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China Syndrome: The True Story of the 21st Century’s First Great Epidemic
Tuesday, March 21, 2006
Asia Society & Museum, New York City
Betsy Williams: My name is Betsy Williams and I direct the HIV/AIDS Initiative here at the Asia Society which has been a three year project funded by the Bill and Melinda Gates Foundation to really look at the impact of AIDS in all sectors of Asia that the Asia Society and more recently we are expanding that to really look at some of the broader public health challenges the region faces starting with tonight’s program. As many of you may know we are a global organization that is dedicated to strengthening relationships and deepening understanding between and among the peoples, leaders, and institutions in Asia and the United States. And we do that through a series of programs such as tonight and at our museum. Tonight’s event really focuses China Syndrome: The Killer Virus that Crashed the Middle Kingdom by Karl Taro Greenfeld. It is an example of the sort of impact that disease and health can have on issues of governance, international relations, and economies in Asia and the US – not to say the least about health. This conversation is especially timely as we see headlines on Avian Flu everyday and I think that might come up in our conversation.
To talk more about what happened in 2003, we are really honored to have two distinguished guests. The author Karl Taro Greenfeld and Ian Lipkin from the Mailman school of public health and bios are in your programs so I am going to let you learn about them on your own
A few housekeeping notes: please turn off you cell phones. And we have questionnaires so please fill out the form and let us know what you like and what you don’t like so we can be sure to create the sort of programming that’s of interest to you.
Without further ado I will ask Karl to come up and he will read a few excerpts from his book. Then we will have a conversation and open up the floor for Q and A. Following the program books are available outside so that Is also available as well as books and snacks so welcome and welcome, Karl.
Karl Taro Greenfeld: Thank you. I am gratified that so many turned out for this when you are writing one of these things you are always alone and so it’s sort of surprising while you are doing it that anyone else would take an interest so it is nice to see that so many of you that would actually show up for a discussion of the process of – I am going to talk a little bit about the process of making the book and then I am going to read a little bit -- I don’t like to read too much. But the process of the writing of this book required that I learn an awful lot quickly, but I think every book is like that and every act of journalism is that like that sort of auto didacticism with a purpose but this even more so because I wasn’t a science writer or a health writer before I embarked on this. And I found that, nor was I necessarily an expert of on China. I had been running TIME Asia, which is time magazines sister publication in Hong Kong that covers the region for a few years yet I had not specifically been a sinologist. And the- so this required not only that I try to get up to speed on sort of public health issues and virology and sort of complexities like that it also required that begin reporting in China in a much more substantial way than I ever had before.
And China for those of you who work there or have been there and have tried to get anything done whether its business or public sector or journalism hosts its own set of issues and very specific problems and obstacles that really until you face them and at first cant comprehend them and certainly cant imagine how to overcome them and this for me spending hours and hours and hours driving around remote Chinese towns trying to convince public health officials and clinicians and health care workers and government officials to try to speak with me and during this period in 2003 when the Chinese government had really authorized the sort of – had initially basically tried to squelch any coverage of SARS and then there had been a little bit of loosening up but there was still in general among public health officials great, great wariness about talking about the subject alone and certainly talking to a foreign journalist about this subject was really not considered a good idea. So I would sort of sit in these cars for six hours with a driver who was inevitably smoking the whole way and my assistant and we sort of arrive in this kind of government ministries or halls or government bureaus and ask to see Mr. so and so and Deputy so and so and never ministers, far too high, but sort of low various officials and invariably they were its not that they wouldn’t see me they just were never there. I mean they were physically never where they were supposed to be and I began thinking of reporting in china of being endless journeys to get to places where no one was ever in and it got to the point—this sort of went on for the first few months of reporting this book, really all of may 2003 and into June while there was still great nervousness about the subject and it got to the point where my assistant who was just very king of tough Chinese girl from shanghai who butted heads with the government over numerous issues it got to the point where she stopped even carrying a pen or a notebook into these respective meetings. I asked her why and she said that she rightly assumed nobody will ever speak to me and I took that as sort of a bad luck talisman but finally as in most of these things or as sometimes happens I guess really I found someone who would talk to me. From the beginning of this process I had this idea in my head inspired by Hollywood and by sort of these other great books about disease outbreaks that I read I had this idea that I want to find sort of this point of convergence. The point at which this virus sort of jumps from animal to human and causes this, what is that point? What is that sort of, you know, that almost microscopic instance and so this was my ambition the whole time.
And the first real cluster of cases in late 2002 was a place called Faoshan and I kept going to the village and talking to doctors there and I actually found the guy, I never, and I found this house, anyway I found his family I never saw him and this was a survivor, this was one of the first known infections and he had survived. And I did everything I could to speak with him, speak with his family and he just would not, he was not interested, he was not interested Chinese media had been all over this guy and it was considered a source of some shame and sort of bad luck to have been so infected with this disease and he just wanted nothing to do with it. And I was, I offered him money I was so desperate to get this thing and at this point mind you I was a book writer not a writer for Time magazine -- that would have been taboo. And I couldn’t get it and I was thinking crap this is the thing I needed and I was so close to it and I was literally outside his door and he wouldn’t talk. So I sort of have to back it out and try to find, there were these other clusters going off right after this Faoshan incident and there was another one in guiyan that was another town that was six hours that was anywhere and I drove there many times and never had any luck but finally through a official who understood what I was doing and who happened, I changed assistants and got a new assistant that always dutifully carried her pen and everywhere we went and she happened to have the same last name as this official – this CDC official I Guangdong and had been from the same region in China and through this sort of weird serendipity he opened up to us and got to like us and understood what I was doing. I was explaining this isn’t a newspaper article this a serious book and I really want to try to get at what happened here and a lot of Chinese officials are going to look really good because of this. A lot of Chinese officials especially in the south did some amazing work, especially around this disease and he basically opened up his flip phone and began reading up on all these official and all these people who’s names id read and world health organization reports and so forth and this is like striking gold, you know? And when someone is actually making themselves available and giving you this stuff from that I was able to get to some of the earliest cases and also to this subsequent cluster in gugang (?) that was in some ways more important than they Faoshan cluster in that it definitely connected to Guangzhou and from Guangzhou you get the global outlook that comes from there. So on one of these visits I went down to the this case that I had gotten to through the Shenzhen CDC and it had been someone they had on their radar but hadn’t yet contact traced out all the way and he was someone who was infected probably the same time as this figure who – who’s name in the book was Xiao Pei (?) – he was the guy who had come down, he was part of what china called the 100 million men march that was more like 200 million march that was really sort of rural immigrants coming to participate in the great economic boon and part of his massive urbanization that was going on in china. And this was coming down from Shanxi and was now settling into his new neighborhood in Shenzhen that was sort of very much backwater in cities that have been emerging all over cities that didn’t exist 25 years that have been legislated into existence. So this describes what he encountered as he explored his new neighborhood.
