Severe Acute Respiratory Syndrome (SARS)
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KeywordsCoronavirus China Globalization World Health Organization Post-Westphalian system
Carl Urbani, an epidemiologist from the World Health Organization’s (WHO) office in Hanoi, was proved absolutely right when he reported in November 2002 that a new communicable disease which had just broken out in China posed “a serious threat to global health security, the livelihood of populations, the functioning of health systems, and the stability and growth of economies” (World Health Assembly 2003, p. 1). Urbani, who himself contracted the SARS virus and died of it, was the first to call international attention to what he correctly acknowledged to be “the first severe infectious disease to emerge in the twenty-first century” (World Health Assembly 2003, p. 1). The outbreak of SARS (2002–2003) makes an interesting case study which illustrates the nexus of infectious disease and global security. Four aspects of the epidemic are particularly significant: the character of the newly emergent pathogen, the unprecedentedly rapid tempo of its worldwide spread, the transformed global public health context in which it occurred, and the potential of microbes to affect state policies.
A Novel Germ
Severe acute respiratory syndrome, named as such by the WHO in March 2003, is a zoonotic disease that arrived in late 2002 after the SARS coronavirus had jumped from animals to humans. The microbe, originally residing in bat populations in Southeast Asia, passed to a small mammal called the palm civet cat wherein it developed an increased capacity to infect humans, then crossed over into the human ecology (perhaps via an exotic meal made from the meat of the palm civet cat), and became a serious person-to-person transmissible infection. The virus settles in the lungs, causing an aggressive form of upper respiratory distress – an atypical pneumonia for which there is no effective treatment. The accompanying symptoms include high fever, cough, and diarrhea. The pathogen is airborne and is transmitted through mucus droplets released during coughing. It is highly contagious and has the short incubation period of a maximum of 10 days, with an average of 4–6 days.
The Outbreak: A Local Epidemic Goes Global
The infection began in the city of Foshan, in densely populated Guangdong Province of southern China, with the first known case reported on 16 November 2002. As the patients infected mostly their family members and hospital staff, the virus spread quickly, breeding a local epidemic. One of the doctors who had treated SARS victims in Guangdong, the 64-year-old Liu Jianlun, traveled to Hong Kong for a wedding ceremony. On 21 February 2003, unaware that he was carrying a coronavirus companion in his body, he checked in at the Metropolitan Hotel. Less than 24 h later he was hospitalized, and he died after few days. The doctor was the index case (or patient “zero”) in what was quickly to become a global SARS outbreak. As the microbe can survive on objects such as doorknobs or elevator buttons for more than 24 h, the “super-spreader” unwittingly passed it on to at least 12 other hotel guests with whom he shared the floor, elevators, lobbies, and dining halls. The infected subjects went on their subsequent journeys, taking SARS to Singapore, Vietnam, Canada, Ireland, and the United States, perhaps also communicating it at successive travel hubs. Thus was a worldwide chain of infectious transmission set off.
Within just 24-h from the time of contact, the pathogen spread to 5 Pacific Rim countries, and within 2 months it had arrived in another 21 across the world. By 12 March 2003, when the WHO issued a global alert about atypical pneumonia (followed on 15 March by an emergency travel advisory, the toughest in the organization’s history), the greatest incidence of cases was reported in China (5327), Hong Kong (1755), Taiwan (665), Canada (251), Singapore (238), Vietnam (63), and the United States (33) (Price-Smith 2009, p. 141). Within 9 months, SARS had spread to 29 countries (including Brazil, South Africa, and Indonesia) and 3 regions (including Hong Kong and Macau).
Pathogens on Networks: The Convergence of Globalization and Disease
SARS revealed that infectious disease had become one of the substantial systemic risks endemic to globalization. Such issues as environmental degradation, depletion of natural resources, or communicable diseases, which until the late twentieth century were understood as purely domestic challenges, came to be perceived as both international and domestic. This intermestic nature of the growing range of human affairs results from global interconnectedness, yet it itself also furthers complex interdependencies.
For, being inherently dialectical, globalization not only triggers the “butterfly effect” but also produces the “butterfly defect.” In a tightly intertwined world, “what happens in any one community can quickly cascade into a global event. Small places and single individuals can become globally significant, just as what happens globally can have dramatic consequences for the most remote locality or community” (Goldin and Mariathasan 2014, p. 1). This growing interdependence has brought new vulnerabilities, such as the local outbreak of an unknown disease developing into a pandemic.
