If not for the voucher, Kwan Sui-chu and her husband would not have stayed at the Metropole Hotel or come within sneezing distance of a Guangdong doctor on its ninth floor.
They would have bunked with their son, whom they had flown from Toronto to Hong Kong to visit last month. But the 78-year-old Mrs. Kwan loved a bargain, and the voucher, courtesy of the airline, offered five free nights at the three-star hotel on Kowloon's peninsula.
She boasted to family and friends after returning to Canada on Feb. 23 that her lovely holiday had "hardly cost her a penny."
But 10 days later it cost her her life. And over the next three weeks, her homecoming would spread a mysterious pneumonia to possibly five dozen people, triggering an epidemic of fear, the closing of hospitals and a school, and mass quarantines - testing the very limits of the health system to contain a crisis and halt a new disease in its tracks.
Despite the dizzying pace of developments surrounding Toronto's outbreak of severe acute respiratory syndrome, some on the front lines wonder whether decisive action should have come sooner, so that thousands of Ontarians would not be at risk and, effectively, under house arrest.
A public-health official said he is grateful that SARS, which has killed three in Canada, has a relatively low death rate. If it was indeed the deadly flu pandemic that doctors predict is overdue, there would be little hope of limiting its spread, he said. "You have to be thankful that this is a dress rehearsal."
Sandy Finkelstein, medical director of the intensive-care unit at Scarborough Grace Hospital and one of the first doctors to treat a SARS patient in Canada, put it this way: "When you're in the middle of a storm, you don't know that you're in the middle.
"I saw [a co-ordinated effort]starting here, I saw people scrambling to do meaningful work, but they didn't take it as a really serious situation in the beginning; the numbers were too small. I'm not faulting anyone, but certainly this is going to happen again, and there are lessons to be learned," Dr. Finkelstein said.
It was on Feb. 26 that Mrs. Kwan began to feel unwell. Her muscles ached, she coughed and her throat felt raw. That same day, on the other side of the world, Johnny Chen, a 48-year-old U.S. garment merchandiser and another guest of the Metropole, had similar symptoms and was admitted to hospital in Hanoi.
He and Mrs. Kwan may have seen each other in the hotel's elevator lobby on Feb. 21, when the Guangdong doctor, dressed to the nines for a wedding reception, sputtered and sneezed in the corridor. Dr. Liu Jianlun had been treating patients with a strange pneumonia in his south China province, and on Feb. 22, he, too, would check himself in to a hospital, telling the Hong Kong staff that his colleagues had been falling ill one by one, according to The South China Post.
By March 2, Mrs. Kwan was too sick to get out of bed. Her family hovered around her: her husband; her eldest son, Tse Chi Kai, along with his wife and their three children; her younger son; and her daughter, who flew up for the weekend from Atlanta.
Nothing could bring Mrs. Kwan's fever down, and on March 5, after struggling for every breath, she died at her home in Toronto's east end. Given her age, and existing diabetes, she was buried without an autopsy.
On March 6, her son, 44-year-old Mr. Tse, his wife and their five-month-old baby, all complaining of a respiratory ailment, paid a 45-minute visit to their family doctor. The next night, Mr. Tse felt so miserable he went to the emergency department at Scarborough Grace. He was alert and able to talk, though he was coughing and was clearly short of breath.
"It looked like a regular pneumonia," Dr. Finkelstein said.
But in a move that may have saved them from infection, nurses covered his face with an oxygen mask and placed him in an emergency room with a 76-year-old man who had come in for observation with a fast, unsteady heartbeat. No other beds were available.
Dr. Finkelstein was on duty on March 8, as Mr. Tse's condition deteriorated. The nurses said that no one in the family looked very well and that the mother, who had just returned from Hong Kong, had recently died.
"Right away I started to worry," Dr. Finkelstein said, assuming the ailment must be tuberculosis. "We have a large immigrant population in this hospital, Chinese and Indian, and here everything is TB until proven otherwise."
By 6 that night, Dr. Finkelstein had moved Mr. Tse into isolation in the intensive-care unit. The nurses looking after him donned protective gear, he said, and the family were outfitted with masks.
Dr. Finkelstein ordered chest X-rays for all of them. Three out of four showed the telltale white marks that signify the fluid buildup of a lung infection.
"I knew we were in trouble," he said. "Some time early Sunday morning, I threw up a wall of X-rays on the light panels, and I said, 'What have they got?' "
"TB," the radiologist said.
It was one thing to come across a single TB case at Scarborough Grace, but a cluster? Dr. Finkelstein had not seen that before, and for the first time in his career, he paged Toronto public health.