Nov 30, 2002. Shenzhen, China. 9 Infected, 1 Dead. That first morning in Shenzhen, Fang Lin explored his new neighborhood. Ka-Ta, or the Click, had been so nicknamed by residing after the whirring electricity meters that clicked away outside most apartments there. The Click was sixty-four-eight story buildings laid out in a perfect grid. Due o the peculiarities of Chinese zoning laws, the Click was actually a cun or “village,” technically still under the jurisdiction of the farming cooperative that had been here twenty years ago when the SEZ – special economic zone – was formed. City architects, planners, and politicians had virtually no sway here, as opposed to the areas zoned as part of Shenzhen itself, where such individuals ruled practically by fiat. If land is zoned as rural land, even if, as with the Click, it is now the downtown of a massive urban center, the farmers who own the land can develop their property however they like to maximize their revenue. This has resulted in abrupt and startling neighborhood divisions throughout the Pearl River Delta. You might be walking along as well planned thoroughfare with wide sidewalks and potted plants every ten meters only to find that the way dead ends into a sprawl of ill conceived tenements.
The Click was just such an arrangement. Ten years ago, the farmer’s collective that owned the land had contracted with a real estate developer to put up these white and pink tiled buildings as housing for the rapidly expanding middle class. What no one had correctly reckoned was how enthusiastically and industriously the new tenants would set about renovating and customizing their new neighborhood. Due to some design quirks, the neighborhood was never likely to become a haven for middle class families. For example, the developers had left just two meters of clearance between each building. As a result, the narrow, unpaved alleys saw light only at high noon every day, and for the rest of the day were swathed in white fluorescence. If you were in the Clock at noon on a sunny day, the sudden appearance of this yellow, natural light was almost confusing.
During the damp summer months, streams trickled between each building; in the winter, these areas became soggy pathways. And while the original plan had provided for commercial space in each ground floor corner unit, enterprising tenants had rented other group floor flats and then simply punched their way through the brick walls facing the alleys to convert their flats into prime, street front retail space. Since urban zoning laws didn’t apply to this cun, there was little that anyone could do to restrain such sledgehammer capitalism. Electrical lines were jury rigged. Once a month, ChinaGas workers arrived in groups of tent o nip away illegally rigged cables that were bootlegging power. Many of the apartments had been subdivided into smaller, one room units, some without water or even windows. The interiors of the buildings had also been similarly modified, with power lines and broadband cables nailed to the walls in tangled masses that occasionally emitted bright showers of sparks. There were buckets of sand deposited at every landing in case of fire, but there were so full of cigarette butts one wondered about heir efficacy at containing a blaze.
Illicit commerce thrived in these alleys. There were barber poles skirling red, white, and blue. The barber pole in China very often denotes a house of ill repute. The hookers in skin tight Lycra pants and tube tops would grab your arm as you walked past. If they thought you were a foreigner, they would proffer “amore, amore” Italian here, for some reason, being the language of love. There were several tiny piecework factories of three sewing machines each; the workers slept under their machines at night. There were four fellows who could repair your shoes, and one fellow who converted old tires into sandals. There were half dozen key duplicators. And no fewer than a dozen doctors in one room practices – fifty square foot shop fronts usually featuring a bench covered with newspapers, a cabinet full of pills, maybe a diploma on the wall, and a stool on which the MD sat, smoking cigarettes. The doctors all specialized in treating venereal diseases, and a frightening few also practiced cut rate plastic surgery. But it was easy to bypass the doctors and head straight for any of the half dozen pharmacies that did a thriving business in aphrodisiacs and antibiotics. There were the pay by the call phone centers, the pay by the hour hotels and pay by the tablet ecstasy dealers. You could buy one of anything in the Click: a cigarette, a nail, a phone call, an injection, a piece of paper, an envelope, a stamp, a match, a tablet, a stick of gum bullet, a brick, a bath, a shave, a battery, even a feel.
Each visit to the Click would reveal new discoveries. One afternoon, I arrived to find the neighborhood in a panic. Somehow, a bag of snakes had been left open, and a dozen serpents had crawled out. Children were running up and down the narrow alleys, trying to catch the serpents before they slithered into pipes and through cracks. The hookers were standing on top of their chairs screaming while the men smoked cigarettes and laughed. The kids would catch just six of the snakes, and for the next few months citizens of the Click would wake up with a start as they felt the slithering muscularity of a snake passing over their feet.
On another occasion, a short man in a while T-shirt offered to sell me a gun.
