Jeddah: As the virus tore through the city’s largest hospital, jumping from bed to bed and afflicting scores of people, terror filled the wards.
Some doctors and nurses refused to treat the sick or stopped coming to work altogether. Patients panicked. One surgeon recalled a man with a broken limb trying to flee the emergency room so he would not catch it, too.
“Everyone was afraid,” the surgeon, Dr Mohammad Ahmad, said of the spike in cases this spring.
It was the darkest hour since the new illness, known as Middle East Respiratory Syndrome, or Mers, first appeared in Saudi Arabia late in 2012. In all, more than 700 cases have been documented in 20 countries, nearly all of them linked to Saudi Arabia. More than 250 people have died.
The sudden spread of a mysterious and fatal new virus is reminiscent of the early days of Sars, or severe acute respiratory syndrome, a related disease that appeared in dozens of countries and killed more than 770 people, principally in Asia in 2003.
Mers circulates most heavily in a region that is the nexus for Islam. This port city, Jeddah, is the arrival point for most of the two to three million pilgrims who make the haj to Makkah each year. Riyadh, the Saudi capital, has had the second-largest outbreak after Jeddah, and cases have also appeared in Makkah. The haj will not take place until October. Already, off-season pilgrims have spread the disease to Iran, Jordan and Algeria.
Saudi officials know how urgently they need to beat the disease, and they say they now have the latest outbreak under control. But the fact that the number of cases and deaths have more than tripled since the end of 2013 has led health experts to cite grave flaws in the way Saudi officials have handled the crisis.
King Abdullah Bin Abdul Aziz fired the country’s health minister and his deputy in April, leaving experts wondering whether the shake-up would bring greater transparency and international cooperation.
“In the US, when you have a crisis like the Veterans Administration scandal, the new head is in front of the TV cameras explaining what the new plan is,” said Dr Peter Daszak, president of EcoHealth Alliance, a veterinary organisation that tracked the disease in animals. “There is no tradition of openness in Saudi Arabia.”
A World Health Organisation panel said this month that the surge in cases that began in April had fallen off, but that “the situation remains serious” and that hospital outbreaks should be investigated for breaches in safety protocols.
“I am not saying we’re not worried, but this is something that can be controlled,” said Hanan Balkhy, executive director for infection prevention and control at Saudi Arabia’s National Guard hospitals. “If this were Ebola, I would go the king myself and tell him, ‘We need to isolate the kingdom.’”
Both Sars and Mers are coronaviruses, named for their shapes. Both are thought to have originated in bats and then spread through other animals to people. But while Sars circulated in obscure forest animals like palm civets that are eaten in southern China, Mers infects camels and seems to jump more easily to humans, possibly in raw camel milk, but it spreads less readily between people than Sars did.
One theory gaining popularity is that Mers cases peak in the spring because camel calves are born at that time. So until a human or veterinary vaccine is developed, people in contact with camels must be careful, especially in the spring.
Yet the outbreak this year suggested that lapses in Saudi Arabia’s health system played a bigger role in spreading the virus than camels did. Most of the hundreds of new infections were linked to hospitals, dialysis clinics or other health facilities, and many were among staff members. Two health workers from Saudi clinics were hospitalised in Indiana and Florida.
The greatest number of new cases was at the King Fahd Hospital in Jeddah. Doctors said a mix of bad management, crowding and lax hygiene helped spread the virus there.
The outbreak came during the busiest time of year, when many Saudis were on vacation, leading to more car accidents, sports injuries and other mishaps, doctors said. New emergency patients were registered in a crowded area, and hospital rooms meant for four people often held 12.
Suspected Mers cases were not always identified and isolated, and patients unwittingly spread the virus around the hospital — one in the cardiac ward, and another among dialysis patients, according to Dr Ahmad Ragab, chief of the hospital’s intensive care unit.
“If one patient came in with the virus, all the others would get it, because they were all next to each other,” Ragab said.
Some medical staff members were lax with sanitary measures, not wearing masks or infrequently sanitising their hands. Many fell ill.
When the king fired the health minister, Abdullah Al Rabeeah, in April, he gave the job to the labour minister, Adel Fakieh, who is known for bypassing the kingdom’s bloated and inefficient bureaucracy. Fakieh enlisted McKinsey & Co, the corporate consulting firm, and opened a command centre in Jiddah to track cases.
The changes at the top soon filtered down to the King Fahd Hospital, where Dr Emmad Al Jahdali became director in May.
“The scene at the time was panic, from the public and from the media,” Al Jahdali recalled. “King Fahd Hospital was the spotlight for everything.”
He divided the hospital in two, with one half exclusively for Mers patients. Anyone with a fever and breathing problems is quickly isolated for testing.
The disease has been surrounded by controversy since it came to light, when an Egyptian microbiologist, Ali Mohammad Zaki, sent a sample from a Jeddah hospital to Rotterdam, in the Netherlands. Dutch researchers patented the new virus and named it after their centre, enraging Saudi officials, who considered the action intellectual property theft. They fired Zaki and petitioned the WHO for a new name for the virus.
Scientists from 18 universities or health agencies in eight countries were recruited to work on the virus. Egos began clashing, especially as teams raced to publish results. Two rivals published the genomes of viruses from the same patient and his camel in separate academic journals.
Some researchers accused the Saudi deputy minister of health, Dr. Ziad Memish, of duplicity and bad management, saying he hampered progress, while others said he was made a fall guy for an outbreak beyond his control.
Memish, described recently in The Lancet, the British medical journal, as “the father of mass gatherings medicine” for his work on protecting pilgrims, denied accusations that he took credit for the work of others or kept sloppy records. But he acknowledged occasionally switching cooperation from one team to another, bruising feelings.
“Some collaborations began and prospered; some did not,” Memish said by email. “That’s the way science and life progresses, sometimes.”
One recent afternoon, a family brought an old woman with a nasty cough to King Fahd Hospital. She was immediately wheeled into an isolation room. Al Jahdali watched proudly as health workers blocked her relatives from following, so they would not get sick. Confirmed cases go to a special wing where rooms with tight sliding glass doors hold one patient each and nurses wear gloves and snug-fitting masks.
Whether Saudi Arabia can get the virus under control will depend, experts said, on how effectively such measures can be applied nationally — not an easy task in a country of long distances and weak government oversight of some health centres.
The number of new cases reported nationally appears to be falling, with about 200 in May and only 27 since then, the health ministry said.
“The most direct cause of this improvement — after, of course, the blessing of Allah — is the stringent implementation of infection control in hospitals,” said Tariq Madani, who heads the health ministry’s Mers task force.