The officials arrived Sunday morning, March 9, and directed the masked family members to return home. Dr. Finkelstein turned his attention back to Mr. Tse.
To him, it didn't fit - TB is a slow disease, he thought, and this was moving in fast and soon. Mr. Tse, hooked to a ventilator, crashed: His blood pressure dropped, his heart slowed and eventually there was respiratory failure.
"By the 12th, there was not much we could do for him," Dr. Finkelstein said.
That same day, the World Health Organization released a rare global alert, urging countries to watch for atypical pneumonia cases that had stricken hundreds in Southeast Asia. Mr. Chen, the U.S. garment merchandiser, had triggered it.
Because he was admitted to hospital in Hanoi, then transferred to a Hong Kong hospital, Mr. Chen had left dozens of health workers sick in his wake.
Mr. Chen died on March 13, the same day Mr. Tse died at Scarborough Grace.
When Mr. Tse's younger brother and sister viewed his body, hospital staff took one look at their sallow faces and sent them to the emergency department.
A doctor there phoned Andrew Simor, head of microbiology at Sunnybrook and Women's College Health Sciences Centre. "She wanted to transfer the younger brother to our hospital. She described the family history and said they needed to be isolation," Dr. Simor recalled.
He agreed to take the younger Mr. Tse, and his mind darted to an e-mail he had received about a severe respiratory outbreak in Hong Kong and its high rate of health-worker infections.
"We said, 'Don't even bring this patient in through emerg. Just bring him straight to a private, negative-air-pressure room.' "
Dr. Finkelstein, meanwhile, realized his instincts were right: three rounds of tests and none of the family tested positive for TB. He phoned microbiologist Allison McGeer, an infectious-disease specialist at Toronto's Mount Sinai Hospital.
Dr. McGeer, who could not be reached for an interview this week, had received the WHO e-mail as well, and assumed the worst from Dr. Finkelstein's call.
It sounds like the outbreak in Asia, she told him, and agreed to admit the sister and Mr. Tse's widow to Mount Sinai's negative-air-pressure rooms.
By 5 p.m. March 13, Drs. McGeer, Simor and Irving Salit, director of the infectious-disease division at the University Health Network, held a conference call to determine the best course of treatment. "We decided on three broad-spectrum antibiotics and two antivirals. We had two deaths, three critically ill patients and we didn't know what we were dealing with," Dr. Simor said.
On March 14, a pathologist autopsied Mr. Tse, harvesting tissue from his lungs, spleen, kidneys and liver. From the other sick family members, doctors collected blood, nasal swabs and other fluid samples and sent them to the National Microbiology Laboratory in Winnipeg.
Frank Plummer, the Winnipeg lab's scientific director, happened to be in Toronto for a conference that Friday, and was glad to hear samples were en route. "We were able to phone over to Winnipeg and order mice [used to incubate suspect viruses]" he said. "If we didn't order them Friday afternoon, we wouldn't get them until Monday." And he knew that scientists would work through the weekend.
That evening, Dr. McGeer consulted Toronto public health, which decided to call an emergency news conference to inform people that a strange respiratory disorder had travelled to Canada with the speed of a jet. They publicized a hot line for those with suspicious symptoms and braced themselves for callers.
When Donald Low, Mount Sinai's chief microbiologist, returned from his March break in Banff that night and checked in with colleagues, they told him, "You get your ass in here."
A 62-year-old man with SARS symptoms and who remains in hospital, flew back from Southeast Asia on Saturday and was transferred to Sunnybrook hospital from York Central Hospital. Last night, health officials announced that a SARS outbreak was discovered at York Central.
But the most troubling patient that turned up on March 15 was a Scarborough family doctor who had immediately recognized the name of the deceased patient as her patient. She recognized the symptoms, as well.
The doctor had fallen ill on March 9, three days after seeing Mr. Tse, and she hadn't recovered.
"Allison [McGeer]was really concerned about this secondary transmission to the doctor," Dr. Low said; 90 per cent of the cases in Hong Kong had broken out among health workers. And now, here was this doctor (who is recovering) sick after a 45-minute exposure. It raised questions about the Scarborough Grace workers.
"It was on all our minds," Dr. Simor acknowledged. "We had several conversations about it, but what can we do at that point? No one seemed ill. In retrospect, we can say we wish we had done this or that earlier or done it differently. But then, no one [at Scarborough Grace]was sick."
What's more, the SARS incubation period seemed unclear. Nurses who had the first unprotected contact with Mr. Tse in emergency on March 7 showed no SARS symptoms, and they have not since.
"They're healthy," Dr. Finkelstein said. "The way the transmission works is very puzzling."