The next selection is about the – the disease goes from Shenzhen up to Heyuan to Guangdong – there is a map in the book so it is easier to follow if you actually look at it – and then it comes to Hong Kong via a doctor in China who had actually been treating patients but took a few days off and had come to Hong Kong and he stays a few days in a hotel in Hong Kong and this seeds the global outbreak. Probably the worst community outbreak was in a place called Amoy Gardens that I could see from my office across Victoria harbor in Hong Kong. And this section explains how the virus gets from the hospital - Prince Whales Hospital—to Amoy Gardens and it’s also a little bit of explanation about how the SARS Corona virus infects the human lung
A Patient comes for a regularly scheduled procedure. The thirty three year old Wang Kaixi lives in Shenzhen and routinely has his dialysis done at Prince of Wales Hospital. He stays with his brother at on the sixteenth floor of Block E of a nineteen building housing complex called Amoy Gardens, a typical middle class development on the Kowloon side of Victoria Harbor: five thousand units, seventeen thousand residents, originally built in 1968.
Wang is admitted to ward 8A, where another patient suffering from pneumonia is being nebulized so that he might expectorate some of the phlegm doctors fear is curtailing his blood oxygenation. That patient inhales a vaguely lemon-scented expectorant; he exhales a lethal viral load in fine, aerosolized droplets.
Nearly every patient and doctor on the ward breathes in infectious load of virus particles.
How many particles? Remember, a virus doesn’t technically do anything. It just sits there, born aloft on a droplet or particle, until by chance it nestles in a respiratory tract or mucous membrane. Perhaps the dialysis patient Wang blinks, and a few dozen, a few hundred, a few tens of thousands of SARS viruses enter his circulatory system. Or even more likely, a thousand or so particles land on his hand, he rubs his eyes, picks his nose, and there, the virus gains entry. The vast majority of particles cannot find the appropriate cells to subvert, or maybe the genomic machinery of red blood cells is inhospitable; likewise the cells in the ocular nerves or even the upper respiratory tract. These virus particles are passed harmlessly through the body and shed via the gastrointestinal tract.
But a few hundred to a few thousand particles find their way onto the highly variegated surface of the lungs, an area that, if unfolded, stretched, and flattened would comprise a quarter acre. The surface consists of hundred of million of minute branches culminating in bronchioles that are the mechanisms for the body’s absorbing oxygen molecules. That tissue layer of alveoli and bronchioles is all that separate the human bloodstream from the air we breathe. “All a microbe had to day to gain entry to the human bloodstream was to get past that .64 micron of protection,” wrote Laurie Garrett in the The Coming Plague. The SARS virus, by chance, falls upon the alveoli, comes upon lung tissue teeming the cells that facilitate the exchange of oxygen into the circulatory system, and upon these cells which it finds by drifting, by falling, by being inadvertently carried and hauled by particles, by other cells, by protein wastes in the body -- it lands on the cell membrane and is able to bond through surface peptides and pass into the cell. And there, in this human lung cell, a most unlikely place for this particular virus, it is able to subvert the cellular machinery and convert the DNA proteins and nucleotides to its own RNA sequences of proteins. The cell itself starts producing more virus, and soon the cytoplasm of the cell is teeming with virus, as John Nichols observed through his electron microscope, and the membrane is ready to burst. A hundred thousand virus particles spill out, and rely entirely on chance to find another cell to infect. Once the virus has found he molecular perch in the leukocytes (lung cells), the body’s own immune system kicks in and there I a massive and rapid infusion of the body’s infection-fighting weapons. The airy, almost fluffy lung tissue then becomes increasingly heavy, pulpy, and meaty, as an inflamed mix of cell debris, fluid, enzymes, and scar tissue transforms into what doctors call consolidation. There is something almost cheerful about the delicate pink of a healthy lung – if you were to slice through it, it would be like taking a straight razor to the meat of raw sea urchin. A SARS patient’s lungs become blue or black, and inelastic, almost hard to the touch. On an x-ray this shows up as the white out effect doctors were noting as SARS cases progressed—when you shoot an x-ray through the dense matter of a pneumonia-stricken lung it appears as lighter than the rest of the lung. A lung this is in the his white out condition is along that has virtually stopped functioning.
It happened in Ward 8A, repeatedly. And in this case, the thirty-three year old Wang inhaled, finished his dialysis, and returned to his brother’s flat on the sixteenth floor of the Amoy Gardens. There, stricken by diarrhea, he used the toilet, repeatedly.
And then this guy actually ends up living two stories from another patient in Amoy Gardens and what happens in Amoy Gardens is probably one of the most frightening scenarios of SARS and probably hasn’t been adequately explained which was a sort of massive community outbreak didn’t really act in pattern like any other outbreaks of disease but those are two sections that are meant to illustrate the seeding of an outbreak and how it begins and as the book goes on it deals with the spread of the outbreak and the clinical response. A great deal of it deals with the Chinese government response at times inadequate and then adequate.
As I was introduced to Ian Lipkin and read some of his bio I was astonished that he wasn’t in the book itself he had been there in may 2003 and had gone through his own version of the heroing version events there and was quarantined upon returning to the united states because he was suspected of having contracted SARS himself. I guess we are going to continue the conversation now on some more specific issues.
Dr. Ian Lipkin: I have had a chance to read this book three times. The first two times I was given this book as a manuscript and then when I realized that Laurie was not going to be able to come this evening I asked for a copy and I guess I owe you fro that copy don’t i. First of all, having read many of these books—and I am on the other side which is more the laboratory side – this book really captured what happened in China. It leaves very little to the imagination. I think you have done an elegant job of capturing how this particular epidemic initiated and what evolved. There are some interesting points I just want to try to bring out.
