【外交政策 20141022】非典与埃博拉

满仓

【中文标题】非典与埃博拉
【原文标题】How to Shut Down a Country and Kill a Disease
【登载媒体】外交政策
【原文作者】LAURIE GARRETT
【原文链接】http://www.foreignpolicy.com/articles/2014/10/22/how_to_shut_down_a_country_and_kill_a_disease_sars_china_ebola


十年前，中国应对非典的方式颇为有效，但有些残忍。是否有更好的方式来阻止埃博拉疫情的传播？



在缺少国际社会积极相应中的每一天，西非的埃博拉病毒让恐怖的气氛持续增长。利比里亚、塞拉利昂和几内亚几乎濒临美国疾病预防控制中心所能预测的最糟结局：到2015年2月1日，新增140万病例，98万人死亡——这种恐怖的预测简直不敢想象。在利比里亚和塞拉利昂，可怕的预兆体现为，由于缺少阻止病毒传播的积极措施，这两个国家将会以每周新增1万名病例的速度发展，直到美国人坐下来享受感恩节晚餐。到复活节，将有14％的人口死亡。

该怎么办？

一个弗吉尼亚研究团队新完成的一项研究仔细分析了目前埃博拉病毒的传播速度，以及各种控制疾病传播的策略所可能造成的影响。结果令人瞠目结舌。首先，病毒传播速度非常快，平均每位利比里亚和塞拉利昂感染者会把埃博拉病毒传染给2.22个人。而且与以往20次埃博拉病毒爆发的情形不同（以往主要的病例都是在医院或者准备葬礼的过程中被传染），病毒现在主要是在普通人群中，通过日常活动传播。这意味着，以前那些成功控制埃博拉病毒传播的方法——清理医院、隔离检查经过消毒的人群、停止进行传统方式的葬礼——在当前灾难性的疾病面前不会收到明显的成效。因此，这些研究人员告诉我们，即使现在出现了一种神奇的治疗方案，在灾难性的疾病面前也是杯水车薪。

弗吉尼亚研究人员的结论是：“至少在近期，多方协作的干预行为是至关重要的。在缺少任何控制疾病传播的重大努力的情况下，利比里亚和塞拉利昂的未来是一片灰色。也就是说，我们目前正处于疾病的爆发期，远非最严重的时刻。”

目前，没有任何一个应对传染病的现存工具和手段可以在2014年击败埃博拉，恐怕在2015年也不会。弗吉尼亚疾病研究人员说，但是有一种方法，如果立即得到积极实施，将会大幅度降低传染病的规模。方法是，找到每一个感染病毒的人和所有密切接触者，“让他们与正常人群隔离，把他们安置在一个与世隔绝又能得到专业治疗的地方。”

这样的行为在现代史中是史无前例的。1918年感冒大流行时，疾病防控人员发现自己手中的工具少得可怜，根本无法浇灭疾病的熊熊烈火。而且火焰似乎在演变成地狱之火。但是在某种意义上，至少从策略上讲，激进的隔离措施类似于主动焚毁一片树林，隔离出一条道路，确保大火不会蔓延到整个森林。

现代史中人类唯一一次被迫采取这样的手段是在2003年。采取如此严厉的措施，与政府的疏忽和过失是分不开的。病毒的名称是“非典”，发生的地点是中华人民共和国。

黑暗时代的教训

与1976年的埃博拉疾病一样，非典在历史上一直属于蝙蝠病毒，从不会传染给人类。人类感染非典是通过某些中间物种——埃博拉的中间物种主要指的是灵长类动物，它们吃掉蝙蝠，或者与蝙蝠搏斗。非典病毒从蝙蝠传染给果子狸，后者是广东人的美食。第一例已知人类感染者在2002年11月蹒跚走进中国南方的一家医院，当年12月份，病例开始在广东省扩散，并且持续到2003年1月。中国人决定不报道疫情，因此外界对于中国大陆发生的事情一无所知，直到来自广东的一位患病游客进入香港的京都酒店（后来改名为维景酒店）。他把病毒传染给居住在同层的其他游客——或许是通过电梯按钮，这些人又继续他们的旅程，前往新加坡、越南、加拿大。

从2003年1月到4月，世界卫生组织领导29个国家进行了一场艰苦卓绝的战斗，同时建立了一个史无前例的系统来迅速分享全球科研和医药信息，在一个又一个国家把病情遏制在可控范围内。但是，世界卫生组织知道非典源于中国，而且还在大陆继续扩散，病患都在北京住院治疗——这些信息遭到了江泽民政府的否认。中国当时正处于一个转型期，人民代表大会即将确认新任命的领导人胡锦涛。江的跛脚鸭政府和共产党害怕这个混乱的消息会干扰权力交接的过程——这是在中国历史上第一次没有暴力和血腥屠杀的权力交接。