On March 16, Scarborough Grace staff had assumed the worst was over, Dr. Finkelstein said. But later that day, the 76-year-old patient who had shared a room with Mr. Tse that first night arrived in the Scarborough Grace emergency department, short of breath and running a temperature. Staff donned their masks, Dr. Finkelstein said, and ushered him directly into an isolation room.
Dr. Low examined the patient two days later, and caught the first inklings that something might be wrong at Scarborough Grace.
"I remember one nurse actually said to me, 'I had a temperature last night, but then it just broke.' "
The comment stopped him, but the nurse seemed completely fine. "Retrospectively, you think, okay, something should have been done, but she wasn't sick. And all this was developing and changing rapidly - so what are you going to do?"
While the new case prompted experts to reconsider the transmission power of the unknown agent, the story shifted from Canada, as there was no explosion of new cases. One suspicious report emerged from Edmonton and another from Vancouver, where a 55-year-old man, also a guest of the Metropole in February, is in serious condition.
Instead, attention turned to the international scientists hunting the source of this baffling disease, and to China, where the government revealed that Guangdong had been battling an atypical pneumonia since last November.
Yet all the while, Toronto's cases were incubating. On March 18, a health worker who had been in contact with the family in the X-ray department at Scarborough Grace fell ill, Dr. Finkelstein said. After that, staff continued to get sick through the week, roughly one person a day for the next three days, he said.
On March 22, the day after the 76-year-old patient died of SARS, Scarborough Grace closed its intensive-care unit. "I think the response time was quite reasonable - but could things have happened a bit quicker? They always can," Dr. Finkelstein said, "But believe me, the next time, we will be quicker."
On Sunday, Dr. McGeer called Dr. Simor from Scarborough Grace to tell him that 12 health workers were symptomatic. It was the call they had dreaded.
"Allison and I talked about closing Scarborough Grace. We even talked about possibly calling in the military . . . to set up a mobile-hospital unit to deal with possible SARS patients [separately]"
"She was sufficiently concerned that she wanted to contact the provincial ministry to take action." Until that time, Dr. Simor said, provincial officials, including the office of Ontario Public Health Commissioner Colin D'Cunha, had generally played a surveillance and advisory role.
Dr. McGeer called Ontario health officials that Sunday night, while plans were made to transfer the nurses into quarantine at the West Park Health Centre, once a TB sanitorium.
Yet that same very night, at 10, a patient was transferred from Scarborough Grace to Mount Sinai's intensive-care unit. No one pegged him as a SARS risk because he was a liver-transplant recipient who was presumed to have picked up a respiratory infection in the community, Dr. Simor said.
But the patient, who was transferred to Toronto General on Tuesday at 4 a.m., led to the closing of Mount Sinai's intensive-care unit and to at least 50 of the hospital's staff being put into quarantine.
Meanwhile, when the Ontario Nurses Association called Scarborough Grace officials on Monday to meet about the quarantined nurses, the hospital insisted on holding the meeting at the hospital on Tuesday, said ONA president Barb Wahl.
"We think, 'This is crazy,' " Ms. Wahl said. "But we needed to have this meeting, and so our staff went. There was no need to meet there; we could have met somewhere else. Now they're under quarantine, as well."
Scarborough Grace officially closed its doors to new patients and most visitors on March 25 - the same day provincial health officials announced the quarantine of the health workers' families.
"I think the full preventive measures weren't taken quickly enough," Ms. Wahl said. "Why wouldn't you close down that hospital last week? You knew this was affecting health workers. You already had three people die. Nurses were starting to get sick. Why wouldn't you close?"
Yet, as Dr. D'Cunha announced the quarantine measures on Tuesday, he faced suggestions that these extraordinary measures may be overreactions to criticisms that his office had underplayed the risks of the mosquito-borne West Nile disease.
Dr. D'Cunha described them as necessary provisions to try to control a disease no one fully understands. The next day the quarantine was expanded to anyone who entered Scarborough Grace since March 16.
Most experts agree, with considerable relief, that SARS is proving not to be a relentlessly fatal scourge. Dr. Finkelstein suggested renaming it, MARS, for mild acute respiratory syndrome.
"I hope this will be a wake-up call to public-health and ministry officials that there must be a quick, co-ordinated effort for when the big one does hit," Dr. Finkelstein said.
But he said that even "the big one" might start with one or two patients, and reacting to that each time could paralyze the system.
Still, Dr. Simors said, the response has not been "a big overreaction, if you look at what's happened in China, what's happening in Hong Kong. This has affected hundreds of people. The difficulty is knowing whether what we are doing now is actually working.
"But it's so amazing to think that all this can be traced back to that one encounter at the hotel."