You allude tot his really briefly. People in New York don’t realize how close we came to having it here. There was physician that was ill that flew through New York that had a respiratory condition. He was evaluated by a buddy of hi and got on a plane and was subsequently detained in Germany where he died. Had he remained behind in New York since he was carrying large amounts of the virus chances are fairly good we would have had it here. The fact that we were spared that I don’t think means that we had any great leg up, if you will, in terms of technology or clinical practice. We were just really, really lucky. There were a couple of other points you brought up that I found really, really interesting in the book. One was the comparison – you alluded to this but maybe you want to talk a little bit more about it – it was a public health practitioner named Eileen Plant from Australia who was detailed to Vietnam and she worked in two hospitals and one of these hospitals, which is called French Hospital, which is a really sophisticated state of the art sort of hospital and the virus ran amuck through this hospital and in the charity hospital there was very, very little disease. As you described the intubation and the use of these various drugs to loosen mucous the fact of the matter was that this virus primarily spread amongst medical professionals. And one of the points that you pointed out as well was that nobody refused, everybody felt that it was their duty to take care of these patients despite the risk which many thought was an obvious risk. I went though this with my own family when we went in may, the other point which I wanted to stress was the insights this outbreak gave us into the political system in China and in Hong Kong in 1997 there was an outbreak of h5n1 influenza and the virus was contained in the matter of a weekend and the total cost was 22 million dollars and at that point Hong Kong had not yet shifted to Chinese control. Contrast that with what happened in china where people very, very slowly responded and contained the outbreak. And then at the close of your book you talk about what has changed in Hong Kong. I think in your last chapter has this demonstration in June that you attended with some 600 thousand people were describing their loss of civil liberties which became quite poignant here when we think about the patriot act and everything else
Karl Taro Greenfeld: Yeah I think that one of the unforeseen side effects of an extreme culture of secrecy which the Chinese government continues to employ and sort of is a knee jerk reaction to any sort of new bad news is the biological one and this is totally unforeseen. I think before 2003 the issue of civil rights in China had been widely discussed but never in terms of posing a global biological threat. SARS sort of brought that to the floor for the first time and revealed that there are all sorts of unforeseen consequences of a culture of secrecy. In the US today when the bush administration is clearly very comfortable with a culture of secrecy and in face wants to move in that direction and combine that with a desire to seek to influence scientific research or impose a moral guidance upon scientific research. The problem with that is you cant foresee what’s going to come of that and I think what we saw in china at that point is the very real cost in terms of human lives of a government that is trying to deny a disease outbreak and also prevent information about crossing boarders. One of the important things I cam across here was that very early on when epidemiological teams went to Heyuan and when to Zhongshang and these were some of the very courageous gentlemen that I am in referring to. You almost never heard of doctors opting out in China or in Singapore or in Canada. You did in Taiwan but that’s a different matter- they felt that they didn’t have adequate protective gear. You had teams going down to at that point what were pretty local outbreaks but at that point probably were already serious enough to draw significant government attention and preparing reports on what they were finding and reports on this emerging disease because local doctors were already coming to the conclusion that they don’t what is going on and had patients who were going into acute respiratory distress much faster than they see when a patient is able to walk in under own power and two days later they were intubated in intensive care unit and they were trying to hit it with antibiotics and using Tama flu and the normal courses of medications and they weren’t getting any response. The teams went down and prepared very thorough reports on what they had seen. They didn’t know what the agent was, they and their ideas but they didn’t know what the agent was but they did know what was seeming to be happening in the hospitals. They made note of how contagious these patients were and they were already, as early as January 2003 recommending light doses of steroids. All sorts of information was already prepared inside china. Now what the Chinese government did with that question remains something of a question but we do know that it wasn’t disseminated as widely as it should have been. And when it was distributed it was labeled as top secret or nabu (?) which prevented anyone from receiving it from being willing to share it with anyone else. Infectious diseases in china are still very often treated as secret.
If what was in those reports was made available internationally as early as January or even really February 2003 its certain that had a doctor showed up in a Chinese hospital in February 11, 2003 and been showing these symptoms that had been observed they would have imposed very strict and very immediate quarantine or isolation in this case. Which means that you might not have had some of the catastrophic hospital outbreaks that then happened around the world (Scarborough, Grace and Toronto). Te point is that that the culture of secrecy has a very real cost in terms of human lives in this case and there is a casual link there. As you go to the question of what has really changed, I mean you’ve made great process in terms of starting collaborative institutions and in terms of the research side in china and that makes a great different. The question to me is, and in Chine there is always a theoretical question of what is going on there and there is always a practice. And in the local level I’ve notice that the practice is always really different from what is going on in the central government theoretical level/ in SARS we saw this all the time. The central government, at least part of it, was trying to find out what was really going on and other parts of it were actually maintaining this culture of secrecy. At the local level there were al sorts of different impulses by local officials of how they thought they should respond to these things. The test of any new institution is how it responds to a crisis. And that was what we saw here.
Dr. Ian Lipkin: I think things have changed dramatically in China. That’s not to say there is not a lot of room for improvement but there government as you point out is really run by engineers and as a result there’s an interest in sciences and entertaining science. But once you move away from the coast and you move toward the interior it’s a very different picture. It’s third world. And even when you travel through shanghai. How many people here have been to China? Well once you step away from the usual streets in Shenzhen, evening shanghai when I was there two weeks ago one block away from the Hyatt there were people who had live animals for sale and they were obviously being used for food. And its still sort of a hodge-podge and it has grown so rapidly that they have problems not only with infectious diseases but with sanitation and the air pollution is extraordinary and the amount of mercury pollution and so forth. That will be one of their major challenges. So I am more confident that they are going to get a head start on infectious disease than I am that they are going to get what needs to be done with regard to toxins and toxicology. That is a huge challenge for china. I go to china every two to three months and every two to three months it feels like it’s doubled in size. It’s an absolutely mammoth undertaking.
