of atypical pneumonia. Two more doctors, two nurses, and another ambulance driver were infected during his transfer, as Zhou gasped for breath, vomited, and spattered phlegm around the ambulance. At the second hospital he was intubated to save him from suffocation. That is, a flexible tube was inserted deep into his mouth, past his glottis, and down his windpipe into his lungs, to help with breathing. This event represents another important clue toward explaining how SARS spread so effectively through hospitals around the world.
Intubation is a simple procedure, at least in theory, but it can be difficult to execute amid the gag reflexes, sputters, and expectorations of the patient. The task was especially hard with Zhou, a portly man, sedated and feverish, and though his disease hadn’t yet been identified, the attending doctors and nurses seem to have had some sense of the danger to which they were being exposed. They knew by then that this atypical pneumonia, this whatever, was more transmissible and more lethal than pneumonias of the common sort. “Each time they began to insert the tube,” according to an account by Thomas Abraham, a veteran foreign correspondent based in Hong Kong, there was “an eruption” of bloody mucus. Abraham continues:
It splashed on to the floor, the equipment and the faces and gowns of the medical staff. They knew the mucous [sic] was highly infectious, and in the normal course of things, they would have cleaned themselves up as quickly as possible. But with a critically ill patient kicking and heaving around, a tube half-inserted into his windpipe and mucous and blood spurting out, there was no way any of them could leave.
At that hospital, twenty-three doctors and nurses became infected from Zhou, plus eighteen other patients and their relatives. Nineteen members of his own family also got sick. Zhou himself would eventually become known among medical staff in Guangzhou as the Poison King. He survived the illness, though many people who caught it from him—directly, or indirectly down a long chain of contacts—did not.
One of those secondary cases was a sixty-four-year-old physician named Liu Jianlun, a professor of nephrology at the teaching hospital where Zhou had first been treated. Professor Liu began feeling flulike symptoms on February 15, two weeks after his exposure to Zhou, and then seemed to get better—well enough, he thought, to follow through on plans to attend his nephew’s wedding in Hong Kong. He and his wife took the three-hour bus ride from Guangzhou on February 21, crossed the border, spent an evening with family, and then checked into a large, midrange hotel called the Metropole, favored by businessmen and tourists, in the Kowloon district of Hong Kong. They were given room 911, across from the elevators in the middle of a long corridor, a fact that became central to later epidemiological investigations.
Two fateful things happened that night at the Metropole Hotel. The professor’s condition worsened; and at some point he seems to have sneezed, coughed, or (depending on which account you believe) vomited in the ninth-floor corridor. In any case, he shed a sizable dose of the pathogen that was making him sick—enough to infect at least sixteen other guests and a visitor to the hotel. Professor Liu thereby became the second known superspreader of the epidemic.
Among the hotel guests sharing floor nine was a seventy-eight-year-old grandmother from Canada. I mentioned her earlier. She had come to visit family and then spent several nights at the Metropole, along with her husband, as part of an airline-hotel package. Her room was 904, just across the corridor and a few steps down from Professor Liu’s. Her stay overlapped with his presence for only one night—the night of February 21, 2003. Maybe they shared a ride on the elevator. Maybe they passed in the hallway. Maybe they never laid eyes on each other. No one knows, not even the epidemiologists. What’s known is that, the next day, the professor awoke feeling too sick to attend any wedding and instead checked himself into the nearest hospital. He would die on March 4.
One day after Professor Liu left the Metropole, the Canadian grandmother left too, having finished her Hong Kong visit. Infected but not yet symptomatic, and presumably feeling fine, she boarded her flight home to Toronto, taking SARS global.
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Another route of international dispersal from the Metropole Hotel led to Singapore, when a young woman named Esther Mok returned from a shopping vacation in Hong Kong, feeling feverish. That was February 25. For the previous four