Razzaq Siddiqui: April 2020

Book Name : China Syndrome : The True Story of 21st Century's First Great Epidemic

Author : Karo Greenfeld Taro

Genre : Non-Fiction

What is it about? : It is about the SARS outbreak in China in 2003. It details how the disease started, how it spread, how the Chinese Govt responded, how Hong Kong responded, how the medical fraternity responded and finally,most exciting of all, how it was identified.

How I came to read it : As I write these lines there have been almost 2.2 million cases of COVID-19 and 150000 deaths. The whole world is taking unprecedented measures to stop its spread. At a time like this fake news spread like wildfires. Half the WhatsApp groups I am in had some kind of fake info about the virus. Conspiracy theories abounded and in some cases racism against the Chinese. In my quest to try to fact check and provide a proper answer to the stuff being shared I decided to get more info about what viruses are. I read about this book in a website listing the top 10 books about pandemics and hence decided to read it.

Did I like it? : Its a brilliant book. This was my first medical non fiction book and I loved every bit of it. Now I know, among many other things, what viruses are, how they mutate and how they spread.
Why/views/summary :
Note : The below section contains a summary of the book. If you want to read the book I suggest you stop here and read the actual book. For others who have no time/inclination to read the book the below summary will suffice.

China Syndrome is the kind of a book, the reading of which, will change your viewpoints on a lot of things. The book starts off with a quote from a Virologist from the University of Hong Kong.
It simply reads,

''There are only four questions you need to ask about a virus.

What is it?
What does it do?
Where does it come from?
And how do you kill it?

- Guan Yi ''

1: What is it?
November 1 2003 | 7 Infected | 0 Dead

China Syndrome follows the above structure in unraveling the timeline of SARS. It starts off by following, in an almost a thriller book fashion, the movements of a young migrant from the interiors of China who arrives in Guangzhou to try his luck in the booming industries there. This is in November, 2002. Here, the ground work is laid down of the city's growth and the popularity of something called the Wild flavor restaurants which serve exotic wild animals from all over the world. A brief digression here. Many people have the question why not shutdown all of these markets once and for all. Its not that simple. Its a culture that is seeped in the people of these regions. Like how we think of checking out a new restaurant every other weekend they think of checking out an exotic animal every now and then. They think that having wild animals is their right. It is a complex problem the solution to which has to be found. Our young migrant gets a job in one of these restaurants where he is given the job of culling and preparing the animals for the chef. Here he comes in contact with a number of wild animals like cats, squirrels, civets, pangolins, bats, snakes etc. The author makes a visit to one of these markets and reads off from a Govt issued banned animal list. To his surprise all of the banned animals are available at the market. The first section ends with the description of what exactly constitutes a Virus which I have reproduced from the book below,

''The most efficient and cruelest killer on earth is not a lion, bear,

shark, or other superpredator, but probably the smallest predator. (The

difference between predator and parasite, at this point, seems to be mainly semantic.)

And this killer is not even alive in the sense that we

are alive, or even in the sense that a lichen or bacterium is alive. Viruses

are described, simply, as active or inactive. They are little more than

bits of nucleic acid (DNA or RNA) wrapped in a skein of proteins self programmed

to subvert more protein and genetic material, which they

can fashion into more virus particles. A virus’s mission is to replicate,

and it does this by landing on a cell and attaching to specific receptors

on the cell membrane, destabilizing the surface of the cell just enough

to pass into the cytoplasm—the initial stages of this replication look

something like the Apollo lander setting down on the surface of the

moon. Once inside, the virus hijacks the cell’s genetic material in order

to fashion more of itself. The process has been described as taking over

a factory and then refitting the assembly line to turn out a new product:

in this case, more viruses. These new viruses will mature and leave the

cell either by “budding,” during which a few viruses at a time pop

through the membrane, or by “lysis,” when the cell itself ruptures and

sends millions of viruses out to infect other cells. After being duped

into subverting itself to become a viral factory, the host cell will deplete

itself and die. When too many cells start dying, the host’s immune system

will react and, in the case of viruses that attack human cells, symptoms

of disease and illness will appear. Just like other predators, viruses

appropriate an animal’s protein in order to survive. (A lion gorging on a

gazelle’s entrails out on the savannah is doing exactly that.) Unlike other

predators, however, viruses are never sated. They don’t eat; they simply

reproduce. In some sense, they are the perfect life-form, only they are

not technically alive. They are nothing more than manifestations of the

urge to propagate. And in so doing, viruses have probably killed more

of everything than anything else in the history of the world.''