于是，直到3月底人民代表大会正式确认胡的新政权之后，中国的领导人才开始考虑分享北京的真实状况——也就是非典已经在首都蔓延，数百名病患据说被秘密隔离。4月初，人民解放军的一名外壳医生蒋彦永在私下把一些文件交给《时代周刊》的记者，证明当局正在搜捕非典患者，在军队机构中进行秘密治疗。蒋对《时代周刊》说，医生“被禁止公开”非典死亡信息“以确保局势稳定”。

4月20日，在世界卫生组织和外国媒体的压力下，胡的政府正式承认非典的存在，并告知全国，一个致死性病毒正在首都蔓延。

非典期间，我正在香港和中国大陆为《每日新闻》报道有关疾病的新闻。接下来发生的事，就是一个拥有13亿人口的超级大国如何阻击这个有可能演化成一场灾难的传染病。

中国政府正式确认了北京的非典疫情，同时立即宣布，出于限制公共活动的目的，取消中国最大的节假日之一——劳动节——的庆祝活动。通常，数百万中国人会利用这个机会回家探亲，或参加全国性的庆祝活动。但是当局没有预料到北京市民对于非典和取消放假双重消息的反应，手机短信中的谣言疯传。人们说，隐藏在取消节日安排之后的，是用非典作借口来逮捕异见人士、学生和来自农村地区的非法农民工的险恶居心。疯狂的谣言迅速传播，学生们戴上口罩，匆匆收拾行李，冲向火车站。4月21日清晨，大规模的迁徙开始了。一个星期的时间里，25万名学生、农民工和害怕非典的北京人离开北京，大部分乘坐火车。我亲眼看到他们登上拥挤的列车，大部分人戴着口罩，奔向广袤国土的每一个角落。几天时间里，400万农民工逃离中国的大城市，回到农村老家。



劳动节期间，领导人发现他们未能及时封锁机场、火车站、汽车站和高速公路，导致携带着非典病毒的运输工具在全国肆意畅游。一度集中在几个重点发病区的病毒，已经在全国范围内蔓延开来。5月9日，北京的官员们承认，非典的蔓延已经无法解释，而且处于不可控的状态。北京流行病学专家梁万年在一次新闻发布会上说：“除了入院病患之外，社会上还有其它传染源。40％的新增病例在我们掌控范围内，并且已经隔离接受医学观察。对于其它新增病例，我们不知道他们在哪里，如何被传染。”

政府已经没有选择，国际卫生组织的官员不得不认为整个国家都被传染了，阻止非典的唯一希望被寄托在采取全国性防控措施上。

与埃博拉相似，非典病毒只有在人体表现出患病症状之后才具有传染性。非典的症状主要是高烧、呼吸困难、咳嗽和极度疲劳。与今天的埃博拉状况相同，应对非典的技术手段极为有限：没有疫苗、没有直接治疗手段、没有在实验室外进行快速诊断的工具。中国应对非典的最主要的武器就是体温计。

埃博拉与非典另外一个惊人的相似之处是糟糕的卫生医疗体系。利比里亚、塞拉利昂和几内亚用来抗击埃博拉的武器是极为糟糕的医疗体系，甚至可以说根本没有什么医疗机构。利比里亚总统埃伦•约翰逊•瑟利夫本周在《华盛顿邮报》上发文，写道：

“利比里亚从未出现过埃博拉病毒，我们没有任何准备，束手无策……埃博拉轻而易举地突破了我们脆弱的医疗卫生防御计划，让利比里亚的医疗系统陷入停滞，因为人们纷纷躲避医疗检查。人们无处可逃。疟疾高发期即将到来，常规的免疫机制已经暂停，即使埃博拉病毒已经停止传播，我们还要准备应对另一次疾病的来袭。埃博拉已经让我们失去了96位医疗看护人员，209名医护人士被感染，整个恢复期是一个巨大的工程。疾病爆发时，我们只有50名医生，却要处理440万名病患，这对整个国家是个巨大的打击。”

中国也同样没有任何准备应对非典，因为它的农村医疗机构已经接近崩溃。据这个国家领头的新闻刊物《21世纪经济报道》提供的信息，从1991年到2000年，政府对医疗服务的补贴比例从12.54％下降到6.59％，社会资金支持比例从6.73％下降到3.26％，而农村贫困人口自己支付医疗费用的比例从80.73％上升到90.51％。这套体系已经完全瘫痪，没有任何信用，以至于大部分中国农村居民详尽一切办法避免到医院就诊。

74岁的龙王头村居民张舒林说：“农民最害怕得病，”这里距北京一个小时车程，“因为政府不管，看个感冒就要100元。”

“100元？别瞎说了！”邻居鲍文英插嘴道，“如果你在医院住一晚，就要2000元！所以我们得病都不去看医生。”中国农村地区的人均年收入在2003年只有2366元人民币。



