shopping spree, in turn sparked an outbreak that sickened at least 195 people in her own country. The doctor who treated the initial Singaporean case later flew to New York for a medical conference and on the way infected a Singapore Airlines flight attendant.
The Chinese American merchandiser continued to Hanoi, where, before succumbing to his sickness, he seeded a Vietnamese outbreak that infected sixty-three others. A French physician in Hanoi who cared for a stricken colleague later carried the virus home to Paris, along the way infecting three others on the Air France flight.
Just four days after Dr. Liu had boarded the bus in Guangzhou, the elderly Canadian woman from the Metropole was back in Toronto, halfway around the globe, and feeling ill. Before she died, this grandmother passed the virus to four family members, ultimately igniting a cluster of 136 cases in Canada. One of those stricken in Toronto was a nurse from the Philippines, who later flew home to help find a faith healer for her cancer-stricken father and instead infected her family with the killer virus, volleying the illness right back to Southeast Asia.
This is how an epidemic becomes a pandemic. This was the first great wave of a still-unnamed virus washing over the world. More would follow.
Of all those sickened at the Metropole, the one who went on to infect the most people directly wasn’t a guest at all. He was a twenty-six-year-old airport freight handler from Hong Kong itself who visited a friend staying on the ninth floor. About two days after this young worker started feeling lousy, he went to the emergency room, where he was diagnosed with a respiratory infection and sent home. Almost a week later, as his condition worsened, he was admitted to Prince of Wales Hospital. As the main referral hospital in the New Territories, this modern medical complex has the feeling of a bus terminal at rush hour, with crowded corridors and long lines at the reception windows. The young man was placed in Ward 8A. He went on to infect at least 143 others, all at the hospital.
From here, the virus again exploded into the world. Nearby in Ward 8A was an elderly Chinese man being treated for an unrelated salmonella infection. His seventy-two-year-old kid brother visited him often. On March 11, the younger brother developed a fever and three days later came down with a cough and chills. Though a physician urged him to get hospital care himself, the man insisted on flying back home to Beijing as planned. On March 15 he did so.
“It was like seeds thrown into the wind,” a doctor in Beijing later remarked. “Who knows where they will land?”
Air China flight 112 was nearly full that Saturday. The Boeing 737 had 112 passengers and 8 crew members. The ailing seventy-two-year-old was slumped in seat 14E. He looked pale, his brow was drenched. He couldn’t quiet his coughing and kept hacking until his handkerchief was soaked. He went to the galley to ask a flight attendant for water to take some pills. In the three hours it took to reach Beijing, he infected 22 passengers between rows 7 and 19 and 2 flight attendants. The first victim would spike a fever within days. By the middle of the next week, three- quarters would develop what initially felt like a bad head cold. Five would later die, as would the elderly traveler himself.
The two flight attendants were from Inner Mongolia, a region of northern China. When they returned home, they sparked an outbreak that accounted for most of its 290 subsequent cases. From there, the virus leapfrogged across the border to the independent country of Mongolia.
Ten of those infected on CA-112 were members of a Hong Kong tour group.
Four were employees of a Taiwanese engineering firm, who eventually carried the virus home with them.
Another was a young woman from Singapore, who later flew home and was hospitalized there.
Yet another was a Chinese official who journeyed to Bangkok. As he headed back to Beijing from that subsequent trip, on a Thai Airways flight, he in turn infected a Finnish official of the International Labor Organization, who had been seated next to him.
It had only been five weeks since Dr. Liu got on the bus. Of the 8,098 cases of SARS ultimately detected, more than 4,000 could be traced back to his overnight stay in the Metropole.
When the Spanish Lady came calling in 1918, no place was too remote to elude her entreaties. She even found the islanders of the Pacific. In prior centuries, when seafaring ships were driven solely by the wind, an epidemic disease brought on board would have time to burn itself out before coming ashore on these distant islands. They were beyond reach. Maritime technology changed that. In October 1918, a U.S. Navy transport called the
For many Eskimo villages of Alaska, the plague was even less forgiving. As winter was closing in, the final ship of the season, a vessel from Seattle called the
The global reach of pandemic flu is thus nothing new. But globalization is. And over the last generation, it has fundamentally recast the threat of infectious disease. As with SARS, the next flu pandemic will spread at the speed of jet aircraft, coursing along an ever-thickening web of international travel, each new thread reducing the time the virus must wait before breaching another frontier.
“As the first severe contagious disease of the twenty-first century, SARS exemplifies the ever-present threat of new emerging infectious diseases and the real potential for rapid dissemination made possible by the current volume and speed of air travel,” said Mark A. Gendreau, a senior attending physician at the Tufts School of Medicine, in testimony before the U.S. Congress. Margaret Chan was even blunter: “SARS was a wake-up call for all of us. It spread faster than we had predicted.” Within six months, it reached more than thirty countries on six continents.
More people are traveling more places than ever before. Though Hong Kong remains an exceptional crossroads, Yi Guan rightly suggests that the world increasingly resembles the ninth floor of the Metropole.
“Today you are in England, tomorrow in New York, and the third day you might be in Hong Kong,” Guan noted. Imagine how many people an infected traveler encounters along the way. “The case lands in London or New York or Hong Kong. Maybe ten thousand people have connecting flights in that airport within two hours. It spreads to the whole world. Globalization accelerates the transmission speed, maybe by a hundred times.”
A century ago, he continued, a novel flu strain could take more than a year to circle the world. “Now, currently, does it take one year? I don’t think so. Maybe one month,” he said.
Over history, each advance in transport and trade has sped disease on its way. The Black Death of the Middle Ages spread faster by merchant ship on the Mediterranean than by horseback on the Asian steppe. The last of three cholera epidemics in nineteenth-century America was the swiftest, exploiting the country’s new railroads. Even since 1968, the date of the last flu pandemic, change has been dramatic. Air traffic has increased about tenfold since then. Using data on the volume of travelers at fifty-two major cities around the world, a team of American researchers projected how long it would take a flu pandemic to spread and compared it to the Hong Kong flu of 1968. They found that the same virus, if it had erupted in 2000, would have struck cities in the Northern Hemisphere nearly four months earlier. And while the Hong Kong flu required almost a year to sweep the globe, in 2000 the virus would have peaked in every one of the cities in half that time. A separate team of researchers in Britain, using a different statistical approach and more recent data, from 2002, concluded that in some cities in the