Now there were some interesting characters who I would also like to talk about a little bit. One was a little man named Hong Tao who I am sure you had and Hong Tao is a revered virologist in china and he was the one who was really responsible for pushing the concept that this was not a viral infection but a bacterial infection. Do you want to just talk a little about him because he was such an interesting character?
Karl Taro Greenfeld: I think you know him much better than I did. The issue initially in the outbreak, like any disease outbreak, there is a great scramble to find out what the agent is and there are all kinds of different ideas that start circulating as to what’s causing it. And there is also a scramble to get disease tissue samples of the agent or what they presumed to be agent. Very early on this idea that it is – I don’t know if Hong Tao originated the Chlamydia idea he certainly ran with it more than anyone else. There was this idea that it was form of Chlamydia infection, which is actually a wider range of infections than the one we are familiar with here. Clinicians were originally very dismissive of this idea. These were the guys fighting the disease and they knew the antibiotics weren’t working so the Chlamydia thing didn’t really make sense at there hospital level. Yet a very prominent virologist who had actually isolated at some point in his career some type of intestinal virus (Dr. Ian Lipkin: right, ??? virus) he had came forth and said that he was observing through his electron microscope what appeared to be Chlamydia infection or strains of Chlamydia. But he had never – that was sort of as far as it went. My understanding was that he had never gotten – and this was only from one sample—
Dr. Ian Lipkin: but the consequence was that people were focused on trying to develop an antibiotic for this disease - which clearly was going to be a dead end. When I went in may I sat between two groups of scientists one of which was Hong Tao who was showing my pictures, an electro micrograph of what he claimed was his Chlamydia particles. On the other side was two young Chinese scientists trained in the US who were showing me what was clearly the corona virus and their photographs dated back to February of the same year. Meaning if they had the opportunity to publish their work china would have gotten credit for characterizing the agent before anyone else would’ve gotten credit for doing so. This is something that the Chinese are very sensitive to right now. It is what is making it very difficult to get access to flu strains because they are very concerned about intellectual property, academic credit and receiving some sort of recognition for what it is they achieve. At Beijing University where I recently accepted a professorship, there is an annual prize for the best paper in science, 1000 US dollar which is a lot of money in Beijing. That is a lot of money here. But you can imagine how this is getting people focused on trying to get credit for what they are doing at their university. And this is going to have an impact on getting them to share materials. Think this is why people are now beginning to realize that if they want to do this kind of work they have to do it inside China-
Karl Taro Greenfeld: But I think one of the reasons Hong Tao was able to go as far as he did with the Chlamydia theory even after a lot of younger scientists were doubted his thesis and clinicians were dismissing it was because of his seniority. Right he was very eminent he was a member of Chinese Academy of Sciences. He was very eminent - he was a very eminent virologist. That is one of the points that I wonder whether it has really changed. Whether a very senior official of scientist goes off on the wrong track whether his underlings will have the courage to go against him because those figures you are talking about were not only frustrated that their thesis wasn’t being heeded they are also shut out from samples at some point. Hong Tao had enough power to say look I want every sample of this new disease sent to my lab and nowhere else so you had a situation in which he was able to prevent effective research outside of his own lab.
Dr. Ian Lipkin: This has changed dramatically and the reason it has changed is because in all of the academic institutions and research institutes promotion is tied to ones ability to publish in highly ranked international journals. And if you can’t get published you can’t get promoted so the Ministry of Science and Technology for example, has become very, very powerful as the Chinese Academy of Sciences. They actually superseded the Ministry of Health, because the Ministry of Health was doing a terrible job addressing this epidemic.
Another thing that I just wanted to bring up, which I think is very, very interesting, which is how we all became aware of this outbreak in the first place. There is a journal call Promed which circulated reports over internet and diseases of any sort involving plants or animals or people and it’s become very, very powerful. But even more powerful is a program called G-fen (sp?). I don’t know if you had any experience with this. There is a Canadian out of Canadian health there is a program that searched the world’s literature online in seven languages. And Larry Brilliant is now the director of the Google Foundation is trying to put additional funds into so it becomes a search engine that searches the internet in twenty languages and it looks for clusters in local papers and tries to gather this information and it lights up with a hot spot which then gets focused directly over WHO. Where a very, very small team- that’s four people, basically - is detailed to try to figure out whether or not this is a significant cluster of diseases or not. So it is one very over worked Irish osteopath and, a man named Mike Ryan, and there is Cathy Roth and there are two people who are detailed to work with them. And they are a total of four people and they are the responsible basically for tracking whatever it is that is going on in the world. It is so (?) if you consider they are four over worked people and they are trying to sort through all of this information. Everything from HIV to Ebola to SARS to influenza. But that really is the entire team.
Now another sobering thought that I just wanted to lay on you about the Centers for Disease Control. The CDC in the US is not allowed to lobby congress. They get a fixed congress and in the event that they have more than one or more than two outbreaks that they expend their entire budget, they are stuck. They are not able to negotiate. Last year there was a Marburg outbreak in Angola. And there wasn’t enough money to send the CDC sot he Canadians went in their stead. Interesting. We had a course - we have been developing rapid diagnostic tools at Columbia that can be used by a number of different people - we had three groups that came from China, two from India, all over Europe. The CDC, our own CDC, didn’t have the money to come to attend this workshop to obtain the latest technology developed in New York an in Palo Alto, CA. So although we have 7.5 billion dollars that’s flowing into Influenza virus, whatever the program is, we are not funding the CDC, our own CDC. So we did magnificently well in tracking this agent and responding to it. The real question would be that if something new came along today would there be resources in the United States to respond to one new outbreak or two new outbreaks or whatever.
Karl Taro Greenfeld: That is something that wasn’t H5N1, something that we are not kind of monitoring right now. One of the reasons SARS was detected when it was because it happened to emerge in southern China which everyone looks at for stirring for the influenza virus. Initially the reason all the trip wires started trembling was because of the worry that it was H5. And that’s what really galvanized and probably got the global outbreak and response network really focused on this very quickly. Now if a similar cluster of respiratory cases had emerged in another part of the world like Africa or India, I wonder whether the response would have been that rapid and that aggressive.