官员们知道，如果非典钻了千疮百孔的农村医疗机构的空子，必将呈燎原之势。一切应对方案都需要绕开现存的医疗卫生制度。一位要求匿名的高官在2003年5月13日对我说：“公共卫生现在已经是一个国家安全问题了，因为没有完善的公共医疗机制，整个社会的稳定就会受到威胁。”

香港大学政治系教授Sonny Lo在2003年5月17日对我说：“有人认为非典会对胡锦涛主席的政权产生正面影响。从长期来看，如果非典得到控制，胡主席会以此来巩固其权力。但如果非典的形势恶化，胡必将惹火烧身。新上任的领导班子是否能有效度过这场危机，我们要拭目以待。”

胡的新政府面对的压力实在太大了。

共产党和专制的公共医疗服务

2003年，中国共产党和国务院在危机时刻可以从北京直接向全国下达最高层的命令，根本不用担心地方的抗拒情绪。于是，严厉的命令被发布了。

首先，散布有关非典的谣言被宣布为犯罪，可被冠以一系列罪名，包括死刑。中国共产党总理温家宝在5月13日宣布了一系列的法规和惩罚措施，新法令下首当其冲被起诉的是一名来自内蒙古临河市的外科医生，李松。

检方认为李在3月到4月之间的行为导致临河市102人感染非典病毒，其中包括23名医护人员，还导致他的父亲、母亲和妻子死亡。李的犯罪过程并不长，在临河一所医院里，他攻击医生，因为对方担心感染非典而拒绝给他死去的父亲穿上寿衣。李当时被判处死刑，他最终的命运不得而知。陆续有其他人步李的后尘，但几乎都没有对外公布。

其次，所有的运输中心、机场、汽车站和公共集会场所在5月10日前都设立了体温检查站。而且，每个酒店、剧院、医院和学校都必须使用非接触性体温测量设备强制筛查发烧症状。在北京的每一天，我都要接受十多次体温检查，通常是在建筑物的入口，或是在驾车过程中被警察拦下。体温检查站里是当地的医护人员，当地政府的人就站在旁边——荷枪实弹的警察或士兵。

与此同时，我有生以来见到的最激动人心的建筑工程开始了。



在北京郊外一个人烟稀少的地区，政府修建了一个配有1100张床位的传染病医院。医院有自己的污水处理系统，自主供水、供电，所有这一切都在短短6天里完成。我目瞪口呆地看着隔离室、防止病毒传播给医护人员的负压力房，就像变魔术一样出现在眼前。工人夜以继日地赶工，用不到一个星期的时间，在一个个活动板房上建立起一座世界级的传染病医院。北京的体温检测站一旦发现有发烧症状的人，立即被戴上口罩，塞入救护车，送到隔离室。没有什么人权、公民自由，甚至没有必要的检查来确定是非典。一个孩子或许只是患有咽炎，但他的咳嗽和高烧有足够的理由让警察把他带离母亲的怀抱，丢到非典隔离医院中。

高烧病患的家人被警察隔离。居民没有权力拒绝，任何违犯隔离法令的人都会被警察鸣枪示警。当地医疗机构每天给隔离的家属送去饮食，检查每个人是否出现非典的症状。任何人如果发烧或咳嗽，都会被立即送入隔离病房。



这些措施在全国所有地区无一例外地实施，似乎一夜之间出现了无数的医院，收容被隔离的成千上万发热患者。（中国政府从未发表过公民被羁押、强制就医、以及因传播非典而被监禁和处决的统计数据。）我在国内各地驾车时，接连不断地被拦截，到有警察看守的检查站强制检测体温。我很害怕自己的体温会上升，从而被带到一个令人绝望的单人牢房中。于是我每天都吃几片阿司匹林，作为一种预防手段来骗过体温感应的监控设备。我记得在2003年5月，在山西省山区里的一条高速公路上的检查站，看到一长串18轮大卡车被一名荷枪实弹的士兵叫停。卡车司机们的脾气不好，但是很顺从。他们老老实实地检测体温，紧张地看着身着全套防护服的医护人员在他们的驾驶室中喷洒消毒剂。虽然当时的场面很严肃，但我实在忍不住要笑出来。因为我在想如果是美国的卡车司机遇到这样的场面该如何应对——那帮人可是后座上挂着散弹枪，听着民用波段的广播、随时与同伴保持联络的家伙，警察一般都要给他们让路。



2003年7月6日，中国官方宣布非典疫情结束（世界卫生组织证实了这个结论），整个国家立即恢复了社交活动，以弥补几个月以来半强制的隔离生活。中国政府从未透露这场激进的控制疾病运动耗资多少，有多少人被强制收容、强制治疗，这些人中真正确诊非典的比例是多少，以及有多少人因违犯传谣或隔离法令被监禁或者处决。我在外交关系协会的同事黄彦中在2004年美国医学研究所的一次会议中估计，中国在非典期间整体的投入拉低了全国GDP一个百分点。包括修建临时医院，以及中央和地方的投入在内，总资金高达11亿美元。这些努力是“成功的”，因为它的确遏制了疫情的扩散。但是社会和经济付出了惨重的代价，这个模式或许只能在另外一个专制社会中再次出现。

