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Last Updated

01 Apr 2003

Source: New York Times, April 1, 2003


Why Epidemics Still Surprise Us



At Novena Square in downtown Singapore normally bustling with shoppers and diners at sparkling-clean restaurants the sidewalks are quiet. Since mid-March, people have been avoiding this area because it's close to a hospital that has been designated to deal with the outbreak of severe acute respiratory syndrome, or SARS. So far, about 90 of the more than 1,500 cases of the illness and four of the 58 deaths it has caused have been in Singapore, a place known for its antiseptic cleanliness and its usual immunity to the contagious diseases that plague its neighbors. It is believed that the illness was brought here by three women returning from a trip to Hong Kong.

As SARS spreads across the globe (Belgium reported its first case yesterday), many have been pointing their fingers at China, which has suppressed information about the illness after it first appeared there in November. The real problem is not how secretive China has been, but how ineffective the World Health Organization has been in creating and enforcing a public health policy suited for a global outbreak like this one.

Since its founding by the United Nations in 1948, the agency has overseen the monitoring and reporting of illnesses but its rules are binding only on its members. Its membership now includes 192 countries but excludes some nations that are not members of the United Nations, like Taiwan, which has recorded five cases of SARS. Moreover, the only diseases that members are required to report are yellow fever, plague and cholera. And if a jurisdiction declines to report, there are no legal consequences.

When it comes to identifying mysterious new illnesses, the policies are even more fluid. Since the advent of the Ebola virus in Africa, the agency has been experimenting with a voluntary system of information gathering through its Global Outbreak Alert and Response Network, made up of 100 partners, with 11 laboratories in 10 countries. Information-gathering is a good thing but the agency's definition of a public health emergency is so broad whether an illness is serious, unexpected, likely to spread internationally, and restrict travel or trade internationally that it could apply to almost anything, or nothing. Without enforcement powers, the agency can do little to stop a country from trying to hide an outbreak that it finds embarrassing until it's spread so much that it's no longer a secret.

And even when a threat has been recognized, conflicting national policies hamper the W.H.O.'s ability to control the response to it. In Hong Kong, which has now reported more than 500 cases, officials first played down the seriousness of SARS and accused the W.H.O. of being too quick to sound an international alarm until one of two doctors overseeing the government's response was himself hospitalized with the illness. In Singapore, the response has been the opposite: last week the government quarantined 740 seemingly healthy people who have been exposed to SARS.

To be sure, the W.H.O. was pivotal in the eradication of smallpox and the control of other deadly infections like malaria, but since then its role has become more an advisory one, issuing extensive but general recommendations, with no way of enforcing them. Last month, the agency went about as far as it could go by issuing a worldwide emergency travel advisory, urging people who thought they might be ill not to travel. The agency's structure is inadequate for a world where infectious diseases aided by international travel and global trade have returned with a fury.

SARS is just one of a number of new and deadly infections that have emerged in the last few decades. Since 1973, about 30 new pathogens, including Ebola and H.I.V., have appeared. Still, those diseases do not spread as widely or as quickly as SARS has. This is the first real test of the W.H.O. global response program and it's easy to see where the flaws are. Let's hope we don't have to wait for a bigger threat like a bioterrorist attack before we create a system that really works.

Andy Ho, a former primary-care doctor, is a columnist for The Straits Times of Singapore.