On March 12, 2003, the World Health Organization issued a global health alert for an atypical pneumonia that was soon dubbed SARS, severe acute respiratory syndrome. The coronavirus had a high fatality rate; it emerged in China’s Guangdong province and within a month affected 8,000 patients, killing 774 of them in 26 countries. Toronto was one of the cities hit hard by the disease, and ace health reporter Helen Branswell of the Canadian Press has written several pieces on ten-year anniversary of the outbreak.
In “A decade ago, SARS raced round the world; Where is it now? Will it return?” Branswell writes for the Canadian Press:
Measures taken in 2003 to contain the outbreak — isolating SARS patients and quarantining people who had been exposed to a SARS case to prevent them from exposing others — succeeded at putting out that particular fire.
“That human adapted virus, that spread all the way to Singapore, Canada and … all that, that is not circulating currently in animals or in humans,” says Malik Peiris, a microbiologist from Hong Kong whose lab was one of two to first identify the virus responsible for the explosive outbreak that killed 916 people worldwide, 44 in Canada.
“(But) you can’t be sure that SARS won’t come back.”
That’s because close relatives of the virus exist in nature. And the cascade of events that led a bat virus to spark a human disease outbreak could repeat themselves, experts warn.
In “Ten years later, SARS still haunts survivors and health-care workers,” Branswell writes that 20% of the global SARS cases and 43% of the Toronto SARS cases were healthcare workers, and some of the survivors suffer from PTSD. The report Ethics and SARS: Learning Lessons from the Toronto Experience by the working group of the University of Tonronto Joint Centre for Bioethics describes some of the strains on healthcare workers:
“Mary,” a nurse in the Intensive Care Unit, is afraid that when she goes to work she will have to care for SARS patients and may become infected. Her husband asks her to call in sick, pleading that it is her duty as the mother of three small children not to risk giving them SARS. “Mary” feels torn. She feels her primary responsibility is to do everything in her power to protect her children. At the same time, “Mary” has a strong commitment to her profession, and the family needs her income. She has studied hard to become a staff nurse, and is aware of the importance the hospital places on good attendance. Her salary is affected by calling in sick. She also wants to support her colleagues on the front lines by going to work.
For the first time in more than a generation, Toronto health care practitioners were forced to weigh serious and imminent health risks to themselves and their families against their obligation to care for the sick. This generation of clinicians had entered their profession in an era when there was little expectation of facing deadly infectious diseases that had no ready cure. Suddenly, a large number of health care workers, particularly nurses and doctors, faced tough choices about how much risk to take. They had to put their lives at risk to help others. Dozens of medical workers, most of them nurses, caught SARS during their work. The most public example of the sacrifice by a health care worker was the untimely and tragic death of Dr. Carlo Urbani, who was infected in Vietnam.
SARS imposed great stresses on health care workers. They feared contagion for themselves and their families, and being shunned by others in case they were infectious. They suffered from disrupted routines, and loss of work for those who were quarantined or were unable to work because their hospitals had cut back on admitting non-SARS cases. Many health professionals had to wear cumbersome and very uncomfortable equipment to protect themselves, causing discomfort and hampering their ability to work. This also reduced the human contact with sick and dying patients.
Hospital patients suffered, too, the report explains, as hospitals canceled surgeries and barred patients’ family members from visiting them.
In several Asian countries, travel restrictions hammered the tourism industry, disrupting families’ livelihoods and harming countries’ economic growth. Economists Jong-Wha Lee and Warwick J. McKibbin calculated that SARS cost Hong Kong 2.63 percent of GDP and China one percent.
In 2007, SARS-inspired revisions to the International Health Regulations entered into force. The IHR require all 194 WHO member states to report certain disease outbreaks to WHO (including novel influenzas) and to strengthen their surveillance and response capabilities. In an interview with Helen Branswell, WHO Director General Margaret Chan — who was Hong Kong’s director of health during the SARS outbreak — explained how global preparedness has improved since SARS:
“SARS was a very important event…. And many countries have learned from SARS…. The SARS event sort of gave them additional impetus and the sense of urgency for them to really revise the International Health Regulations.”
“…All in all, and because of the impetus coming from the SARS outbreak in 2003, countries of this organization reviewed and also renewed and also updated the IHR and all these requirements actually paved the way for countries to build their capacity and also understand the need for transparency.”
“And we have noticed that the time from event diagnosis to reporting to WHO has decreased tremendously. And the country capacity is much better than pre-SARS. It’s a long way to tell you: Yes. Because of SARS, I think the world is in a much better position to detect events.”
Global communication about disease outbreaks can only happen once a new outbreak has been identified, and that relies on local surveillance capacity. Both surveillance and response capacity can easily fall prey to budget cuts, though, as memories of past epidemics fade. The US saw a big investment in preparedness after 9/11 and the anthrax attacks, but funding has since declined. SARS’ 10-year anniversary should serve as a reminder that we won’t get a warning before the next outbreak hits, and we need to be ready.