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Last Updated

07 Apr 2003

Source: Wall Street Journal, April 7, 2003


Divergent Asian Responses Show Difficulties in Dealing With SARS


In the month since the SARS crisis began sending shockwaves from its ground zero in southern China, affected countries have adopted widely divergent postures toward severe acute respiratory syndrome. These have ranged from denial to reasoned caution to mass quarantine of even the healthy.

So far, the lessons on how different governments and peoples respond to a siege that can be neither seen nor smelled aren't particularly encouraging. China, where the pathogen first appeared, bottled up information and scientific access until long after SARS had been exported. Thailand, with only seven cases reported, threatened to jail anyone who has spent time recently in a country where SARS has been found and who fails to wear a face mask while on Thai soil.

The central question now: In an increasingly globalized world, can any national response adequately protect against a potential pandemic?

Compared with the pantheon of infectious ailments, SARS so far seems scary but not catastrophic. Though there is no drug that cures it, the overwhelming majority of people infected with the virus seem to recover. SARS has killed fewer than 100 of the 2,600 people it is reported to have afflicted in 18 nations, according to the World Health Organization and reports from individual countries.

In the U.S., where there have been 115 suspected SARS cases but no deaths, communication between federal and state health officials has improved since the government's initial clumsy response to anthrax in the fall of 2001. But there is no consensus on the readiness of the American public-health system to handle the myriad medical, social and legal issues raised by SARS -- from how to isolate suspected cases on airplanes to how to quell panic and head off racial backlash against Asians believed to harbor SARS. On Friday, President Bush issued an unusual executive order, adding SARS to a list of diseases for which health authorities may quarantine citizens against their will -- the first disease added to that list since Ebola in 1983.

To illustrate the difficulty of responding to a highly infectious disease in an age when the Internet and wireless communication can spread fear faster than illness travels, it is useful to look at the divergent public-health campaigns against SARS in the Asian nations hit hardest.

While China dithered on the danger growing within its borders and kept the World Health Organization from visiting its infected regions for critical days, Singapore imposed a mass quarantine on even healthy citizens and shuttered all schools after the island's first SARS death. Hong Kong responded as a freer, Western society might: balancing civil-liberties concerns against medical risks. The result: a rampant outbreak.

Denial in China

The Chinese response to SARS looks like a textbook case of how not to react to a public-health emergency. When several alarming cases appeared in the city of Foshan, near Guangzhou in southern China, in mid-November, local officials didn't report the circumstances up the chain of command and treated it as a common respiratory illness. Several weeks later, three patients came down with the disease in Heyuan, a city about 125 miles away, and infected several doctors and nurses. They recovered, but the disease's highly infectious nature was by then clear.

"The Ministry of Health did not make any warnings. They did not even tell the hospitals where they were transferring the patients about this," said a doctor at a major Guangzhou city hospital which handled some of the SARS patients. "I think that most of the people in the medical establishment are very dissatisfied with the government," added the doctor, who asked not to be named.

China's tightly controlled media didn't help. During January, as the disease appeared in one city in Guangdong after another, newspapers tried to calm the populace -- one even saying that "atypical pneumonia," a more general term for SARS, was not serious at all. By early February, when fears were rampant, reporters had been ordered by the government not to write about the illness, journalists in different cities say. That didn't stop people from stocking up on folk remedies such as white vinegar and herbal medicines. Not until Feb. 11 did the Guangdong government announce that 305 people had been infected and five had died.

Because of China's rigid hierarchy, if a person reports a potential health crisis to a higher-up and the higher-up does nothing, the matter can end there. Information only moves laterally when it hits the top: A meeting last week to form a high-level task force to respond to SARS had to wait to be led by Premier Wen Jiabao, the country's No. 3 official.

In another sense, though, the poor state of China's health-care system leaves officials with little room to maneuver. Its hospitals and doctors are ill-equipped to handle a potential epidemic, even were it properly publicized. Any health-care emergency could immediately flood the country's already overburdened hospitals, where it is common for a single doctor to see more than 100 patients in a normal day.

"If they gave a total picture and it shows something catastrophic, I don't think the system would be able to handle it," said Robert Pollard, managing director of Isis Research in Beijing, which advises pharmaceutical companies there. "People traipse into the hospital for the smallest cough or cold. If [health officials] get information out, they worry that they will be flooded."

But the price paid for public calm in China may be high, as the disease continues to spread. In the bustling city of Guangzhou, even now the sense of complacency is strong. Face masks are uncommon because the authorities have played down the risk. A doctor at a hospital that has already had several SARS deaths still insisted that there is no need to wear one outside of wards for the most-ill patients.

The combination of popular ignorance and assurance is unsettling. "It is a mental thing -- if you have a lot of mental pressure, you will more likely get this disease," asserted Peng Chaoxue, who books ticket and hotel reservations at the Guangzhou airport.