Dr. Ian Lipkin: I don’t think we would have captured it. And this is, you know, if you think in terms of risks in different parts of the world, because they all vary, in central Africa we are worried about blood borne pathogens: Ebola, Marburg, new sexually transmitted diseases, things of that nature. In China, particularly in Guangzhou, Guangdong and Shenzhen, they typically are respiratory pathogens. If we think about certain portions of the subcontinent in India we have other agents, vector born diseases, enormous burden of diarrhea diseases. And then in South America we have all sorts of diseases that carried by rodents. We are not doing much at all in South America, we are doing very little in central Africa, we are doing precious little in India. All of our focus right now seems to be around this area in south China which means that we are basically set up for something else. If history is any guide the prediction would be that we are going to have three outbreaks this year, three to five of something in the United States maybe not, but certainly elsewhere. So we need to be vigilant, we need to develop surveillance that works. They are very, very large and comprehensive. And there is a great deal, I think, that we have learned from SARS. I am very confident that the Chinese, at least the highest levels, have learned from this issue of failure to disclose. But I am very concerned as an American citizen that we are going the opposite direction here. Whether we are talking about global warming or other sorts of research, American scientists are finding it increasingly difficult to do work in the United States
Karl Taro Greenfeld: I agree that China learned the lesson because the pr humiliation of what happened in 2003. I am not necessarily as sanguine, I mean I agree there has been progress, but I am not as sanguine that there has been an evolution. And I would go to the example of Dr. Jiang Yang Yong who was the whistle blowing doctor in Beijing who made it impossible for the Chinese government to lie about the number of SARS cases in Beijing. They were saying, I don’t remember hat the number was, it was a ludicrous number. 9 or maybe 10 dead in Beijing and this was a line in the sand, they were not going to budge from this number. There were cases there, cases here, everywhere and every morning they were willing to go into the press conference and it was almost as if they were saying ‘screw you world, this is what we are doing.’ You know we had a couple of correspondents who were in Beijing and were doing amazing work. And one fellow, Wang Young, was going into hospitals. We called it bombing hospitals. And he was actually counting cases. Talking to doctors talking to nurses and trying to get a handle on how many cases there were. But we are reporters and journalists and we didn’t feel qualified to come out and say conclusively they were SARS cases. For all we knew they could be pneumonia cases and we could be proved wrong.
To really took this doctor. Dr. Jiang, who was a party member and a really sort of high ranking doctor at this hospital to come forward and say, “you know the official numbers are just wrong. I know of this many cases here and this many cases there. I know of this meeting that was help in which doctors were told not to reveal the numbers to the press. So he came forward and did this. He originally wrote this in a letter. Which he sent to phoenix tv and cctv. He expected Chinese news stations to air this letter and inform the world. He is a very naïve man in some ways and the letter wasn’t acknowledged at all. We found out about it through someone who was sort of vaguely connected to the dissident letter. He said there was this guy who had this letter and it was really interesting. Initially we didn’t believe it because it is so unlikely and previously really unknown, that a high ranking party member inside china would attach his name to a document saying the government is lying. I cannot think of another example of this happening. It happened with officials who fled china and then were willing to contradict the government. But I can never recall anyone doing this while he was living inside China. So Suzy, Suzy Jakes, went to meet with this guy to see if he was on the level, if he was who he says he is, is he crazy. There were all these things we were trying to find out about him. We concluded he boldly understood what he was doing and really understood what he was doing and really believed it was a matter of global urgency and global health to come forward and blow this whistle on the cover-up. The reason I bring this up at this point is that in 2003 when this is happening we are all looking at him and thinking is he going to get arrested? Is he going to go to reeducation? Is something bad going to happen to him? Right? Because this is a tricky case. He is a high ranking official who had been into internationally as a hero. But everyone knew who he was at that point. Certainly in the medical community everyone was very aware of who this guy was. But this is China and they don’t take well to someone public ally contradicting them. As it turned out because of recognition of the Ministry of Health had boggled this. As also the very highest levels of the Chinese government, Hu Jintao who had been locked in a power struggled with Jiang Zemin in a way, sort of seized on SARS as being his populist agenda. Right, he kind of became the anti SARS guy which meant that if you were opposed to him you were de facto the pro SARS guy. Who wants to be that guy? So he really quickly seized on this and instituted one of the most amazing sort of national infection control measures probably ever taken, or fever check measures ever taken. In that you could not a kilometer in China without having your fever taken four or five times in May 2003. If you were there you remember it was astonishingly difficult to just get around that country and if you had a fever god help you. You would sort of be taken away in a van and quarantined for 10 days.
So there had been this governmental shift and it appeared that Dr. Jiang was going to be ok. I think Xinhua did a story about him, the official Chinese news agency did a story about him because you know, they tend to ignore those they don’t like. So we thought it was going to be ok and then as I sort of watched him over the last few years his own situation has become more perilous. And I sort of took that in some ways he is my canary in the coalmine. I guess in 2003 here was a period in which there was a realization that this bad press was just bad for China and there was a lot of talk that if this had been an Olympic year China would have lost the Olympics. In 2005, dr. Jiang was arrested the reasons had to do with the fact that he had written another letter- he happened to be a doctor that had been on duty the night of Tiananmen square, he is a surgeon, and a lot of the students who were shot were brought to his hospital and he treated them. He actually wrote a letter, an ill-advised letter certainly, addressing this and saying what he experienced that night. This is certainly not a good idea to take on the government about the elephant in the room which is always Tiananmen Square. He did that and then he was arrested and his wife was arrested. He had a few very difficult months. And now he won’t talk anymore, he has shut down for awhile. But I sometime look at him and think that this is a real test of the openness. If China is really going to change and is really going to respond differently next time, they have to be willing to allow a guy like this to live his life unfettered.