The SARS event exposed that the networks of global travel and trade, the very arteries for the flows of people and goods, can equally swiftly transport germs over great distances. Historically, commerce has long facilitated microbial transmission, but today the scope and speed of worldwide interconnectedness makes pandemics a substantial systemic risk. A single infected individual moving within the global network may suffice to set in motion the snowballing spread of a pathogen.
SARS manifested the ramifications of globalization for the contemporary geopolitics of disease: both developing and highly developed countries are fairly susceptible to novel infectious agents. Zoonotic (animal-to-human) transfers and epidemic outbreaks in densely populated poorer regions can spread to First World societies within hours and become global in less than 3 days. Thus SARS demonstrated that developed states “are only as secure as the world’s weakest public health system and for as long as it takes a passenger to travel from that location” (Prescott 2003, p. 213). The fact that global health security was a public good had been proven before SARS by HIV/AIDS and later again by Ebola. It was, however, SARS that indicated the unfolding transformation of public health toward its new “post-Westphalian” phase.
A Post-Westphalian Pathogen
The international public health regime developed in the nineteenth century to help reduce the harmful ramifications of virulent cross-border diseases (such as plague, cholera, and yellow fever) for trade and travel. Its nature was “Westphalian”; it was built upon the two cores of the post-1648 international system: the firm norm of state sovereignty and the principle of nonintervention. Thus, at the international level, “only those aspects of infectious disease that related to the intercourse among states” were addressed. And states were by no means bound to undertake improvements in their public health. It was solely up to governments to decide how to deal with epidemics that broke out on their territory (Fidler 2003, p. 487).
A widened agenda, as public health escapes the narrow interests of nation states and extends into the realms of human rights (health as a public good) and international security (securitization).
The active role of non-state actors, who increasingly influence global health governance and policy-making.
International public health management, run mainly by the WHO, is guided not only by governmental but also by other diverse sources of vital epidemiological information and global disease surveillance.
The rise and expansion of public-private partnership in the research on identifying pathogens, designing diagnostic tests, and producing new drugs and vaccines.
This transformation of global public health was propelled by globalization, developments in information technologies, and the experience of dealing with the HIV/AIDS pandemic. SARS can in fact be seen as “the first post-Westphalian pathogen” (Fidler 2003, p. 486) because it epitomizes the ongoing transition to a post-Westphalian stage in public health. Having failed to notice this paradigm shift, in its handling of the disease China “acted Westphalian in a post-Westphalian world” (Fidler 2003, p. 490), as discussed in the following section.
China’s Westphalian Response
Initially, China followed a policy pattern typical to the Westphalian template and considered the problem as purely domestic. Much concerned with the ineluctable harmful repercussions for economic development and unfavorable international perception, the authorities decided to cover up the disease. All reports on the outbreak were classified as “top secret,” and any discussion of it was deemed a violation of national secrets (Price-Smith 2009, p. 141). China misled the WHO and repeatedly assured it that the epidemic was being brought under control. On 27 February, after the Hong Kong outbreak, and at a time when SARS was already going global, the Chinese Ministry of Health claimed the disease to be contained, thereby reaffirming its earlier false declaration of 14 February (Price-Smith 2009, p. 141; Chan et al. 2010, p. 2). This denial and the ensuing passivity in employing adequate control and prevention measures prompted the dissemination of the epidemic. Local authorities mishandled the problem by being too slow to recognize the advancing new infection and too reluctant to alert the central government. This negligence abetted SARS’ spread to Beijing and beyond.
Yet the Chinese efforts to suppress the information failed as the news leaked out, passed on by thousands of anxious citizens exchanging text messages about an unknown disease that was spreading in Guangdong. The information revolution impaired the effectiveness of the Westphalian-like policy of hiding epidemic events from the world. But even after SARS had been exposed, China chose to understate the problem and obstruct the arrival of the WHO’s investigative team.
Adapting to the Post-Westphalian Context
With its reputation tarnished, and its subjection to immense international criticism, China markedly changed its approach. The new president, Hu Jintao, introduced greater openness and began to cooperate with the WHO, which on 2 April was eventually permitted to visit Guangdong province. Despite having finally acknowledged the epidemic, the authorities nevertheless underplayed its severity. Only in late April did they significantly alter their position, by intensifying collaboration with the WHO and other governments, including Taiwan. In early May a group of Chinese officials was dismissed or penalized for mishandling the initial response to the outbreak (Price-Smith 2009, p. 149). Strict epidemiological steps were undertaken, such as the law adopted on 15 May which introduced the draconian measure of 7 years of imprisonment for evading compulsory medical examination or treatment and capital punishment for breaking quarantine. After the zoonotic links (i.e., the animal-to-human transmission) were confirmed, nearly a million animals were confiscated from the wildlife markets in Guangdong (Karesh and Cook 2005, pp. 42–43).
