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Tracking Down the SARS Mystery: A Historical Perspective - 2003-03-28

The flu-like respiratory illness that has killed at least nine people and sickened about 500 others in the past few months is sparking serious concern among public health officials. An international surveillance effort is underway to identify the infectious microbe and to figure out how to contain and treat it.

The United Nations' World Health Organization has declared the ailment - known as SARS, for Severe Acute Respiratory Syndrome to be a major threat. It is characterized by a high fever, muscle aches, a sore throat and progressive pneumonia.

Outbreaks of SARS, which began in China last November, have since been reported in Thailand, the Philippines, Indonesia, Vietnam and also in Canada. But there's no evidence yet that these outbreaks are linked.

Investigation of new cases among travelers to Asia is underway in other countries. No confirmed cases have been reported in the United States.

Julie Gerberding heads the U.S. Centers for Disease Control and Prevention in Atlanta. She says the agency is supporting the global surveillance effort. She says it is improbable that the infectious agent is a biological weapon. "This does look to be like a very contagious disease to health care workers and to the family members who have it," she says. "But we don't see anything that looks like a terrorism attack right now. We do have to keep an open mind, however because this is a very difficult time for us, and we want to make sure that we don't overlook something like that."

The World Health Organization has mobilized experts from eleven laboratories in nine countries to find the cause of the mysterious illness. Howard Markel, director of the Center for the History of Medicine at the University of Michigan, says that like detectives on a criminal case, the medical team must first rule out the "usual suspects."

Markel: "Influenza would be right up there, but there is a whole menu of other viruses or bacterial infections that could cause these problems. And then they start to look at the actual victims, particularly those who died and try to culture body fluids from them and see what grows. They also try to put all the pieces of the puzzle to come together."
Skirble: "Why are they having such a hard time identifying [the illness]? The New York Times reports that laboratories in at least five countries have failed to identify any known infectious agent."
Markel: "It is a reflection of the 21st century that we like answers very quickly, but we have to remember that with every new epidemic disease, or new wrinkle of epidemic disease, we really don't get those answers as quickly as we'd like, which for lay people would be yesterday before [the occurrence] ever happened. But, I would predict that within the next week or two we will know exactly, what is going on, and if you compare that to previous times that we have faced epidemic diseases that is rather quick. Even with HIV which is in our era, it started twenty years ago it took a couple of years before they actually identified the human immunodeficiency virus as the cause of AIDS. If it is a usual suspect and say [it is] a very different influenza, the culture methods that we have would readily answer that question. If it is completely different infectious agent, that requires all new sets of methodologies and techniques to culture out, we have to figure out that too."
Skirble: "How do you go about doing that?"
Markel: "That is the magic of microbiology. It is a very clear pattern of what you do. First, you hear about cases, and that has gone on about the last couple of weeks with the man who was diagnosed in China and then a few people in Britain and so on. So, you start gathering cases and getting information and asking questions about it. What were the clinical features? How many died? How did it spread? Where is it being discovered now? Is it traveling from place to place? So you try to shape the contours of the clinical features of the disease. Then if you have people who die of it or patients with the disease, you try to get body fluids from them that would help you diagnose this. Because pneumonia is a leading component of this disease removing some sputum that's the gross stuff you cough up when you have bad cold and trying to culture that would be a real good place to start. Blood cultures would be another. And then you do a variety of tests that are either bacterial or viral in methodology and try to find that agent."
Skirble: "Why is this considered dangerous? Or is it hype?"
Markel: "That is a good question. And, as an historian I am always more comfortable answering that question fifty years after it happened than in real time. I think it is very common whenever we have a new infectious agent discovered or recurring in some way that we all get scared about it, and we all react in a sudden way. It may very well happen that this [illness] may peter out and that this [illness] may be yesterday's news in a relatively short manner of time. On the other hand, it could be a very strange strain of an influenza type virus that traverses the world. Influenza still kills 40,000 to 50,000 people a year in the United States largely elderly people or people with other serious illnesses - but don't forget when it swept the world in 1918 it killed about 30 to 40 million people. It killed far more people than died in World War I. Something was different about that strain of influenza than what we had seen before or have seen since. So, it is impossible to predict the future, but if I were a betting man, I would say this would probably be contained and handled. That is what I am counting on."
Skirble: "In the context of the history of medicine is this a rare or a common event?"
Markel: "In terms of this particular virus, if that what it is, that is somewhat unique. In terms of the contours of how society is responding, it is extremely common."
Skirble: "But, is the context any different today because someone can travel anywhere within twenty-four hours?"
Markel: "Oh yeah, you are right. Technology has changed the contour so that certainly you can get anywhere around the world in less than 24 hours. So germs can travel far faster than they ever had the ability to travel before. By the same token there are a lot of technological advances that help us answer these serious questions far more quickly than ever before in the history of humankind. The fact that we can sit here and predict here in relatively short order I can't tell you the exact time line but I believe the WHO [World Health Organization] and the various teams working on this will figure this out pretty quickly. And, we'll also figure out if not an exact medication for it, we will figure out ways to isolate and contain those [people] with it very quickly."

Experts working on the surveillance teams report that Severe Acute Respiratory Syndrome has not responded to antibiotics. If the SARS pathogen proves to be a bacterium, public health officials will face a larger problem, the declining effectiveness of antibiotics in the fight against bacterial infections.