WHO’s to blame for the SARS panic?

Severe Acute Respiratory Syndrome – better known as SARS – may have reached its peak in China and other affected areas of the world. But the SARS panic remains as infectious as ever.

Three months on from the first mention of this new disease, it is worth asking: how did a relatively insignificant health issue like SARS develop into an international scare, causing alarm even in countries that have had no cases, or very few?

At the time of writing, SARS has claimed 643 lives, out of 7864 probable cases reported to the World Health Organisation (WHO) (1). In the grand scheme of things, this represents a small number of deaths.

But the SARS panic was not sparked by dangers posed by the disease itself. Rather, the health authorities – in particular, the WHO – consistently stoked up the fears before the facts. At every stage, the WHO’s precautionary warnings about SARS ran ahead of the actual cases of the disease. A look at the chronology of SARS indicates how we got from a new health problem to a full-blown epidemic of fear.

The first mention about the possibility of a new disease came in February 2003, when the WHO began investigating cases of an atypical pneumonia in the Guangdong province in southern China. At the time, the Chinese authorities claimed that there were just over 300 cases and that they had brought the outbreak under control.

Internationally, experts were not especially concerned. Their original fear had been that the new disease might turn out to be a new strain of influenza, fearing a repeat of the killer flu outbreaks of the past. Once it was shown not to be influenza, interest in the outbreak waned.

The starting point for wider attention was a case later on in February in Hanoi, Vietnam. In early March, seven healthcare workers who had dealt with this patient fell ill. The initial case drew the attention of a WHO epidemiologist, Dr Carlo Urbani, who then linked the Hanoi cases to the earlier illness in Guangdong. When the number of cases increased to 22 by 10 March, Dr Urbani alerted the WHO that there was something new and important going on.

On 12 March, the WHO issued a global alert about the new atypical pneumonia, suggesting that any patient presenting with the symptoms should be isolated, and that healthcare staff should wear protective clothing (2). On 15 March, emergency travel advice was issued by the WHO (3). It was at this point that SARS became worldwide news.

‘This syndrome, SARS, is now a worldwide health threat’, said WHO director general Dr Gro Harlem Brundtland in the 15 March press release. ‘The world needs to work together to find its cause, cure the sick, and stop its spread.’ At the time of the alert, there had been 150 cases reported to the WHO, and only a handful of deaths. Noteworthy, maybe, but a ‘worldwide health threat’?

Most of the cases reported during the rest of March were in Hong Kong, with substantial numbers of cases in Singapore, Vietnam and Canada. There appeared to be no further cases reported from China, even after the cases from Guangdong were confirmed as being the same illness found elsewhere. The Chinese authorities stated that the disease was under control on the mainland.

It was only on 26 March that hundreds of extra cases were reported from China, taking the reported figure there from 305 cases to 792. Meanwhile, one particular Hong Kong tower block, at Amoy Gardens, had experienced a large number of cases in a very short time, leading to fears that the virus might be more contagious than first thought. By the end of March, there had been 1622 cases worldwide reported to the WHO.

On 2 April, the Chinese authorities announced a further 361 previously unreported cases in Guangdong. On the same day, the WHO issued its first travel advisory, to avoid non-essential travel to Hong Kong and parts of mainland China. Previously, the WHO had dealt with disease outbreaks by suggesting measures to resolve them. A travel advisory was a significant new step: effectively quarantining whole nations, and highlighting the potential of a worldwide epidemic.

By 8 April, it was becoming clear that the Hong Kong outbreak had started when an academic from Guangzhou had visited the Metropole Hotel, infecting a number of people who had close contact with him. One of these infected guests, in turn, was the case identified in Hanoi. (4)

There was a mixed reaction from governments. China was widely criticised for not allowing the WHO access, and for downplaying the seriousness of the outbreak until it had got out of hand. As a reaction to this, the Chinese authorities then acted in a draconian manner, enforcing quarantine, closing schools and shortening public holidays.

In Hong Kong, isolation orders were placed on the residents of Amoy Gardens, and some residents were moved to ‘holiday camps’. Anyone with contact to a confirmed SARS case was ordered to remain isolated.

The Thai government forced foreigners from SARS-affected regions to wear face masks at all times or face a jail sentence. Thais returning from these regions had to stay at home for 14 days. The Australian government, among others, took powers of arrest over anyone refusing to cooperate with quarantine orders.

On the other hand, it was not just China that had problems with the WHO. On 23 April, the WHO extended its travel advisory to other parts of China, and to Toronto (5). The local authorities in Toronto were livid, claiming that the WHO had overreacted to an outbreak that was limited to those who had contact with known SARS patients. After much discussion, the Toronto advisory was withdrawn a week later.