The Chinese covert, state-centric response and the cascading foreign pressure it prompted were in a sense a watershed for the communist regime. China’s soft power, which had been so laboriously built up, suffered, and its aspiration to be recognized as a responsible state jeopardized. The tight intersection of epidemics and politics produced grave repercussions. The outbreak was, rather hyperbolically, seen as China’s 9/11 insofar as it forced it “to pay attention to the real meaning of globalization,” a dramatic event which “caused the most severe socio-political crisis for the Chinese leadership since the 1989 Tiananmen crackdown” (Eckholm 2003; Huang 2004, p. 116). Some observers even went as far as to speculate that it could become “China’s Chernobyl” – pressure for reform might eventually undermine communist rule, as happened in the Soviet Union. Overall, SARS was, in a way, consequential in the recent history of China’s rise as a global power.
The long-term effect of the outbreak has been China’s increased willingness to engage with international organizations on an array of global health issues, particularly HIV/AIDS. The lessons learned after SARS were reflected in the country’s strict and determined response to the 2009 outbreak of H1N1 swine flu. While in 2002–2003 the authorities were at first passive and indulgent, in 2009 their reaction was the polar opposite – vigilant, if not overeager. It even met with criticism for the imposition of a stringent quarantine of all travelers from Mexico, the epicenter of the influenza outbreak (Chan et al. 2010, p. 4). Moreover, China has developed its own global health diplomacy, pursued mostly in Africa (i.e., through building hospitals and training medical staff). Although, on balance, SARS fueled changes in China’s public health governance, the country’s behavior has not yet become truly post-Westphalian. It remained “fundamentally state-centric, contrary to the essence of global health diplomacy and governance,” reflecting the regime’s “grave concern about the loss of national sovereignty to external or nongovernmental actors” (Chan et al. 2010, p. 5).
At the other end of the spectrum in dealing with SARS was Vietnam, the country whose prompt and cooperative response was most post-Westphalian. The government swiftly closed the northern border with China, assigned $2.6 million to prevent a second wave of the epidemic, and straightaway undertook epidemiological procedures to contain the disease (crucial here was the isolation of the French Hospital in Hanoi, where the first case of infection occurred). Contrary to China, instead of protecting its economy, Vietnam focused on taming the coronavirus and willingly accepted foreign assistance. The Canadian government could not be equally praised; at first it demonstrated a greater concern for the short-term impact on tourism and related business than a genuine commitment to address the disease. For example, it disregarded the WHO’s advice to introduce medical screening of all passengers departing from Toronto airport.
In sum, the epidemic revealed that in the era of complex interconnectedness, public health ceased to be solely a domestic issue, and it became impossible to keep it separated from foreign policy concerns.
A Happy End with a Warning Message
SARS sparked a worldwide fear of a coming pandemic, but both the properties of the virus and the international response enabled the disruption of its transmission cycle and the halting of the epidemic. Thus, eventually, on 5 July 2003, the WHO could announce that the disease was under control globally. Ultimately, then, to quote Larry Brilliant, an American epidemiologist who was earlier engaged in the smallpox eradication program, SARS was “the pandemic that did not occur” (The Economist 2006). Fortunately, its cost in human lives was not very heavy. The total toll between 1 November 2002 and 31 July 2003 amounted to 8096 cases (morbidity) and 774 deaths (mortality), with the overall fatality rate reaching less than 10% (World Health Organization 2004).
Modern technologies not only facilitate the risk of pandemics by accelerating human mobility. They are also decisive in containing the spread of pathogens. The SARS contagion is illustrative here: though it was suppressed by the Chinese government, the information about a newly emerging disease reached the international community courtesy of text messaging and emails sent by concerned citizens. The global media coverage generated popular anxiety, yet it was also crucial in keeping people updated, cautious, and aware of the necessary epidemiological countermeasures. Singapore even launched a special public television channel dedicated exclusively to SARS. The WHO’s efforts to contain the threat succeeded primarily due to the functioning of the Global Outbreak Alert and Response Network (GOARN). Established in 2000, it incorporates research institutes, universities, technical institutions, laboratories, international health organizations, and technical networks that focus on the detection and surveillance of pathogens and the response to them. GOARN, which hinges on interconnectivity empowered by information and communication technologies (data exchanged through special secure websites, teleconferencing, etc.), helped deploy international teams and coordinate the reaction (Mackenzie et al. 2004).