一定有更好的方法

弗吉尼亚的研究人员发现，利比里亚和塞拉利昂（当然也包括几内亚）目前的形势与中国在2003年4月20日之后极为相似——官方通报非典的状况；学生和农民工逃离城市造成的大混乱。疾病已经蔓延到这两个非洲国家的几乎每一个角落、每一座建筑物。医疗机构完全停止运作，只有一些束手无策的埃博拉病毒关爱组织面对受到病毒侵袭的病人。政府的公信力遭到严峻的挑战，不着边际的阴谋论和留言满天飞。

尽管利比里亚总统约翰逊•瑟利夫否定了外界对这个国家与埃博拉斗争结果悲观的预期，但她正在敦促立法机构授予她关闭媒体和广播的权力，以阻止流言的扩散。有人援引国家安全部的话，质疑政府是否还有存在的必要。食品价格在过去两个月里飙升了24％，饥饿的阴影笼罩全国。国家的经济直线下降，世界银行和国际货币基金组织预测它们将面临更严峻的财政和贸易困境。国际货币基金组织说，埃博拉给整个非洲大陆蒙上了一层阴影。

约翰逊•瑟利夫10月19日在BBC上撰文《致全世界的一封信》中说：“纵观西非，市场和边境线的关闭让一大批年轻人面临倾家荡产的风险。由于缺少足够的应急、医疗和军事力量，病毒传播极为迅速。”

遏制埃博拉疫情扩散的治疗方案并不成功，即使近期掀起的一阵国际援助热潮也远远不能满足当地的需求，病人依然被人满为患的医院拒之门外。负责协调国际援助的联合国办公室最近发布了一份详细的计划和预算需求，但目前只有三分之一的资金到位。最放任自由的当属加拿大，它最初承诺3500万加元支持联合国的计划，但到目前为止，只提供了430万加元。

美国的策略需要一大批国际机构和志愿者来帮助实现，其主要关注点是采取传统的接触跟踪方式，识别埃博拉染病者。这种人力密集型方法需要首先查出与已知埃博拉患病者有过密切接触的人的姓名，然后找到他们，隔离出已经有发烧等症状的人，密切观察其他人。尼日利亚采取这种方法成功阻止了国内埃博拉疫情的蔓延，在42天时间里监控超过1200人，最终把死亡人数控制在8个人。当然，利比里亚、塞拉利昂和几内亚的发病状况远超过尼日利亚的规模，接触跟踪意味着要监控数万人口。

美国在一个多月之前制定出的这种策略，估算费用为1.9亿美元。在它出台之后，疾病已经迅速蔓延。在没有足够资金支持的每一天里，计划都在变得更加落后。接触跟踪的成本仅仅是一小部分，因为需要医疗救助的已经不仅仅是埃博拉患病者，还包括成千上万不能得到常规治疗的病患，从疟疾患者到车辆事故受伤者。总体的费用在9月份估算为10亿美元。



国际卫生组织全球相应预警部门负责人Isabelle Nuttall在接受采访时说：“我们不能低估接触跟踪方法的效果。”她说出现疫情的国家缺少执行这项策略的能力，其它非洲邻国也无能为力。这三个非洲国家连最基本的疾病控制工作也不能胜任，包括统计病患和死亡人数，官方向国际卫生组织通报的统计数据明显是一个粗略的估算。没有人知道这些数字与真实情况有多大出入——两倍？三倍？

代替接触跟踪和人道主义隔离治疗方案的是，这些国家采取了封锁大城市中某个地理区域和社区的方法，这对食品生产和运输造成了极其严重的影响。而且，与非典期间中国专制制度下人民的顺从态度不同，当地经常出现民众的抗拒，甚至暴动行为。塞拉利昂曾经把整个国家封锁了三天，强制隔离所有居民，用这种极端手段找出受感染者并阻止疾病蔓延的努力，最终以失败告终。

如果全世界不能设法筹集足够的资金，并且动员更多的人员和设备来应对疫情，塞拉利昂、几内亚和利比里亚政府将不得不采取像中国收拾非典残局一样的策略——丢掉所谓的人权和公民自由，强迫收容隔离数千人，甚至不惜用枪口来威胁。世界绝不定容忍这种残暴的行为。或者会使用不那么令人反感、稍微人性化一些的手段，大规模修建高质量的治疗机构，让数千名贫困的病人得到治疗，并且提供足够的关心和照顾，把那些躲藏起来的埃博拉患者吸引出来。这样的方法在今天依然会奏效。这种方法的确非常昂贵，而且需要来自全世界、大量经过培训的医护人员和志愿者。但是，如果没有足够的援助，三个刚刚从内战阴影中勇敢地走出、迈向民主黎明的国家，将不得不回到埃博拉的独裁恐怖中。



原文：

China’s response to SARS a decade ago was effective but brutal. Is there a better way to stop the spread of Ebola?

