Evidence mounts

However, the web search led WHO-Beijing—which typically did not review the daily regional press—to accounts of two Guangzhou press conferences that day, February 11. There were no foreign media present, but Chinese journalists covered them. In the first, the vice mayor announced an epidemic of atypical pneumonia; in the afternoon, the Guangdong Health Bureau announced 305 cases and five deaths between November 16 and February 9 from atypical pneumonia of unknown cause. A third of the cases, it said, had affected health workers. Officials at both press conferences offered reassurance that the outbreak was contained.

To Schnur and Bekedam, the official statements seemed plausible; there was nothing unusual about an increase in atypical pneumonia cases in winter. The only piece which did not fit was “the clustering and the affecting of the health workers. That was unusual” for either ordinary flu or atypical pneumonia, notes Schnur. Moreover, H5N1 in its previous appearance had not sickened large numbers of people (and those mainly had contact with infected chickens). On Wednesday, February 12, Schnur drafted and Bekedam signed an official letter to the MoH which requested additional epidemiological information on the outbreak in Guangdong, and offered WHO’s assistance. The ministry officially responded on Friday that all was under control. It said the cause of the outbreak was unknown, but was likely viral. The letter acknowledged cases in six municipalities in Guangdong Province, but added that in three there were no recent ones.[10]

Bekedam and Schnur knew that any new, and more deadly, strains of avian influenza would likely be reported first as atypical pneumonia. It was also widely known that the central government had difficulty getting reliable data on many subjects, including health, from the provinces. Says Schnur:

So the central government doesn’t always believe the data they’re getting out of the provinces. We had no basis to provide alternative data, but I think we were waiting for more information before taking it at full value.

Bekedam on Monday, February 17 sent MoH a follow-up letter, again requesting more detail and offering to help. The ministry replied on February 19 that the cause of the Guangdong outbreak was almost certainly chlamydia (a pathogen that also caused a common sexually-transmitted disease). “We will keep you informed of the further developments in due course,” it concluded. The office found the chlamydia conclusion hard to credit. For one thing, says Bekedam, “the combination of infectiousness, the disease pattern [meant] it was not difficult to think that a virus was most likely the likely cause. Chlamydia just didn’t fit.” The WHO office was unsure how to respond. Recalls Schnur:

We weren’t quite sure how big this was.  If it was an ordinary outbreak, China certainly has capacity to investigate and respond to outbreaks.  And it’s not WHO’s role to jump in on every outbreak. 

But that same day, February 19, health authorities in Hong Kong reported to WHO the case of a family, recently returned from China, suffering from an unidentified respiratory disease—possibly bird flu. The WHO Western Pacific Regional Office, already concerned by the cases of atypical pneumonia in China, went on alert. Its experts wondered whether the Hong Kong cases might be related to whatever was going on in Guangdong. The only way to be sure was to go to Guangdong, take samples from patients and send them to a laboratory for analysis. On Thursday, February 20, WPRO Director Dr. Omi formally asked the Chinese Ministry of Health for permission to send a team of international health experts to help investigate the Guangdong outbreak.

But the ministry insisted that it needed no help—so the Beijing office asked instead that the team members be allowed into China to help local WHO staff. They were certainly in the dark. As Bekedam remembers: “It was uncertainty from the start. We didn’t know what was going on… We didn’t know what the causative agent was. And we didn’t know how it would evolve.”

[10]  WHO, SARS, p.6.