2: What does it do?
January 03 2003 | 48 Infected | 9 Dead

This part starts off by describing cases of a strange new disease affecting people in the interior of China. People were coming to the hospitals with respiratory illness and many of them die within weeks. A team is sent to investigate and they bring out a report. This report would be the first official document on SARS. But at that time it had no name. Nobody even knew what it was and its significance. Here enters Zhong Nanshan, a charismatic doctor who would go on to play an important role in the fight against SARS. As the cases keep mounting up China responds by centralization of infected patients. They allot 4 Hospitals in Guangzhou to deal specifically with this new disease. All other medical problems are referred to other Hospitals. This is still one of the most effective ways to deal with an epidemic. Also described here is the process of intubation which doctors and nurses perform. The author calls it a process which is 'violent and brutally simple'. The main purpose of this procedure is to bring air to the lungs. This is done by inserting a tube carrying oxygen straight into the throat and end near the T shaped junction which leads to the lungs. Now the major hurdle here is the glottis, which is a protective cover near the base of the tongue. This glottis has to be moved aside while inserting the tube. This is done by a laryngoscope. But our body has something called the gag reflex, the involuntary vomiting that the body responds to insertion of any foreign material into our throat. This movement of the patient makes the whole process tricky. Multiple attempts are made to insert the tube. All this while the patient is coughing out droplets of his saliva all over the place including the doctors and nurses. As you can imagine this is a nightmare if the patient has any disease that can transmit by droplets. Which is precisely how SARS could transmit. But the medical personnel did not know this at that time. Many hospital staff got infected this way. This part made me realize what the Healthcare workers are involved in and it only made my respect for them increase manifold.

At this time China was still holding back a lot of critical info about this new disease which was burning through some Chinese provinces. The world was aware about this new disease but there was not much info available. At this point the Department of Microbiology, University of Hong Kong start their own investigation into what was happening in their neighboring country. One of the heroes of the whole SARS episode, Guan Yi, who was an Assistant Professor in the Department of Microbiology decides to smuggle swab samples of infected patients from China into Hong Kong. He does this with the help of the earlier mentioned Zhong Nanshan. With these samples Guan Yi and Malik Peris, another professor in the same department start their investigation to try to identify the micorbe causing this. But the first set of samples yield no result. All this while China is reluctant to share information with WHO and the World. They maintain that this is nothing to worry about and they have it under control.

3: Where does it come from?
February 21 2003 | 479 Infected | 49 Dead

Guan Yi goes into China to get more samples. Meanwhile a Chinese scientist announces that he has identified the culprit which he believes is Chlamydia. The team of University of Hong Kong do not agree with him and they carry on their own investigation. The disease reaches Vietnam where a brave doctor, Carlo Urbani takes proactive and quick steps in trying to stop the spread but ultimately succumbs to his death with the same disease. Before his death he instructs to send his lung tissue sample to the US Center for Disease Control. This doctor I believe deserves more recognition. Meanwhile the disease spreads to Beijing, one of the most heavily populated cities in the world. China is still in denial. They claim that Beijing has single digit cases.

Meanwhile the effort to identify this previously unknown virus was going on. The generally followed rule was the Koch's postulate that states that for a microbe to be considered the causative agent of a disease only when satisfies the following 4 conditions.
1. It has been isolated from the diseased host
2. It has been cultured outside the host
3. It has been introduced via those cultures to cause disease in another host
4. It has been re-isolated from this newly infected host.

At the UHK, the second batch of samples also yield no result. They get a lung tissue sample from a Hospital in Hong Kong where the disease has reached. Around this time this new disease is given its name. The people who named it did not want to name it after a place as is usually done like nipah virus, zika virus, marburg virus. They decided on Severe Acute Respiratory Syndrome or SARS in short.

Finally on Friday 21 2003, the team of UHK find success. They identify the agent as a Corona virus.
3 days later US CDC independently identifies the agent as Corona virus using Carlo Urbani's lung tissue sample.Even though this was major success there was still the issue of what was happening inside China. Nobody outside of China knew the extent of the spread of SARS inside China. At this point a senior former doctor called Jinang Yanyong decides to talk to the media.

Here an explanation is provided of the SARS Corona-virus which I have reproduced as it is.