Dr. Ian Lipkin: well I am not suggesting for a moment that it is a political paradise. All I am saying that they have learned that with infectious diseases you cannot keep them contained. And that the-
Karl Taro Greenfeld: in this specific issue-
Dr. Ian Lipkin: right, but they’ve already invested-
Karl Taro Greenfeld: but there have been issue with samples
Dr. Ian Lipkin: But they, but you see, again, that is a separate issue. This is something that is really common in Asia generally. There is a pattern for European, North American scientists going in to a third world country collecting samples, writing papers, making vaccines, collecting intellectual property and not giving credit to people who have done the work that is not on the ground. So there has been a desire to do the work here. Which is what China is saying: “you can do that work but you have to do it here.” Which is no different from what they say about automobiles or anything else. So I think from that vantage point, as long as you are willing to do the work in china you can make real headway.
It’s time to wrap.
(Inaudible…)
Questioner: Hi, I am Emily Penn and this is a very interesting discussion. I am just asking a question. You had said it was difficult for scientists to do work in the US today. I was wondering if you could just comment a little bit on that.
Dr. Ian Lipkin: Many of the viruses and bacteria that we would like to study are very, very tightly regulated. There is a concern that they are going to somehow get in to the community and cause damage and I think the extent of the restrictions has really become oppressive. We have to get fingerprinted, we have to get- there is a concern that people are going to take these things sorts of things and create bio weapons from them. For example, we have been trying to do some work on Plum Island which is not really that far away. It is easier for me to record sample form Africa or China than it is fro me to bring things over from Plum Island. I have to have a month worth of paper work, I have to get people fingerprinted. We have a very short time plan of when I can go there and we are actually trying to develop tools and ways we can address what we consider to be important domestic threats. That is one example. Another example, the amount of funding which is now going to research ever since the end of the Clinton administration – I think I am showing my colors here - you probably gathered that anyway – has dropped dramatically. I mean to the point where you see a point of 20 percent in a budget, this means that a kid that is in high school or college who is thinking about do I want to become a scientist or do I want to become a businessman or what have you, is you going to say everything I have seen suggestions that this is not a lifestyle is viable. If you are going to do research you have to have some consistent base for funding. You cant go like this because you have to hire people who can work in teams, you have to purchase supplies, and you have projects that sometimes take several times to achieve. That is the second example of an issue we have. So the climate for science now in the US while it is still the best in the world is not what it was even five years ago. And I think that is a real threat to us economically politically medically and so forth.
Questioner: Hi, my name is Dr. Bill Klusawski (sp?) and I am halfway through your book, Karl, and you do a marvelous job in portraying a virology lab. My training including clinical pathology so I did a stint and you did a great job explaining aspects of – its really impressive. I know you are talking about SARS but I am recommending your book to a lot of people who are interested in discussing the issues surrounding H5N1. You really give a clear view of the role of governmental secrecy, I know its getting a little bit better in China but certainly people in this country are wondering post Katrina, what our government response will be, Will it be any better? Is there any doubt about the government plan? I was reading an article from December in the Lancet, an editorial about Hong Kong about how it is very well prepared now since it hit the outbreak in 1997. From what I understand they have physician activist groups. There is one, the action group on medical policy, and they feel that their role is to examine the governmental plans, the public health plans, and then scrutinize them and comment on them in order to give their critiq2ue. And I am wondering if that is appropriate in this country, whether their should be activist physicians, as you mentioned Dr. Lipkin the CDC can’t lobby for funds but certainly private physician groups or activists could bring up the short comings and I wonder if you think that, have you experienced, have you spoke with these people in Hong Kong. Do you think it’s appropriate that the same level of involvement be occurring in this country.
Karl Taro Greenfeld: Well, I think Hong Kong had a very specific issue which had to do with the structure of Hong Kong’s actual hospital system and that you actually had the hospital authority almost existed separate from their department of health. And that, those parallel chains of command turned out to be a real problem in terms of information going back and forth. I think a lot of the physician concern in Hong Kong was around bureaucratic information that like. In that it took days for information to get from local Bureaus of Health to the Hong Kong. I think that is one issue that, I don’t know the hospital system as well as I know it in Hong Kong. I think there is – Ian will know better than me about this. One of the complexities here is that SARS happened in place where we were looking and what are the odds of that really happening. You are watching, watching, watching and then something happens. What I wonder about, and you said there will be three outbreaks around the world this year, how do you prepare for something that is essentially unknowable. Before this corona virus goes from (??) into human beings, this was a scenario that I don’t think anyone had spun out there as something to be concerned about. We were worried about wild animal markets. It just looked wrong. It is an instinctive thing. Masses and masses, unregulated, messy wet markets. All kinds of micro-swapping is facilitated. But I am not sure that anyone could have pointed to this exact scenario as being the one and one of the risks of saying we have to form action groups that are going to address every emerging disease threat, you can do that at the hospital level. You can say one of the things that worked at hospital level was this reversion to almost 19 th century sanitation standards in terms of infection control measures and strict barrier nursing and isolation and quarantine and all of these things that modern hospitals haven’t had to do for years because of modern antibiotics. So at the hospital level physician groups can take action. In places like Hong Kong and Taiwan and countries where physicians were really laid low from SARS there is a real motivation to do that and to implement those measures. I am not sure in terms of identifying infectious disease emergence whether, I don’t know what a physician activist group. Ian can-