With every passing day the absence of a powerful international response to West Africa's Ebola epidemic allows the horror to grow, pushing the nightmares in Liberia, Sierra Leone, and Guinea closer to the catastrophic worst-case scenario forecasted by the U.S. Centers for Disease Control and Prevention: an estimated 1.4 million cumulative cases, with 980,000 dead, by Feb. 1, 2015 -- a prediction so dire as to be impossible to imagine. For Liberia and Sierra Leone, the dire augury translates to this: In the absence of radical measures to stop the virus's spread, the two countries could witness a combined 10,000 new cases per week by the time Americans sit down for Thanksgiving feasts, and they could see some 14 percent of their populations perish by Easter.

What is to be done?

A dramatic new study from a team of Virginia-based researchers dissects the current rates of the spread of Ebola and the likely impact of various strategies for controlling the epidemic. The results are deeply sobering. First, the virus is spreading very fast now, with each infected person in Liberia and Sierra Leone passing Ebola on to, on average, 2.22 others. And contrary to the experiences in 20 past Ebola epidemics (in which the majority of cases were transmitted in hospitals or during funeral preparations), the virus is now primarily spreading in the general population through everyday activities. This means that the strategies that were used to successfully control past Ebola epidemics -- cleaning up the hospitals, quarantining infected souls within those newly sanitized facilities, and stopping traditional funeral practices -- will not have the same significant impact in the current catastrophe. Therefore, according to these researchers, even if there were a miraculous treatment available right now, it would barely make a dent in the epidemic.

The Virginia researchers concluded: "[F]or at least in the near term, some form of coordinated intervention is imperative. The forecasts for both Liberia and Sierra Leone in the absence of any major effort to contain the epidemic paint a bleak picture of its future progress, which suggests that we are in the opening phase of the epidemic, rather than near its peak."

None of the currently available tools and strategies for countering the epidemic will actually beat Ebola in 2014, perhaps even in 2015. But there is one strategy, the Virginia disease-modelers say, that will dramatically reduce the scale of the epidemic if it is aggressively implemented immediately. The plan: Find every single person who is infected and all of their close contacts and then "remove infected individuals from the general population and plac[e] them in a setting that can provide both isolation and dedicated care."

Such a course of action is unprecedented in modern times. Not since the great influenza pandemic of 1918 have epidemic-fighters found themselves with such a scanty toolbox, unable to douse viral flames. The fire, it seems, will be an inferno. But in a sense, at least in this strategy, the drastic quarantine proposed is like the deliberate burning of hillsides so as to remove woodland fuel out of the path of a more massive, unwieldy forest fire.

The only modern outbreak forced to draw from a tool kit somewhat of this nature occurred in 2003. The necessity of resorting to draconian methods in this case was the result of government blundering and obfuscation. The virus was SARS (severe acute respiratory syndrome). And the place was the People's Republic of China.

Lessons From a Dark Time

Like Ebola in 1976, SARS for millions of years was a bat virus never previously known to infect human beings. Also akin to the Ebola situation, people were exposed to SARS through an intermediary species -- with Ebola it's typically primates that eat or fight with bats. SARS spread from bats to civets, which were consumed as a Cantonese delicacy. The patient with the first known human case of SARS staggered into a southern Chinese hospital in November 2002, and subsequent cases spread across Guangdong province during December of that year and into January 2003. The Chinese chose not to report the epidemic, and it went unnoticed outside the Chinese mainland until an ailing traveler from Guangzhou staggered into Hong Kong's Metropole Hotel (since renamed the Metropark Hotel), where he infected fellow guests, all staying on his floor -- who probably were infected via his floor-level elevator button -- who then went on their respective journeys to Singapore, Vietnam, and Canada.

From mid-January to April 2003, the World Health Organization (WHO) led a goliath battle against SARS in 29 countries, creating unprecedented systems for rapid global sharing of scientific and medical information, and, one by one, wrangled each outbreak under control. But the WHO knew that SARS had originated and spread inside mainland China and that people with the disease were hospitalized in Beijing -- points that the government of Jiang Zemin denied. China was in transition, awaiting formal endorsement from the National People's Congress of its newly designated leader, Hu Jintao. The lame-duck Jiang government and the Communist Party feared that any disturbing news could upset the transition process -- the first in recent Chinese history to unfold without violence or a targeted political bloodbath.

