GUANGZHOU, China - For three members of the Chen family, the first sign of trouble was the fainting. Within days, they spiked fevers and labored to breathe, victims of a mysterious sickness that would soon start spreading around the globe.
Chen Huixiong, 39, a bus driver, was released from the hospital two weeks ago. But his elderly parents died late last month - two previously undisclosed casualties of the respiratory disease in southern China's Guangdong province.
This densely populated coastal city near Hong Kong is the apparent epicenter of a worldwide outbreak that has confounded doctors, scientists and public health experts. In addition to the more than 300 cases and five deaths officially reported in Guangdong, the World Health Organization has identified 386 suspected cases of severe acute respiratory syndrome, or SARS, in 14 countries, including the United States. At least 11 people have died.
WHO epidemiologists tracing the illness are visiting China this week in an effort to determine where and when it first broke out, and what contact its earliest victims had with each other. Though some evidence suggests the culprit may be from the paramyxovirus family - responsible for measles, mumps and other respiratory ailments - scientists have yet to conclusively identify the cause.
While new infectious diseases emerge fairly regularly, most are spread primarily from animals, such as mosquitoes or mice, rather than from person to person. But scientists believe the new illness is being transmitted from patients to family members and health workers through droplets released when sneezing or coughing.
Even doctors prepared to contend with contagious diseases found this one to be surprisingly aggressive. Several medical staff at Guangzhou No. 1 Hospital were infected by the first patient they treated early last month, a middle-age male.
"The doctors in other hospitals told me that this disease was very infectious," said a supervising physician, speaking on condition of anonymity. "I was wearing a surgical mask. Everybody was, but we still got infected."
The Chinese government, fearing panic, was slow to react when the illness broke out, slow to inform the public and slow to develop a strategy to contain the disease. And China's thinly stretched public health system may have been poorly equipped to quickly recognize or identify the illness. It likely claimed more victims than officials have acknowledged; the deaths of the Chens, for example, are not included in the official count.
Accounts from local health experts suggest that two patients showed symptoms of the atypical pneumonia in Foshan, an industrial and fish-farming city near Guangzhou, in mid-November. About the same time or in early December, several more cases occurred in the town of Heyuan, 120 miles outside Ganghzou. Seven or eight doctors and nurses there were apparently infected.
In January, more cases were beginning to show up at Guangzhou hospitals from outside the city, reportedly infecting ambulance workers. From late January until late February, possibly hundreds of family members of patients and their doctors and nurses became infected. Sometime during that period, a sick physician took a bus to Hong Kong and stayed at the Metropole Hotel, which may have introduced the illness there.
The Chen family had heard rumors about the illness from a local doctor before the Chinese New Year holiday in early February, so they drank a popular Chinese herbal medicine, ban lan gen, as a precaution. But when 77-year-old Chen Jianchang fainted around midnight Feb. 3, neither his doctors nor his family knew what they were facing. The acute respiratory illness' telltale symptoms - a fever above 100.4, cough, shortness of breath and, later, difficulty breathing - had yet to become familiar.
"The doctor said he was not seriously ill, just a fever, so my father stayed in the hospital for five days of observation and was released," said Chen Huixiong. "But when he came back home, that night he fainted again, so he went back immediately in an ambulance."
During those early days, Chen, a retired military veteran, likely infected at least his wife and one son, who in turn may have infected others. Chen Huixiong fainted over dinner with friends Feb. 13, was diagnosed with a cold, and drove his bus for two days before falling ill again. His mother, Li Shuhua, 69, fainted Feb. 14 and was admitted to Xiong Ke Hospital in eastern Guangzhou with pneumonia. The hospital where her husband was a patient, Guangzhou Hospital No. 8, was full of others stricken by the illness.
"My father was given antibiotics and vitamin C," said Chen's son, Chen Guoying, 41, who was not infected. "The doctors said there was no special medicine for this kind of illness, so they told the patients to drink milk in the morning and in the evening and to eat oranges to strengthen their health."
The Chen brothers speculate that their father may have contracted the disease while on one of his near-daily trips to the neighborhood market, where he bought fish and chicken. His hearing was poor, they said, so he would have to lean in close to vendors to hear them.
Meanwhile, Li also took antibiotics and seemed to improve in the first three or four days. Believing she was better, she switched from expensive foreign medicines to traditional Chinese herbal medicine. A feverish Chen Huixiong decided to go to the same hospital Feb. 20.
Several days later, he lay in a hospital bed unaware that his mother was failing in another hospital wing, requiring forced oxygen to breathe, and that his father had just died. Chen's sister, Chen Li Li, 32, also came down with a fever and was hospitalized. She left a day later by boat for Hong Kong, where she has citizenship, and eventually recovered. "She was not seriously ill, and she was afraid the situation in Guangzhou was getting worse," said Chen Guoying.
Indeed, back at Xiong Ke Hospital, his brother, Chen Huixiong was not encouraged by his doctor's treatment plan. He coughed up blood, which doctors took away for analysis, but they never reported back to him. Other patients nearby were receiving oxygen, and he didn't want to be like them. "The patients who had to take the oxygen were about to die, so I tried not to have to take oxygen," he said. "I tried my best to survive by willpower."
With Chinese health officials playing down the threat of the disease and declining to seek international assistance, physicians resorted to trial and error. "The doctor told me that they are not sure which particular medicine is good for the sickness, so they're trying out different medicines to see if they work," Chen Huixiong said.
At Zhongshan No. 2 Hospital, patients were divided into three test groups, each of which was given different medications to determine which was most effective, said a senior doctor there who spoke on condition of anonymity. At another hospital not far away, doctors told questioning patients that since they had no idea what to prescribe, they would just keep trying new drugs until they found one that worked. For the less-severe cases in some hospitals, the drugs of choice were vitamin C, antibiotics and traditional herbal medicines - plus the admonition to eat well.
Released from the hospital March 6, Chen Huixiong is taking herbal medicine three times a day, just in case, and he has quit smoking, on the advice of his doctor. Rail-thin, with a mop of black hair and smoke-stained teeth, he has a sort of snaggletooth smile that reveals nothing of the painful weeks he and his family have endured.
The outbreak has tapered off in Guangzhou, but Chen and his doctors are haunted about its cause.
Officials at the World Health Organization and the Centers for Disease Control and Prevention report progress, and have developed a diagnostic test. Still, investigating a disease outbreak can be incredibly complicated. "It's like a giant jigsaw," said Barbara Robinson-Dunn, technical director of microbiology at William Beaumont Hospital in Royal Oak, Mich.
Hundreds of scientists in 11 laboratories have been working around the clock to identify the infectious agent, analyzing samples of blood, sputum and organ tissue. They peer through powerful electron microscopes, try to culture the agent, or type its DNA. The WHO investigators visiting China hope to gather some important clues on the ground, but the tough questions most likely will be answered in a high-tech laboratory far away.
"As a doctor, I really want to find out the cause, but that's not my job," said the senior doctor at Zhongshan No. 2. "Nothing like this has happened in 50 years."
Sun staff writer Erika Niedowski contributed to this article.