systems for surveillance, investigating and reporting SARS cases are not good enough," he added, hampering effective control and creating uncertainty about the future course of the disease, which is fatal in about 4 percent of patients.

A major problem with the Beijing data, the team discovered, is that, contrary to repeated assertions last week by senior national and city officials, the city's case reports have not included patients in hospitals run by the military, which serve both military families and civilians but do not answer to civilian health agencies.

That revelation, which emerged from the team's visits on Tuesday to two major military hospitals, vindicated Dr. Jiang Yanyong, 71, a military surgeon who in an unusual protest letter said officials were not counting at least 60 SARS patients in military hospitals. He later told reporters that the number of overlooked patients surpassed 100.

"We came to the conclusion that it was very credible," Henk Bekedam, resident representative of the W.H.O., said of Dr. Jiang's letter. Yet the experts said they are still prohibited from revealing the actual figures from military hospitals without special permission from the Defense Ministry.

A second source of undercounting, the experts said, is that many cases have been labeled in local hospitals or district offices as "suspect" when the patients clearly had SARS.

Beyond patients with confirmed or suspected SARS, Beijing's hospitals are holding more than 1,000 people in temporary quarantine for observation, the team was told.

These include some people who were closely exposed to sick patients and others with forms of pneumonia that may be more ordinary and curable, but have not yet been identified. Many of these quarantined people are not likely to develop SARS, the experts said, and they called for more consistent criteria for putting people in isolation. But the presence of large numbers of sequestered patients may help explain the rampant rumors about high case loads at various city hospitals.

SARS is believed to be caused by a new form of corona virus, which may have originated in China's Guangdong Province last fall and then spread to Hong Kong, and those two locations have borne the brunt of the epidemic. After a recent mission to Guangdong, which recorded a total of 1,273 cases with 45 deaths as of April 15, W.H.O. officials said that officials there had belatedly tackled the disease well, and that new cases are declining.

Mr. Schnur said that Beijing's research and records on SARS patients were not good enough to enable calculation of the epidemic's future course. But he said he believes that, with the more extensive and determined control measures that are now starting, the city can avoid a spread on the scale seen in Guangdong.

In Beijing, perhaps in part because of concern about the image of the nation's capital, officials for weeks have played down the threat and the numbers. But a growing credibility gap emerged as local doctors and international news media reported seeing far more patients than were officially reported.

With public fears and economic losses mounting, the Chinese last week finally asked for the review of Beijing's programs and the team said it was generally satisfied with the cooperation they received.

"We were allowed to visit any place we asked to, sometimes at the last minute, and we had a good feeling about our access," said James Maguire, an epidemiologist on loan from the American Centers for Disease Control.

While the international team painted a dismal picture of Beijing's early measures to track and fight the disease, they also said they were encouraged by a new recognition of the threat by top national and city leaders. In recent days the president and prime minister have spoken more frankly of a "grave" problem, called for openness and pledged to spend whatever sums it takes to defeat SARS.

W.H.O. experts said that in discussions today of their findings, Chinese officials pledged to fix the reporting problems, including the incorporation of military data. The international experts also recommended that, in part to counter rumors, Beijing should publicly report on suspected cases and patients put under observation, though officials apparently made no commitment to do so.

Apart from political sensitivities and a longstanding official penchant for secrecy, China has been slow to confront SARS because it has neglected public-health measures, Mr. Bekedam said.

"The government has under-invested in health in the last 20 years, leaving it to individuals to pay the bills," Mr. Bekedam said. "Things like disease surveillance and control are `public goods' and the government needs to invest."

Mr. Bekedam also said that it was vital that the government offer advanced medical care to all SARS patients regardless of income. "If patients can't be treated and isolated properly, for sure you'll have a major outbreak," he warned.

Officials have announced that destitute SARS patients will receive free care, but it is not clear how the policy will be enforced around the country, where hospitals are struggling financially and often turn away those who cannot pay.

These experts are most worried about the potential spread of SARS through poorer, medically backward interior provinces and rural areas.

The May 1 holiday period, traditionally a time for travel, poses a special challenge. This week the government announced new steps to discourage sick people from boarding planes, buses and trains, but these will be hard to enforce.

The W.H.O. will continue investigations in Beijing, Mr. Bekedam said, and also plans missions to several other sites around the country in coming weeks.

Mr. Bekedam noted that SARS, for all the damage it has done in a hurry, does not spread nearly as easily as some common threats. "If this were influenza, we'd have one or two million cases in the world now, instead of 3,000," he said.

"We hope this will be a wake up call for China and the world, a call to prepare for the bigger epidemic that one day will come."