So it wasn't until after the late-March National People's Congress session and its formal installation of the Hu government that China's leaders would consider divulging what many in Beijing already knew -- that SARS was widespread in the capital and that hundreds of patients were secretly said to be hidden from public view. In early April a surgeon from the People's Liberation Army, Jiang Yanyong, secretly passed documents to Time magazine reporters that proved the authorities were rounding up SARS patients and secretly treating them in military facilities. Jiang told Time that physicians were "forbidden to publicize" the SARS deaths "in order to ensure stability."

On April 20, under pressure from the WHO and the foreign media, the Hu government formally admitted the presence of SARS and told the Chinese nation that a deadly virus lurked in its capital.

I was in Hong Kong and mainland China during the SARS epidemic while covering the epidemic for Newsday, and what follows is how the enormous nation of 1.3 billion people stopped what could have been a genuinely calamitous pandemic.

Once the Chinese government admitted to the existence of SARS in Beijing, it simultaneously announced, in hopes of limiting movement, the cancellation of China's biggest holiday, May Day, when millions of Chinese travel to visit families or join in national celebrations. But authorities failed to appreciate how Beijing residents would react to the dual SARS and May Day cancellation announcements -- texted rumors raced across mobile phones, hinting that behind the cancellations were dark plans to use the epidemic as a pretext for rounding up dissidents, students, and illegal migrant workers from rural parts of the country. Wild rumors spread anonymously in mass-texted phone alerts, prompting masked students to grab what they could in haste, stuff bags, and race to train stations. As dawn broke on April 21, a mass migration commenced, and within a week some 250,000 students, migrant workers, and SARS-fearing citizens fled Beijing, mostly by train. I watched them cram into train cars, most wearing face masks, fleeing to every corner of the vast nation. Within days, more than 4 million migrant workers fled urban centers across China, returning to their rural homelands.

By the time May Day rolled around, leaders knew that their failure to close off airports, trains, buses, and highways had hemorrhaged SARS-carriers across the vast geography of China. What had been a focused set of outbreaks was now an epidemic, generalized across the vast country. And inside Beijing on May 9, officials acknowledged that most of the spread of SARS was unexplained and outside the control of authorities: "Apart from hospitals there are other sources of infection in society," the city's top epidemiologist, Liang Wannian, said in a press conference. "Forty percent of new cases are in our control, under medical observation or in quarantine. For the rest of the cases, we do not know who they are or how they got infected."

The government had no choice: Health officials had to assume that their entire nation was infected, and any hope of stopping SARS rested with implementation of a national strategy of control.

Like Ebola, SARS was only contagious once individuals had developed symptoms. In the case of SARS, those symptoms were fever, difficulty breathing, uncontrolled coughing, and severe fatigue. As is the case with Ebola today, the technology tool kit for dealing with SARS was bare: There was no vaccine, no direct treatment, and no rapid diagnostic test that could be performed outside a laboratory. The primary weapon in China's war on SARS was the thermometer.

Another striking parallel between the Ebola outbreak and SARS: ravaged health-care systems. Liberia, Sierra Leone, and Guinea are struggling to combat Ebola with health-care systems so abominable that they are virtually nonexistent. As Liberian President Ellen Johnson Sirleaf wrote in the Washington Post this week:

In Liberia, a country that never before had an incidence of Ebola, we were utterly ill-equipped and unprepared.... Having worked its way through the cracks in our fragile health infrastructure, Ebola has effectively brought health care to a halt in Liberia, as people avoid seeking medical attention. There is nowhere to go. So, with the malaria season setting in and routine immunization programs stopped, even when this outbreak is over we must prepare for other diseases to take hold. Yet, with Ebola having claimed the lives of 96 of our health workers and infected more than 209 others, recovering is going to be hard. This is a huge hit for a country that had barely 50 doctors to care for a population of 4.4 million at the start of this outbreak.

China was similarly ill-prepared to handle SARS, having allowed its rural health infrastructure to nearly collapse. According to China's 21st Century Economic Herald, the country's leading financial magazine, between 1991 and 2000, the proportion of government funds subsidizing health declined from 12.54 percent to 6.59 percent, social funds declined from 6.73 percent to 3.26 percent, and the proportion of health expenses paid out of pocket by the rural poor rose from 80.73 percent to 90.15 percent. The system was so broken and lacking in credibility that most rural Chinese did everything possible to avoid clinics and hospitals.

"The biggest fear of the peasant is being sick," 74-year-old Zhang Shulin of the village of Longwangtoucin, located about an hour's drive from Beijing, told me, "because the government won't pay for it. A cold costs 100 yuan."  

"One hundred! Are you crazy?" chimed in neighbor Pao Wenying. "If you go to the hospital for one day, it costs 2,000! So we usually don't go see doctors when we are sick." Average annual per capita income for rural Chinese in 2003 was a mere 2,366 yuan.