With no workable diagnostic tests, vaccine, or treatment, only two control measures were available: the tracking, identification, and isolation of the infected individuals and the quarantine of those possibly exposed to infection. As to the former, thermal-screening and the removal of symptomatic passengers with high fever from airlines were introduced at air hub points. The Hong Kong airport set an example in mid-April by implementing temperature checks for all arriving, departing, and transit passengers. Residents in Singapore were not only issued a million toolkits containing thermometers and facemasks but were also regularly screened at public places for temperature checks. Quarantine, however old and simple a measure, turned out to be effective in curbing the virus’ transmission. In some places it was backed up by technological solutions like cameras and electronic bracelets, as used in Hong Kong to help the public services enforce home quarantine, or software to track the spread of the disease in urban areas (National Intelligence Council 2003, pp. 11–12).
Vital in arresting the proliferation of SARS was its short incubation period. As symptomatic patients could be identified and isolated, the encounter filter in the transmission of the pathogen could be narrowed and eventually closed, thereby enabling the prevention of a pandemic.
The Economic Toll
The global cost of SARS in 2003 was estimated to be at least $40 billion, but the overall figure may have been as much as $54 billion (Lee and McKibbin 2004, p. 103). Asia evidently experienced the most severe adverse economic effects. China lost 0.5% of its total annual GDP ($6.2 billion), yet, when the overall final expenditures are included, this amounted up to 1.3% of GDP ($17.9 billion) (Price-Smith 2009, p. 144; Hanna and Huang 2004, p. 111). Due to the large role of the service sector and the strong reliance on trade, it was, however, Hong Kong that suffered the worst, with a 2.63% decline in GDP. The next-worst-affected areas were Taiwan (with a 0.49% drop in GDP) and Singapore (0.47%) (Lee and McKibbin 2004, p. 103). Canada, too, experienced brief and limited economic ramifications resulting from the fall in tourism, particularly in Ontario (in 2003 Toronto suffered an estimated 18% drop and a corresponding loss of nearly C$ 1 billion) (Canadian Press 2003).
In Hong Kong, public anxiety about the spreading virus caused a significant shock on the demand side, which dealt a serious blow to its economy. The airline industry was temporarily harshly affected as people stopped traveling and were forced to limit their mobility to and from the city as a result of flight cancelations. At the apex of the epidemic, in April 2003, Hong Kong experienced an almost 80% decline in air traffic compared with the preceding month. Travel by sea and by land also declined dramatically – of 72% and 52%, respectively. Overall, between March and April 2003, the total number of visitors arriving in Hong Kong dropped by 63% or around 850,000 people (Siu and Wong 2004, p. 74). Given that tourism-related activities constitute a substantial share in the export and import of Hong Kong services, a dire direct economic impact inevitably followed. Businesses suffered considerable losses in income as domestic consumption fell as a result of the impasse in tourism and constrained social interactions. Early anecdotal evidence indicated that restaurants and shops reported a drop in retail sales of up to 50% (Siu and Wong 2004, p. 70).
The fear of the new disease, which disseminated faster than the virus itself, did not incur major disruptions in trade and investment flows, but the economic fallout it produced – referred to as the “SARS tax” – was considerable. The SARS event illustrates the typical psychological and subsequent social, political, and economic reactions. It was an exemplary “epidemic of fear, generated by the great levels of uncertainty about the etiology of the pathogen, its vectors of transmission, its possible communicability and virulence, and the efficacy (or lack thereof) of possible prophylactics and treatments” (Price-Smith 2009, p. 32). Fear and anxiety can produce very real and acute economic downsides.
“What If” Scenarios: A Stern Warning for the Future
SARS showed that with concentrated international effort, it may be possible to contain a novel pathogen through traditional public health methods. Still, the profile of the virus was quite favorable in this respect: it spread mostly through close contact as the mucus droplets it causes are relatively heavy, which prevents them from traveling far through the air. Should, however, the microbe have been of greater infectiousness and virulence, a pandemic could easily have erupted.
