The Singapore Model on SARS

[Dave Farber <dave () farber net>]

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From: The.Wallstreet.Journal () central cis upenn edu
Reply-To: Sg_Review () yahoogroups com
Date: Fri, 28 Mar 2003 00:32:53 +0000
To: dave () farber net
Subject: [Sg_Review] The Singapore Model on SARS

REVIEW & OUTLOOK  
 
A new type of atypical pneumonia dubbed Severe Acute Respiratory
Syndrome continues to spread globally, with 1,316 cases and 48 deaths
reported so far, most of them in China and Hong Kong. Despite the
fact that health care professionals are practicing rigorous isolation
techniques when they treat known or suspected victims, the disease is
causing tens of new victims to fall gravely ill every day. It's now
clear that early guesses about the pathogen's infectiousness were too
optimistic, and that means more stringent measures to contain the
outbreak are now justified.

Yesterday, doctors in Hong Kong announced that 14 people in one
apartment block appear to have contracted SARS from another resident,
who in turn got the disease from visiting his brother in hospital.
The new victims live on different floors, meaning that they probably
got the disease by inhaling small amounts of virus in airborne water
droplets, perhaps left in the air by the "index patient" when he
coughed in the building's elevators or lobby.

Also this week it emerged that 10 members of a tour group contracted
the disease after taking the same flight as an infected person. And
the earliest source of the Hong Kong outbreak was a medical professor
from mainland China who transmitted the disease to six other people
staying on the same floor of his hotel last month. All this suggests
the pathogen, probably a virus, does have the capability to keep
spreading through the community by casual contact, even though it
isn't as contagious as common strains of influenza.

If SARS does continue to spread at an increasing rate, it could
overwhelm hospitals. The disease is extremely virulent; around 25% of
patients require intensive care, and even with that care about 4% of
them succumb to the disease. Combine that with the fact that health
care workers have been catching the disease from patients and it's
easy to see how hospitals could soon not have enough healthy workers
or equipment to handle the influx of new cases. That could then
increase the mortality rate. That is especially a concern in Hong
Kong, where hospitals are already overstretched and the number of
cases increased by 25 on Tuesday and 29 yesterday to a total of 300
confirmed cases still showing symptoms.

You would think this would scare governments into taking decisive
action. But so far that hasn't been the case, except in Singapore.
For the last month, Beijing has insisted that the initial outbreak in
Guangdong province ended in mid-February with a total of five deaths.
Then this week it admitted that the death toll was much higher, and
cases were still occurring. Yesterday, the official death toll in
China stood at 34, including three deaths in the city of Beijing, the
first deaths outside Guangdong. But the government still seemed to be
trying to suppress information in order to avoid alarming the public.
Not only did it take four months for Beijing to request help from the
World Health Organization, but it is still hampering the
international body's work by not allowing investigators to work in
Guangdong province.

In Hong Kong, there has been much more transparency about the number
of cases and their details, but officials have also been trying to
play down the problem, perhaps to minimize the economic impact to the
tourism industry. Secretary for Health, Welfare and Food Yeoh Eng-
kiong reassured the public that the disease was not spreading within
the community, a statement that we now know was premature. Schools
are being closed only after a student comes down with the disease,
despite alarm among parents. There is no plan to create a quarantine
system to ensure that family members of patients don't spread the
disease further. This failure to act in a resolute and timely fashion
has created distrust of the government.

Singapore, on the other hand, has been both transparent and proactive
in fighting the spread of SARS. Although there have only been 69
cases and one fatality in the city state, much fewer than Hong Kong,
it has taken several decisive steps. The government closed all
schools and designated the Tan Tock Seng Hospital to handle all cases
and closed it to other admissions. It has also forcibly quarantined
841 people who had exposure to the victims; those under a quarantine
order can't leave their apartments for 10 days under penalty of a
$2,832 fine.

Such an approach has some drawbacks. Governments need to educate and
encourage their citizens to seek medical attention promptly if they
display the symptoms of SARS. Singapore may have created a
disincentive for people to come forward, since they may fear that if
they turn out to just have some milder disease, they could
unnecessarily inconvenience many of their friends, family and
colleagues who have to spend time in quarantine. The resulting delay
in seeking medical treatment could then end up increasing the number
of people infected. Moreover, in Hong Kong doctors say that the
number of people exposed could be more than 1,500, making quarantine
difficult.

Nevertheless, the risks of doing nothing are becoming unacceptably
high. Hong Kong and China have a responsibility to try to contain
this disease before it possibly causes a global pandemic. The closure
of schools at least temporarily seems like a prudent measure, since
children are often a pathway for the spread of disease and their less
developed immune systems are more vulnerable. Singapore's approach of
dedicating certain medical facilities to treatment of SARS is also
prudent. It may be necessary to restrict visits by family members in
order to stop this route of transmission back into the community. And
finally, a system of voluntary quarantine could be created, perhaps
including an economic incentive. Those who have been exposed should
at the very least be asked to stay home from work for seven days, the
maximum incubation period, and wear a mask if they have to go outside
their apartments.

We've sometimes been critical of Singapore's degree of protection of
civil liberties, but when public health is seriously threatened, as
is now the case, it's difficult to find fault with a quarantine. In
fact it is a valuable experiment to see if this is an effective way
to contain the disease now that isolation measures within hospitals
have proved insufficient. If only Hong Kong and China would take SARS
as seriously.

Updated March 27, 2003
 




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