If SARS got into the awful rural medical facilities, officials knew, it would spread like wildfire. Any solution would require shunning the existing health system altogether. "Public health is a national security issue now," one top official told me on May 13, 2003 on condition he not be identified, "because the lack of decent public health has the potential to destabilize the entire society."

"One can argue that the SARS situation positively affects the power of President Hu Jintao," Sonny Lo, a professor of politics at the University of Hong Kong, told me on May 17, 2003. "In the long run, President Hu will even reinforce his power base if SARS dies down. But if SARS worsens, Hu will be in trouble. Then we will observe whether there will be a backlash against the current leadership."

The stakes for the new Hu government could not be higher.

The Communist Party and Authoritarian Public Health

From Beijing, the Chinese Communist Party and State Council in 2003 could exercise unlimited power over the rest of the nation during a crisis, and there was no real danger of popular resistance. Severe orders were issued.

First, rumor-mongering about SARS was declared a crime, punishable by a range of means, including execution. Chinese Communist Party Premier Wen Jiabao announced on May 13 a series of laws and punishments, and the first to be charged under the edict was a traditional-medicine physician named Li Song, of the small Inner Mongolian town of Linhe.

Prosecutors argued that Li's actions during March and April led to the infections of 102 people in Linhe, including 23 fellow health-care workers, and to the deaths of his father, mother, and wife. Li's crime was a brief but violent outburst in a Linhe hospital, during which he attacked doctors for refusing to dress his dead father in appropriate funeral garb, out of their fear of contracting SARS. Li was scheduled for execution; his ultimate fate is still unknown. Other heads rolled after Li's, though few were publicly revealed.

Second, fever-check stations were installed at every transport hub, airport, truck stop, and site of public congregation in the country by May 10. In addition, every hotel, theater, hospital, and school conducted mandatory fever checks routinely through non-contact thermometer devices. On any given day in Beijing, I was subjected to more than a dozen fever checks, typically at the entries of buildings or after being pulled over along a roadway by police. Fever stations were staffed by local health departments' personnel alongside visible authority figures -- uniformed police or soldiers.

Meanwhile, the most dramatic construction effort I have ever witnessed unfolded.

On Beijing's outskirts, in an unpopulated area, the government erected a 1,100-bed quarantine hospital with its own sewer-treatment system, water supply, and electricity supply -- all built in just six days. I watched in astonishment as isolation rooms, complete with negative air pressure to prevent the virus from spreading to health workers, appeared almost as if by magic. Crew members toiled around the clock, creating from prefab modules a world-class infectious diseases hospital in less than a week. Anybody presenting with a fever at check stations in Beijing was masked, packed into an ambulance, and deposited in the new isolation facility. There were no human rights, civil liberties, or even tests to confirm SARS infection -- a child might have strep throat, but his cough and fever were all police needed to drag him out of his mother's arms and haul him away to the SARS quarantine hospital.

The homes and families of fever patients were then quarantined by police. Residents had no right of refusal, and quarantine violation could be "prosecuted" immediately with the firing of a policeman's pistol. Health authorities brought food and supplies to the quarantined households daily, examining each of the residents for SARS symptoms while they were there. Any fever or coughing would result in immediate transport to the isolation wards.

This strategy was implemented the same way across the entire country, with hospitals that seemed to sprout up overnight and hundreds of thousands of people placed in isolation for their fevers. (The Chinese government never released an actual tally of the numbers of its citizens detained, forcibly hospitalized, executed, or imprisoned in relation to the SARS epidemic.) As I drove across the country, repeatedly pulling over to undergo mandatory inspections at police-manned fever stations, I feared something might make my temperature rise, putting me in a dreaded isolation ward. I popped aspirins several times a day as a precaution -- a provision that could foil temperature-based surveillance. I recall in early May 2003 pulling into a highway checkpoint in the mountains of Shanxi to find a long line of 18-wheeler cargo trucks held in position by an armed officer. The truck drivers were a surly but obedient lot, submitting to fever tests and nervously watching health officials dressed in full PPE (personal protective equipment) spacesuits spray their truck cabs with disinfectants. Despite the gravity of the situation, I couldn't help but laugh, imagining how a similar group of American truck drivers would behave, rifles hooked in their cabs, hearing CB radio warnings from other drivers, and demanding that the cops get the heck out of their way.

By July 6, 2003, China officially declared its SARS epidemic over (a declaration certified by the WHO), and the country eagerly set out to socialize, making up for months of mandatory or self-imposed epidemic isolation. The Chinese government has never revealed how much this radical approach to epidemic control cost, how many people were placed in mandatory confinement or treatment, what percentage of them actually turned out to have SARS, and how many individuals were imprisoned or executed for violating rumor-mongering or quarantine edicts. My Council on Foreign Relations colleague Yanzhong Huang estimated in 2004 for the U.S. Institute of Medicine that China lost nearly a full percentage point in GDP during SARS and that the mass-control effort, including the construction of instant hospitals, cost $1.1 billion to the central and local governments combined. The effort "worked," in that it brought China's epidemic to a halt. But the social and economic costs were exorbitant, and the model could only be repeated in an authoritarian setting.

