by Yanzhong Huang
February 4, 2013
Last week, I was in Beijing for an international conference while the city experienced record levels of air pollution.
I had a feeling of déjà vu as I saw people wearing face masks. Ten
years ago, at the height of the SARS epidemic, a sea of people in white
masks—most of them scared migrant workers and university
students—flocked to train and bus stations and airports in the hope of
fleeing the city. Then, face masks were a symbol of the fear of a deadly
and seemingly omnipresent virus that was responsible for 349 deaths and
over 5,300 infections in China alone. As the first severe infectious
disease to emerge in the twenty-first century, SARS caused the most
serious socio-political crisis for the Chinese leadership since the 1989
While SARS wreaked havoc for approximately nine months from November
2002 to August 2003, it is no match for the HIV/AIDS pandemic in terms
of duration, which has lasted for more than 30 years. However, SARS has
had a lasting impact on our collective psyche. In September 2012, a novel coronavirus was identified
in two patients from the Middle East, raising the specter of a new
SARS-like outbreak. To better prepare for the next disease outbreak, it
might be necessary to unravel the following myths about SARS and other
Myth #1: Strong political commitment and a centrally coordinated
response was the most important factor in the control of SARS in China.
Not really. Once the initial dilly-dallying gave way to decisive and
swift state action, resources were effectively mobilized against the
epidemic and policy coordination was significantly improved. Yet many of
the measures widely credited for stopping the spread of the virus, such
as isolation and quarantine, were only implemented after the virus
reproduction number or Rt—a critical value below which
sustained transmission of the virus is impossible—dropped below one, or
when the epidemic was already dying down. According to a study published in Tropical Medicine & International Health,
those decisive government measures might have played a role in speeding
up the disappearance of SARS or preventing the outbreak in yet
unaffected regions, but they “contributed little to the factual
containment of the SARS epidemic.”
Myth #2: Those patients who survived SARS lived happily ever after.
Not true. As a novel virus, SARS defied treatment and proved fatal in
many cases. Zhong Nanshan, a Guangzhou-based doctor, initiated steroid
therapy to treat SARS patients. This therapy, widely used during the
SARS outbreak, was believed to have saved the lives of many SARS
patients in China—indeed, during the 2009 H1N1 outbreak, steroid glucocorticoid was also used to treat critically-ill H1N1 patients.
However, there have been adverse effects of this aggressive treatment.
In late 2003, doctors began to suspect that the use of high doses of
steroids for an extended duration was responsible for the crippling of
hundreds of SARS patients. According to China Daily, roughly 30 percent of SARS survivors in China who received the therapy have developed severe bone degeneration. A study carried out in the Beijing
municipality found that 88 percent of the SARS survivors had symptoms
of osteonecrosis, 80 percent were forced to quit their jobs, 60 percent
saw their families break up, and about 39 percent suffer from severe
Myth #3: Government cover-up is no longer a major concern in the post-SARS era.
Not true. The SARS crisis has forced the Chinese leaders to take
steps to be more open and transparent in disease reporting and
information sharing. Yet as shown in the 2008 hand, foot, and mouth disease (HFMD) outbreak,
local government officials found it difficult to adjust their existing
behavioral patterns for crisis management, which still value secrecy and
inaction. Similar communication problems also bedeviled the
government’s response to the 2009 H1N1 outbreak. China’s SARS crusader Zhong Nanshan publicly expressed his distrust in government data
on H1N1 fatalities. Political expediency continues to be put before
epidemiological reality in sharing disease-related information with the
public. The health authorities stopped updating the spread of H1N1 cases
between September 30 and October 9, apparently fearing that reporting
H1N1 deaths would ruin the celebrations planned for October 1, the
National Day that marked the 60th anniversary of the People’s Republic
of China. That said, government cover-up and inaction are not unique to
China; India’s response to the 2012 dengue fever epidemic was riddled with similar problems.
Myth #4: Poor or failed states pose a bigger infectious disease
threat to the international community than stronger developing
Not necessarily. In his thought-provoking book, Weak Links,
my colleague and a leading global governance expert, Stewart Patrick,
argues that stronger developing countries such as China and Indonesia
“may actually pose a bigger infectious disease threat to the United
States and the global community than weaker states.” In these countries,
the rapid economic development and land use change has significantly
increased the chances of human exposure to natural hosts who are
carrying novel and lethal viruses of zoonotic origin. Coronaviruses that
were implicated in the SARS outbreak, for example, have been detected in multiple species of bats. As described in the movie Contagion,
the eating habits in some countries make it more likely for a virus to
jump from one species to another. Indeed, In Guangzhou in southern
China, 20,000 wild birds are estimated to end up in the human stomach every day.
The integration of these countries into the global economy means that a
lethal virus can travel at jet speed to other parts of the world. It is
no coincidence that SARS was first discovered in Guangdong, a highly
developed province with a robust export sector, and arrived in Toronto
before it first appeared in Beijing. It also came as no surprise that
Cambodia and Myanmar, two of the least developed countries in Asia, were
spared by SARS in 2003.
Myth #5: Infectious disease outbreaks remain the primary public health concern in the Asia-Pacific region.
Wrong. According to the World Health Organization,
non-communicable diseases or NCDs, which includes cancer,
cardiovascular diseases, chronic respiratory diseases, and diabetes, are
the most frequent causes of death in most countries in the region.
Today, NCDs account for
85 percent of mortality in China and 70 percent of total disease
burden. Indeed, even in sub-regions of Asia-Pacific that are still
facing the double burden of communicable and non-communicable diseases,
NCDs will soon be the predominant cause of mortality. According to the World Bank, the share of total deaths attributable to NCDs will increase to 72 percent in 2030 from 51 percent in South Asia in 2008.
Since 2003, tremendous progress has indeed been made in improving
global health security, especially in areas of capacity building for
disease surveillance and response. However, our ability to effectively
address the next SARS-like disease outbreak is still constrained by our
lack of understanding of the evolving biological and political worlds.