Dr. Ian Lipkin: You raise several points. I think this a very reasonable approach. I think it’s reasonable to suggest we could in fact lobby on behalf of the Department of Health and the CDC and other groups that are charged with public health. In terms of how to find out where things next emerge, there are a number of strategies. One of them is G-fen (sp?) which is really, really very powerful. That is why Larry Brilliant is focused on it as the first project for the Google Foundation because again these things get reported locally and as long as you can capture them, you realize that things are changing. You mentioned in your book when you talk about vinegar flying off the shelves. There are people who have tried to do what we call syndromic (Sp?) surveillance to model on the basis of over the counter cold remedies or diarrhea remedies being used at a rapid rate. If you can find some way to track those you can get information. But in addition and there are a number of groups that have tried to define areas where infectious diseases are likely to emerge or reemerge, and the modeling there is done, for example the Consortium for Conservation Medicine, which is here in New York, there is a lot of this. What they do is look for intersections of bush meat, wild animal markets, population density, political instability, sounds like a lot of places doesn’t it? Right? And specific times of year in one hemisphere or another where you can predict that things will emerge. That is one side. The other side is to be able to develop the technologies which really do now exist to go into animals and to characterize and pull out their native flora so for example bats which have been shown to be the origin of the SARS corona virus and are probably the origin of Ebola and Marburg and many other things that we are not even thinking about much, rabies. If you think about chimpanzees and apes and so forth we have HIV and hepatitis C. So for example if we were to look at these animal species and see what exists there I think we would be much better prepared to deal with these diseases as they emerge in human populations. So you need technology and surveillance systems which are syndromic and you also need the ability to detail people rapidly. The four people at the WHO responding for the global alert response network is clearly inadequate. So there is a lot of things we can do. So if you want to be a physician activist the first thing we need to do is try to buttress the go RN and the next think I would focus on would be the CDC. Now this past summer I had the opportunity to speak some people who were in a position to do something about these sort of things. At the Bohemian Grow, which is a small group of very powerful men who gather every year in the forest, I told them about this problem with the CDC and I think some moneys did transfer as a result of that.
Questioner: Two in one question, please. Karl, at any point did you feel that your health was at risk? And while I am still speaking, Dr. Lipkin, you spoke of how this country might not be well prepared, and I am speaking of a bird flu epidemic, does the burden of fighting fall on the CDC or the Department of Homeland Security? And in what case, how well do you feel that we are prepared in fighting it?
Karl Taro Greenfeld: No, I never felt at any personal risk in reporting this book. Some of the reporters at Time and the Wall Street Journal in Hong Kong put themselves at risk. We had a policy that anyone who had been talking to anyone in a hospital or any suspected case had a seventy two hour hotel cooling off period during which they weren’t allowed back in the hospital. That sort of fell apart because some of our production people and support people who were not out interviewing in Hong Kong had family members who ended up getting infected and the did not impose the quarantine upon themselves because they were not part of the reporting team. Partially because I don’t even think they were aware of that policy. But no, I never felt at risk. But you, you might have been more at risk.
Dr. Ian Lipkin: I was at risk but I am here. In terms of general preparedness for h5n1, if all of the funding or most of the funding goes for a vaccine for h5n1, I don’t think that is an appropriate response. I think what we really need is to develop a generic vaccine platform that can be rapidly deployed I would make my major investment not in a specific vaccine but rather try to improve the technology and get what we call GMP facilities where we can produce major vaccines. Many of us are not as worried about h5n1 as we are about other viruses that are circulating but once we have the major infrastructure to produce vaccines, produce drugs, then we can address whatever is coming down the pike. And I think one of the things that will change dramatically is if you consider the time line. By the time we decide to make up a major vaccine for flu and the time that we have a vaccine ready for distribution is approximately 9 months because there is a serendipity associated with the process of making vaccines. You have to put it into an egg and you have to hoe that you can recover an appropriate recombined virus. The virus cannot be to toxic to kill the egg because if you kill the egg you cannot get enough virus stock with which to make the vaccine. We are moving towards a cell based system and when that is achieved, regardless of whether it’s a h5n1 or h2n3 or something we have never heard of before, we are going to be in a position to respond rapidly. Instead of requiring nine months we are going to be able to jump in and develop something and respond very, very rapidly. Most of the problems at this point are not really scientific they are regulatory. It’s being able to get something rapidly through the pipeline, get it approved by the Food and Drug Administration. Make sure there is a market so that people are able to actually produce and use these drugs. And that is the other sort of lesson we are moving towards. I am very concerned we are putting all of our money into developing a specific vaccine instead of putting any money into infrastructure for public health vaccine and drug delivery.
Karl Taro Greenfeld: And you are worried about this specific vaccine because the mutability of the virus. You think the eventual pandemic threat is actually from a mutated form-
Dr. Ian Kipkin: I mutated form of this virus we could have 300 million doses of a vaccine that really doesn’t have much value. Yes, you can some cross protection but again if we can make a vaccine in two months, which I think we can do if we really gear up for it. And this is where the Chinese have an advantage because they will do that. They will gear up in that fashion. If we can gear up in that fashion then we can have a vaccine that is appropriate and that is exquisitely effective and that is really where we need to be focusing.
Karl Taro Greenfeld: I have a question for you. One of the things I have always wondered about as the WHO was struggling to get access to southern China and sort of get to the hot spots was how willing would the US be if there were outbreaks say in Arizona, how willing would the US be to allow the WHO team comprised of Chinese physicians to roam about the country at will.
Dr. Ian Lipkin: Well remember the Cubans wanted to help us with Katrina. Remember that, they had a boat and said we will send in physicians we are used to dealing with these types of disasters. I think that is – you’ve made an excellent point. We wouldn’t.
Karl Taro Greenfeld: Right.
Dr. Ian Lipkin: And look at the way we feel about spongaforinsephalophathes (sp?) and so forth that emerge in deer. We are not exactly forthcoming so we should probably look at ourselves as well.
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