There Must Be a Better Way

As the Virginia researchers found in their study, the current epidemic in Liberia and Sierra Leone (if not also Guinea) has reached a stage akin to that which followed China's April 20, 2003, announcement and subsequent mass disbursement of SARS by fleeing students and migrant workers. The epidemic has spread across nearly every nook and cranny of the two African countries and into every social setting. The health infrastructure has disappeared entirely. In its place stands nothing more than Ebola care centers with little to offer ailing virus victims. Public faith and trust have eroded; wild conspiracy theories and rumors are rampant.

Although Liberia's President Johnson Sirleaf has recently rejected dire forecasts for her country's Ebola fight, she is pushing legislation granting her the power to shut down press and broadcasters that spread false rumors. The language of national security has been invoked, questioning the very survival of the state. Food prices across the region have soared some 24 percent over the last two months, and starvation looms. The economies of the affected countries are in tailspins, and the World Bank and IMF predict much worse financial and trade hardships. The IMF now forecasts continentwide economic gloom, thanks to Ebola.

"Across West Africa, a generation of young people risk being lost to an economic catastrophe as harvests are missed, markets are shut, and borders are closed," Johnson Sirleaf said in a BBC "Letter to the World" on Oct. 19. "The virus has been able to spread so rapidly because of the insufficient strength of the emergency, medical, and military services that remain underresourced."

The treatment approach to limiting Ebola's spread is failing, as even a recent surge in international support hasn't come close to matching needs and patients are still being turned away from overcrowded facilities. The U.N. office that is coordinating the global response recently issued a detailed strategic plan and budget requirements -- so far only about a third of the money has been provided. Among the worst scofflaws is Canada, which initially promised CA$35 million in support for the U.N. effort and, has to date, delivered a mere CA$4.3 million.

The U.N. strategy, portions of which would be executed by a variety of agencies and international responders, focuses on identifying people who are infected with Ebola through the classic public health method of contact tracing. The highly labor-intensive tactic starts with getting the names of individuals who had close contact with each known Ebola sufferer, finding every one of them, separating out those who have fevers or other symptoms of the disease, and monitoring the others over time. Nigeria successfully prevented an Ebola epidemic in its country by using this technique, monitoring more than 1,200 contacts for 42 days and limiting the disease's death toll to eight individuals. Of course, the scale of Liberia's, Sierra Leone's, and Guinea's epidemics is orders of magnitude larger than Nigeria's. Effective contact tracing would entail tracking down and monitoring tens of thousands of people.

The United Nations' strategic plan, which was originally drawn up more than a month ago, reckoned that the cost of effective contact tracing would be just under $190 million. The epidemic has grown enormously since the plan was drawn up, and with each day of inadequate financing, the effort falls further behind. Contact tracing costs are just a small part of the big strategy, which envisioned providing medical care not only for all Ebola victims, but also for the thousands of people no longer able to obtain routine treatment for everything from malaria to auto accidents -- a total price tag of just under $1 billion in September.

Isabelle Nuttall, director of the WHO's global capacities, alert, and response effort, told reporters, "We cannot underestimate the importance of contact tracing," and she warns that the affected countries lack the capacity to execute such tactics, as do most of their African neighbor states. At the most basic level of epidemic control -- counting the numbers of sick, dead, and recovered disease victims -- all three countries are failing miserably and officially reported tolls delivered to the WHO are universally believed to be gross understatements. But there is no clear agreement about just how far off the numbers are -- twofold? Threefold?

In lieu of effective contact tracing and humane isolation with treatment, the countries have resorted to quarantines of entire geographical areas and neighborhoods within their capital cities. The tactic has had a chilling impact on food production, trade, and the movement of supplies. And unlike in China's SARS situation, where authoritarianism bred compliance, outrage and resistance have often emerged. Sierra Leone shut down the country for three days of mandatory quarantine of all citizens in a drastic effort to find the infected and halt the spread -- it failed.

If the world cannot manage to muster promised monies and mobilize far more personnel and equipment to confront the epidemic, the governments of Sierra Leone, Guinea, and Liberia may be compelled to implement strategies as severe as China's SARS endgame, dragging thousands into isolation without respect for their rights or civil liberties, and even at gunpoint. The world must not compel such hellish action. The less odious, more humane alternative of building quality treatment centers on a scale to actually absorb thousands of needy patients and provide meaningful care that improves survival and thus lures Ebola sufferers out of hiding could still work today. It is hugely expensive, and it demands thousands of skilled health workers and support staff from all over the world. But in the absence of ample aid, three nations that nobly came back from the horrors of civil war into their dawns of democracy may be forced backward into an Ebola authoritarian horror.