THE LESSONS FROM SARS
15 Apr 2003
Source: Wall Street Journal, April 15, 2003
The Lessons From SARS
By MADELINE DREXLER
In recent years, public-health departments worldwide have been girding for the terrifying consequences of weapons of mass destruction -- biological, chemical, and radiological. They have been stocking up on drugs and ventilators, staging practice exercises and forging international agreements.
Instead it was a naturally evolving agent -- the new virus behind the deadly SARS epidemic -- that exposed the strengths and weaknesses in our bulwark against catastrophic outbreaks, including those triggered by terrorists. No one knows how the mysterious epidemic -- which has already infected 3,000 individuals and killed more than 100 -- will unfold. But the lessons learned barely one month after the World Health Organization issued a global alert have been invaluable.
The primary lesson is that nations have a moral duty immediately to report any suspicious outbreaks of disease and permit outside experts to investigate. In public health, knowledge is power -- and the key to timely intervention. Although SARS first appeared last November in southern China's Guangdong province, not until late January did the Chinese government classify the infection as a potential epidemic. Not until the end of March did authorities release reliable statistics about the number of cases and deaths from the infection. Not until early April did authorities permit WHO researchers to travel to Guangdong. Even today, there still aren't credible figures on the number of cases in Beijing.
China's inexplicable and inexcusable tardiness in releasing these facts and in permitting access to outside scientists has blocked key avenues of research. The delay stymied efforts to track down a possible animal reservoir of the new virus. It prevented investigators from mapping the initial movement of the virus. And, of course, China's refusal to notify journalists or alert its own citizens has most likely led to hundreds of infections that could have been prevented.
But what if the disease had instead been smallpox or plague? Here, too, if the SARS experience is any gauge, public health has a long way to go. In preparing for terrorism, what many officials worry about most is the "surge capacity" of a nation's health system: the ability to quickly diagnose and treat large numbers of acutely ill patients.
Hospitals have been among the hardest hit by SARS. Some have become epicenters of disease. At Hong Kong's Prince of Wales Hospital, a single patient infected nearly 50 doctors and nurses from just one ward. In Hanoi's French Hospital, a businessman infected dozens of employees. Likewise in Singapore, a "super-spreader" transmitted the illness to dozens of medical workers.
This extra burden only compounded a chronic problem in health care. Most hospitals around the world operate with very little slack. Even on normal days when nothing unusual is afoot, emergency rooms are full and staff shortages routine. In today's world-wide recession, most medical centers operate in the red or barely break even. So it's no surprise that the institutions hit by SARS had to cut back on their regular duties, canceling elective surgeries and releasing other patients early. In early February, before the world had even learned of SARS, the Guangdong Infectious Disease Hospital saw 150 of its 400 beds occupied by SARS patients.
And yet, compared to other diseases on the horizon -- such as pandemic flu or the dreaded prospect of smallpox -- the SARS epidemic has been relatively mild. If health-care facilities in Asia and Canada have been crippled and in some cases forced to close by this comparatively contained epidemic, how would they care for massive numbers of contagious patients in a large-scale disaster?
Indeed, the SARS outbreak has been mainly confined to nations where public-health surveillance and medical-care institutions are fairly advanced. Hong Kong -- a global center of influenza surveillance -- has one of the finest disease-tracking systems in the world. What if the infection had first sprung up in Somalia or Haiti or impoverished swaths of India -- places where surveillance is weak and health-care facilities survive on a shoestring, where essential diagnostic tests are lacking and basic infection control may be impossible? Would the outbreak have been caught early? Could it have been reined in? Or would it have killed thousands before the world could even marshal a counterattack?
The WHO recently reported that in Guangdong province, the epidemic may be leveling off, thanks to efficient reporting of new cases, strict hospital precautions and contact tracing. That gives cause for hope that SARS may burn out before it catches fire world-wide. But the WHO also noted "many remaining concerns about the ability of other provinces, where health systems are not as strong as the one in Guangdong, to respond promptly and effectively to the challenge of SARS."
This caveat applies to all nations. And it equally pertains to the consequences of bioterrorism. If the unthinkable happened and the smallpox virus were released, wealthier societies such as the United States or Japan would probably contain its spread within four generations of the virus, via quick immunization campaigns. But in poor nations, the death toll would be devastating. Billions could conceivably die.
The ultimate message of SARS is that we must be on the alert for all kinds of infectious agents, which could strike at any moment. "New virus" is one of the most frightening phrases in public health -- as we've seen with the 1918 flu, the Ebola virus, and AIDS. Viruses and bacteria do not need visas to cross national borders and only strong global-health networks can protect us against these potential disasters.
In particular, uniform disease-surveillance systems are needed in every country, so that the WHO can track the spread of a new infection in real time. Equally crucial is strong collaboration between government laboratories, so that these facilities can quickly exchange results and specimens. We need rigorous strict infection control in hospitals and clinics -- not just well-publicized guidelines, but gowns and masks and negative pressure rooms to prevent a new virus from escaping, and enough backup staff and equipment. We need new antibiotics, antivirals, and vaccines to halt known and unknown pathogens. And to prevent terrorist-planted epidemics, we need international agreements that would remove potential bioweapons from groups or individuals that would maliciously deploy them.
Above all, we need to upgrade health care everywhere. Emerging infections are improbable, unpredictable -- and inevitable. With SARS as with every other surprising outbreak, global public health is only as strong as its weakest link.
Ms. Drexler is a Boston-based journalist and author of "Secret Agents: The Menace of Emerging Infections" (Penguin, 2003).