Some alternative scenarios can therefore help reveal the true global systemic risk posed by infectious disease. One potentially worrying path would be the existence of a dozen super-spreaders instead of just one. Another scenario assumes different travel destinations of the infected passenger-vectors. Suppose, for example, that “the virus had flown from Hong Kong to Durban instead of Toronto. It is a city of a similar size but without a similar health infrastructure, and with a significant proportion of its inhabitants immunocompromised owing to HIV-1 infection. Then Africa could have become endemic for SARS by now” (Weiss and McLean 2004, p. 1139).
If it is trivial to argue that globalization has accelerated the dynamics of epidemics, the remarkable scope and speed of this growth in geo-temporal expansion is less self-evident. Based on the SARS example and drawing on the global connectivity in air traffic in 2005, German researchers in complex systems, networks, and computational epidemiology assessed the spread dynamics of a future new infectious germ (Brockmann et al. 2005). Their probabilistic mathematical model of the worldwide proliferation of a novel pathogen incorporates 95% of the entire civilian aviation traffic, covering 500 major airports in 100 countries. Assuming the availability of vaccine and depending on the number of flights undertaken by a single infected individual, the simulation indicates the percentage of world population required to be immunized if the spread of a microbe of SARS-like virulence is to be effectively contained. It is only a small fraction for one flight, but if an index patient travels twice, as much as 75% of the world population would need to be vaccinated. In case of three journeys by air, total global vaccination is required to prevent a pandemic. The isolation of the world’s largest cities as an epidemiological countermeasure can significantly lower the necessary scope of vaccination: from nearly 75% to 37.5%. Yet, to achieve the same reduction, as many as 27.5% of aviation connections would need to be closed down, meaning an enormous burden for the global economy (Brockmann et al. 2005, p. 91). The model is illustrative of how global connectivity and network complexity induce cascading epidemiological consequences.
One of the most significant lessons to be learned from the outbreaks of new diseases, which, just like SARS, fortunately did not turn pandemic, is that it is imperative to conceptualize them in terms of global systemic risk. For what does not happen now might materialize next time. SARS, then, demonstrated in a powerful way that the risk of a global health emergency clearly needs to be approached with a post-Westphalian mindset.
Although short-lived, geographically contained, and ultimately with a relatively low casualty rate, SARS was a wake-up call. It indicated that each and every apparently local new pathogen is just a plane trip away from even the most remote locations. The outbreak was a vivid manifestation of the globally interdependent character of public health and all the consequent vulnerabilities arising from increasingly extensive global trade and travel.
The emergence of SARS points to some general conclusions. To begin with, it was the first dire global public health threat since the arrival of HIV/AIDS in the 1980s. When compared to SARS, which was characterized by fast and effective human-to-human respiratory transmission, numerous earlier emergent infectious microbes had a limited power to imperil international health security. Second, combined multinational efforts involving such traditional measures as isolation and quarantine proved essential in containing the disease. It is, however, naïve to be overoptimistic about the forthcoming pathogenic risks, as, given the short time from incubation to symptoms, SARS was relatively easy to curb. This may not be as simple in the future when it comes to the most challenging infections – those with long incubation periods. Third, the event showed the power of microbes to boost changes in the framing and conduct of public health policies, both domestic and foreign. Fourth, in China’s example, SARS demonstrated that public health policy was no longer exclusively a domestic issue but would inevitably become subject to international scrutiny. The digital revolution changed the global surveillance context, dooming any cover-up efforts to failure. Governments ceased to be the sole source of epidemiological information. As the WHO observed, “in a globalized, electronically connected world, attempts to conceal cases of an infectious disease (…) must be recognized as a short-term stopgap measure that carries a very high price—loss of credibility in the eyes of the international community” (World Health Organization 2003, p. 8). Finally, the outbreak became a reminder of how rapidly a new disease can proliferate when turbocharged by global networks.
SARS was but the first of the serious new diseases to have emerged in the twenty-first century, followed, as it has been, by H1N1 (2009), Ebola (2009), Middle East respiratory syndrome (2015), and Zika (2015), among others. It reaffirmed what was already known: that the changing patterns of human ecology and behavior (such as a taste for exotic food and urbanization) have been important triggers for the development of new zoonotic diseases. As pathogenic microbes naturally continue to evolve and at times cross the Darwinian divide between species, SARS conveys a salutary lesson.
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