''The SARS coronavirus, Caroline Astell, project leader
at the Michael Smith Genome Sciences Centre, would tell me, was
“the largest RNA virus we’ve ever seen.” Every organism on earth,
besides a few viruses, stores and deploys its reproductive instructions
by DNA, or deoxyribonucleic acid, the familiar double-helix “code of
life,” rendered in Ping-Pong ball and pipe cleaner models in high
school biology classrooms around the world. RNA, ribonucleic acid,
is generally used as a messenger to carry genetic instructions. A few
viruses, such as the SARS coronavirus, instead store their genes as
RNA. DNA is far better suited than RNA to serve as a storage
medium for genetic information. The “double” part of the helix can,
in effect, check on the work of the genetic machinery as it replicates
itself, “correcting” most errors, i.e., mutations, as they occur. Viruses
with their genetic code stored as RNA instead of DNA lack this
proofreading ability to check on their own reproduction. As the
nucleotides of a next-generation virus are assembled according to
information stored on the viral RNA, there is a far higher chance of
an error occurring. Adding volatility to the process is the fact that
RNA is a more reactive polymer than DNA, which means that there
is more likelihood that any part of the genome may become altered
because of the presence of foreign chemicals or proteins.
Though not a reliable storage medium, RNA does provide an
interesting survival strategy for a virus. All viruses go through a very
rapid duplication cycle. A single RNA virus can produce ten thousand
copies of itself in six hours; a human being might reproduce,
perhaps, every eighteen months. Hence viruses, even more stable
DNA viruses, are evolving much faster than we are.
An RNA virus accelerates that already quickened process. As the
RNA replicates one strand of itself, it averages one mistake per ten
thousand nucleotides copied. Such instability means that once an
RNA virus has entered a cell and successfully begins to create copies
of itself, it is producing numerous mutated versions, with differences
ranging from just a few nucleotides to dozens or perhaps hundreds.
The vast majority of these genetic changes—perhaps 99.9999 percent
of them—are inconsequential or unsuccessful, or they create a
virion that is not successfully “active.” Occasionally, however,
because of the tremendous rate of mutation, an evolved virus will
emerge, one that it is actually better suited to its cellular environment.
It might have different spike proteins or a slight variation of
peptides that enables it to bind more efficiently with a host cell,
making the disease it causes more infectious or contagious.
The SARS coronavirus, it turned out, had nearly thirty thousand
nucleotides—a nucleotide is a specific combination of purine or
pyrimidine, a sugar molecule, and phosphate; genes are the
sequences spelled out by groups of these nucleotides—making it the
largest RNA virus ever recorded. While genome size does not automatically
correlate with mutability, it is a depressing fact that RNA
viruses do mutate more rapidly than DNA viruses, and that this was
a very large RNA virus. “SARS is a big, big boy,” said Kathryn
Holmes, who literally wrote the book—or at least the relevant chapter
of the book Field’s Virology—on coronaviruses. Viruses from the
coronavirus family had previously been known to cause only mild
infection in humans; along with rhinoviruses, they are a major culprit
for the common cold. They were traditionally so nonthreatening that
the 2,629-page Harrison’s Principles of Internal Medicine, the
world’s best-selling English-language medical textbook, devotes just
a page and a half to them. Yet coronaviruses that infect animals can
undergo troubling mutations. For example, a coronavirus that
caused gastroenteritis among pigs mutated in the late 1980s into
porcine respiratory infection. Another coronavirus that was the cause
of shipping fever among calves became the reason for dysentery
among adult cattle.''
4: How do you kill it?
April 08 2003 | 2941 Infected | 293 Dead

Susan Jakes, a TIME magazine journalist based in Hong Kong gets wind of Jinang Yanyong's disclosure. She meets the doctor and gets full information about the present state of the SARS situation in China. What she learns is startling. There is a full blown epidemic in China with the number of cases several times higher than what was claimed by the government. After verifying this piece of info with another source and by another reporter on the field Susan publishes the report. That article can be read here. It creates a furor in the world and directly leads to the resignation of the Health Minister and a change in tactics of the government.After a second expose of a Beijing Hospital China holds a press conference admitting about that mistakes have been made about the handling of the crisis. Here the author makes an interesting observation. Something which we are seeing again in some countries. Politicians taking advantage of the situation for their political gains.

Slowly cases begin to decline in Hong Kong. All this while Guan Yi still has one question to which he has no answer. How to kill or stop it? For this he needed to find the Vector. Along with a group of researchers in China he begins his investigation. All animals carry some kind of virus with them. Most of the time these virus stay within their hosts. Sometimes they crossover into new hosts. And in some extremely rare events they make the jump from animals to humans.This is called a Zoonotic transmission. Guan Yi believed that this jump must have happened in one of the thousands of wet markets that dot the southern region of China. He visits a number of these wet markets taking samples from the animals and and checking for the presence of the SARS virus in them. He finally finds one in Civets. He publishes his result and measures are taken to cull the animals. Slowly the SARS disease dies out.

Towards the end theres a chilling statement.

''Yet SARS had been the first disease to go H2H, or human to
human, since AIDS. And the reasons it had not wiped the human
slate were still unclear. Clinically, the consensus had emerged that
the virus had been stopped by better infection control.''

What is worrying is that There is still no vaccine for SARS and we still dont know why exactly SARS stopped.

Overall the author does a tremendous job of bringing out the timeline of SARS in a way that keeps the reader hooked. Like I mentioned in the beginning this plays out more like a thriller book. The only distraction I found in the book was when the author gets personal and describes his situation. This must have been to present an outlook covering all angles but to me it was a digression that I did not want. Apart from that the book is a must read for all of us!

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Some useful Links of the stuff mentioned in the book
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Friday, April 17, 2020

Book Post 12 : China Syndrome : The True Story of 21st Century's First Great Epidemic

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