The MERS outbreak

Life in Korea has taken a dramatic turn in the last few weeks, as there has been a major outbreak of the deadly disease Middle East Respiratory Syndrome (MERS) in the country.

It's major in the sense that it's the largest outbreak that the world has seen outside of the Middle East. And it's of real concern because the disease has a high fatality rate and there is no cure or vaccine. But the absolute numbers are small. As I write, 126 people (in a country of 50 million) have been diagnosed with the disease, and 10 have died. Most (perhaps all) of the fatalities have been elderly people with compromised health; the latest was a 75-year-old man with terminal lung cancer.

My impression is that this has not been major news in the US, but it has generated high levels of panic here in Korea and also, notably, in neighboring China. Objectively it would seem that most of the panic is not justified, but there were some crucial missteps by the government early on that have eroded public trust. That trust wasn't very high to begin with because of the way the Sewol ferry tragedy played out last year.

It looks to me like, with a little luck and no further mistakes on the part of the authorities, the outbreak should come to a natural end pretty soon, but it's hard to say for sure.

The proximate impact has so far been minimal. I've read news stories saying that sales of face masks are up by some incredibly high percentage (was it 700%?) and that people are avoiding public transportation, but here in sleepy Gyeongju I've not noticed any change at all in public life. Restaurants are open and bustling, people walk the streets casually as before.

But there have been many significant ripple effects that are beginning to touch our lives, and are definitely affecting the lives of many Koreans. Large numbers of people (about 3,800) are under quarantine because of the possibility of exposure to the disease.* They remain under quarantine until they test negative for the virus or pass through the two-week incubation period without developing symptoms. Over 1,000 schools in the country are closed (pointlessly, it would seem). Conferences and excursions of all sorts are being canceled.

The sense of alarm in China appears to be especially high. Koreans are being asked not to enter China. Hundreds of thousands of tourists from China have canceled planned visits and tours to Korea. There are many direct flights from China to the tourist mecca Jeju Island, off the southern coast. Although not a single MERS case has been reported there, flights from China are so empty that some are being canceled because they literally have zero passengers.

As you might imagine, all this is not good for the economy.

To a large extent the panic is unwarranted, and is reminiscent of the kind of the irrational fears we saw last year in the US around ebola. MERS is actually extremely difficult to catch. It is not airborne, and is transmitted between humans only through intense, extended contact. Worldwide, it has mostly been contracted between family members or among patients and caregivers in hospitals. It doesn't appear that you can catch the disease in public. The US Centers for Disease Control and Prevention describes it this way:*

Person-to-person spread of MERS-CoV, usually after close contact, such as caring for or living with an infected person, has been well documented. Infected people have spread MERS-CoV to others in healthcare settings, such as hospitals. Researchers studying MERS have not seen any ongoing spreading of MERS-CoV in the community.

In fact, to date all confirmed cases of MERS infections in Korea have happened in hospitals.* It is purely a hospital-transmitted infection. Initially the government refused to say which hospitals were housing MERS patients, probably in order to avoid generating panic. Of course, as is usually the case with this sort of obfuscation, the effect was counter-productive, generating rumors and conspiracy theories. Eventually the government had to give in and make a full declaration of which hospitals have MERS patients. As it turns out, 58—nearly half—of all cases have originated at a single hospital, the prestigious Samsung Medical Center in southern Seoul.*

The outbreak has revealed both strengths and weaknesses of the country's medical system. The weaknesses are both procedural and cultural. In terms of procedure, the hospitals seem to have done a terrible job with basic hygiene and isolation of contagious patients. I don't know enough to say if the problem has to do with practices or technology, or a combination of both. But an equally significant problem is cultural. As The Economist put it:*

One contributing factor is that many South Koreans, like the first MERS patient, visit several hospitals to look for the best care. This can spread disease faster. Hospitals are sociable places where people share rooms with strangers, and where family and friends crowd around to take care of the sick.

There's more than meets the eye in that last sentence. In fact, nursing care of the comprehensive US type is not the norm in Korea, so patients often need family and friends to provide some of that basic care. Those people are not medical professionals and don't always follow best practices (like rigorous hand-washing).

As for strengths, it is presumably the overall quality of care that has created such a low death rate here. Prior to this outbreak, MERS had a shockingly high fatality rate of about 40%. Here it's been about 10%.

As we enter starting to feel affected more and more. Tek's daycare wasn't closed, but a number of his field trips were canceled. Today when I picked him up, the teacher who answered the door literally sprayed my whole body down with disinfectant before I was allowed to enter the building. Parents have been requested to report any visits to hospitals where MERS was contracted to the director of the daycare.

A major international conference that I was supposed to attend next week in Seoul was canceled, not because of any real danger to participants, but because so many attendees from China were pulling out that it was no longer practical to hold the conference.

I think I broke my toe last week. As the swelling has finally started to go down, I'm noticing the toe is misshapen. I should probably go to a hospital to get it splinted. But a hospital is the one place in this country that I'm afraid to go right now. (A lot of people are feeling the same, of course. Lucky for me I hardly have a life-threatening emergency. I would guess that the broader effect on public health of so many people avoiding hospitals is going to be significant.)

And then there are these two signs that just got posted on the door of the studio apartment building where Erma and I rent a room to serve as our office, next to the sign that went up in the winter requesting that residents keep the door closed so that stray cats don't go in.

Some information about MERS and a public service announcement about hand washing

And here's the sign that was posted by the front entrance of our apartment complex.

Dos and Don'ts for MERS. Two of the Don'ts aren't likely to come into play here, since they involve camels.

"Avoid intimate contact with camels." Check.
"Avoid drinking unpasteurized camel milk and uncooked camel meat." Check.

We are now 3 weeks into the outbreak. It's possible it will peak soon, but it's hard to say. In the meantime, things sure are weird around here.

P.S. Just to reiterate, we feel completely safe here.


*Sources and additional references:

CDC on MERS transmission: here
News article from Nature on why MERS doesn't spread easily: here
Recent statistics: here
The Economist on missteps in dealing with MERS in Korea: here
Problems at Samsung Medical Center: here