Sales of paper masks surged in many countries, including the USA, despite the fact that nobody had died from SARS there and there were relatively few cases. Wearing a paper mask soon became a symbolic precautionary measure among the public, even though there was no sound medical reason to do so.

Previously busy streets in affected cities like Toronto were much quieter than before. Trade in Chinatown restaurants fell, even in unaffected areas of the world. Many conferences and events in affected countries were cancelled, even where the chances of infection were very small. East Asia concerts by the Rolling Stones, Santana and others were postponed or relocated.

At the time of writing, the SARS outbreak has been running for just over six months. While it has been shown to be an important medical problem that is best dealt with as quickly as possible, the death toll has been relatively small.

For example, in Hong Kong there have been 1714 cases with 251 deaths. (6) In 2001, tuberculosis accounted for 7262 cases and 311 deaths in the territory. (7) Pneumonia has always been a common cause of death in the territory. Over the past 30 years, about 10 percent of all deaths in Hong Kong have been due to pneumonia (8). In other words, SARS cases have not been out of proportion to other diseases, and Hong Kong is bringing SARS under control.

A more extreme comparison came with the WHO’s report on 25 April 2003, that 3000 African children die every day from malaria: showing that SARS is a relatively minor concern compared to some much older diseases (9).

Moreover, SARS outcomes appear to be very sensitive to age. A recent report in the Lancet medical journal suggests that death rates for the under-60s are running at about 7 to 13 percent in Hong Kong, but rise to 40 to 50 percent for the over-60s (10).

The fact that SARS was thrust under the spotlight so quickly has had some positive outcomes. The disease has been identified quickly as something novel; systems of quarantine and contact tracing have worked effectively in many countries; international cooperation over identifying the agent responsible and developing tests for it has been remarkably swift.

But overall, the impact of the SARS panic has been overwhelmingly negative. Economies have been disrupted, cities have been quarantined, people’s daily lives have been organised around avoiding a disease that has been unlikely to infect them, and even less likely to kill them. Institutions from the WHO to national governments have spent precious time and energy scaring the world about this disease, while the global media have ensured that panic has spread like a rash.

And for what? To ensure that a world of several billion people was scared witless about a disease that might kill a few hundred.

When the SARS panic finally does abate, we can only expect more of the same. New diseases are more easily identified now; increasing international travel and greater concentrations of population allow diseases to spread more quickly; and a global media means that reports in one country can quickly become news worldwide.

But far more important than any of these factors is the current mindset of, as Dr Michael Fitzpatrick has put it, ‘Apocalypse from now on‘. The propensity to see disaster lurking around every corner means that the world is wide open to panics about everything from SARS to smallpox, and the very institutions that are charged with the responsibility for containing these problems instead lead the way in creating a global scare.

Take the WHO’s response to the SARS outbreak. Declaring a ‘global threat’ on the basis of 150 cases was excessive, particularly when followed up by unprecedented travel advisories. It seems as though the WHO was already on the look-out for The Big One, and then reacted as if SARS was it.

Yet, even in the worst affected areas, the chances of any individual being infected were still very small. In media appearances, WHO spokesmen failed to calm the situation, making statements that seemed equivocal rather than giving clear advice based on the best available knowledge.

In our precautionary climate, institutions like the WHO are motivated as much by the fear of being accused of not doing enough to protect people from the potential consequences of a disease, as much as they are by the fear of the disease itself. This leads to a situation where overreaction precedes sound science and good advice, with the frightening consequence of a global panic.

To counteract such reactions, it is worth keeping in mind that these new problems are almost invariably overstated, and our capacity to deal with them is now much greater than it was in the past. Otherwise, we risk letting ourselves be scared sick by institutions that should know better.

Read on:

Apocalypse from now on, by Dr Michael Fitzpatrick

Viral scares, by Stuart Derbyshire

The SARS farce, by Mischa Moselle

(1)Severe Acute Respiratory Syndrome, World Health Organisation

(2)WHO issues a global alert about cases of atypical pneumonia, World Health Organisation, 12 March 2003

(3) World Health Organization issues emergency travel advisory, World Health Organisation, 15 March 2003

(4) SARS Update 24, World Health Organisation, 8 April 2003

(5) SARS Update 37, World Health Organisation, 23 April 2003

(6) Severe Acute Respiratory Syndrome, World Health Organisation

(7) Tuberculosis in Hong Kong, Hong Kong Department of Health

(8) Leading causes of death, Hong Kong Department of Health [pdf 690KB]

(9) Malaria is alive and well and killing more than 3000 African children every day , World Health Organisation, 23 April 2003

(10) Hong Kong’s SARS Death Rate Estimated, Associated Press, 6 May 2003