Perspectives in Health Magazine
The Magazine of the Pan American Health Organization
Volume 8, Number 2, 2003

In mid-June, when outgoing Director-General
Gro Harlem Brundtland of the World Health Organization
(WHO) announced that severe acute respiratory syndrome (SARS) had been "stopped dead in its tracks,"
people around the world sighed with relief.
Yet many in the international public health community
believe it is unlikely that SARS has really gone away.
Should it begin spreading again-or should some other threatening new disease emerge-what are
some of the lessons we have learned from
the first outbreak?
 

I would start, not last November, when word of a strange new illness began to emerge, but in the 1850s, when the legendary John Snow showed that a single water pump was responsible for infecting a large number of London residents with cholera. Snow was the quintessential "shoe-leather" epidemiologist, who painstakingly plotted an epidemic's path and traced it to its origins, providing scientific documentation of his conclusions and producing dramatic results with his remedy.

Fast-forward to the past 20 years, which are replete with stories of talented, committed physicians and medical experts who risked their own health and well-being to visit the scene of a particularly nasty outbreak and observe, record and rapidly report their findings. Hanta, Ebola, Lassa, Marburg and West Nile viruses, along with anthrax, plague, Rift Valley fever, dengue, dracunculiasis-all are recent examples of how local, regional and global expertise and resources have been mobilized at the scene and coordinated at distant points to determine the cause and possible solutions to disease outbreaks.

At the core of all such investigations are certain principles that serve as the basis for effective and honest public health action:

• All data should be gathered, collected and shared in a quick, intelligent and scientific manner.
• Governments should cooperate fully in the investigation because the health of those they represent is at stake.
• Under no circumstances should the science be compromised, since the findings will underpin a final determination on how to control and prevent further disease spread.

False first steps

In the case of SARS, we can only speculate how many lives might have been saved and economic damage avoided had officials in China (at the provincial perhaps even more than at the national level) been forthcoming earlier with information and requests for assistance. They had no farther to look than Hong Kong to see the merits of openness and international cooperation. In mid-1997, right around the time Hong Kong reverted to Chinese rule, an epidemic of avian flu broke out. But Hong Kong's health officials reached out, and the World Health Organization (WHO), with help from the U.S. Centers for Disease Control and Prevention (CDC), responded swiftly and effectively with measures to stop the disease's spread.

By contrast, official information on China's SARS epidemic was sparse and suspect until early April, when the Communist Party fired China's minister of health as well as the mayor of Beijing and ordered greater transparency in reporting on the epidemic. Acknowledging the error of the country's initial response, the English version of the official China Daily News observed in an editorial: "Harsh reality demands clear information from the authorities, so the public can be fully informed of the situation and take appropriate measures." A subsequent article in The Asian Wall Street Journal also criticized government officials, saying they "thought first not of the public's health, but of the economic and social harm that might be caused by a panic."

It is important to note that China's response did not violate any international agreements. Like all WHO member countries, China is a signatory to its International Health Regulations (IHR), but these require compulsory reporting on only a small number of diseases. At the most recent World Health Assembly-in Geneva in May, as SARS was dominating world headlines-WHO's member countries expanded the organization's authority to respond to such international epidemics. It is now authorized to consult unofficial sources of outbreak information, and it no longer needs permission from member governments to conduct on-site investigations (though it must inform governments and let them know of its teams' whereabouts).

These changes, part of an ongoing process of revamping the IHR, will come in handy should a new SARS or other dangerous international outbreak occur. But equally important is each affected country's immediate voluntary response. Openness is not always easy, even more so when the stakes are as high as they are in the case of SARS. Affected countries know that if their epidemic appears to international observers to be out of control, they risk serious economic loss. At the domestic level, health officials must alert health workers and the public to be vigilant, but without causing undue panic. Openness and effective use of information are critical to gaining the public trust needed for effective contagion control.

The next time

There is still much to learn about SARS, whether its cause is indeed a single virus and what kinds of treatments and vaccines might be effective against it. There is no better way to tackle these challenges than through a multitude of talented scientific minds evaluating both the epidemiology and the laboratory aspects of this illness as we move toward definitive findings. Just such work is now taking place in labs and public health offices around the world, and continuing openness and information sharing are essential to its success.

Our planet grows smaller every day as a result of global travel, commerce and exploding populations. SARS is unlikely to be the last public health threat of its kind. It has never been more important for elected and appointed officials to cooperate fully with their international colleagues, scientific bodies and global health organizations in combined efforts to battle such diseases. We must work together, with skill, speed, openness and dedication -all elements of the best tradition of public health.

Robert J. Howard heads a health communications consulting firm in Duluth,Georgia,USA, and teaches at Harvard University, the University of South Florida and six National Public Health Leadership institutes.

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