China, which prizes its membership in the World Trade Organization and other international groups, is now scrambling to confront criticism from abroad. A WHO team landed in Guangdong Thursday for a six-day inspection visit, and the government grudgingly offered new statistics on SARS cases. At least 1,220 cases have been reported so far in China, with 52 deaths, according to the WHO.

But while the WHO has issued a rare travelers warning to avoid southern China, government spokesman Wang Guoqing last week urged people who had cancelled travel plans to China to reconsider.

Orderly Singapore

In contrast, Singapore, a tightly controlled city-state of four million at the tip of the Malaysian peninsula, has grappled aggressively with SARS. It took definitive steps to try to "ringfence," a local term meaning cordon off, cases the moment it found in mid-March that more than a dozen nurses had been infected.

Officials ordered nearly 1,000 people who had had contact with SARS cases to undergo a 10-day home quarantine, with violators facing stiff fines. Health authorities also centralized all cases in a single hospital and outfitted health-care workers in full bioterror suits. On March 27, the government closed all schools. They will begin reopening this week.

Singapore's generally compliant population has barely uttered a word of protest, even as some restrictions seemed to verge on the extreme. Television producers kept filming "live" shows, but without the live audiences. Visitors to the zoo were banned from hand-feeding the orangutans -- ordinarily a big attraction.

Even with these measures, the free flow of people from infected areas brought the disease to Singapore. Four cases of imported SARS have been reported, including a 29-year-old Singaporean who visited Hong Kong and China and died nine days after returning very ill on a flight from Beijing. Many Singaporeans refused to use taxis for the two days it took authorities to track down the taxi driver who took her from the airport to the hospital.

"Our defenses seem to be holding up quite well, but I wouldn't declare victory," Health Minister Lim Hng Kiang said last week. Singapore has reported 106 SARS cases and six deaths. But Mr. Lim noted that some Asian countries were just now seeing the "initial stages" of SARS. "Can they institute controls?" If any one country fails, Mr. Lim added, "we run the risk of SARS running out of control."

Hong Kong's Balance

Unlike Singapore's example, Hong Kong's experience with SARS has illustrated that strong laws protecting privacy and freedom of movement can hinder a swift response to a health crisis.

As an outbreak began to unfold last month at Hong Kong's Amoy Gardens apartment complex, it received real-time media coverage. By the time the government summoned the political courage to order the complex's residents into isolation for 10 days, more than half the families had already fled.

A strikingly small team of only 30 officers from the financially strapped Hong Kong police department are tracking the 113 families who fled and might be infecting others, but the police can't use the threat of law to persuade people to come forward. Unless an isolation order has been delivered to a person face-to-face, "they have committed no offense under current legislation," said Tang How-kong, chief-superintendent of the police. Despite urgent government pleas, most Amoy Gardens refugees remain in hiding.

The SARS response of Hong Kong, a cosmopolitan free-market trade center neighboring Guangdong province, is perhaps the most apt case study in Asia for how an outbreak could affect a U.S. city. Like the U.S., Hong Kong has a free press, a government that provides information on many topics and respect for civil liberties. In addition to top-notch hospitals, it also has a highly regarded surveillance system for emerging diseases.

Especially troubling about Hong Kong's SARS experience is that the city has a wealth of experience with infectious disease coming from China. The city's health department went on alert upon the first media reports of atypical-pneumonia cases in Guangdong. In mid-February, the department asked local hospitals to report the number of pneumonia patients on a weekly basis, and to provide details about severe cases, said Dr. Marina Sum, a senior medical officer with the department.

Yet even as that system seemed to work -- the department was promptly notified on March 10 about a strange cluster of flu-like cases among staff at Ward 8A of Prince of Wales Hospital -- the disease was one step ahead. By the time authorities had grasped the extent of the Prince of Wales outbreak, SARS had already infected scores of doctors and nurses.

One wrong diagnosis -- almost inevitable with a new disease such as SARS -- can degrade even the best-laid lines of defense. A patient screened for SARS at Prince of Wales Hospital on March 15 was mistakenly diagnosed with influenza and was discharged four days later. He then went to visit his brother at Block E of the Amoy Gardens.

"You can see the dilemma in fashioning a response," said Dr. Malik Peiris, a University of Hong Kong microbiologist whose team discovered the virus believed to cause SARS. "It's very important to take a proactive approach to an emerging disease. The problem is, as soon as you raise the alert, you cause panic."

Since the SARS outbreak began, Hong Kong officials have already identified 2,000 people believed to have had "direct contact" with known SARS patients. That doesn't include a much larger number of strangers or acquaintances who may have come close enough to contract the disease. Tracking them down will be a herculean task.

SARS is already stretching Hong Kong's medical resources dangerously thin and threatening to tip an already weakened economy into recession. A more contagious disease could easily overwhelm even the most carefully constructed and best-funded system. "There are possibly greater threats out there," said Dr. Peiris. "If you have something like influenza spreading from person to person, I think even SARS could look like a picnic."

-- Marilyn Chase, Richard Borsuk and Elena Cherney contributed to this article.